2023 Nederland Final RFP 3-22-2023 1
REQUEST FOR PROPOSALS
City of Nederland
RFP Data
Proposal Number: 23-01
Title: HEALTH AND WELFARE BENEFITS REQUEST FOR PROPOSAL
Issue Date: March 22, 2023
Request For Proposal To Market
Date: March 22, 2023
Distributed by: HUB International
10000 N. Central Expressway
Suite 1200
Dallas, Texas 75231
Proposal Due
Date: April 20, 2023
Time: 10:00 a.m. CST
Location/Mail Address: 1 original sealed bid and 1 electronic copy (via flash drive):
City of Nederland
Attn: Joni Underwood, City Clerk
207 N. 12th Street
Nederland, TX 77627
Or
P. O. Box 967
Nederland, TX 77627
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Request for Proposal Contents Listing
1. Requirements & Instructions
2. Contractual Provisions for Consideration
3. Assumptions and Expectations
4. RFP Overview
5. Coverage Funding Matrix
6. Contract Length
7. Plan Summaries and Historical Rate Information
a. BCBSTX Medical/Rx
b. BCBSTX Dental
c. BCBSTX Life and Disability
8. Submission Forms
a. Medical/Rx
b. Dental
c. Basic Life, Voluntary Life and LTD
9. References
10. Vendor Selection Criteria
11. Summary Conditions & Specifications Signature Page – Required
Attachments:
Conflict of Interest Questionnaire – Return Completed and Signed
Census
Medical Certificates
Medical Experience Reports
Medical Provider Disruption
Dental Certificate
Dental Experience Reports
Dental Provider Disruption
Life/DI Certificates
Life/DI Experience Reports
Non-Profit Trust
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1. REQUIREMENTS & INSTRUCTIONS
I. Important Dates:
RFP Issue Date: March 22, 2023
Q&A Deadline: March 30, 2023 5:00 pm
Final Addendum April 10, 2023
RFP Due Date: April 20, 2023 10:00 am
Coverage Effective Date: July 1, 2023
II. Submission Information: One fully prepared, signed proposal and one electronic copy via flash
drive should be submitted to City of Nederland, City Clerk, 207 N. 12th Street, Nederland, TX
77627. You must label the envelopes or packages – ‘HEALTH AND WELFARE BENEFITS
REQUEST FOR PROPOSAL – 23-01.’
No telephone or faxed proposals will be accepted. Proposals will be accepted only if delivered in
person, by the U.S. Postal Service, or by delivery service such as UPS or Federal Express. The
City will not be responsible for or consider missing, lost, or late deliveries.
III. Vendors requesting additional information: Requests for additional information should be
made no later than 5:00 p.m. on Thursday, March 30, 2023 and should be directed to Caysi
Mitchell, HUB International, via email at caysi.mitchell@hubinternational.com or via fax at
214-443-2424. All requests must be made in writing.
IV. Confidentiality: Information contained in the RFP is confidential and is to be used only for the
purpose of preparing legitimate proposals for all or part of the benefits plans stipulated in this
RFP.
V. Proposal Review: The City reserves the right to accept or reject, in part or in whole, any portion
of the proposals, waive minor technicalities, and select the proposal which best serves the interest
of the City. The City also reserves the right to waive or dispense with any of the formalities
contained herein.
VI. Certificate of Interested Parties Form: In 2015, the Texas Legislature adopted House Bill
1295, which added section 2252.908 of the Government Code. The law states that a
governmental entity or state agency may not enter into certain contracts with a business entity
unless the business entity submits a disclosure of interested parties to the governmental entity or
state agency at the time the business entity submits the signed contract to the governmental entity
of state agency. The law applies only to a contract of governmental entity or state agency that
either (1) requires an action or vote by the governing body of the entity or agency before the
contract may be signed or (2) has a value of at least $1 million. The disclosure requirement
applies to a contract entered into on or after January 1, 2016.
The Texas Ethics Commission was required to adopt rules necessary to implement that law,
prescribe the disclosure of interested parties form, and post a copy of the form on the
commission’s website. The commission adopted the Certificate of Interested Parties form (Form
1295) on October 5, 2015. The commission also adopted new rules (Chapter 46) on November
30, 2015 to implement the law.
Filing Process:
On January 1, 2016, the commission made available on its website a new filing application that
must be used to file Form 1295. A business entity must use the application to enter the required
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information on Form 1295 and print a copy of the completed form, which will include a
certification of filing that will contain a unique certification number. An authorized agent of the
business entity must sign the printed copy of the form and have the form notarized upon award.
Information regarding how to use the filing application is available
at https://www.ethics.state.tx.us/filinginfo/1295/. Please follow instructional Video for
Business Entities
VII.Premium Costs: All premium costs related to the RFP must be clearly defined, and all
deviations from the specifications must be clearly identified and explained.
The information contained in the RFP is believed to be accurate and up-to-date, but is not
intended to be an expressed or implied warranty. Requests for interpretation of the specifications
should be directed to caysi.mitchell@hubinternational.com.
VIII.Legal Consideration: All parties submitting proposals are expected to comply with all federal,
state, and local laws and regulations pertaining to the preparation of proposals and the services to
be provided. Specifically, the services to be provided are expected to be in compliance with the
Americans with Disabilities Act (ADA), insurance laws and insurance regulations. All proposals
that are submitted will be presumed to be in compliance with applicable laws.
IX.Carrier Information: It is expected that those submitting RFPs will provide full disclosure on
the insurance carriers who will be used for each coverage requested. Failure to provide this
information may result in disqualification or rejection of the RFP.
X.RFP Notification: Parties who are selected to provide benefits coverage to the employees, based
on the RFP submitted, will be notified as soon as possible following thorough review by City
management and City Council.
XI.Submission Forms: All Respondents must fill out all submission forms.
XII.Proposal Format:
A.Proposals must be clearly explained and identified. All costs, including optional
programs, must be clearly stated and summarized. Alternative proposals will also be
considered, provided the alternatives are clearly explained. Exceptions to or deviations
from the specifications must be explicitly identified.
B.Those submitting proposals are responsible for the full costs associated with the
preparation of the proposal.
C.Proposals may be withdrawn prior to the closing time for RFPs. Thereafter, all proposals
shall remain open and valid for a period of 180 days or the effective date of the new plan,
whichever is latest.
D.Accuracy in the proposals submitted is essential. All parties are asked to proof proposals
for compliance with all stipulations of the RFP and accurate numbers submitted.
XIII.Disqualification and Rejection of Proposals: Failure to comply with the requirements or the
procedures set forth herein, or to satisfy the insurance and servicing criteria as set for the in the
specification, may result in disqualification. It is not intended that exceptions to the
specifications will, in and of themselves, result in disqualification.
