City of Perth Amboy Department of Administration Division of Purchasing 260 High Street Perth Amboy, NJ 08861

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1 City of Perth Amboy Department of Administration Division of Purchasing 260 High Street Perth Amboy, NJ REQUEST FOR PROPOSALS FOR INSURANCE BROKER SERVICES FOR HEALTH BENEFITS (MEDICAL/PRESCRIPTION/DENTAL/VISION) ISSUED October 20, 2018 DUE November 20, 2018

2 NOTICE Notice is hereby given that sealed Proposals will be received by the City of Perth Amboy (the City ), 260 High Street, Perth Amboy, New Jersey 08861, on November 20, 2018 at 12:00 p.m. prevailing time for the services listed below, at which time they will be opened in public: INSURANCE BROKER SERVICES FOR HEALTH BENEFITS (MEDICAL/PRESCRIPTION/DENTAL/VISION) This Request for Proposals (RFP) is issued in accordance with Executive Order and Section et seq. of the City Code, which requires that the City utilize a fair and open procurement process when soliciting insurance services, among other services. This RFP also satisfies the requirements of a fair and open process pursuant to N.J.S.A. 19:44A-20.4 et seq. Insurance services are exempt from bidding pursuant to N.J.S.A. 40A:11-5(1)(m). The RFP documents may be obtained from Gary Muska, Purchasing Agent, 260 High Street, Perth Amboy, New Jersey between the hours of 9:00 a.m. and 4:00 p.m. Monday through Friday, or can be downloaded from the City s website: An original, two (2) copies and one saved in a flash drive of proposals in response to this RFP must be submitted to the City of Perth Amboy, Division of Purchasing, Att: Gary Muska, Purchasing Agent, City Hall, 260 High Street, Perth Amboy, New Jersey 08861, prior to the date and time set forth above. At the above place and time, proposals received shall be opened, and the names of all respondents and their respective price proposals shall be announced in public. Proposals must be submitted in a sealed envelope, clearly marked on the outside with the words RFP, Insurance Broker Services for Health Insurance Benefits (Medical/Prescription/Dental/Vision). Respondents are required to comply with the requirements of P.L. 1975, c.127. (Affirmative Action Program, Equal Employment Opportunity). The City of Perth Amboy reserves the right to consider submitted proposals for sixty (60) days after receipt thereof, and further reserves the right to reject any and all proposals, waive informalities, and make an award or take any other action as may be in the best interest of the City, consistent with applicable law. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 1

3 GLOSSARY The following definitions shall apply to and are used in this Request for Proposals: 1. City refers to the City of Perth Amboy. "Proposal" refers to a complete response to this RFP submitted by a Respondent. 2. Respondent or Respondents refers to the interested firm(s) that submits a response to the RFP. 3. "RFP" - refers to this Request for Proposals, including any amendments or supplements thereto. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 2

4 1.1 Introduction and Purpose SECTION 1 INTRODUCTION AND GENERAL INFORMATION The City of Perth Amboy is soliciting Proposals for the provision of insurance broker services for employee health benefits covering medical, prescription, dental and vision services as described herein. Through a Request for Proposal ( RFP ) process described herein, firms interested in providing the requested services must prepare and submit a Proposal in accordance with the procedure and schedule in this RFP. The City will review only those Proposals that include all the information required to be included as described herein (in the sole judgment of the City). The City intends to award a contract to the qualified Respondent whose Proposal is in the best interest of the City, as determined by the City, in accordance with applicable law. 1.2 Procurement Process and Schedule This RFP is issued in accordance with Executive Order , and with Section et seq. of the City Code, which requires that the City utilize a fair and open procurement process when soliciting insurance services, among other services. This RFP also satisfies the requirements of a fair and open process pursuant to N.J.S.A. 19:44A-20.4 et seq. Insurance services are exempt from bidding pursuant to N.J.S.A. 40A:11-5(1)(m). The City has structured a procurement process that seeks to obtain the desired results described above, while establishing a competitive process to assure that each firm is provided an opportunity to submit a Proposal in response to the RFP. Proposals will be evaluated by an evaluation committee in accordance with the criteria set forth in Section 4 of this RFP, which will be applied in the same manner to each Proposal received. Under no circumstances will a member of the evaluation committee review responses to an RFP if they have a personal or financial interest in any of the Respondents. Based upon the totality of the information contained in the Proposal, the City will select the Successful Respondent whose Proposal, in the City s sole judgment, best serves the interests of the City, in accordance with law. The timetable for award of any contract hereunder is set forth in Section 1.8 hereof. The City reserves the right to, among other things, amend, modify or alter the Procurement Schedule upon notice to all potential Respondents. All communications concerning this RFP or the RFP process shall be in writing and directed to the City s Designated Contact Person, no later than 12:00 p.m. on November 1, Designated Contact Person: Sonia Neira, Personnel Officer City of Perth Amboy 260 High Street Perth Amboy, New Jersey sneira@perthamboynj.org The City (through the issuance of addenda to all firms that have received a copy of the RFP) may modify, supplement or amend the provisions of this RFP in order to respond to inquiries received from prospective Respondents or as otherwise deemed necessary or appropriate by the City. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 3

