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MORGAN COUNTY GOVERNMENT REQUEST FOR QUALIFICATIONS FOR BROKER SERVICES SUBMISSIONS ARE DUE AT THE ADDRESS SHOWN BELOW NO LATER THAN MONDAY, APRIL 1, 2013, AT 4:00PM, EST MORGAN COUNTY BOARD OF COMMISSIONERS ATTENTION: LORI SAYER, FINANCE DIRECTOR 150 E. WASHINGTON STREET MADISON, GA 30650 THE RESPONSIBILITY FOR SUBMITTING A RESPONSE TO THIS RFQ ON OR BEFORE THE STATED DATE AND TIME WILL BE SOLELY AND STRICTLY THE RESPONSIBILITY OF THE OFFEROR. ISSUE DATE: MARCH 20, 2013 ---PAGE BREAK--- 2 Broker Services I Morgan County Government MORGAN COUNTY, GEORGIA REQUEST FOR QUALIFICATIONS FOR BROKER SERVICES SECTION I – GENERAL OVERVIEW A. PURPOSE Morgan County Board of Commissioners is issuing this Request for Qualifications (RFQ) to seek qualified brokers to assist with strategically planning, designing and negotiating the best coverage and cost for selective employee benefit programs. The County has approximately 178 full-time employees. Our leadership is looking to ensure we have financially competitive and affordable benefit programs to offer our employees. The County does not guarantee a minimum value for this contract. This RFQ is not an authorization to approach insurers or other underwriting sources on behalf of the County. We specifically request that no insurance market contact or solicitation be made on behalf of Morgan County at this time and that no insurance market reservations or commitments be made for any purpose as respects any insurance or reinsurance to be provided for the County. B. INFORMATION TO VENDORS 1. RFQ TIMETABLE The anticipated schedule for the RFQ is as follows: RFQ Released March 20, 2013 Pre-Bid Conference Meeting None Deadline for questions to Morgan County tol [EMAIL REDACTED] March 27, 2013 at 1:00PM Deadline for Addenda posted on www.morganga.org under Bids & RFQs March 28, 2013 at 5:00PM Submittal deadline Monday, April 1, 2013 at 4:00P M, EST Tentative Award Date Monday, April 2, 2013 at 7:00PM 2. BID SUBMISSION One original and four copies of the complete signed submittal must be received Monday, APRIL 1, 2013 at 4:00 PM, EASTERN STANDARD TIME. Proposals must be submitted in a sealed envelope stating on the outside, the vendor's name, address, title of RFQ BROKER SERVICES to: ---PAGE BREAK--- 3 Broker Services I Morgan County Government Morgan County Board of Commissioners Attention: Lori Sayer, Finance Director 150 E. Washington Street Madison, Georgia 30650 Hand delivered copies may be delivered to the above address ONLY between the hours of 8:00AM and 5:00PM EST, Monday through Friday, excluding holidays observed by the Morgan County Government. For a complete listing of holidays please visit www.morganga.org. Vendors are responsible for informing any commercial delivery service, if used, of all delivery requirements and for ensuring that the required address information appears on the outer wrapper or envelope used by such service. NOTE: Express mail and delivery services may not guarantee overnight delivery by 4:00 PM toMorgan County. Submission by US Mail must be sent to the below address: Morgan County Board of Commissioners Attention: Lori Sayer, Finance Director 150 E. Washington Street Madison, Georgia 30650 The Submittal must be signed by a company officer who is legally authorized to enter into a contractual relationship in the name of the vendor. 3. CONTACT PERSON Vendors are encouraged to contact Lori Sayer, Finance Director at (706) 342- 0725, by fax at (706) 343-6450 or email [EMAIL REDACTED] to clarify any part of the RFQ requirements. All questions that arise prior to the DEADLINE FOR QUESTIONS due date shall be directed to the contact person in writing via facsimile or email. Any unauthorized contact shall not be used as a basis for responding to this RFQ and also may result in the disqualification of the vendor's submittal. Vendors may not contact any elected official or other county employee to discuss the bid process or bid opportunities except: through the Finance Director named herein, or as provided by existing work agreement(s). This policy shall be strictly enforced and the County reserves the right to reject the submittal of any vendor violating this provision. 4. ADDITIONAL INFORMATION/ADDENDA Morgan County will issue responses to inquiries and any other corrections or amendments it deems necessary in written addenda issued prior to the due date posted on the county’s website under the bid information. Vendors should not rely on any representations, statements or explanations other than those made in this RFQ or in any addendum to this RFQ. Where there appears to be a conflict between the RFQ and any addenda issued, the last addendum issued will prevail. Vendors are advised to check the website for addenda before submitting their ---PAGE BREAK--- 4 Broker Services I Morgan County Government bids. Vendors must acknowledge any issued addenda by including Attachment B- Addenda Acknowledgement with the submittal. Proposals which fail to acknowledge the vendor’s receipt of any addendum will result in the rejection of the offer if the addendum contains information which substantively changes the Owner’s requirements 5. LATE SUBMITTAL AND LATE MODIFICATIONS Submittals received after the due date and time will not be considered. Modifications received after the due date will not be considered. Morgan County Government assumes no responsibility for the premature opening of a proposal not properly addressed and identified, and/or delivered to the proper designation. 