XIV.Basis for Consideration: The City will review all proposals for completeness based on the
requirements in this RFP. Those found to be incomplete or fail to address the needs of the City
will not be evaluated. Only those proposals that are complete, with all required documentation
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will be evaluated. Respondents should initially submit their best offer. If an award is made,
primary consideration will be given to the respondent’s proposal deemed to the best interest of
the City.
XV. Service Considerations: The City will evaluate the proposals on factors other than cost,
including level of benefits and coverage area. After a preliminary evaluation of the technical
criteria, the cost proposal will be included in the evaluation process. Costs will be evaluated on
an equal basis with the technical criteria, including benefit level and coverage area.
XVI. Right to Reject: Merely submitting a proposal does not warrant an expressed or implied contract
for the insurance program for the City of Nederland.
XVII. Authorized Signature: All proposal forms must be signed by persons who have the legal
authority to bind the respondent to the proposed coverages.
XVIII. The City of Nederland and/or City of Nederland Employee Benefit Trust requires the selected
carrier, at no additional costs, at contract termination to provide an electronic deductible report
that shows for each covered individual the amount applied towards the deductible and the
amount of coinsurance paid for the calendar or Plan year.
XIX. The City of Nederland and/or City of Nederland Employee Benefit Trust requires the selected
carrier to provide a monthly list bill broken out by Class, Plan and Employment Status.
XX. The City of Nederland and/or City of Nederland Employee Benefit Trust requires the selected
carrier to provide a physical ID card for each participant. The physical ID card must include a
toll-free telephone number for customer service and benefits verification.
XXI. The City of Nederland and/or City of Nederland Employee Benefit Trust requires that the
selected carrier provide the benefit booklets within forty-five (45) days of being awarded the
contract.
XXII. The City of Nederland and/or City of Nederland Employee Benefit Trust requires the selected
carrier to maintain a sufficient Fidelity Bond for employee theft.
XXIII. The proposer should not assume that any other insurance product will be placed through the
carrier when submitting proposed rates in response to this request for competitive proposals. The
City of Nederland and/or City of Nederland Employee Benefit Trust may consider discounts
available from awarding other benefit contracts to the same carrier in their evaluation of medical
proposals. The City of Nederland and/or City of Nederland Employee Benefit Trust will place
the other insurance products with the vendor that is most advantageous to the City of Nederland
and/or City of Nederland Employee Benefit Trust.
XXIV. It is the responsibility of the proposer to examine the entire specification package, seek
clarification from HUB of any item or requirement that may not be clear to it, and to check all
responses for accuracy before submitting the response.
XXV. The City of Nederland and/or City of Nederland Employee Benefit Trust requires that all
proposals be submitted on a no loss/no gain basis.
XXVI. The information provided in these specifications has been provided by the City of Nederland
and/or City of Nederland Employee Benefit Trust and its current vendors. It has been reviewed
and organized in good faith and with reliance on the information provided to HUB, but no
guarantees or warranties are implied.
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XXVII. All proposals are to be submitted net of commission AND premium tax. The City of
Nederland and/or City of Nederland Employee Benefit Trust have created Trusts that exempts
the insurer from premium tax under §222.002(c)(5) of the Texas Insurance Code.
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2. CONTRACTUAL PROVISIONS FOR CONSIDERATION
The firm, who enters into a contract with the City of Nederland to provide services to the employees, will
be required to abide by the contract provisions outlined here. Potential Contractors should consider the
following carefully, and it is assumed by submitting a proposal that these conditions will be acceptable
and included in the final signed document.
I. Handling of Claims & Customer Service:
A. The contractor must agree to deliver quality customer service to the City and its employees
and follow all applicable regulations and industry standards. Any problems related to servicing
the contract, the employees, or the City with regard to billing procedures must be rectified
immediately.
B. The contractor shall submit separate invoices, in duplicate, for payment as directed by the
City. Invoices should include the contract number and will be itemized in accordance with the
components of the contract. Payment will not be due until thirty (30) days after the date the
above instruments are submitted or the work is actually performed. Whichever is later.
C. If invoices have not been paid by the due date, the contractor will submit an overdue reminder
notice. The City reserves the right to review all of the contractor’s invoices after payment and
recover any overpayments discovered in such review.
II. Continuity of Coverage: All employees and dependents covered by the current plan are to
receive immediate coverage under the new plan. Fair credit will be allowed for all or any part of
deductibles, coinsurance, etc. satisfied prior to the July 1, 2023 effective date.
III. Claims Experience Monitoring: The contractor shall provide monthly reports allowing the city
to monitor claims experience on a monthly basis.
IV. Contractor Insurance Coverage: During the duration of any agreed contract, the contractor
shall maintain, at its sole cost and expense, Professional E&O Liability insurance with a
minimum policy limit of $1,000,000. The insurance policy must name the City of Nederland as
an additional insured. A certificate of insurance evidencing such coverage shall be furnished to
the City prior to the commencement of any work for the City.
V. Contractor Provision Requirement: The contract shall provide any necessary tools, equipment,
supplies, materials, employees, management, and other items or services necessary in order to
provide full service to the contract.
VI. Indemnity Clause: By submitting a proposal and/or accepting an agreement for services, the
contractor will agree to hold harmless the City of Nederland, its officers, agents, and employees,
from and against any and all claims, losses, damages, causes of action, suits and liability of every
kind, including all expenses of litigation, court costs, and attorney’s fees, for injury to, or death
of, any person, or for damage to any property arising out of, or in conjunction with, the work
done by the contractor, regardless of whether such injuries, death or damages are caused in whole
or in part by the negligence of the City.
VII. Expectations of the Contractor: It is understood upon submission of a proposal that;
A. The Contractor shall not assign or subcontract any of its rights, duties, or obligations under
the contract without prior written consent from the City. The contractor shall be entitled to
assign, pledge or encumber its right to receive payments under this contract pursuant to
security interests based upon the Uniform Commercial Code, so long as the City shall never
be obligated to negotiate with any such third party in respect to compliance with the terms
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and conditions of the agreed contract. Any such assignment, pledge or encumbrance shall be
limited by any rights of offset by the City for damages or claims arising under this Contract
or any other obligation owed by the Contractor to the City.
B. At all times during the term of the contract, the company awarded the contract shall operate
as an independent contractor to the City, and the contractor shall not in any event be deemed
an employee or other representative of the City, nor shall he/she hold themselves up as such.
VIII. Contractor Employee Arrangements: All employees of the Contractor shall at all times be
considered an employee of the Contractor, and the Contractor will be solely liable for the
payment of all wages and benefits made available to such employees in connection with their
employment. In addition, it is expected and understood that the Contractor will be responsible at
all times for the supervision and performance of their employees. All employees of the
Contractor shall warrant that all employees are fully covered by workers compensation insurance
and that each employee has been carefully screened as to character and fitness for the
performance of his/her job.
