RFCSP EXCESS WORKERS COMPENSATION INSURANCE

Transcription

1 Solicitation For Scope Direct all questions to: Pre-Bid Conference and Site Visitation: Send Response to Proposals will be received until: Public Opening Bid Security Anticipated Award Date NO BID NOTICE TO VENDORS Clear Creek Independent School District (Owner) Is Accepting Competitive Sealed Proposals This Is A Competitive Sealed Proposal Only, Not An Offer To Purchase RFCSP EXCESS WORKERS COMPENSATION INSURANCE To establish Workers Compensation coverage for Please direct your questions to Greg Cruthirds, Director of Purchasing at: (281) or gcruthir@ccisd.net Not Applicable Sealed proposals will be received at the Education Support Center, Purchasing Department, Attn: Bid Clerk, Clear Creek Independent School District, 2145 West Nasa Blvd., Webster, TX :00 PM, Monday, June 27, 2016 Any proposal received later than the specified time, whether delivered in person or mailed, shall be disqualified and returned to the vendor unopened. Sealed Procurements will be publicly opened and read in accordance with Texas Education Law The responses will be under evaluation and not available for public review until seven business days after approval by the Board of Trustees Not Applicable July 27, 2016 IF YOU ARE NOT RESPONDING TO THIS PROCUREMENT, PLEASE CHECK THE NO-BID BOX AND FILL-IN ACKNOWLEDGEMENT INFORMATION BELOW Acknowledgement Company Name: Name Of Agent Authorized to sign bids or contracts: Title Physical Address: City, State, Zip: Telephone: Fax: for Correspondence: Having carefully examined the Notice to Vendors, General Terms and Conditions, Certifications, Special Conditions, Specifications, Proposal Sheets and all other parts and attachments to this proposal, the undersigned Vendor's Agent proposes to furnish materials, equipment and services at the prices or discounts quoted. Failure to sign WILL disqualify the offer. Authorized By Greg Cruthirds, Director of Purchasing, CCISD Date Signature Authorized Vendor s Agent Date

2 SCOPE The purpose of this proposal is to acquire the following category of material(s): Excess Workers Compensation Insurance. Clear Creek Independent School District, "the District," intends to purchase immediate requirements and supplemental needs. The District expects to award this proposal in August Upon award, a recap of the proposals and the selected vendor will be available within seven days at our web site: GENERAL TERMS AND CONDITIONS These terms and conditions are applicable to and form a part of all contract documents and purchase orders issued as a result of award. 1. CONTRACT TERM This contract will be effective for one (1) year, with renewal options for additional one year periods (as listed below), at the District s option and with the acceptance of the awarded vendor(s). Initial Term September 1, 2016 through August 31, 2017 First Annual Renewal Option September 1, 2017 through August 31, 2018 Second Annual Renewal Option September 1, 2018 through August 31, 2019 Third Annual Renewal Option September 1, 2019 through August 31, 2020 Fourth Annual Renewal Term September 1, 2020 through August 31, INTERPRETATION - If a person contemplating submitting an offer for the proposed contract is in doubt as to the true meaning of any part of the proposal documents, he/she may submit a written request for an interpretation. 3. LATE PROPOSALS - Proposals not received and date/time stamped by the District Purchasing Office by or before the proposal closing time are not accepted. Late courier and/or hand delivery attempts will be refused. Late mail deliveries will be held unopened (Vendor will be advised by mail that the proposal was late and not accepted and will be allowed to pick up the proposal package or furnish a call tag and have the package picked up by a courier. The District is not responsible for mail, courier or other delivery methods' in-transit time or non-delivery. U.S. Mail is not delivered to the District until after 11:00 A.M., daily. Fax or electronically transmitted proposals are not acceptable. 4. CERTIFICATIONS The following signed forms and certifications are required submissions by all vendors offering proposals. Vendor Information Form, W-9, Non-Collusive Bidding Certificate, Resident/Non-Resident Certification, Felony Conviction Notification, References, Validity, Acknowledgement, Clean Air and Water Act, Debarment / Suspension Form. 5. PROPOSAL FORMAT / SUBMISSION Submit the Original Signed proposal and two (2) copies in a sealed envelope on the forms and in the format provided. Mark the envelope with the contract number and name and mail or deliver. 6. SUITABILITY - The District reserves the right to accept or reject all or any part of any proposal, waive minor formalities, to be the sole judge of quality and suitability and award the proposal deemed to be most advantageous to the District. 7. EXCEPTIONS - Any exceptions taken to the terms and conditions of this proposal request must be clearly stated, in writing, and attached as a part of the proposal. 8. PRICES - All prices are to be freight prepaid, include INSIDE delivery charges and are to be F.O.B. Clear Creek Independent School District. Upon mutual agreement, proposal prices can be extended beyond the firm price offer date. 9. UNIT PRICES - Submit unit price on quantity specified - extend and show total. In case of errors in extension, unit prices shall govern.