5 Responses to this RFP must be submitted to Gary Muska, Purchasing Agent, City of Perth Amboy, 260 High Street, Perth Amboy, New Jersey 08861, and be received by, the City, via United States mail or hand delivery, by 12:00 p.m. Prevailing Time on November 20, Proposals not received at that time and place will not be accepted but will be returned unopened by the City. Responses will not be accepted by facsimile transmission or Conditions Applicable to RFP Upon submission of a Proposal in response to this RFP, the Respondent acknowledges and consents to the following conditions relative to the submission, review and consideration of its Proposal: All costs incurred by the Respondent in connection with responding to this RFP shall be borne solely by the Respondent. The City reserves the right (in its sole judgment) to reject for any reason, consistent with law, any and all responses to the RFP. The City reserves the right (in its sole judgment) to reject any Respondent that submits incomplete responses or a Proposal that is not responsive to the requirements of this RFP. The City reserves the right, without prior notice, to supplement, amend, or otherwise modify this RFP, or otherwise request additional information. All Proposals shall become the property of the City and will not be returned. All Proposals will be made available to the public in accordance with law. The City may request Respondents to send representatives to the City for interviews. Neither the City, nor its staff or consultants, shall be liable for any claims or damages resulting from the solicitation or preparation of the Proposal, nor there any reimbursement to Respondents for the cost of preparing and submitting a Proposal or for participating in this procurement process. Respondents are advised of the responsibility to file an annual disclosure statement of political contributions with the New Jersey Election Law Enforcement Commission pursuant to N.J.S.A. 19:44A (P.L. 2005, c.271, s.3) if the Respondent receives contracts in excess of $50,000 from public entities in a calendar year. It is the Respondent s responsibility to determine if filing is necessary. Additional information on this requirement is available from ELEC at (888) or at Rights of City The City reserves, holds and may exercise, at its sole discretion, the following rights and options with regard to this RFP and the procurement process in accordance with the provisions of applicable law: To determine that any Proposal received complies or fails to comply with the terms of this RFP. To supplement, amend or otherwise modify the RFP through issuance of addenda to all prospective Respondents who have received a copy of this RFP. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 4

6 To waive any technical non-conformance with the terms of this RFP. To change or alter the schedule for any events called for in this RFP upon the issuance of notice to all prospective Respondents who have received a copy of this RFP. To conduct investigations of any or all of the Respondents, as the City deems necessary or convenient, to clarify the information provided as part of the Proposal, and to request additional information to support the information included in any Proposal. To suspend, abandon or terminate the procurement process described in this RFP at any time. If abandoned or terminated, the City may determine to commence a new procurement process or exercise any other rights provided under applicable law without any obligation to the Respondents. The City shall be under no obligation to complete all or any portion of the procurement process described in this RFP. 1.5 Addenda or Amendments to RFP During the period provided for the preparation of responses to the RFP, the City may issue addenda, amendments or clarifications to written inquiries. Those addenda will be noticed by the City and will constitute a part of the RFP. All responses to the RFP shall be prepared with full consideration of the addenda issued prior to the proposal submission date. 1.6 Cost of Proposal Preparation Each Proposal and all information required to be submitted pursuant to the RFP shall be prepared at the sole cost and expense of the Respondent. There shall be no claims whatsoever against the City, its staff or consultants for reimbursement for the payment of costs or expenses incurred in the preparation of the Proposal or other information required by the RFP. 1.7 Proposal Format Responses should cover the information requested in Section 3 hereof. Responses that, in the judgment of the City, fail to meet the requirements of the RFP or that are in any way conditional, incomplete, obscure, contain additions or deletions from requested information, or contain errors may be rejected. 1.8 Anticipated Procurement Schedule Issuance of Request for Proposals: October 20, 2018 Deadline for Submission of Written Questions: November 1, 2018 Receipt of Responses: November 20, 2018 Completion of Evaluation of Responses: December 7, 2018 Award of Contract: Between December 12, 2018 and January 16, 2019 CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 5