IX. Equal Opportunity: It is expected during the performance of the contract, all Contractor
employees will be treated under the requirements of an Equal Employment Opportunity employer
and honor all protected rights afforded to employees under the law. The Contractor will be
advised of any complaints filed with the City alleging that the contractor is not operating in good
faith as an equal employment opportunity employer. The City reserves the right to consider such
complaints, along with other considerations, in determining whether or not to terminate any
portion of this contract for which the services have not yet been performed.
X. Advertising: The contractor awarded the contract agrees not to advertise or publish, without the
City’s prior consent, the information related to the entry into a contract, except as required to
comply with requests for information from an authorized representative of the federal, state or
local authority.
XI. Contract Amendments & Enforceability: No amendments, modifications, or changes to the
provisions outlined here may be made absent from the written agreement of both parties. Further,
the contract awarded to the firm will be interpreted, construed, and governed by the laws of the
United States and the State of Texas and shall be enforceable in any court of competition
jurisdiction in Jefferson County, Texas.
XII. Termination: The City retains the right to terminate for default on all or any part of its contract
if the contractor breaches any for the terms hereof or if the contractor becomes insolvent or files
for bankruptcy. Such right of termination, in addition to, and not in lieu of, any other remedies,
which the City may have in law or equity, specifically including, but not limited to, the right to
sue for damages or demand specific performance. The City additionally has the right to terminate
this Contract without cause by delivery to the Contractor a “Notice of Termination” specifying
the extent to which performance hereunder is terminated and the date upon which such
termination becomes effective.
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3. ASSUMPTIONS AND EXPECTATIONS
Assumptions are as follows:
1. The proposal is to be based on the RFP plan of benefits.
2. The quote is to be based upon the census provided with the RFP.
3. All participants enrolled in the Employee Benefits Plan as of June 30, 2023 are to receive
immediate coverage under the new plan. All health services incurred on or after July 1,
2023, for currently enrolled participants are to be eligible expenses. The City’s
enrollment records are to be the basis for “take-over.”
4. Credit is to be given for accumulated deductible and coinsurance. Current carrier is
required to release deductible accumulator report within 45 days. New vendor is required
to process deductible accumulator report within 15 days of it being received.
5. All Respondent proposal offerings will comply with the Patient Protection and
Affordability Care Act of 2009.
6. Coverage for eligible employees becomes effective on the 1st day of the month following
date of hire, and terminates at the end of the month in which the employer notifies the
insurance provider. Retirees are eligible for continued coverage provided they had these
benefits as of the day preceding the date of retirement.
7. This RFP is for a five-year contract. A three-year contract with two one-year renewal
options, a two-year contract with three one-year renewal options or a one-year contract
with options for four one-year renewal options will be considered. If it is the
respondent’s intent to increase rates at the renewal date, the City must be notified of
the maximum increase for each renewal period and the basis for calculating the
increase. The City must be notified of renewal rates at least ninety (90) days prior to the
effective date of the rate change.
8. The City maintains a single non-profit premium trust for premium payments. Proposers
for fully insured medical should exclude premium taxes from premiums per Chapter 222,
Section 222.002 of the Texas Insurance Code.
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4. RFP OVERVIEW
Client: City of Nederland
Industry: Municipality
Group to be Covered: All Eligible Employees and Retirees
Size: 121 Eligible Employees
77 Retirees
02 COBRA
Location: Nederland, TX 77627
Coverages to Bid: Fully Insured Medical/Rx, Dental, Life/Disability
Geo Access: Medical: 2 PCPs in 10 miles;
2 Specialists in 10 miles; 1 Hospital in 10 miles
Dental: 2 within 10 miles
Current Carrier: Fully Insured Medical/Rx – BCBSTX
Dental – BCBSTX
Life/Disability – BCBSTX
Plan Offerings: See attached summaries
Expectations: Please match current plans as closely as possible and
provide any cost saving alternates.
Commission: ALL COVERAGES TO BE QUOTED NET OF
COMMISSION
Timetable: Release of Request For Proposal 3/22/2023
Deadline for Questions 3/30/2023
Final Addendum 4/10/2023
Proposal Deadline 4/20/2023
New Coverage Effective 7/1/2023
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5. COVERAGE FUNDING MATRIX
FUNDING MATRIX
City of
Nederland Coverages Contributory Non-
Contributory Funding Retiree
Coverage
Current
Retiree
Rates
Requested
Retiree
Rates
Medical/Rx Current X Fully
Insured
Yes-Pre
and Post
65*
Blended Blended
Dental Current X Fully
Insured
Yes - Pre
and Post
65
Blended Blended
Basic Life
and AD&D Current X Fully
Insured Yes Unblended Unblended
Vol. Life
and AD&D Current X Fully
Insured N/A N/A N/A
LTD Current X Fully
Insured N/A N/A N/A
*Note: Post-65 retirees are not eligible to stay on the medical plan upon receiving Medicare and
their dependents are provided notice of COBRA eligibility at that time. The City does allow
post-65 retirees to stay on Dental coverage.
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6. CONTRACT LENGTH
Selection Criteria: In addition to cost, the City of Nederland is looking for
carriers or vendors who can provide a high level of service
and whose products hold with long term cost containment
goals.
Length: This RFP is for a five-year contract.
OPTION 1 A three-year contract with two one-year
renewal options,
OPTION 2 a two-year contract with three one-year renewal
options or
OPTION 3 a one-year contract with options for four one-
year renewal options will be considered.
Opportunity for Presentation: To be determined
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7. PLAN SUMMARIES AND HISTORICAL RATE
INFORMATION
CITY OF NEDERLAND
CURRENT MEDICAL BENEFITS – PPO PLAN
MEDICAL BENEFITS BCBSTX
PPO Plan
Deductible
In-Network $1,500 Ind. / $3,000 Fam.
Non-Network $5,000 Ind. / $10,000 Fam.
Out Of Pocket Max Includes Deductible / Embedded
In-Network $6,500 Ind. / $13,000 Fam.
Non-Network $10,000 Ind. / $20,000 Fam.
Coinsurance
In-Network 80%
Non-Network 50%
Lifetime Max Unlimited
Emergency Room
In-Network $300 + Ded./20%
Non-Network $300 + Ded./20%
Physician Office Visit
In-Network $10 Copay
Non-Network Ded./50%
Specialist Office Visit
In-Network $40 Copay
Non-Network Ded./50%
Preventive Care
In-Network Covered Fully
Non-Network Ded./50%
Urgent Care
In-Network $25 Copay
Non-Network Ded./50%
Major Lab & X-Ray (MRI,
MRA, CAT SCAN)
In-Network Ded./20%
Non-Network Ded./50%
In-Patient / Out-Patient Hospital
In-Network Ded./20%
Non-Network Ded./50%
Prescriptions
Network Retail Pharmacy $10 / $35 / $60
Non-Network Retail Pharmacy $25/ $87.50 / $150
Telemedicine $10 Copay (MDLive)
Note: This is a brief summary and not intended to be a contract.