3 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 3 OF PRICE DECREASES - In the event of a price decrease during the full term of the contract, such decrease must be made available to the District. 11. TAXES - The District is exempt from Federal Excise Tax, State and Local Tax. Do not include tax in your proposal totals. If it is determined that tax was included in the proposal, it will not be included in the tabulation or any awards. Tax exemption certificate will be furnished upon request. 12. GOVERNING LAW - All items and services offered shall conform to all applicable local, state and federal laws, ordinances and regulations. 13. INDEMNIFICATION - Successful vendor(s) shall indemnify and save harmless Clear Creek Independent School District from and against any and all claims, demands, damages, lawsuits, expenses, costs, liabilities, injuries, liens, and causes of action of any and every nature whatsoever, arising out of, resulting from, or in any manner connected with or concerning the performance of the work hereunder, and the contractor hereby agrees to defend any and all such actions brought against Clear Creek Independent School District for any and all expenditures, or expenses, including, but not limited to, court costs and attorney's fees, made or incurred by Clear Creek Independent School District, and/or by reason of any such suit or suits. 14. EQUAL EMPLOYMENT OPPORTUNITY - All Vendors shall be in compliance with Executive Order 11246, entitled Equal Employment Opportunity as amended by Executive Order 11375, and as supplemented in the Department of Labor Regulations (41CFR Part 60). No individual shall be excluded from participating in, denied the benefit of, subjected to discrimination under, or denied employment in the administration of, or in connection with, any such program because of race, color, religion, sex, national origin, age, handicap, or political application or belief. 15. PATENT RIGHTS - Successful vendors shall indemnify and protect the District from any claim involving patent right or copyright infringement on goods supplied. 16. APPROPRIATED FUNDS - For any fiscal year beginning September 1, the District's obligation under any purchase order, contract, or service agreement arising from this proposal request is contingent upon the availability of appropriated funds from which payment for purchase orders, contracts, or service agreements can be made. No legal liability on the part of the District nor any payment or continuation of any agreement may arise until funds are made available to the District for this purchase order, contract, or service agreement and until successful vendor receives notice of such availability. 17. SPECIFIED/ALTERNATE ITEMS - Any catalog, brand name, and/or manufacturer s reference used is descriptive, not restrictive, and is intended only to indicate type and quality desired. Proposals on brands of like nature and quality will be considered unless otherwise specified. If offering an alternate product, proposal must show manufacturer, brand, model, etc. of item being offered. Complete descriptive information of each alternate product must be included with the proposal. If the vendor takes no exception to the specifications, vendor shall be required to furnish brand names, models, etc. as specified. 18. AUTHORITY/ DISTRICT OPTION - All proposals must meet or exceed the District's specifications. The District shall be the sole authority in evaluating and determining the equality of all alternate proposals. Substitutions below the minimum specifications shown will not be accepted. 19. PROPOSAL SAMPLES - Samples, if applicable or when requested, shall be furnished at no cost within five (5) days of request. DO NOT ENCLOSE IN OR ATTACH PROPOSAL TO SAMPLE. If not destroyed during examination, samples will be returned to the vendor upon request, at the vendor s expense. Each sample, when submitted, must be clearly marked with the vendor s name and item number found on the proposal. The District reserves the right to make the final decision as to comparable items. Be very certain that items proposed and