6. REJECTION OF PROPOSALS/CANCELLATION Morgan County Government reserves the right to reject any and all submittals and reserves the right to waive irregularities or informalities in any submittal or in the submittal procedure, when to do so would be to the advantage of Morgan County. Morgan County reserves the right to cancel this RFQ at any time. 7. MINIMUM RFQ ACCEPTANCE PERIOD Submittals shall be valid and may not be withdrawn for a period of 60 days from the date specified for receipt of submittals. 8. NON-COLLUSION AFFIDAVIT By submitting a response to this RFQ, the vendor represents and warrants that such proposal is genuine and not a sham or collusive or made in the interest or in behalf of any person not therein named and that the vendor has not directly or indirectly induced or solicited any other vendor to put in a sham proposal, or any other person, firm or corporation to refrain from submitting and that the vendor has not in any manner sought by collusion to secure to that vendor any advantage over any other vendor. By submitting a proposal, the vendor represents and warrants that no official or employee of Morgan County Government has, in any manner, an interest, directly or indirectly in the proposal or in the contract which may be made under it, or in any expected profits to arise there from. 9. COST INCURRED BY VENDORS All expenses involved with the preparation and submission of the RFQ to theMorgan County Board of Commissioners, or any work performed in connection therewith is the responsibility of the vendor(s) 10. RFQ OPENING Only the names of the firms responding to this RFQ will be read aloud publicly due to the fact that the proposals will be subject to an evaluation review for accurate qualifications. ---PAGE BREAK--- 5 Broker Services I Morgan County Government 11. OPEN RECORDS All materials submitted in connection with this RFQ will be public documents and subject to the Open Records Act and all other laws of the State of Georgia, the United States of America and the open records policies of Morgan County Board of Commissioners. All such materials shall remain the property of Morgan County and will not be returned to the respondent. 12. VENDOR INFORMATION All submissions shall include a completed vendor information form, current copy of W-9. Failure to provide this information could result in the disqualification of the vendor from submitting a proposal. 13. INSURANCE Selected vendor will be required to provide Morgan County with a Certificate of Insurance for liability and workman’s compensation insurance before work can begin on this County project and be effective for the duration of the work as described in the contract documents, including authorized change orders, plus any period of guarantee as required in the general warranty. General liability insurance should be at least one million dollars ($1,000,000) combined single limit per occurrence. Automobile insurance should be at least five hundred thousand dollars ($500,000) combined single limit per accident for bodily injury or property damage; and Workman’s Compensation insurance should be as required by the State of Georgia. 14. BONDS If required, under SECTION II – SCOPE OF WORK of this document any combination of the following bonds may be requested by Morgan County. A five percent bid bond, a one hundred percent (100%) payment bond, and a one hundred percent (100%) performance bond. All bonds would be payable toMorgan County Board of Commissioners. Failure to submit appropriate bonding will result in automatic rejection of bid. Bonding company must be authorized to do business in Georgia by the Georgia Insurance Commission, listed in the Department of Treasury’s publication of companies holding certificates of authority as acceptable surety on Federal bonds and as acceptable reinsuring companies, and have an A.M. Best rating. 15. ANTI-DISCRIMINATION Morgan County, in accordance with Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d to 2000d-4 and Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A, Office of the Secretary, Part 21, Nondiscrimination in Federally-assisted programs of the Department of Transportation issued pursuant to such Act, hereby notifies all bidders that it will affirmatively ensure that in any contract entered into pursuant to this advertisement, disadvantaged business enterprises as defined at 49 CFR Part 23 will be afforded full opportunity to submit bids in response to this Request for Qualifications and will not be discriminated against on the grounds of race, color, ---PAGE BREAK--- 6 Broker Services I Morgan County Government national origin, sex, handicap/disability in consideration of an award. By submitting their bids, all bidders certify to Morgan County that they will conform to the provisions of the Federal Civil Rights Act of 1964. In every contract of over $10,000 the provisions in 1. and 2. below apply: 1. During the performance of this contract, the contractor agrees as follows: a. The contractor will not discriminate against any employee or applicant for employment because of race, religion, color, sex or national origin, except where religion, sex or national ori gin is a bona fide occupational qualification reasonably neces sary to the normal operation of the contractor. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices setting forth the provisions of this nondiscrimination clause. b. The contractor, in all solicitations or advertisements for employees placed by or on behalf of the contractor, will state that such contractor is an equal opportunity employer. c. Notices, advertisements and solicitations placed in accordance with federal law, rule or regulation shall be deemed sufficient for the purpose of meeting the requirements of this section. 2. The contractor will include the provisions of 1 above in every subcontract or purchase order of over $10,000 so that the provisions will be binding upon each subcontractor or vendor. SECTION II – GENERAL CONDITIONS A. PURPOSE ---PAGE BREAK--- 7 Broker Services I Morgan County Government Morgan County Board of Commissioners is issuing this Request for Qualifications (RFQ) to seek qualified brokers to assist with strategically planning, designing and negotiating the best coverage and cost for selective employee benefit programs. The County has approximately 178 full-time employees. Our leadership is looking to ensure we have financially competitive and affordable benefit programs to offer our employees. The County does not guarantee a minimum value for this contract. This RFQ is not an authorization to approach insurers or other underwriting sources on behalf of the County. We specifically request that no insurance market contact or solicitation be made on behalf of Morgan County at this time and that no insurance market reservations or commitments be made for any purpose as respects any insurance or reinsurance to be provided for the County. B. CONTRACT PERIOD The initial term of a contract awarded as a result of this RFQ shall be from award date (April 2, 2013) through June 30, 2014. The contract may be renewed according to the terms stated herein for two additional one year periods. The contract shall terminate absolutely and without further obligation at such time as appropriated and otherwise unobligated funds are no longer available to satisfy the obligations of the County under this contract. The County does not guarantee a minimum value for this contract. If, at any time, the County determines it is in its best interest to discontinue use of these services the County reserves the right to cancel this Agreement by giving thirty (30) days advance written notice. C. SCOPE OF WORK Provisions of brokerage services to Morgan County under any agreement ensuing from this proposal will entail the following, at a minimum: 1. Auditing resulting contracts for accuracy of coverage, terms and conditions; 2. Assisting with annual benefits renewals, including negotiation of changes in contracts; 3. Assisting the County in determining specification for future insurance coverage; 4. Marketing the County’s desired insurance package through identification of appropriate markets, analysis of proposals, provisions of recommendations, and assistance in contract negotiation; 5. Preparing, disseminating, and analyzing bid packages in accordance with County specifications, should formal bidding package for quality of benefits be deemed necessary; 6. Reviewing the employee benefit package for quality of benefits provided, cost effectiveness, competitiveness and plan administration on an annual basis; 7. Monitor ongoing contracts, including third party administrators, to ensure contract compliance; 8. Analyzing claims history and insurance utilization at least quarterly; ---PAGE BREAK--- 8 Broker Services I Morgan County Government 9. Providing information on employee benefit issues, trends and proposed or new legislation; 10. Meeting with the County administrative staff as needed; 11. Assisting in the design of employee benefit communication and participating in Benefit Fairs and annual enrollment process; 12. Providing a key contact person to be available to answer questions and resolve issues that arise during the year regarding employee benefits, contract adminis tration and service provisions; 13. Providing a key contact person that specializes in Benefits Services assisting employees and families with claims and questions. This stipulation is required in order to stay in compliance with HIPPA regulations. 14. Evaluating various insurance products submitted by carriers, agents and brokers; and 15. Perform other related consultation services as needed or requested. D. STATEMENT OF QUALIFICATIONS Broker Proposal Questionnaire: The Broker Proposal Response Questionnaire must clearly demonstrate the required qualifications, expertise, competence, and capability of the vendor. Please provide a concise description of your firm’s ability to provide the services required in the Scope of Work of this document. Additionally, please include the answers to the following questions (Address each by number): 1. Describe your organizational structure (i.e. publicly held corporation, partnership, etc.). Review each area of your organization and describe their function. Describe the process for handling concerns/questions/calls from client staff and employees. 