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CITY OF NEDERLAND
CURRENT MEDICAL BENEFITS – HDHP PLAN
Note: This is a brief summary and not intended to be a contract.
MEDICAL BENEFITS BCBSTX
HDHP HSA Plan
Deductible
In-Network $2,800 Ind. / $5,400 Fam.
Non-Network $5,000 Ind. / $10,000 Fam.
Out Of Pocket Max Includes Deductible / Embedded
In-Network $5,400 Ind. / $10,800 Fam.
Non-Network $10,000 Ind. / $20,000 Fam.
Coinsurance
In-Network 80%
Non-Network 50%
Lifetime Max Unlimited
Emergency Room
In-Network Ded./20%
Non-Network Ded./20%
Physician Office Visit
In-Network Ded./20%
Non-Network Ded./50%
Specialist Office Visit
In-Network Ded./20%
Non-Network Ded./50%
Preventive Care
In-Network Covered Fully
Non-Network Ded./50%
Urgent Care
In-Network Ded./20%
Non-Network Ded./50%
Major Lab & X-Ray (MRI,
MRA, CAT SCAN)
In-Network Ded./20%
Non-Network Ded./50%
In-Patient / Out-Patient Hospital
In-Network Ded./20%
Non-Network Ded./50%
Prescriptions
Network Retail Pharmacy Deductible then $10 / $35 / $60
Non-Network Retail Pharmacy Deductible then $25 / $87.50 / $150
Telemedicine $49 Copay (MDLive)
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CITY OF NEDERLAND
CURRENT MEDICAL BENEFITS – HMO PLAN
Note: This is a brief summary and not intended to be a contract.
MEDICAL BENEFITS BCBSTX - Proposed
BE HMO Copay / Alternative
Deductible
In-Network $1,500 Ind. / $3,000 Fam.
Non-Network n/a
Out Of Pocket Max Includes Deductible / Embedded
In-Network $6,500 Ind. / $13,000 Fam.
Non-Network n/a
Coinsurance
In-Network 80%
Non-Network n/a
Lifetime Max Unlimited
Emergency Room
In-Network $300 + Ded/20%
Non-Network $300 + Ded/20%
Physician Office Visit
In-Network $10 Copay
Non-Network n/a
Specialist Office Visit
In-Network $40 Copay
Non-Network n/a
Preventive Care
In-Network Covered Fully
Non-Network n/a
Urgent Care
In-Network $25 Copay
Non-Network n/a
Major Lab & X-Ray (MRI,
MRA, CAT SCAN)
In-Network Ded./20%
Non-Network n/a
In-Patient / Out-Patient Hospital
In-Network Ded./ 20%
Non-Network n/a
Prescriptions
Network Retail Pharmacy $10 / $35 / $60
Non-Network Retail Pharmacy $25/ $87.50 / $150
Telemedicine Included - MDLive ($10 Copay)
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CITY OF NEDERLAND
CURRENT DENTAL BENEFITS
Note: This is a brief summary and not intended to be a contract.
DENTAL BENEFITS BCBSTX
Nederland LOW HIGH
Type I – Preventive Services 100% 100%
Waiting Period
Oral Examinations Type I ( 2 per 12 months) Type I ( 2 per 12 months)
X-rays
- Bite Wings Frequency Type I ( 1 per year) Type I ( 1 per year)
- Full Mouth Frequency Type I ( 1 per 60 months) Type I (1 per 60 months)
Cleanings Type I ( 2 per 12 months) Type I (2 per 12 months)
Topical Fluoride Treatment Type I ( 2 per 12 months to age 19) Type I (2 per 12 months to age 19)
Space Maintainers Type I (1 per lifetime to age 19) Type I (1 per lifetime to age 19)
Sealants Type I (1 per lifetime to age 16) Type I (1 per lifetime to age 16)
Type II – Basic Services 80% 80%
Waiting Period None None
Fillings
- Amalgam Type II Type II
- Composite Type II Type II
Root Canal Treatment Type III Type II
Root Planning Type III Type II
Periodontic Maintenance Type III Type II
Periodontal Surgery Type III Type II
Extractions Type III Type II
General Anesthesia Type II Type II
Palliative Treatment (Relief of Pain) Type II Type II
Type III – Major Services 50% 50%
Waiting Period None None
Crowns Type III Type III
Inlays and Onlays Type III Type III
Removable / Fixed Bridge-Work Type III Type III
Partial or Complete Dentures Type III Type III
Denture Relines / Rebases Type III Type III
Implants Not Covered Type III
Type IV - Orthodontia 50% 50%
Waiting Period None None
Orthodontia Lifetime Maximum $1,000 $1,500
Orthodontia Eligibility Adult/Child Adult/Child
Calendar Year Deductible
Individual $50 $50
Family $150 $150
Dental Annual Maximum $1,000 $1,500
Maximum Rollover N/A N/A
Waiting Period Applies to: None None
UCR Out of Network Percentile 90th 90th
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CITY OF NEDERLAND
CURRENT BASIC LIFE AND AD&D PLAN
BASIC LIFE BENEFITS BCBS
Class Description
Class 1: All Full Time Employees
Class 2: Retirees
Definition of Earnings BAE
Basic Life Schedule
Class 1: 2x Annual Earnings
Class 2: $10,000
Maximum Benefit
Class 1: $200,000
Class 2: $10,000
Guarantee Issue Amount
Class 1: $200,000
Class 2: $10,000
Age Reduction Schedule
65% at age 70; 50% at age 75
Class 2: None
Terminates at Retirement
Class 1 Terminates.
Class 2 for retirees where benefits terminate at
age 99
Waiver of Premium
Class 1: Included-disabled prior to age 60; 9
month EP; to age 65
Accelerated Death Benefit Lesser of 75% to Max of $250,000
Conversion Included
Portability Not Included
Spouse Life Amount Not Included
Child(ren) Life Amount Not Included
BASIC AD&D
BENEFITS
Class Description All FT Employees
Definition of Earnings BAE Including Commissions
Basic AD&D Schedule 2x Annual Earnings
Maximum Benefit $200,000
Applies to Spouse/Children Not Included
Age Reduction Schedule 65% at 70; 50% at 75
Education - Spouse $3,000
Education - Child 5% Principal Sum to $5,000/year to 4 years
Seatbelt 10% of Principal Sum to $25,000
Air Bag 10% of Principal Sum to $25,000
Bereavement Counseling Included
Note: This is a brief summary and not intended to be a contract.