4 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 4 OF 20 delivered are EQUAL to items listed. Materials which are not equal will be returned to the supplier, transportation charges collect. 20. EVALUATION CRITERIA - It is not the policy of the District to award contracts based solely on 'low price'. The following factors are used by the District to evaluate the overall 'best value' per Texas Education Code (b): - 50% Purchase price. - 10% The reputation of the vendor and the vendor s goods and services. - 10% The quality of the vendor s goods and services. - 10% The extent to which the goods and services meet the District s needs. - 10% The vendor s past relationship with the District. - 0% Historically Underutilized Business. - 10% The total long-term cost to the District to acquire the goods or services. - 0% State of Texas preference. - 0% Any other relevant factor specifically listed in the request for bids or proposals. 21. PROPOSAL AWARD - The District reserves the right to award contracts for any, all, or none of the parts and/or items of this proposal request. Contracts for purchase shall be put into effect by means of purchase order(s) executed by the District's Purchasing Director after this proposal has been awarded. 22. NON-EXCLUSIVE AWARD - Except as noted, proposal award resulting from this request is not an exclusive agreement to purchase. The District reserves the right and option, without penalty, to purchase like materials and services from other sources when and if such purchases, in the opinion of the District, are necessary and in the best interest of the District. If the low proposal exceeds the District's budget allocation, the district may elect, upon determination that the budget can be achieved through value engineering, to negotiate value engineering possibilities with the low contractor and award the contract upon agreement of items necessary to meet the budget. 23. DELIVERY ARO - Proposals must show the number of days required to deliver the article(s) to the specified location under normal conditions after receipt of an order (ARO). Delivery time will be considered in the evaluation process. 24. DELIVERY CONDITIONS / FREIGHT TERMS - proposals shall include all shipping, handling, freight and/or delivery charges. All deliveries shall be to the site(s) specified on the purchase order, include all shipping, handling, freight and/or delivery charges be freight prepaid, F.O.B. destination, (Clear Creek I.S.D., TX). 25. DELIVERY RESPONSIBILITY - The District will not be responsible for any material being delivered or services performed without a purchase order, signed by an authorized representative of the District. 26. WARRANTY Equipment / Products shall be new and the latest model. 27. SUPPLIER'S WARRANTY RESPONSIBILITY - The successful vendor(s) is ultimately responsible for and must assure the District that any warranty service shall be performed to the satisfaction of the District, regardless of whether the successful vendor or his/her agent performs the warranty work. If there is a question of whether it is the responsibility of the successful vendor or the manufacturer to repair a given defect, then it shall automatically become the successful vendor's responsibility to see that the repair(s) is made to the satisfaction of the District. 28. WARRANTY WORK AND GENERAL TERMS OF WARRANTIES - The District's purchase order(s) will be issued to the successful vendor(s). The successful vendor(s) has the ultimate responsibility of insuring the delivery of complete, full functioning products that meet the District's specifications in all details and are free of defects in materials and workmanship. The products are warranted against defects in materials and workmanship by the manufacturing company (ies)/successful vendor.