2. Confirm that you are a licensed broker in the State of Georgia and provide documentation. Confirm that you serve as a broker, independently, and are not employed by any insurance company, third party administrative agency or provider network. 3. Briefly describe your company’s organization, philosophy and management. Also, please provide a brief company history. 4. Describe your contractual relationship, if any, with organizations or entities necessary to your proposal’s implementation (i.e. actuarial services, data information services, third party providers for Open Enrollment, etc. 5. How long has your organization been providing brokerage services? Has your organization ever operated under a different name? Why was the name changed? 6. Provide a list of known complaints filed with the Insurance Commissioner’s Office, against your firm, over the past ten (10) years. Include the nature of the complaint and disposition. ---PAGE BREAK--- 9 Broker Services I Morgan County Government 7. How many public sector clients does your firm currently provide brokerage services to? 8. Indicate the method of service provision your organization would utilize in implementing your proposal (i.e. individual broker, individual broker with supporting back up, team of brokers). Please provide resumes of individual brokerage staff that would provide services to the County. Include a brief professional history for each individual and how they are qualified to provide services to Morgan County. 9. Briefly describe the level of service and support provided to Morgan County by your broker(s) on a day-to-day basis. Describe the level of service and support by your staff on a day-to-day basis. Are your customer service employees licensed insurance agents and are they certified under COBRA and HIPAA? 10. How does your firm provide continuing education to ensure that each broker is educated on current market trends and legislative developments? How is this information communicated to your clients? 11. Describe how you build an understanding of the direction and priorities of the County employee benefit program and how you would utilize this information to recommend changes and project future trends. 12. Detail how your organization assists clients in developing a strategic benefit plan. 13. Describe your organization’s anticipated involvement in the annual renewal process. Include information regarding process timeframes, negotiation of rates and vendor selection. NOTE: Morgan County’s current plan year for health and dental insurance is July 1st to June 30th. 14. Discuss any innovative mechanisms you have used to minimize insurance and service costs to your clients. 15. How do you keep your clients aware of trends and new developments in employee benefits i.e. flex spending? 16. How does your firm assist Morgan County in developing plan specifications? Explain your process for providing plan recommendation to your clients. 17. Explain the process your organization would utilize to assist Morgan County in selecting an insurance vendor. How would your company’s experience and expertise benefit the County in this process? 18. Please provide a list of the vendors you have relationships with in regard to health, disability, life, supplemental health and dental insurance plans. Describe your preferred carrier relationships and the benefits of these relationships to your clients. Describe any blocks or pools of business that your firm has access to and ---PAGE BREAK--- 10 Broker Services I Morgan County Government what benefits are to your clients. 19. Describe how your organization strives to streamline benefit administration for your clients. Include any services you provide for automation of the benefit process (i.e. electronic capabilities, outsourcing options). How many of your clients are enrolled online? How many employees does this represent? Does your staff build these enrollment websites? Attach any associated cost for these services on a separate fee schedule. 20. Describe process for Open Enrollment for client staff and its employees. 21. Detail how you develop a benefit communication strategy with your clients. Include what tools or resources you have available to assist your clients in effectively communication not only the specific plan details but also the value of the benefits offered? 22. What training resources does your organization provide to assist you clients in education and training their employees? 23. Describe your compliance services. What resources does your organization utilize to answer compliance questions from your clients? List three recent compliance questions and show the format and content of your response. 24. Please provide a case study on a recent client that has begun working with your firm in the past three years and show the financial impact on claims that your firm has made through benefit consulting. Describe your recommendation and how these related to the financial impact on their plan. 25. What makes your organization unique from the other organizations that may submit proposals fortheCounty’sconsideration? 