7 SECTION 2 SCOPE OF SERVICES 2.1 Scope of Services It is the intent of the City to solicit Proposals from Respondents that have expertise in the provision of health insurance broker services regarding the evaluation and obtaining of insurance coverage and management of a Self-Insured Health Insurance Program for employees and retirees. Respondents shall have a minimum of 10 years experience in providing insurance consultant/broker services to self-insured public entities having an annual cost exceeding $10 million. Firms and/or persons responding to this RFP shall be able to demonstrate that they will have the continuing capabilities to perform these services and possess the necessary license and/or certification to do so. a. Assigned Personnel: The Successful Respondent shall designate a principal to be assigned to this account to act as the primary contact for the City. The City must approve the principal and any other personnel assigned to perform services for the City (hereafter collectively referred to as assigned personnel ). If for any reason the City finds, in its sole discretion, that the service provided by any assigned personnel is unsatisfactory, the Successful Respondent will agree to assign replacement personnel that must be approved by the City. Personnel assigned to the account must have a minimum of (10) ten years full time experience as a broker and a minimum of (10) ten years full time experience with public entities. Insured and self-insured insurance program management is highly preferred. b. Health Insurance Program Administration and Consulting Services: Program administration and consulting services duties shall include, but not be limited to the following: 1. Act as an independent insurance advisor to the City, and proactively provide ongoing unbiased professional advice and recommendations that benefit the City. 2. Proactively provide ongoing review, recommendations, and analysis of the City s insurance programs and identification of risk transfer and risk financing options. 3. Assist in the procurement of health benefits insurance coverage, including preparation of any required requests for proposals, pursuant to and in compliance with Executive Order (Appendix L). 4. Analyze proposals received in connection with insurance procurement, including but not limited to evaluation of proposals and recommendations. 5. Have knowledge of all the major exposures of the City. 6. Have knowledge of and familiarity with the coverage provided by all relevant insurance policies and documents issued to the City. 7. Have knowledge of ACA compliance regulations. 8. Assure that insurance policies are placed in a timely manner, without lapse in coverage periods, with reputable and financially responsible insurers. 9. Service the insurance policies placed for the City including processing all changes, endorsements and verifying the accuracy of invoices within a reasonable time. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 6

8 10. Provide early notice of rate and coverage changes or renewal problems through a process to be mutually agreed upon with the City. 11. Ensure that all policies purchased are reviewed, and that policies are provided to the City before renewal date or within 30 days of receipt. 12. Provide loss runs annually and provide a loss analysis when requested for each policy written 45 days prior to renewal. 13. Through a mutually agreed upon process, monitor the City s operations and loss exposures and make any appropriate recommendations for coverage changes or new coverage. 14. Be available to answer questions or obtain answers from underwriters for policy coverage questions. 15. Meet with City staff and designated representatives on a monthly basis and provide monthly loss exposure reports. 16. Provide consultation service and written reports on a regular basis, consistent with industry standards. 17. Provide loss control services and assistance with claims as requested by the City. 18. Analyze loss exposures from existing and new operations and determine the appropriate risk management alternatives, including changes to types, availability, costs and extent of coverage that should be considered. 19. Act as a resource to advise the City in the areas of COBRA, HIPPA, ERISA, EEO, FMLA, Health Care Reform laws and other areas in the insurance field where expertise and guidance may be requested. 20. Provide preliminary renewal figures during the budget process. 21. Upon request of the City, but at least once a year, provide a comprehensive report that reviews all of the City s health insurance programs, exposures, cost controls, etc. 22. Provide additional services related to insurance coverage as the City may reasonably request. 23. Review Collective Negotiation s Agreements, make recommendations for modifications to improve services and control costs. 24. Prepare annual COBRA rates for both health insurance contributions and for charges to employees on leaves of absence & following termination of employment. Brokerage and consulting services must be provided for annual policy renewals and on an as needed basis. The Successful Respondent must provide a thorough renewal presentation each year at least thirty (30) days before the expiration date of then-current policies, with policy recommendations to include an analysis of available alternatives in consideration of the City s exposures. Brokerage services must also include market research, policy endorsements, certificates of insurance, and coverage consultation on claims filed against the City. The Successful Respondent will also advise on a continuing basis, and in a timely manner, of any and all significant matters and developments regarding carrier service issues. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 7

9 c. Employee Services 1. Provide full services regarding open enrollment, new employee orientations, and support services. 2. Develop and print annual enrollment materials and guidelines. 3. Respond to all employee issues and questions in a timely manner regarding their benefits. 4. Provide a client call center/help desk to assist employees with resolving any plan participants health insurance related issues. 5. Provide an online website to assist employees with resolving any plan participants health insurance related issues. 6. Provide assistance in creating and/or educating employees about available wellness programs. 7. Provide communications such as brochures, posters and other communications regarding health benefits and wellness programs. 8. Attend City events to discuss insurance and employee benefits, and employee open enrollment / health fairs. 9. Assist the City in evaluating and negotiating employee grievances related to health benefits issues. 10. Prepare annual ACA reporting, including IRS Form 1095-C. 11. Provide COBRA administration including but not limited to monthly reporting. 12. Act as a liaison for the Administration for enrollment/status changes due to qualifying events. 13. Prepare and mail annual notifications of Creditable Coverage. d. Compliance with Executive Order All services shall be performed in accordance with Executive Order , included herein as Appendix L. In accordance with Executive Order No , included at Appendix L is information pertaining to the City s health benefits plans (medical, dental, vision and prescription), which depicts the types of plans, COBRA rates, and lives covered. All solicited insurance carriers shall be rated (A) or better by the most recently published A. M. Best Rating Guide. Unless otherwise specified, it shall be the responsibility of the successful respondent to insure that all subcontractors comply with the same insurance requirements spelled in this RFP. The City reserves the right to accept or reject the insurance carrier. Qualified firms wishing to respond to this RFP must provide all services described in this document, whether directly or through sub-consultants. The City reserves the right to approve or disapprove of any sub-consultants Term The term of the contract for Insurance Broker Services for Health Benefits will be a one (1) year contract with two (2) optional one (1) year term extensions subject to the requirements of N.J.S.A. 40A:11-15 but it is the intention of the City to do a (3) three year contract. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 8