5 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 5 OF DEFECTIVE WORKMANSHIP - If defective workmanship and/or materials is found after acceptance and payment has been made, the supplier shall replace/repair the defective component(s), as required, at his/her own cost, within a reasonable amount of time (normally 10 working days), and at no extra cost to the District. 30. PENALTIES - Upon refusal of the successful vendor to make satisfactory and timely adjustment(s), the District reserves the right to claim and recover from said successful vendor by due process of law, such sums as may be sufficient to correct the error or make good the defect in material and/or workmanship. 31. CANCELLATION: The Clear Creek Independent School District reserves the right to cancel any contract (purchase order) resulting from this Request For Proposal at any time, for any reason (or for no reason) with a thirty (30) day written notice to the contractor(s). If the vendor fails to perform as required in the proposal document, contracts may be terminated without notice. Contractor may cancel any resulting contract, at any time for any reason, or for no reason with a sixty (60) day written notice. Any notice required or permitted to be delivered to the contractor(s) shall be deemed to be delivered when mailed by registered or certified mail, return receipt requested, postage prepaid, and addressed to the bidders address appearing on the face of the Request For Proposal (or as subsequently revised or changed). Any compensation due the contractor(s) will be limited to items received and/or services performed and accepted by the District. 32. INVOICING REQUIREMENTS - The District's purchase order number shall appear on all invoices. All invoices shall include the following: The Invoice will be in duplicate. Purchase Order Number (Clear Creek Independent School District s). Invoice Date. Name of Company. Complete mailing address and telephone number. Brief description of the item or service, quantity, unit price and extended price. Any other substantiating documentation or information as required by the contract. All Invoices are to be sent to: Clear Creek Independent School District Accounts Payable Department P.O. Box 799 League City, TX PAYMENT TERMS - The District shall pay all undisputed invoices for accepted merchandise and/or services within 30 days of delivery or acceptance, whichever is later. Contracts requiring a monthly charge will be billed and paid on a monthly basis. 34. SELF-INSURANCE POOLS AND COOPERATIVES What is your pool rating, AM Best Rating, or S & P Rating? Is the pool reviewed annually by the Texas Department of Insurance (TDI)? Does TDI Insurer Insolvency Fund protect your pool? Is your pool reviewed and rated by an independent agency? Provide a copy of your excess insurance policy, disclosing aggregate levels for all members Provide a copy of your last two independent audited financial reports

6 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 6 OF 20 Provide explanation and details about the pool s reinsurance program to include names of participating carriers and Shared Loss Fund Attachment points by line of insurance coverage SPECIAL CONDITIONS The provisions of this section entitled "SPECIAL CONDITIONS" shall govern in the event of any conflict between them and the "GENERAL CONDITIONS" of this agreement. ASSIGNMENT Any award made as a result of this solicitation will not be transferred, assigned, subcontracted or mortgaged by the successful proposer. CHANGES Any changes to the requirements specified herein will be communicated to all proposers by the issuance of an addendum. Any addendum(s) issued in response to this proposal shall be complied with. DISQUALIFICATION A proposer may be disqualified before or after the proposals are opened, upon evidence of collusion with intent to perform illegal activities for the purpose of obtaining an unfair competitive advantage. FINANCIAL RESPONSIBILITY CCISD assumes no financial responsibility for any costs incurred in developing and submitting a PROPOSAL. INTERPRETATION This solicitation represents the basis for any negotiations between the proposers and CCISD, and supersedes all prior offers, negotiations, exceptions and understandings (whether orally or in writing). The information submitted in the PROPOSAL should be self-explanatory, and require no follow-up questions from CCISD. MODIFICATIONS CCISD reserves the right to negotiate during the term of the contract to establish mutually acceptable terms and conditions. NON-APPROPRIATION OF FUNDS Should funding be withdrawn or not be available, CCISD reserves the right to terminate the contract in accordance with paragraph entitled Termination For Convenience. PERFORMANCE The successful proposer shall use best efforts to provide the services identified herein. If CCISD determines the successful proposer is not meeting their contractual requirements, CCISD will send a cure notice, which will outline those specific activities the successful proposer needs to undertake in order to remain in compliance with the mutually agreed upon terms and conditions. POSTPONEMENT The time and place established for receipt of the PROPOSALS will not be changed unless otherwise specified in writing by CCISD s Director of Purchasing. PRICES All prices quoted shall remain firm for the duration of the contract, or the rates shall be guaranteed for multiple years. QUESTIONS CCISD will not answer verbal questions regarding the requirements specified in this solicitation. Questions must be ed to gcruthir@ccisd.net on the proposer s letterhead, and signed by an authorized representative of the proposer s company. Any response(s) to questions will be replied to in writing by CCISD and provided to all proposers. RESPONSIBLE PROPOSER Is a proposer who has adequate financial resources (or the ability to obtain such resources), and is qualified to provide the services described herein. RESPONSIVE PROPOSAL Refers to a proposal that complies with all material and administrative aspects of this solicitation. RETURN OF PROPOSALS All PROPOSALS shall become the property of CCISD, and will not be returned.