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CITY OF NEDERLAND
CURRENT VOLUNTARY LIFE AND AD&D PLAN
VOLUNTARY LIFE BENEFITS BCBS
Class Description All FT Eligible Employees
Definition of Earnings BAE
Employee Life Schedule Increments of $10,000
Employee Maximum Benefit 5x Earnings to $500,000
Employee Guarantee Issue Amount 5x Earnings to $100,000
Age Reduction Schedule to 65% at age 70; to 50% at age 75;
Waiver of Premium Included- disabled prior to age 60; 9
month EP; to 65
Accelerated Death Benefit 80% to $500,000
Spouse Life Schedule Increments of $5,000
Spouse Maximum Benefit $50,000
Spouse Guarantee Issue Amount $5,000 - $50,000 subject to 50% of
employee amount
Child(ren) Life Schedule
Live Birth to 14 Days: $100
15 Days - 6 months: $250
6 months to age 26: $10,000
Child(ren) Maximum Benefit $10,000
Conversion Included
Portability Included
Suicide Clause 2 years
Note: This is a brief summary and not intended to be a contract.
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CITY OF NEDERLAND
CURRENT LONG TERM DISABILITY PLAN
Note: This is a brief summary and not intended to be a contract.
LTD BENEFITS BCBS
Class Description All Full Time Employees
working 30+ Hours
Definition of Earnings Basic Monthly Earnings
Monthly Percentage 60%
Monthly Maximum $10,000
Guarantee Issue $10,000
Minimum Benefit 10% or $100
Elimination Period 90 Days
20
HISTORICAL RATE INFORMATION AND CONTRIBUTIONS
CITY OF NEDERLAND
MEDICAL RATE HISTORY
Medical Rates –
PPO Plan
BCBSTX
2022-2023
BCBSTX
2019-2022
UHC
2017-2019
Employee/Retiree Only $687.39 $613.06 $595.69
Employee/Retiree + Spouse $1,624.33 $1,448.68 $1,407.63
Employee/Retiree + Children $1,196.49 $1,067.10 $1,036.86
Employee/Retiree + Family $2,010.41 $1,793.01 $1,742.20
Medical Rates –
HDHP HSA Plan
BCBSTX
2022-2023
BCBSTX
2019-2022
UHC
2017-2019
Employee/Retiree Only $564.36 $503.33 $489.07
Employee/Retiree + Spouse $1,333.60 $1,189.39 $1,155.69
Employee/Retiree + Children $982.34 $876.11 $851.28
Employee/Retiree + Family $1,650.58 $1,472.09 $1,430.38
Medical Rates –
HMO Plan (NEW)
BCBSTX
2022-2023
Employee/Retiree Only $623.88
Employee/Retiree + Spouse $1,474.24
Employee/Retiree + Children $1,085.93
Employee/Retiree + Family $1,824.65
21
DENTAL RATE HISTORY
LIFE AND DISABILITY RATE HISTORY
BASIC LIFE (BCBSTX) :
2020-2023 (PER $1,000) - $0.098 (Active)
- $1.347 (Retiree)
BASIC AD&D (BCBSTX):
2020-2023 (PER $1,000) - $0.03 (Active)
Dental Rates –
Low Plan
BCBSTX
2022-2023
UHC
2020-2022
BCBSTX
2019-2020
Employee/Retiree
Only $20.18 $19.59 $21.77
Employee/Retiree
+ Spouse $44.66 $43.36 $48.18
Employee/Retiree
+ Children $43.75 $42.48 $47.21
Employee/Retiree
+ Family $69.85 $67.82 $75.37
Dental Rates –
High Plan
BCBSTX
2022-2023
UHC
2020-2022
BCBSTX
2019-2020
Employee/Retiree
Only $25.31 $24.57 $27.31
Employee/Retiree
+ Spouse $56.51 $54.86 $60.98
Employee/Retiree
+ Children $54.94 $53.34 $59.29
Employee/Retiree
+ Family $87.82 $85.26 $94.77
22
VOLUNTARY LIFE AND AD&D
2023-2020
FINANCIALS (per $1,000) BCBSTX
Age of Employee Employee & Spouse
Up to 24 $0.09
25 –29 $0.10
30 – 34 $0.11
35 – 39 $0.14
40 – 44 $0.21
45 – 49 $0.36
50 – 54 $0.60
55 – 59 $0.94
60 – 64 $1.46
65 – 69 $2.63
70 – 74 $4.71
75 – 79 $7.76
80 – 84 $15.72
85 – 89 $15.72
90 – 94 $15.72
95 – 99 $15.72
Employee AD&D Rate (per $1,000) $0.04
Spouse AD&D Rate (per $1,000) $0.04
Child(ren) Rates (per $1,000) Life: $.16
AD&D: $.04
LONG TERM DISABILITY (BCBSTX):
2021-2023(PER $100) - $0.240
2020 (PER $100) – $0.169
23
ACTIVE MEDICAL CONTRIBUTIONS
Standard PPO Medical Rate City Contribution ($) City Contribution (%)
Employee Contribution
($)
Employee $687.39 $687.39 100.0%$0.00
+ Spouse $936.94 $407.48 43.5%$529.46
+ Children $509.10 $119.58 23.5%$389.52
+ Family $1,323.02 $666.57 50.4%$656.45
Enrollment Unit Costs
HSA Medical Rate City Contribution ($) City Contribution (%)
Employee Contribution
($)
Employee $564.36 $564.36 100.0%$0.00
+ Spouse $769.24 $530.51 69.0%$238.73
+ Children $417.98 $242.61 58.0%$175.37
+ Family $1,086.22 $789.60 72.7%$296.62
HMO Medical Rate City Contribution ($) City Contribution (%)
Employee Contribution
($)
Employee $623.88 $623.88 100.0%$0.00
+ Spouse $850.36 $422.22 49.7%$428.14
+ Children $462.05 $127.59 27.6%$334.46
+ Family $1,200.77 $687.39 57.2%$513.38
RETIREE MEDICAL CONTRIBUTIONS
Standard PPO Medical Rate City Contribution
($)
City Contribution
(%)
Retiree
Contribution ($)
Employee $687.39 $0.00 0.0% $687.39
+ Spouse $936.94 $0.00 0.0% $936.94
+ Children $509.10 $0.00 0.0% $509.10
+ Family $1,323.02 $0.00 0.0% $1,323.02
HSA Medical Rate City Contribution
($)
City Contribution
(%)
Retiree
Contribution ($)
Employee $564.36 $0.00 0.0% $564.36
+ Spouse $769.24 $0.00 0.0% $769.24
+ Children $417.98 $0.00 0.0% $417.98
+ Family $1,086.22 $0.00 0.0% $1,086.22
HMO Medical Rate City Contribution
($)
City Contribution
(%)
Retiree
Contribution ($)
Employee $623.88 $0.00 0.0% $623.88
+ Spouse $850.36 $0.00 0.0% $850.36
+ Children $462.05 $0.00 0.0% $462.05
+ Family $1,200.77 $0.00 0.0% $1,200.77
24
CITY OF NEDERLAND
DENTAL CONTRIBUTIONS – ACTIVE
Dental – High Plan
Total
Premium
($)
City
Contribution
($)
Employee
Contribution
($)
Employee Only $25.31 $25.31 $0.00
Employee + Spouse $56.51 $25.31 $31.20
Employee + Child(ren) $54.94 $25.31 $29.63
Employee + Family $87.82 $25.31 $62.51
DENTAL CONTRIBUTIONS – RETIREE
Dental – Low Plan
Total
Premium
($)
City
Contribution
($)
Employee
Contribution
($)
Employee Only $20.18 $20.18 $0.00
Employee + Spouse $44.66 $20.18 $24.48
Employee + Child(ren) $43.75 $20.18 $23.57
Employee + Family $69.85 $20.18 $49.67
Dental – High Plan
Total
Premium
($)
City
Contribution
($)
Retiree
Contribution
($)
Retiree Only $25.31 $0.00 $25.31
Retiree + Spouse $56.51 $0.00 $56.51
Retiree + Child(ren) $54.94 $0.00 $54.94
Retiree + Family $87.82 $0.00 $87.82
Dental – Low Plan
Total
Premium
($)
City
Contribution
($)
Retiree
Contribution
($)