10 2.3 Certification Regarding Commissions and Fees During the term of any contract awarded hereunder, the Successful Respondent shall provide the City with the annual certifications regarding commissions and fees, as required pursuant to Executive Order (Appendix L). CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 9

11 SECTION 3 SUBMISSION REQUIREMENTS 3.1 General Requirements The Proposals submitted by the Respondent must meet or exceed the professional, administrative and financial qualifications set forth in this Section and shall incorporate the information requested below. In addition to the information required as described below, a Respondent may submit supplemental information that it feels may be useful in evaluating its Proposal. Respondents are encouraged to be clear, factual, and concise in their presentation of information. THE SUCCESSFUL RESPONDENT WILL BE REQUIRED TO REPRESENT THE INTERESTS OF THE CITY IN THE NEGOTIATION, PLACEMENT AND SERVICING OF ITS INSURANCE PROGRAMS, AND PROPOSALS SUBMITTED BY INSURANCE AGENTS SHALL BE DISCLOSED AS SUCH. FURTHER THE SUCCESSFUL RESPONDENT SHALL BE REQUIRED TO PROCURE INSURANCE FOR THE CITY IN ACCORDANCE WITH THE REQUIREMENTS OF EXECUTIVE ORDER NO , WHICH IS INCLUDED HEREWITH AS APPENDIX L. Any Respondent who operates as a managing general agent, managing general underwriter, has any ownership interest in an entity which contracts with a joint insurance fund, has any financial interest in any joint insurance fund, or in any similar capacity for any underwriting organization shall fully disclose the nature and extent of its service as such. Such statement shall include confirmation that such service shall not present a conflict of interest with regard to Respondent s responsibilities to the City, should Respondent be selected, which responsibilities shall be paramount under any circumstance. 3.2 Content and Form of Proposal Response a. Proposal Format. Proposal content and completeness will be important criteria in the evaluation process. In order to streamline the evaluation process and insure that all proposals are evaluated on an equal basis, it is required that Proposals adhere to the standard format outlined below for presentation of the requested information. Section/Title 1. Letter of Transmittal 2. Qualifications 3. Experience of the Firm 4. Key Personnel 5. Fee Proposal and other Proposal Checklist Forms b. Proposal Content i. Letter of Transmittal (Section 1) The Respondent must provide a Letter of Transmittal signed by the individual who is authorized to commit the firm to the Scope of Services of this RFP. This letter must incorporate the following: An acknowledgment of receipt of this RFP stating that it is understood that all conditions contained in this RFP may be incorporated into any resulting contract. A narrative statement of the Respondent s understanding of the City s needs and goals. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 10

12 A statement that guarantees that the proposal is valid for 90 days from the date of receipt by the City. A statement acknowledging that all information contained in the Proposal is factual and accurate. A statement that the Respondent is in compliance with all applicable affirmative action regulations. A statement acknowledging that the individual signing the letter of transmittal has the authority to commit the firm to all the provisions contained in this RFP and the firm's corresponding Proposal. Respondent must identify any existing or potential conflicts of interest, and disclose any representation of parties or other relationships that might be considered a conflict of interest with regard to this engagement, or to the City. The submission shall be accompanied by Request for Proposals Checklist (Appendix A); Fee Proposal (Appendix B); Executed Letter of Transmittal (Appendix C); Insurance Requirements and Acknowledgement Form (Appendix D); Business Entity Disclosure Certification for Fair and Open Contracts (Appendix E); Non-Collusion Affidavit (Appendix F); Request for References (Appendix G); Certification of Compliance with City of Perth Amboy s Local Pay to Play Ordinance (Appendix H); Certification of Compliance with City of Perth Amboy s Public Contracting Ordinance (Appendix I); Mandatory Equal Employment Opportunity Notice Acknowledgement (Appendix J); American with Disabilities Act of 1990 (Appendix K); Respondent s Business Registration Certificate (Appendix L); Professional Services Entity Information Form (Appendix M); Data Form Summary (Appendix N); Respondent s Qualification Statement (Appendix O); Compliance with Executive Order Regarding Procurement of Insurance Services (Appendix P); Firm s Affidavit of No Disciplinary Sanctions or Professional Negligence (Appendix Q); Disclosure of Investment Activities in Iran (Appendix R); Disclosure of Investigations and Actions Involving Service Entity (Appendix S); and Acknowledgement of Receipt of Addenda (Appendix T). ii. Qualifications (Section 2) (1) Respondent s Experience The Respondent must demonstrate the experience and qualifications of the firm. Respondent must provide the following: Brief history of the firm; highlight the benefits the firm believes it can contribute to the City. An explanation of fields of expertise and reputation in the field. An explanation of the Broker s experience (Minimum of 5 years in providing services to self-insured public entities) and knowledge in providing broker services to municipalities similar in size to the City of Perth Amboy, and which are also self-insured. Respondent shall have knowledge, training and experience in all forms of municipal insurance and all other types of insurance products necessary for the City of Perth Amboy. An explanation of licensures held and familiarity and experience with public entity insurance. Any other information the Respondent deems pertinent and which demonstrates an ability to perform the requested services. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 11