7 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 7 OF 20 SAMPLE POLICIES Each PROPOSAL shall include samples of any policies or contracts CCISD would have to sign and endorse. SCOPE The successful proposer will be required to provide all the necessary resources to provide one (1) of the following workers compensation coverage to CCISD: a. Fully or partially insured (see Table A ) b. Pool/Cooperative (see Table A.3 ) CCISD will select the Workers Compensation proposal that is in the best interest of CCISD. WORKERS COMPENSATION Payroll History Classification Code 2011/ / / / / /2017 Bus Drivers $5,909,564 $6,355, $7,106, Professional 8868 $164,653,524 $195,709,433 $187,120,036 $197,309,964 $202,384,353 $211,491,649 All Other 9101 $19,562,959 $11,973,064 $12,648,859 $19,647,623 $13,678,527 $21,720,048 Clerical Office 8810 $28,464, $20,045,717 $20,534,752 $21,680,946 $22,656,589 Total $212,680,707 $213,592,061 $226,169,940 $237,492,339 $244,850,034 $255,868,286 Notes: Professional includes all teachers/librarians/nurses/counselors/campus admin/instructional admin/central administration professionals Clerical includes all clerical staff, full-time and part-time, as well as substitutes All other includes maintenance, food service, security, full time and part-time as well as custodial substitutes. Bus drivers includes bus drivers and bus substitutes

8 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 8 OF 20 REQUIRED FORM RETURN ORIGINAL IN SEALED ENVELOPE CERTIFICATIONS FAILURE TO COMPLETE THE FOLLOWING INFORMATION WILL RESULT IN PROPOSAL DISQUALIFICATION. 1. VENDOR INFORMATION COMPANY NAME: ORDERING ADDRESS: PHONE: TOLL FREE: ACCOUNTS PAYABLE ADDRESS: FAX: TOLL FREE FAX: INTERNET ADDRESS: CUSTOMER SERVICE DO YOU ACCEPT PURCHASE ORDERS CASH PAYMENT TERMS (Net 30 Days) MINIMUM ORDER AMOUNT, IF ANY OR % Discount in Net Days PRESIDENT / OWNER: PRINCIPALS AND KEY PERSONNEL GENERAL MANAGER: ACCOUNTING / ACCOUNTS RECEIVABLE MANAGER: SALES MANAGER: YEARS / MONTHS IN BUSINESS WITH PRESENT NAME: NUMBER OF EMPLOYEES: COMPANY IS: MANUFACTURER OR PRODUCER, DISTRIBUTOR, WHOLESALER, RETAILER, CONSULTING, CONSTRUCTION, BROKER, SERVICE, OTHER:

9 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 9 OF 20 REQUIRED FORM RETURN ORIGINAL IN SEALED ENVELOPE 2. VENDOR INFORMATION / TAXPAYER IDENTIFICATION

10 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 10 OF 20 REQUIRED FORM RETURN ORIGINAL IN SEALED ENVELOPE Company Name: 3. DISCLOSURE: CONFLICT OF INTEREST Questionnaire (see page 5 for completion instructions) CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity. OFFICE USE ONLY Date Received By law this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section , Local Government Code. A person commits an offense if the person violates Section , Local Government Code. An offense under this section is a Class C misdemeanor. Name of person doing business with local governmental entity. Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section (a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) Name each employee or contractor of the local governmental entity who makes recommendations to a local government officer of the governmental entity with respect to expenditures of money AND describe the affiliation or business relationship.