Retiree Only $20.18 $0.00 $20.18
Retiree + Spouse $44.66 $0.00 $44.66
Retiree + Child(ren) $43.75 $0.00 $43.75
Retiree + Family $69.85 $0.00 $69.85
25
SUBMISSION FORMS
DEVIATIONS FROM SPECIFICATIONS
1. Describe, in detail, any deviations from the specifications.
• Does your organization agree to the Specifications for Proposers as outlined in the
RFP?
• Would you be willing to agree to a performance-based contract using these criteria? If
so, please outline your proposed performance guarantees.
• Will your organization administer and/or underwrite the benefits as outlined in the
"Proposed Benefit Plans" section?
_____________________________________
Signature of Officer
26
CITY OF NEDERLAND
MEDICAL SUBMISSION FORM – PPO PLAN
MEDICAL BENEFITS Carrier Name
Plan Name
Deductible
In-Network
Non-Network
Out Of Pocket Max (Includes/Excludes Deductible)
In-Network
Non-Network
Coinsurance
In-Network
Non-Network
Lifetime Max
Emergency Room
In-Network
Non-Network
Physician Office Visit
In-Network
Non-Network
Specialist Office Visit
In-Network
Non-Network
Preventive Care
In-Network
Non-Network
Urgent Care
In-Network
Non-Network
Major Lab & X-Ray (MRI,
MRA, CAT SCAN)
In-Network
Non-Network
In-Patient / Out-Patient Hospital
In-Network
Non-Network
Prescriptions
Network Retail Pharmacy
Non-Network Retail Pharmacy
Telemedicine
The Benefits above are based upon duplication of the current plan of benefits
Signature __________________________________
27
CITY OF NEDERLAND
MEDICAL RATE FORM – PPO PLAN
ACTIVE / RETIREE EMPLOYEES CARRIER NAME
PPO PLAN
Employee/Retiree Only
Employee/Retiree + Spouse
Employee/Retiree + Child(ren)
Employee/Retiree + Family
Rate
$________
$________
$________
$________
#Lives
_______
_______
_______
_______
Total Monthly Costs
$__________________
Rate Guarantee
__________________
AM Best Rating
__________________
Premium Taxes Excluded
___________________
The costs above are based upon duplication of the current plan of benefits.
_____________________________________
Signature
28
CITY OF NEDERLAND
MEDICAL SUBMISSION FORM – HDHP PLAN
MEDICAL BENEFITS Carrier Name
Plan Name
Deductible
In-Network
Non-Network
Out Of Pocket Max (Includes/Excludes Deductible)
In-Network
Non-Network
Coinsurance
In-Network
Non-Network
Lifetime Max
Emergency Room
In-Network
Non-Network
Physician Office Visit
In-Network
Non-Network
Specialist Office Visit
In-Network
Non-Network
Preventive Care
In-Network
Non-Network
Urgent Care
In-Network
Non-Network
Major Lab & X-Ray (MRI,
MRA, CAT SCAN)
In-Network
Non-Network
In-Patient / Out-Patient Hospital
In-Network
Non-Network
Prescriptions
Network Retail Pharmacy
Non-Network Retail Pharmacy
Telemedicine
The Benefits above are based upon duplication of the current plan of benefits
Signature __________________________________
29
CITY OF NEDERLAND
MEDICAL RATE FORM – HDHP PLAN
ACTIVE / RETIREE EMPLOYEES CARRIER NAME
HDHP PLAN
Employee/Retiree Only
Employee/Retiree + Spouse
Employee/Retiree + Child(ren)
Employee/Retiree + Family
Rate
$________
$________
$________
$________
#Lives
_______
_______
_______
_______
Total Monthly Costs
$__________________
Rate Guarantee
__________________
AM Best Rating
__________________
Premium Taxes Excluded
___________________
The costs above are based upon duplication of the current plan of benefits.
_____________________________________
Signature
The City is requesting a $10K Wellness Allowance
30
CITY OF NEDERLAND
MEDICAL SUBMISSION FORM – HMO PLAN
MEDICAL BENEFITS Carrier Name
Plan Name
Deductible
In-Network
Non-Network
Out Of Pocket Max (Includes/Excludes Deductible)
In-Network
Non-Network
Coinsurance
In-Network
Non-Network
Lifetime Max
Emergency Room
In-Network
Non-Network
Physician Office Visit
In-Network
Non-Network
Specialist Office Visit
In-Network
Non-Network
Preventive Care
In-Network
Non-Network
Urgent Care
In-Network
Non-Network
Major Lab & X-Ray (MRI,
MRA, CAT SCAN)
In-Network
Non-Network
In-Patient / Out-Patient Hospital
In-Network
Non-Network
Prescriptions
Network Retail Pharmacy
Non-Network Retail Pharmacy
Telemedicine
The Benefits above are based upon duplication of the current plan of benefits
Signature __________________________________
31
CITY OF NEDERLAND
MEDICAL RATE FORM – HMO PLAN
ACTIVE / RETIREE EMPLOYEES CARRIER NAME
HMO PLAN
Employee/Retiree Only
Employee/Retiree + Spouse
Employee/Retiree + Child(ren)
Employee/Retiree + Family
Rate
$________
$________
$________
$________
#Lives
_______
_______
_______
_______
Total Monthly Costs
$__________________
Rate Guarantee
__________________
AM Best Rating
__________________
Premium Taxes Excluded
___________________
The costs above are based upon duplication of the current plan of benefits.