13 A detailed description of the services to be provided including examples. Clearly outline the approach that the Respondent intends to utilize in providing the services outlined in the Scope of Services. Provide at least three (3) client references where the services provided were comparable to those requested in the Scope of Services section of this RFP; Identify any existing or potential conflict of interest, or any relationships that might be considered a conflict of interest, that may affect or involve the provisions of services to the City. Describe any pending, concluded or threatened litigation, administrative proceedings or federal or state investigations or audits, subpoenas, or other information requests of or involving your firm or the owners, principals or employees thereof during the past three (3) years. Describe the nature and status of the matter and the resolution, if any. Provide account retention experience for clients similar to the City, and employee retention experience. (2) Experience of Key Personnel The Respondent must demonstrate the experience and qualifications of the firm and its professionals who will be performing work for the City. Therefore, Respondent shall provide the following: Resumes of the professionals who will be assigned and committed to the City, identifying each professional's status in the firm, i.e., partner, associate, etc., and his or her applicable experience with other governmental agencies of similar size and budget. A list of all immediate relatives of Respondent s principal(s) who are City employees or elected officials of the City. For purposes of the above, immediate relative means a spouse, parent, stepparent, brother, sister, child, stepchild, direct-line aunt or uncle, grandparent, grandchild, and in-laws by reason of relation. Other information Respondent deems pertinent which demonstrates an ability to perform the requested services. iii. Fee Proposal (Section 3) Respondents shall provide a fee proposal on a fixed fee basis for services to be provided under this RFP. In accordance with Executive Order (Appendix L), a fee proposal MAY NOT be expressed as a percentage of premium costs. The Successful Respondent shall fully disclose all commissions, fees, incentives, bonuses or reimbursements (collectively, compensation )received from anyone, including insurance carriers or insurance providers related to the Successful Respondent s performance of brokerage services on behalf of the City. In accordance with Executive Order , any such Compensation shall offset any fees due by the City to Respondent for performance of services to the City under this RFP. It is the City s intent that the Successful Respondent shall not receive any fees, commissions, incentives, bonuses or reimbursement, from any source, other than the fees to be paid by the City pursuant to Respondent s proposal. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 12

14 SECTION 4 EVALUATION The City s objective in soliciting Proposals is to enable it to select a firm or organization that will provide high quality and cost effective services to the employees and citizens of Perth Amboy. The City will consider Proposals from firms or organizations that, in the City s judgment, have demonstrated the capability and willingness to provide high quality services to the City in the manner described in this RFP. Proposals will be evaluated by the City on the basis of the most advantageous submission, all relevant factors considered. The evaluation will consider: 1. Experience and reputation in the field as evidenced by references given (evaluation will consider the outcome of reference checks). 2. Prior experience with the City, if any, and the subject matter addressed under the contract. 3. Availability to accommodate the required meetings of the City, as well as other factors demonstrated to be in the best interest of the City. 4. Reasonableness of the fees for the services. 5. Familiarity with City s self-insurance program, and/or self-insurance programs of other cities/municipalities of similar size, number of employees, budget and health benefits budget. 6. History of success with cost savings. 7. Satisfaction of requirements listed in Section 2 and Description of Respondent s approach to the scope of services that will be supplied to the City. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 13

15 APPENDICES CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 14

16 APPENDIX A REQUEST FOR PROPOSALS CHECKLIST THIS CHECKLIST MUST BE COMLETED AND SUBMITTED WITH YOUR PROPOSAL Please initial below next to each item, indicating that your Proposal includes the required documents. Submitting a Proposal without the completed checklist may be cause for rejection of the Proposal. Proposer s Initials 1. An original, two (2) signed copies and a flash drive of complete proposal (including Fee Proposal (Appendix B) 2. Authorized signatures on all forms 3. Executed Letter of Transmittal (Appendix C) 4. Insurance Requirements and Acknowledgement Form (Appendix D) 5. Ownership Disclosure Statement (Appendix E) 6. Non-Collusion Affidavit (Appendix F) 7. Request for References (Appendix G) 8. Business Entity Disclosure - City Code (Appendix H) 9. Business Entity Disclosure - City Code (Appendix I) 10. Mandatory Equal Employment Opportunity Compliance and Contract Language (Appendix J) 11. Americans With Disabilities Act of 1990 (Appendix K) 12. Business Registration Certificate (See Appendix L) 13. Professional Services Entity Information Form (Appendix M) 14. Data Form Summary (Appendix N) 15. Respondent s Qualification Statement (Appendix O) 16. Compliance with Executive Order Regarding Procurement of Insurance Services (Appendix P) 17. Firm s Affidavit Of No Disciplinary Sanctions Or Professional Negligence (Appendix Q) 18. Disclosure of Investment Activities in Iran (Appendix R) 19. Disclosure of Investigations and Actions Involving Service Entity (Appendix S) 20. Acknowledgement of Receipt of Addenda (Appendix T) The undersigned hereby acknowledges the above-listed requirements. Name of Proposer: By: [Signature of Authorize Representative] [Title] Print Name: CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 15