11 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 11 OF 20 Name each local government officer who appoints or employs local government officers of the governmental entity for which this questionnaire is filed AND describe the affiliation or business relationship. REQUIRED FORM RETURN ORIGINAL IN SEALED ENVELOPE Company Name:

12 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 12 OF 20 DISCLOSURE: CONFLICT OF INTEREST STATEMENT, continued CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity Page 2 Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A, B, or C is YES.) This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or other relationship. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? Yes No B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government officer named in this section AND the taxable income is not from the local governmental entity? Yes No C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director, or holds an ownership of 10 percent or more? Yes No D. Describe each affiliation or business relationship. Signature of person doing business with the governmental entity Date

13 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 13 OF 20 REQUIRED FORM RETURN ORIGINAL IN SEALED ENVELOPE 4. NON COLLUSIVE BIDDING CERTIFICATE & ACKNOWLEDGMENT By submission of this proposal, the Vendor certifies that: (a) the proposal has been independently arrived at without collusion with any other vendor or with any competitor. (b) The proposal has not been knowingly disclosed and shall not be knowingly disclosed, prior to the opening of proposals for this project, to any other vendor, competitor or potential competitor. (c) No attempt has been or will be made to induce any other person, partnership or corporation to submit or not to submit a proposal. (d) The person signing this proposal certifies that he has fully informed himself regarding the accuracy of the statements contained in this certification and under the penalties being applicable to the Vendor as well as to the person signing in its behalf. I certify that the above information is true and correct. YES 5. RESIDENT / NONRESIDENT CERTIFICATION RESIDENT VENDOR - I certify that my company is a "resident vendor. YES NONRESIDENT VENDOR - As defined by Texas Government Code , a "nonresident vendor" means a vendor whose principal place of business is not in Texas, but excludes a contractor whose ultimate parent company or majority owner has its principal place of business in Texas. If you qualify as a "nonresident vendor," you must furnish the following information: Resident state address? (The state in which your principal place of business is located.) Street, City, State, Zip: 6. FELONY CONVICTION NOTIFICATION State of Texas Legislative Senate Bill No.1, Section , Notification of Criminal History, Subsection (a), states: "a Person or business entity that enters into a contract with a school district must give advance notice to the district if the Person or an owner or operator of the business entity has been convicted of a felony. The notice must include a general description of the conduct resulting in the conviction of a felony." Subsection (b) states "a school district may terminate a contract with a person or business entity if the district determines that the person or business entity failed to give notice as required by Subsection (a) or misrepresented the conduct resulting in the conviction. The District must compensate the person or business entity for services performed before the termination of the contract. This Notice Is Not Required of a Publicly Held Corporation. Check the appropriate box and sign the form. My firm is a publicly held corporation; therefore, this reporting requirement is not applicable. My firm is not owned or operated by anyone who has been convicted of a felony. My firm is owned or operated by the following individual(s) who has/have been convicted of a felony: Name of Felon: Details of Conviction(s) I (We) the undersigned, agent for the firm, named below certify that the above information is true and correct to the best of my knowledge. Name/Title: Company Name: Original Signature: Date