26. Provide any additional information regarding your organization or services that you feel would be beneficial in helping the County to select a benefits broker. 27. Please provide a list of four verifiable public sector references, all of whom are abletocommentofyourorganization’srelevantexperience.Pleasefurnish: Group Name; Contact name and telephone number; Services you provided; Time period covered; Benefit programs addressed; and number of covered employees. 28. List any and all accounts held by local governments (city and county) in Georgia within the last five years. If any, do you still hold that account? If no, why not? If no Georgia local governments, indicate so. Pricing: It is Morgan County’s expectation that brokerage fees and commissions will be borne by the selected insurance provider. If additional brokerage fees are expected of Morgan County, or if your firm offers additional fee-supported services which are supplemental ---PAGE BREAK--- 11 Broker Services I Morgan County Government to your proposal, please clearly outline such costs and services on a separate fee addendum at the end of the proposal in a separate, sealed envelope clearly identified as “FinancialProposal.” Oral Presentations: During the evaluation process, Morgan County may at its discretion, request oral presentations from any or all respondents for the purpose of clarification or amplifying the materials presented. However, respondents are cautioned that the County is not required to request clarification; therefore, all proposals should be complete and reflect the most favorable terms available from the broker. Criteria for Evaluation: All proposals will be evaluated according to, but not necessarily limited to, the following: Your firm’s indicated ability to provide a level of service sufficient to meet the County’s needs, as stated in your response to Scope of Work and Broker Proposal Questionnaire. 1. Extent and success of previous work your firm has provided to organizations similar in nature and size to Morgan County, as determined by Morgan County’s contact with references provided. 2. Theproposalitselfasanexampleofyourfirm’sworkproduct. 3. Qualifications/experience of key personnel to be assigned to the project as stated in question 8 of Broker Proposal Questionnaire. 4. Adherence to RFQ requirements, including: completion of all required forms; provision of all requested information; adequacy of responses, and return of the RFQ by the stated deadline. E. Administration The project will be administered by the Morgan County Board of Commissioners with the Morgan County Human Resources Director being the main point of contact for all questions during the term of the contract. F. Bidder’s Checklist – Required Forms The following documents are also required to be included in your proposal packet: REQUIRED FORMS Documentation that is required for a complete proposal includes: 1. Documentation listed under Section D: Statement of Qualifications 2. Vendor Information Form 3. Execution of Proposal Form 4. Addenda Acknowledgment Form 5. Proposer’sCertificationandNon-CollusionAffidavit 6. SAVE Affidavit 7. Completed W-9 8. Copy of current Georgia Insurance Brokerage license 9. Proof of Insurance (Liability and Worker’s Compensation) – Sample document may be given at time of RFQ submittal. Once the contract is awarded, vendor must provide a Certificate of Liability Insurance and a copy of the insurance policy naming Morgan County as an additionally insured. ---PAGE BREAK--- 12 Broker Services I Morgan County Government G. PROCEDURES AND MISCELLANEOUS ITEMS 1. All questions shall be submitted in writing (e-mail is acceptable) and shall be communicated in the form of an addenda if the scope specifications are to be affected and posted on the County’s website under the bid information, all firms responding to this RFQ should check the website before responding to this RFQ. 2. All respondents to this RFQ shall indemnify and hold harmless the Morgan County Board of Commissioners, and any of their officers and employees from all suits and claims alleged to be a result of this RFQ. The issuance of this RFQ constitutes only an invitation to present a proposal. It does not constitute an Invitation to Bid nor does it commit the County to issuing an Invitation to Bid. TheMorgan County Board of Commissioners reserves the right to determine, at its sole discretion, whether any aspect of a respondent's submittal meets the criteria in this RFQ. The Morgan County Board of Commissioners also reserves the right to seek clarifications, to negotiate with any vendor submitting a response, to reject any or all responses with or without cause, and to modify the procurement process and schedule. In the event that this RFQ is withdrawn or the project canceled for any reason, the Morgan County Board of Commissioners shall have no liability to any respondent for any costs or expenses incurred in connection with this RFQ or otherwise. 3. The RFQ is subject to the provisions of the Morgan County Purchasing Policy and any revisions thereto, which are hereby incorporated into this RFQ in their entirety except as amended or superseded herein. 