17 APPENDIX B FEE PROPOSAL THE UNDERSIGNED RESPONDENT PROPOSES TO FURNISH AND DELIVER THE REQUIRED SERVICES PURSUANT TO THE TERMS OF THE REQUEST FOR PROPOSALS FOR INSURANCE BROKER SERVICES FOR HEALTH BENEFITS, AT THE PRICES SET FORTH BELOW: CONTRACT YEAR FIXED FEE FOR SERVICES UNDER THIS RFP Year 1: $ Year 2: $ Year 3: $ Total for 3 years: $ RESPONDENT S NAME: ADDRESS: FEDERAL I.D. NUMBER: SIGNATURE OF AUTHORIZED REPRESENTATIVE PRINT NAME TITLE/POSITION CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 16

18 APPENDIX C EXECUTED LETTER OF TRANSMITTAL (Note: To be typed on Respondent s Letterhead. No modifications may be made to the content of this letter) [Insert Date] Gary A. Muska, Purchasing Agent 260 High Street Perth Amboy, NJ Re: The CITY OF PERTH AMBOY is soliciting proposals through the competitive contracting process in accordance with N.J.S.A. 40A:11-4.1(a), et seq. for LEGAL SERVICES from experienced law firms in response to this Request for Proposals (RFQ) to provide legal services to the City of Perth Amboy. The term of such agreement will be for a one year period covering 01/01/18 to 12/31/18. Proposals will be evaluated in accordance with the criteria set forth in this RFQ. The City of Perth Amboy may select one or more law firms to provide the services requested herein. Dear Mr. Muska: The undersigned, Qualified Respondent, has submitted the attached Proposal Statement in response to a Request for Proposals (RFQ), issued by the City of Perth Amboy (the City ) dated October 24, 2018, in connection with the City s need for Legal Services. The undersigned hereby states: 1. The Proposal Statement contains accurate, factual and complete information to the best of my/our knowledge and belief. The Proposal Statement is submitted in good faith. I/we understand that any false statement may result in my/our disqualification. 2. I/We agree(s) to participate in good faith in the procurement process described in the RFQ and to adhere to the City s procurement schedule. 3. I/We acknowledge(s) that all costs incurred by me/us in connection with the preparation and submission of the Proposal Statement, amendments thereto, and any other documents prepared and submitted in response to the RFQ, or any negotiation which results therefrom, shall be borne exclusively by the undersigned. 4. I/We hereby declare that the only persons/business entities anticipated by the undersigned to perform the professional services for which the undersigned s Proposal Statement is submitted are the two other members of the Project Team named herein and that no other persons or business entities participated in submission of the undersigned s Proposal Statement or will participate in any contract to be entered into between Respondent Project Team and the City. The undersigned declares that its Proposal Statement is made without connection with any other person, firm or parties, except the other two members of the Project Team who have submitted Proposal Statements with the undersigned, and t h a t t h e u n d e r s ig n e d s Proposal S t a t e m e n t is b e ing prepared and submitted in good faith and without collusion or fraud. 5. I/We acknowledge(s) and agree(s) that the City may modify, amend, suspend and/or terminate the procurement process (in its sole judgment). 6. I/We acknowledge(s) that if the Project Team of which I/We (am/are) a member becomes the Successful Respondent and is awarded a contract to provide the Services, I/We shall comply with all applicable affirmative action and equal employment opportunity laws:. Signed: Printed: Title: Date: *If the Qualified Respondent is part of a joint venture, partnership or organization other than a natural person, the Letter of Proposal and Letter of Intent must be signed by an individual with the authority to bind the organization. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 17

19 APPENDIX D INSURANCE REQUIREMENTS AND ACKNOWLEDGEMENT FORM Certificate(s) of Insurance shall be filed with the City s Clerk s Office upon award of contract by the Municipal Council. The minimum amount of insurance to be carried by the selected Professional Service Entity shall be as follows: Professional Liability Insurance Limits shall be a minimum of $1,000, for each claim and $2,000, aggregate each policy period. *Vendor / Firm shall not commence operations until City has been furnished original certificate(s) of Insurance and certified original copies of endorsements or policies of insurance in the amounts and/or minimum coverage(s) required in this proposal. Acknowledgement of Insurance Requirement: (Signature) (Date) (Printed Name and Title) CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 18