14 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 14 OF 20 REQUIRED FORM RETURN ORIGINAL IN SEALED ENVELOPE 7. ADDENDA If no amendments were received then leave this blank or write N/A. If any amendments were received, Respondent acknowledges receipt of Addenda numbered through and has incorporated the provisions thereof into the bid/proposal. 8. RENEWAL OF CONTRACT This contract will be effective for one (2) years with renewal options for two (2) additional one year periods (as stated in the terms and conditions), at the District's option and with the acceptance of the awarded vendor(s): In the event this proposal expires before another proposal is awarded, the vendor shall extend the contract on a month-to-month basis by mutual agreement. 9 CERTIFICATION REGARDING DEBARMENT SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS This certificate is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 7 CFR Part 3017, Section , Participants' responsibilities. The regulations were published as Part IV of the January 30, 1989, Federal Register (pages ). Copies of the regulations may be obtained by contacting the Department of Agriculture agency with which this transaction originated. 1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by a Federal department or agency. 2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. PR/Award # or Project Name: Check applicable box I (We) certify that our company has not been debarred and is not participating in lobbying activities. See attached explanation and complete disclosure forms. 10. PROPOSAL VALIDITY Proposal shall remain valid, pending award for 60 days YES or (date): Prices & Discounts effective for one year YES or (date): Prompt payment discount allowed: (% / Days) % Days I (We) the undersigned, agent for the firm, named below certify that the above information is true and correct to the best of my knowledge. Name/Title: Company Name: Original Signature: Date

15 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 15 OF 20 REQUIRED FORM RETURN ORIGINAL IN SEALED ENVELOPE 11. CLEAN AIR & WATER ACT CERTIFICATION (This is a Federal requirement) I certify that my company is in compliance with all applicable standards, orders or regulations issued pursuant to the Clean Air Act of 1970, as amended ( 42 U.S.C. 1857(h), Section 508 of the Clean Water Act, as amended (33 U.S.C. 1368), Executive Order and Environmental Protection Agency Regulation, 40 CFR Part 15 as required under OMB Circular A-102, Attachment O, Paragraph 14 (1) regarding reporting violations to the grantor agency and to the United States Environmental Protection Agency Assistant Administrator for the Enforcement. 12 CERTIFICATION REGARDING LOBBYING for FEDERAL FUNDS - Applicable to grants, Subgrants, Cooperative Agreements, and Contracts Exceeding $100,000 in Federal Funds. Submission of this certifications a prerequisite for making or entering into this transaction and is imposed by section 1352, Title 31, U.S. Code. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. The undersigned certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member of Congress in connection with the awarding of a Federal contract, the making of a Federal grant, the making of a Federal loan, the entering into a cooperative agreement, and the extension, continuation, renewal, amendment, or modification of a Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member of Congress in connection with this Federal grant or cooperative agreement the undersigned shall complete and submit Standard Form-LLL, SF-LLL Disclosure of Lobbying Activities Form in accordance with its instructions (see following page). (3) The undersigned shall required that the language of this certification be included in the award documents for all covered subawards exceeding $100,000 in Federal funds at all appropriate tiers and that all subrecipients shall certify and disclose accordingly. Check applicable box I (We) certify that our company has not been debarred and is not participating in lobbying activities. See attached explanation and complete disclosure forms. I (We) the undersigned, agent for the firm, named below certify that the above information is true and correct to the best of my knowledge. Name/Title: Company Name: Original Signature: Date

16 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 16 OF 20 REQUIRED FORM RETURN ORIGINAL IN SEALED ENVELOPE 13. QUESTIONNAIRE TABLE A SCOPE OF SERVICE FULLY OR PARTIALLY INSURED At a minimum, the successful proposer will be required to provide the following services: Item Description of Service Able to Provide A.1 Claims Administration Yes No A.2 Claims Investigation Yes No A.3 Payments of claims or nonpayment of claims Yes No A.4 Notification of payment and/or nonpayment decisions to claimant Yes No A.5 Provide loss information Yes No A.6 Approach to subrogation Yes No A.7 Reserving Yes No A.8 Litigation Management Yes No A.9 Medical Case Management & Rehabilitation Services Yes No A.10 Loss Control Services Yes No Name of Individual Signature of Authorized Individual