4. Failure to submit all the mandatory forms from this RFQ package shall be just cause for the rejection of the qualification package. However, Morgan County reserves the right to decide, on a case by case basis, in its sole discretion, whether or not to reject such a bid as non-responsive. 5. In case of failure to deliver goods in accordance with the contract terms and conditions, Morgan County, after due oral or written notice, may procure substitute goods or services from other sources and hold the contractor responsible for any resulting additional purchasing and administrative costs. This remedy shall be in addition to any other remedies which Morgan County may have. 6. By submitting a qualification package, the vendor is certifying that they are not currently debarred from bidding on contracts by any agency of the State of Georgia, nor are they an agent of any person or entity that is currently debarred from submitting bids on contacts by any agency of the State of Georgia. 7. Any contract resulting from this RFQ shall be governed in all respects by the laws of the State of Georgia and any litigation with respect thereto shall be brought in the courts of the State of Georgia. Then contractor shall comply with applicable federal, state, and local laws and regulations. 8. It is understood and agreed between the parties herein that Morgan County shall ---PAGE BREAK--- 13 Broker Services I Morgan County Government be bound hereunder only to the extent of the funds available or which may hereafter become available for the purpose of this agreement. H. FINAL SELECTION Following review of all qualified proposals, selection of a suitable vendor, and preliminary contract negotiations, a recommendation will be made to the Morgan County Board of Commissioners by the project representative. Following Commission approval, the County will complete contract negotiations. The selected vendor should be prepared to commence working on the employee benefit package immediately following contract execution. The Morgan County Board of Commissioners reserves the right to accept the response that is determined to be in the best interest of the County. The County reserves the right to reject any and or all proposals. EXECUTION OF PROPOSAL DATE: The potential Contractor certifies the following by placing an in all blank spaces: That this proposal was signed by an authorized representative of the firm. ---PAGE BREAK--- 14 Broker Services I Morgan County Government That the potential Contractor has determined the cost and availability of all materials and supplies associated with performing the services outlined herein. That all labor costs associated with this project have been determined, including all direct and indirect costs. That the potential Contractor agrees to the conditions as set forth in this Request for Qualifications with no exceptions. Therefore, in compliance with the foregoing Request for Qualifications, and subject to all terms and conditions thereof, the undersigned offers and agrees, if this proposal is accepted within sixty (60) days from the date of the opening, to furnish the services for the prices quoted within the timeframe required. Business Name Authorized Signature Date Typed Name & Title THIS PAGE MUST BE COMPLETED AND SUBMITTED AS A PART OF YOUR PROPOSAL ---PAGE BREAK--- 15 Broker Services I Morgan County Government RFQ BROKER SERVICES BIDDER REFERENCE FORM All references must be from customers for whom your company has completed work similar to the specifications of this bid. Attach additional page if necessary. References for: (Company Name) 1. Company Street Address City, State & Zip Contact Person Name Title Phone FAX Email Describe Scope of Work and dates of project/service: 2. Company Street Address City, State & Zip Contact Person Name Title Phone FAX Email Describe Scope of Work and dates of project/service: ---PAGE BREAK--- 16 Broker Services I Morgan County Government 3. Company Street Address City, State & Zip Contact Person Name Title Phone FAX Email Describe Scope of Work and dates of project/service: THIS PAGE MUST BE COMPLETED AND SUBMITTED AS A PART OF YOUR PROPOSAL RFQ BROKER SERVICES ADDENDA ACKNOWLEDGEMENT The vendor has examined and carefully studied the Request for Qualifications and the following Addenda, receipt of all of which is hereby acknowledged: Addendum No. Addendum No Addendum No. Addendum No. ---PAGE BREAK--- 17 Broker Services I Morgan County Government Authorized Representative (Signature) Date Authorized Representative/Title (Print or Type) Vendors must acknowledge any issued addenda. Proposals which fail to acknowledge the vend or’s receipt of any addendum will result in the rejection of the offer if the addendum contained information which substantively changes the Owner’s requirements. THIS PAGE MUST BE COMPLETED AND SUBMITTED AS A PART OF YOUR PROPOSAL RFQ BROKER SERVICES PROPOSER’SCERTIFICATIONAND STATEMENT OF NON-COLLUSION I that this proposal is made without prior understanding, agreement or connection with any corporation, firm or person submitting a proposal for the same services and is in all respects