20 APPENDIX E BUSINESS ENTITY DISCLOSURE CERTIFICATION FOR FAIR AND OPEN CONTRACTS REQUIRED PURSUANT TO N.J.S.A. 19:44A-20.8 The following is statutory text related to the terms and citations used in the Business Entity Disclosure Certification form. Local Unit Pay-To-Play Law (P.L. 2004, c.19, as amended by P.L. 2005, c.51) 19:44A-20.6 Certain contributions deemed as contributions by business entity. 5. When a business entity is a natural person, a contribution by that person's spouse or child, residing therewith, shall be deemed to be a contribution by the business entity. When a business entity is other than a natural person, a contribution by any person or other business entity having an interest therein shall be deemed to be a contribution by the business entity. 19:44A-20.7 Definitions relative to certain campaign contributions. 6. As used in sections 2 through 12 of this act: business entity" means any natural or legal person, business corporation, professional services corporation, limited liability company, partnership, limited partnership, business trust, association or any other legal commercial entity organized under the laws of this State or of any other state or foreign jurisdiction; Interest" means the ownership or control of more than 10% of the profits or assets of a business entity or 10% of the stock in the case of a business entity that is a corporation for profit, as appropriate; Temporary and Executing 12. Nothing contained in this act shall be construed as affecting the eligibility of any business entity to perform a public contract because that entity made a contribution to any committee during the one-year period immediately preceding the effective date of this act. ~~~~~~~~~~~~~~~~~~~~~ The New Jersey Campaign Contributions and Expenditures Reporting Act (N.J.S.A. 19:44A-1 et seq.) 19:44A-3 Definitions. In pertinent part p. The term "political party committee" means the State committee of a political party, as organized pursuant to R.S.19:5-4, any county committee of a political party, as organized pursuant to R.S.19:5-3, or any municipal committee of a political party, as organized pursuant to R.S.19:5-2. q. The term "candidate committee" means a committee established pursuant to subsection a. of section 9 of P.L.1973, c.83 (C.19:44A-9) for the purpose of receiving contributions and making expenditures. r. the term "joint candidates committee" means a committee established pursuant to subsection a. of section 9 of P.L.1973, c.83 (C.19:44A-9) by at least two candidates for the same elective public offices in the same election in a legislative district, county, municipality or school district, but not more candidates than the total number of the same elective public offices to be filled in that election, for the purpose of receiving contributions and making expenditures. For the purpose of this subsection: ; the offices of member of the board of chosen freeholders and county executive shall be deemed to be the same elective public offices in a county; and the offices of mayor and member of the municipal governing body shall be deemed to be the same elective public offices in a municipality. 19:44A-8 and 16 Contributions, expenditures, reports, requirements. While the provisions of this section are too expensive to reprint here, the following is deemed to be the pertinent part affecting amounts of contributions: The $300 limit established in this subsection shall remain as stated in this subsection without further adjustment by the commission in the manner prescribed by section 22 of P.L.1993, c.65 (C.19:44A-7.2) CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 19

21 STATEMENT OF OWNERSHIP DISCLOSURE N.J.S.A. 52: (P.L. 1977, c.33, as amended by P.L. 2016, c.43) This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal. Name of Organization: Organization Address: Part I Check the box that represents the type of business organization: -Profit Corporation (skip Parts II and III, execute certification in Part IV) - ited Partnership Part II The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS SECTION) OR No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV) (Please attach additional sheets if more space is needed): Name of Individual or Business Entity Home Address (for Individuals) or Business Address Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART II If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 20

22 Website (URL) containing the last annual SEC (or foreign equivalent) filing Page # s Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52: has been listed. Attach additional sheets if more space is needed. Stockholder/Partner/Member and Corresponding Entity Listed in Part II Home Address (for Individuals) or Business Address Part IV Certification I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer; that the <name of contracting unit> is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with <type of contracting unit> to notify the <type of contracting unit> in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the <type of contracting unit> to declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): Signature: Title: Date: CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 21

23 APPENDIX F NON-COLLUSION AFFIDAVIT Project: Request for Proposals for Insurance Broker Services for Health Benefits STATE OF NEW JERSEY) COUNTY OF ) ss.: I,, live at, in the City of, State of. I am of full age and being duly sworn according to law on my oath depose and say: 1. I am (title) of the (Respondent), who has made the proposal for the above named Project. 2. I executed the Proposal with full authority to do so. 3. The proposal is genuine, submitted in good faith and not a sham. 4. Neither the proposer nor any of its employees or agents have, directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free, competitive proposing in connection with the above-named project. I further certify that neither the proposer, nor any of its employees or agents, have directly or indirectly with any other proposer or person colluded to put in a sham bid or refrain from submitting a proposal, and have not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference, with any person to fix the prices of the proposer or of any other proposer to secure any advantage. 5. All statements contained in this Proposal and Affidavit are true and correct and were made with full knowledge that the City of Perth Amboy relies upon the truth of the statements contained in the Proposal and the truth of the statements contained in this Affidavit, in awarding the Contract for the Project. I am aware that I am personally subject to the penalties of perjury, as is the proposer, if statements made herein are untrue. 6. I further warrant that no person or selling agent has been employed or retained to solicit or secure this Contract under an agreement or understanding for a commission, percentage, brokerage or contingent fee. If the proposer engages bona fide employees or a bona fide established commercial or selling agency to perform any similar related acts, the names are set forth as follows: (see N.J.S.A. 52:34-15) (SEAL) Subscribed and sworn to before me this day of, 20 (Signature) (Type or print name of Affiant) (Title) (Company) A Notary Public of New Jersey My Commission Expires: CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 22

24 APPENDIX G REQUEST FOR REFERENCES Project: Request for Proposals for Insurance Broker Services for Health Benefits (Medical/Prescription/Dental/Vision Insurance) 1. Name Address Telephone address Contact Individual 2. Name Address Telephone address Contact Individual 3. Name Address Telephone address Contact Individual 4. Name Address Telephone address Contact Individual 5. Name Address Telephone address CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 23