_____________________________________
Signature
32
SUBMISSION FORM
DENTAL
DENTAL BENEFITS CARRIER CARRIER
PPO HIGH PPO LOW
Type I – Preventive Services
Waiting Period
Oral Examinations
X-rays
- Bite Wings Frequency
- Full Mouth Frequency
Cleanings
Topical Fluoride Treatment
Sealants
Type II – Basic Services
Waiting Period
Fillings
- Amalgam
- Composite
Space Maintainers
Root Canal Treatment
Root Planning
Periodontic Maintenance
Periodontal Surgery
Extractions
General Anesthesia
Palliative Treatment (Relief of
Pain)
Type III – Major Services
Waiting Period
Crowns
Inlays and Onlays
Removable / Fixed Bridge-Work
Partial or Complete Dentures
Denture Relines / Rebases
Implants
Type IV - Orthodontia
Waiting Period
Orthodontia Lifetime Maximum
Orthodontia Eligibility
Calendar Year Deductible
Individual
Family
Dental Annual Maximum
Maximum Rollover
Preventive Max Waiver
Waiting Period Applies to:
UCR Out-of-Network Percentile
The Benefits above are based upon duplication of the current plan of benefits
Signature __________________________________
33
SUBMISSION FORM
DENTAL
Blended EE
& Retiree
Blended EE
& Retiree
Low Plan Monthly Premium & Administration
Employee/Retiree Only
Employee/Retiree + Spouse
Employee/Retiree + Child(ren)
Employee/Retiree + Family
Total Monthly Costs
Premium Taxes Excluded
Rate
$_______
$_______
$_______
$_______
$_______
# Lives
________
________
________
________
________
________
High Plan Monthly Premium & Administration
Employee/Retiree Only
Employee/Retiree + Spouse
Employee/Retiree + Child(ren)
Employee/Retiree + Family
Total Monthly Costs
Participation Requirements
Rate Guarantee
AM Best Rating
Rate
$_______
$_______
$_______
$_______
$_______
# Lives
________
________
________
________
________
________
________
________
Premium Taxes Excluded
________
The Benefits above are based upon duplication of the current plan of benefits
Signature __________________________________
34
CITY OF NEDERLAND
BASIC LIFE AND AD&D SUBMISSION FORM
BASIC LIFE BENEFITS Carrier Name
Plan Name
Class Description Class 1:
Class 2:
Definition of Earnings Class 1:
Class 2:
Basic Life Schedule Class 1:
Class 2:
Maximum Benefit Class 1:
Class 2:
Guarantee Issue Amount Class 1:
Class 2:
Age Reduction Schedule Class 1:
Class 2:
Terminates at Retirement Class 1:
Class 2:
Waiver of Premium Class 1:
Class 2:
Accelerated Death Benefit Class 1:
Class 2:
Conversion (Included/Not Included)
Portability (Included/Not Included)
Spouse Life Amount (Included/Not Included)
Child(ren) Life Amount (Included/Not Included)
BASIC AD&D BENEFITS
Class Description
Definition of Earnings
Basic AD&D Schedule
Maximum Benefit
Applies to Spouse/Children (Yes/No)
Age Reduction Schedule
Education
Seatbelt
Air Bag
Bereavement Counseling (Included/Not Included)
The Benefits above are based upon duplication of the current plan of benefits
Signature __________________________________
35
CITY OF NEDERLAND
BASIC LIFE AND AD&D RATE FORM
BASIC LIFE AND AD&D
RATES (per $1,000) Carrier Name
EE Volume
EE Rate (per $1,000) - Life
EE Rate (per $1,000) - AD&D
Retiree Volume
Retiree Rate (per $1,000) - Life
Monthly Premium
Annual Premium
Rate Guarantee
Actively at Work (Waived/Not Waived)
AM Best Rating
The costs above are based upon duplication of the current plan of benefits.
_____________________________________
Signature
36
CITY OF NEDERLAND
VOLUNTARY LIFE AND AD&D SUBMISSION FORM
VOLUNTARY LIFE BENEFITS Carrier Name
Plan Name
Class Description
Definition of Earnings
Employee Life Schedule
Employee Maximum Benefit
Employee Guarantee Issue Amount
Age Reduction Schedule
Waiver of Premium
Accelerated Death Benefit
Spouse Life Schedule
Spouse Maximum Benefit
Spouse Guarantee Issue Amount
Child(ren) Life Schedule
Child(ren) Maximum Benefit
Conversion (Included/Not Included)
Portability (Included/Not Included)
Suicide Clause (2 years?)
VOLUNTARY AD&D BENEFITS
Class Description
Definition of Earnings
Basic AD&D Schedule
Maximum Benefit
Applies to Spouse/Children (Yes/No)
Age Reduction Schedule
Education
Seatbelt
Air Bag
Bereavement Counseling (Included/Not Included)
The Benefits above are based upon duplication of the current plan of benefits
Signature __________________________________
37
CITY OF NEDERLAND
VOLUNTARY LIFE AND AD&D RATE FORM
VOLUNTARY LIFE AND
AD&D RATES (per $1,000) Carrier Name
Age of Employee (Rate applies to Employee AND/OR Spouse?)
(Spouse Rate is Based on Employee or Spouse age?)
Up to 24
25 –29
30 – 34
35 – 39
40 – 44
45 – 49
50 – 54
55 – 59
60 – 64
65 – 69
70 – 74
75 – 79
80 – 84
85 – 89
90 – 94
95 – 99
Employee AD&D Rate (per
$1,000)
Spouse AD&D Rate (per $1,000)
Child(ren) Rate (per $1,000) Life: $
AD&D: $
Participation Requirement
Rate Guarantee
Actively at Work (Waived/Not Waived)
True Open Enrollment (Included/Not Included)
Grandfather Current Amounts (Yes/No)
Annual Coverage Increase (Included/Not Included)
AM Best Rating
The costs above are based upon duplication of the current plan of benefits.
_____________________________________
Signature
38
CITY OF NEDERLAND
LTD SUBMISSION FORM
LTD BENEFITS Carrier Name
Plan Name
Class Description
Definition of Earnings
Monthly Percentage
Monthly Maximum
Guarantee Issue
Minimum Benefit (10% or $100?)
Elimination Period (90 Days?)
Maximum Benefit Duration (RBD?)