fair and without collusion or fraud. I understand that collusive bidding is a violation of state and Federal law and can result in fines, prison sentences and civil damages awards. I certify that this proposal has been prepared independently and the price submitted will not be disclosed to another person. I certify that there has been no contact or communication by the proposer or the proposer’s associates with any County staff, or elected officials since the date this Broker Services was issued except: 1) through the Finance Department 2) at the Pre-Proposal Conference (if applicable) or 3) as provided by existing work agreement(s). The County reserves the right to reject the proposal submitted by any proposer violating this provision. ---PAGE BREAK--- 18 Broker Services I Morgan County Government I agree to abide by all conditions of this proposal and certify that I am authorized to sign this proposal. COMPANY NAME: Authorized Representative (Signature) Date Authorized Representative/Title (Print or Type) THIS PAGE MUST BE COMPLETED AND SUBMITTED AS A PART OF YOUR PROPOSAL RFQ BROKER SERVICES VENDOR’S INFORMATION FORM 1. Legal Business Name 2. Street Address 3. City, State & Zip ---PAGE BREAK--- 19 Broker Services I Morgan County Government 4. Type of Business: State of Registration: (Association, Corporation, Partnership, Limited Liability Company, etc) 5. Name & Title of Authorized Signer: 6. Primary Contact 7. Phone Fax 8. E-mail 9. Company Website 10. Has your company ever been debarred from doing business with any federal, state or local agency? Yes No If Yes, please state the agency name, dates and reason for debarment. ATTACH COPY OF A COMPLETED W-9 FORM THIS PAGE MUST BE COMPLETED AND SUBMITTED WITH PROPOSAL ---PAGE BREAK--- 20 Broker Services I Morgan County Government MORGAN COUNTY BOARD OF COMMISSIONERS SAVE Affidavit (Systematic Alien Verification for Entitlements) Affidavit for a Public Benefit as required by the Georgia Immigration Reform and Enforcement Act of 2011 By executing this affidavit under oath, as an applicant for a public benefit as referenced in the Georgia Illegal Immigration Reform and Enforcement Act of 2011 [O.C.G.A.§50-36-1(e)(2)], I am stating the following: I am a United States citizen; or I am a legal permanent resident of the United States*; or I am an otherwise qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18 years of age or older and lawfully present in the United States.* *Alien registration number for non-citizens issued by the Department of Homeland Security or other federal immigration agency is: At least one secure and verifiable document for identification purposes must be provided as required by O.C.G.A. § 50-36-1 See list on page 2 of this document. In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of Code Section 16-10-20 of the Official Code of Georgia and face criminal penalties as allowed by such criminal statute. Applying on behalf/Name of associated business Signature of Applicant Date Printed Name SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF 20___ [NOTARY SEAL] Notary Public My Commission Expires: *NOTE: O.C.G.A. 50-36-1(e)(2) requires that aliens under the Federal Immigration and Nationality Act, Title 8 U.S.C., as amended, provide their alien registration number. Because legal permanent residents are included in the federaldefinitionof“alien”,legalpermanentresidentsmustalsoprovidetheiralienregistrationnumber. SECURE AND VERIFIABLE DOCUMENTS UNDER O.C.G.A. §50-36-2 ---PAGE BREAK--- 21 Broker Services I Morgan County Government [Issued August 1, 2011 by the Office of the Attorney General, Georgia] The following list of secure and verifiable documents, published under the authority of O.C.G.A. §50-36- 2, contains documents that are verifiable for identification purposes, and documents on this list may not necessarily be indicative of residency or immigration status. INDICATE AND ATTACH A COPY OF THE DOCUMENT (front and back). United States passport or passport card UnitedStatesmilitaryidentificationcard MerchantMarinerDocumentorMerchantMarinerCredentialissuedbytheUnitedStatesCoastGuard SecureElectronicNetworkforTravelersRapidInspection(SENTRI)card Driver’s license issued by one of the United States, the District of Columbia, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth gender, height, eye color, and address to enable the identification of the bearer. Identification card issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth gender, height, eye color, and address to enable the identification of the bearer. Tribal identification card issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth gender, height, eye color, and address to enable the identification of the bearer. Passportissuedbyaforeigngovernment FreeandSecureTrade(FAST)card NEXUScard UnitedStatesPermanentResidentCardorAlienRegistrationReceiptCard EmploymentAuthorizationDocumentthatcontainsaphotographofthebearer. Certificate of Citizenship issued by the United States Department of Citizenship and Immigration Services (USCIS) [Form N-560 or Form N-561] Certificate of Naturalization issued by the United States Department of Citizenship and Immigration Services (USCIS) [Form N-550 or Form N-570]