25 APPENDIX H CERTIFICATION OF COMPLIANCE WITH THE CITY OF PERTH AMBOY S LOCAL PAY TO PLAY ORDINANCE (Article I, Contributions by Public Contractors, 98.1 et seq., Perth Amboy City Code, attached) Name of Proposer Address I,, of full age, certify as follows: 1. I am an authorized representative of the above named Professional Business Entity. 2. On behalf of the above named Proposer, I have read Article I, Contributions by Public Contractors, 98.1 et seq., of the Perth Amboy City Code (the City Pay-to-Play Ordinance ), attached hereto, and certify, under penalty of perjury, that: a) I understand the definition of Professional Business Entity, contained in the City Pay-to-Play Ordinance, and acknowledge that the above-named Proposer is a Professional Business Entity in accordance with therewith; b) The above-named Proposer has not made a contribution in violation of the attached City Payto-Play Ordinance, and if awarded a contract, will comply with the City Pay-to-Play Ordinance during the term of the contract. In accordance with 98.3 of the City Code, I hereby certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements are willfully false, I am subject to punishment. Signature Type or Print Name Date, 20 Title CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 24

26 AN ORDINANCE LIMITING CONTRIBUTIONS BY PUBLIC CONTRACTORS (Amended by Ord. No ) Prohibition on awarding public contracts to certain contributors. A. To the extent that it is not inconsistent with state or federal law, the City of Perth Amboy and any of its purchasing agents or departments or instrumentalities of the municipality thereof, as the case may be, shall not enter into any agreement or otherwise contract to procure services from any professional business entity, including those awarded pursuant to any process including a fair and open process, if such professional business entity has solicited or made any contribution of money, or pledge of a contribution, including in-kind contributions, to (i) a campaign committee of any Perth Amboy municipal candidate or holder of public office having ultimate responsibility for the award of a contract, or (ii) to any City of Perth Amboy or Middlesex County party committee, or (iii) to any political action committee (PAC) that regularly engages in the support of Perth Amboy or Middlesex County elections and/or municipal or county parties, in excess of the thresholds specified in subsection (d) within one (1) calendar year immediately preceding the date of the contract or agreement. A business entity that is awarded a contract by the city may not make any such contribution during the term of the contract and for twelve calendar months thereafter. B. No professional business entity or vendor who submits a proposal for, enters into negotiations for, or agrees to any contract or agreement (including non-emergency contracts awarded by N.J.S.A. 40A:11 et seq. or the "Fair and Open" Process pursuant to N.J.S.A. 19:44A-20 et seq.) with the municipality or any departments thereof, for the rendition of professional services, or goods and services, as the case may be, shall knowingly solicit or make any contribution of money, pledge of contribution, including in-kind contributions, to: (i) any Perth Amboy candidate or holder of public office having ultimate responsibility for the award of a contract, or (ii) to any City of Perth Amboy or Middlesex County party committee, or (iii) to any PAC that regularly engages in the support of Perth Amboy or Middlesex County elections and/or municipal or County parties, between the time of first communication between that professional business entity or vendor and the municipality regarding a specific professional services agreement or goods and services agreement, as the case may be, and the later of the termination of negotiations or rejection of any proposal, or the completion of the contract or agreement. C. For purposes of this Article, a "professional business entity" and a "vendor" seeking a public contract means an individual including the individual's spouse, if any, and any child living at home; person; firm; corporation; professional corporation; partnership; organization; or association. The definition of a business entity and vendor includes all principals who own ten percent (10%) or more of the equity in the corporation or business trust, partners, and officers (in the aggregate) employed by the entity or vendor, as well as any subsidiaries directly controlled by the business entity or vendor. D. Any individual meeting the definition of "professional business entity" or "vendor" under this section may annually contribute a maximum of three hundred dollars ($300.) each for any purpose to any candidate for mayor or governing body, or three hundred dollars ($300.) to the City of Perth Amboy party or five hundred dollars ($500.) to the Middlesex County party committee or to a PAC referenced in this ordinance, without violating subsection (a) of this section. However, any group of individuals meeting the definition of "professional business entity" or "vendor" under this section, including such principals, partners, and officers of the entity or vendor in the aggregate, may not annually contribute for any purpose in excess of two thousand five hundred dollars ($2,500.) to all City of Perth Amboy candidates and officeholders with ultimate responsibility for the award of the contract, and all City of Perth Amboy or Middlesex County political parties and PACs referenced in this ordinance combined, without violating Subsection A. of this section. E. For purposes of this section, the office that is considered to have ultimate responsibility for the award of the contract shall be: (1) The Mayor or Governing Body of Perth Amboy, if the contract requires approval or appropriation from the Mayor or Governing Body. (2) The Mayor of the City of Perth Amboy, if the contract requires approval of the Mayor, or if a public officer who is responsible for the award of a contract is appointed by the Mayor. CITY OF PERTH AMBOY - RFP - INSURANCE BROKER SERVICES FOR HEALTH BENEFITS 25