17 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 17 OF 20 House Bill 1295 IMPORTANT CONTRACT DISCLOSURE REQUIREMENTS: Texas Legislature passed House Bill 1295, which amended the Texas Government Code by adding Section Disclosure of Interested Parties. Subsequently, the Texas Ethics Commission adopted new rules, effective for contracts entered into on or after January 1, A governmental entity may not enter into a contract subject to Section unless the business entity submits a Disclosure of Interested Parties (Form 1295) at the time the business entity submits the signed contract. The governmental entity must then submit a copy of the disclosure to the Texas Ethics Commission not later than 30 days after the date the governmental entity receives the required disclosure. According to the Texas Ethics Commission s website, a new mandatory filing application to file Form 1295 will be available on its web site by January 1, More filing information can be found at CCISD requires that all proposers submit a completed Form 1295 to the Texas Ethics Commission upon contract award within 30 calendar days and submit the certificate of filing to the CCISD Purchasing Department. COMMERCIAL INSURANCE APPLICATION INFORMATION INSURED: Clear Creek Independent School District 2145 West Nasa Blvd. Webster, Texas PROPOSED EFFECTIVE DATE: September 1, 2016 to August 31, 2017 INSPECTION CONTACT: Alice Benzaia, Director of Business Services & Financial Planning LOCATIONS: Attached NATURE OF BUSINESS: Independent School District LOSS DATA: See Attached

18 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 18 OF 20 WORKERS COMPENSATION SPREADSHEET QUESTIONNAIRE WORKERS COMPENSATION FULLY INSURED Expiring Renewal Option I Renewal Option II Agency Insurance Company Best Rating Subject to Texas Guaranty Fund Standard Premium Deviation (Increased Limits) Schedule Credit Experience Modifier Premium Discount Other Discount (Expense Constant) Net Premium Classification/Payroll Expiring Renewal Bus Drivers (7380) $7,106, Schools, professional (8868) $202,384,353 $211,491,649 Schools, all others (9101) $13,678,527 $21,720,048 Clerical Office (8810) $21,680,946 $22,656,589 Total Payroll $244,850,034 $255,868,286 Assumed Annual Average Losses - $ Assumed Annual Average Losses - # Assumed O/S Claims - # Estimated Experience Modifier Employers Liability Named Insured: the School, Board Member, Employee, Teacher, Student, Volunteer Or School Foundation Minimum Loss Prevention Hours Including Industrial Hygiene Reports Quarterly Claim Review with Adjuster Loss Reports Monthly (Yes/No) By Department by Campus By Type of Injury Others on Demand On Line Rate Guarantee Policy year 1 Policy year 2 Policy year 3 Other:

19 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 19 OF 20 WORKERS COMPENSATION SPREADSHEET QUESTIONNAIRE EXCESS INSURANCE Expiring Agency / Pool Maxim Insurance Company Safety National Best Rating A+ XV S & P Rating Subject to Texas Guaranty Fund Yes Standard Premium $1,571,860 Net Premium $108,713 Specific Excess Limit ($300,000) $ Premium Rate (per $100 of payroll) Basis $244,850,034 Premium $108,713 Retention - Attachment Point $500,000 Maximum Limit Statutory Aggregate Excess ($3,000,000) Estimated Payroll $244,850,034 Workers Compensation Limit Statutory Specific Retention $500,000 Estimated Aggregate Retention $2,986,534 Liability Period Other available Administrative Charge Composite Excess Rating Basis Rate Premium Renewal Option I Renewal Option II Other Pays On Behalf Of Yes Specific Limit/Retention applies per Loss or Occurrence Yes Aggregate applies per Year Yes Claim Expense in Addition to Limit Yes 60 Day Notice of Cancellation Yes Cash Flow Protection

20 RFCSP# , EXCESS WORKERS COMPENSATION INSURANCE PAGE 20 OF 20 PROPOSAL SUBMISSION FORM By my signature, I (type name) Certify that on, 2016 (type name of company) has reviewed CCISD s solicitation for Workers Compensation, and has responded in accordance with the terms and conditions specified herein: Authorized Signature Title of Individual Address of Company City, State, Zip Code Telephone Number Facsimile Number