Definition of Own Occ/Any Occ
Residual/Partial
Social Security Integration
Earnings Test
Loss of Earning (AND/OR) Loss of Duties
% Loss - Own Occ
% Loss - Any Occ
Survivor Benefit
Pre-existing Limitations
Mental/Nervous Limits
Drug & Alcohol Limits
Self-reported Limitations
EAP Program (Included/Not Included)
Taxable Benefit (Yes/No)
W2 Preparation (Included/Not Included)
The Benefits above are based upon duplication of the current plan of benefits
Signature __________________________________
39
CITY OF NEDERLAND
LTD SUBMISSION FORM
LTD RATES (per $100) Carrier Name
Volume
Rate (per $100)
Monthly Premium
Annual Premium
Actively At Work (Waived/Not Waived)
Rate Guarantee
AM Best Rating
The costs above are based upon duplication of the current plan of benefits.
_____________________________________
Signature
40
SUBMISSION FORM
NETWORK STATISTICS
MEDICAL NETWORK - GEO (PPO Network Name)
GeoAccess (2 PCPs within 10 miles) % coverage
GeoAccess (2 Specialists within 10 miles) % coverage
GeoAccess (1 Hospital within 10 miles) % coverage
MEDICAL NETWORK - DISRUPTION (PPO Network Name)
Provider Record Match % coverage
PHARMACY DISRUPTION
DENTAL NETWORK - GEO (PPO Network Name)
GeoAccess (2 General Dentists within 10 miles) % coverage
GeoAccess (2 Specialists within 10 miles) % coverage
DENTAL NETWORK - DISRUPTION (PPO Network Name)
Provider Record Match % coverage
41
REFERENCES
Provide three Texas client references (preferably cities):
NAME OF
CLIENT
CONTACT
PERSON
TELEPHONE
NUMBER
NUMBER OF
EMPLOYEES
1.
2.
3.
Provide two terminated Texas client references (preferably cities):
NAME OF
CLIENT
CONTACT
PERSON
TELEPHONE
NUMBER
NUMBER OF
EMPLOYEES
1.
2.
42
7. VENDOR SELECTION CRITERIA
(Fully Insured Medical/Rx, Dental, Life/Disability)
The City will, in accordance with Section 252.043 of the Texas Local Government Code, award
the contract to the lowest responsible respondent or the respondent who provides goods or services
at the best value for the City. In determining the best value for the City, the City will consider:
Cost (40%)
• Fixed Costs: includes insurance costs and administrative costs
• Variable Costs: costs stated as a percentage of paid claims, cost management, (i.e., shifting of
more/less workload to the City of Nederland and the City of Nederland’s staff)
• Ability to reduce claims expense (Disease management and Wellness Initiatives)
Financial Stability (15%)
• Insurance Company, AM Best Rating
Communication (5%)
• Educational materials for employees
• Summary Plan Description capabilities
• Administrative kits for locations
• Bilingual capability
Claims Processing (15%)
• Turnaround time excluding medical review of claims
• Pended claims procedures
• Statistical accuracy
• General service procedures
• Willingness to contractually establish performance criteria
Claims Management Reports (10%)
• Frequency of claims reports
• Format of claims reports
• Access to claims reports
Integrated Systems / Technology Initiative (10%)
Integrated systems linked to database are integral to the provider selection. The following
components make up the whole of an integrated system:
• Eligibility
• Utilization review
• Claims function
• Claims payment
• Electronic claims inquiry
• Employer and employee self service
References (5%)
43
8. SUMMARY CONDITIONS & SPECIFICATIONS - RFP
In submitting this quote/proposal, the respondent agrees and certifies to the following
conditions:
1. Non-Inducement Statement: The respondent certifies that no employee, representative,
or agent of the firm offered or gave gratuities in any form (i.e. gifts, entertainment, etc.)
to any council Member, official, or employee of the City of Nederland in order to secure
favorable treatment or consideration in awarding, negotiating, amending or concluding a
final agreement for this proposal.
2. Non-Debarment Statement: The respondent hereby certifies that he/she is not included
on the U.S. Comptroller General’s Consolidated List of Persons or Firms currently
debarred for violations of various contracts incorporating labor standards/provisions.
3. Validity Statement: If this proposal is accepted and a firm contract is entered, the
undersigned offers and agrees, within one-hundred twenty (120) calendar days from the
proposal date, to supply any or all items/services upon which prices are offered at the
designated point and within the time specified.
4. Non-Collusion Statement: The respondent hereby certifies that he/she has made this
quote independently, without consultation, communication, or agreement, for the purpose
of restricting competition as to any matter relating to this proposal, with any other
respondent or with any other competitor.
5. Conflict of Interest Statement: The respondent agrees that and warrants that no employee,
official, or member of the City Council is, or will be, peculiarly benefited, directly or
indirectly, in this proposal or any ensuing contract that may follow.
6. Conduct Statement: The respondent certifies by signing below that all of the above
statements are true, and he/she has read the entire proposal document and agrees to abide
by the terms, certifications, and conditions outlined.
Company Name: _______________________________________________________________
Contact Name: _________________________________________________________________
Title: _________________________________________________________________________
Business Address: ______________________________________________________________
Phone Number: ________________________________________________________________
Printed Name:__________________________________________________________________
Signature: _____________________________________________________________________
44
45
HOUSE BILL 89 VERIFICATION
I, ____________________________________________, the undersigned representative of
________________________________________________, (hereafter referred to as company)
being an adult over the age of eighteen (18) years of age, after being duly sworn by the
undersigned notary, do hereby depose and verify under oath that the company named
above, under the provisions of Subtitle F, Title 10, Government Code Chapter 2270:
1. Does not boycott Israel currently; and
2. Will not boycott Israel during the term of this agreement
Pursuant to Section 2270.001, Texas Government Code:
1. “Boycott Israel” means refusing to deal with, terminating business activities with, or
otherwise taking any action that is intended to penalize, inflict economic harm on, or
limit commercial relations specifically with Israeli-controlled territory, but does not
include an action made for ordinary business purposes; and
2. “Company” means a for-profit sole proprietorship, organization, association,
corporation, partnership, joint venture, limited partnership, limited liability partnership,
or any limited liability company, including a wholly owned subsidiary, majority-owned
subsidiary, parent company or affiliate of those entities or business associations that
exist to make a profit.
______________________________ __________________________________________
DATE SIGNATURE OF COMPANY REPRESENTATIVE
ON THIS THE __________ day of _______________________________, 20______,
personally appeared _________________________________________, the above named
person, who after by me being duly sworn, did swear and confirm that the above is true and
correct.
Notary Seal __________________________________________
NOTARY SIGNATURE
46
ATTACHMENTS
Conflict of Interest Questionnaire – Return Completed and Signed
Census
Medical Certs and SBC’s
Medical Experience Reports
Medical Provider Disruption
Dental Certificate(s)
Dental Experience Reports
Dental Provider Disruption
Life/DI Certificate
Life/DI Experience Reports
Non-Profit Trust