COMMISSIONERS' COURT AGENDA REQUEST
~~1~~031.~.~>
PLEASE FURNISH ONE ORIGINAL AND NINE COPIES OF THIS REQUEST AND DOCUMENTS TO BE
REVIEWED BY THE COURT.
MADE BY: Pat Tinley OFFICE: Coun Jud e
MEETING DATE: July 14 2003 TIME PREFERRED:
SUBJECT: (PLEASE BE SPECIFIC)
Consider and discuss authorizing Request for Proposals for Kerr County Employee Benefits
(Health Insurance) and policy period of same.
EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON)
NAME OF PERSON ADDRESSING THE COURT:
ESTIMATED LENGTH OF PRESENTATION:
IF PERSONNEL MATTER -NAME OF EMPLOYEE:
County Jude
Time for submitting this request for Court to assure that the matter is posted in accordance with Title 5, Chapter
551 and 552, Government Code, is as follows:
Meeting scheduled for Mondays:
THIS REQUEST RECEIVED BY:
THIS REQUEST RECEIVED ON:
5:00 P.M. previous Tuesday.

All Agenda Requests will be screened by the County Judge's Office to determine if adequate information has been
prepared for the Court's formal consideration and action at time of Court Meetings. Your cooperation will be
appreciated and contribute towards you request being addressed at the earliest opportunity. See Agenda Request Rules
Adopted by Commissioners' Court.
KERB COUNTY, TEXAS
NQTIC~ TO BIDDER
Sealed proposals addressed to the Commissioners' Court of Kerr County for Employee
Benefits will be received at the County Auditor's Office until m. on the
day of - _200_. Any proposals received after closing time will be
returned unopened. Return sealed proposals to the County Auditor's Office, Kerr County
Courthouse, 700 Main, Kerrville, Texas 78028. Mark outside of envelope "PROPOSAL"
EmPlo~ee Benefits.
Additional proposal sheets and specifications may be picked up in the Kerr County Auditor's Office,
700 Main, Kerrville; Texas 78028.
Proposals will be opened , 200_, at .m., at Kerr County
Courthouse in the Commissioners Courtroom.
The County of Ken does not discriminate on the basis of race, color, national origin, sex, religion,
age and disability in ernplayment or the provision of services.
KERR COUNTY, TExAS
BID PROPOSAL
Date:
Bid Opening:
Date:
Time:
Place: Commissioners Courtroom
Kerr County Courthouse
Ken County, Texas
KERR COUNTY COMMISSIONERS' COURT
KERB COUNTY COURTHOUSE
KERRVILLE, TEXAS
Gentlemen:
Pursuant to General Specifications listed below and/or attached, the undersigned makes the following offer,
F.O.B. Kerrville, Texas, with allowable exempt taxes (if applicable), having been removed from bid price.
ITEM NO. DESCRIPTION AMOUNT
Employee Benefits
See attached specifications.
Delivery/Completion will be made on or before , 200_. The equipment or
supplies will be new and will meet the general specifications.
KERB COUNTY COMMISSIONERS' COURT RESERVES THE RIGHT TO ACCEPT ANY QUALIFIED
BID OR REJECT ALL BIDS.
Company
By
(Title}
Address
Phone
Fax No.
NOTE: USE THIS FARM ONLY, ADDITIONAL INFORMATION MAY BE ATTACHED.
The County of Kerr does not discriminate on the basis of race, color, national origin, sec, religion, age and
disability in employment or the provision of services.
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
SECTION TITLE
1.0	PACKET INFORMATION
2.0	PROPOSAL INSTRUCTIONS
3.0	BACKGROUND INFORMATION
4.0	EVALUATION CRITERIA
5.0	PROPOSAL SUBMITTAL REQUIREMENTS
6.0	SCOPE OF SERVICES
7.0	REFERENCES
8.0	OTHER PROJECTS INVOLVED WITH
9.0	PROPOSAL SUMMARY
10.0	SUBMITTAL OF SIGNATURE PAGE
11.0	SUBMITTAL OF INSURANCE REQUIREMENT AFFIDAVIT
12.0	SUBMITTAL OF PROPOSAL AFFIDAVIT
I3.0	SUBMITTAL OF RESIDENCY CERTIFICATION
14.0	SUPPLEMENTAL INFORMATION PACKET
PAGE
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REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERB COUNTY
1.0 RETURN SUBMIT PACKET TO:
Ken County Auditor's Office
Ken County Courthouse
Kerrville, Texas 78028
The enclosed REQUEST FOR PROPOSAL (RFP) is for your convenience in submitting a proposal for
the enclosed referenced services for Ken County.
1.1 Submission of Proposals: One (1) original and two (2) copies of all RFP documents shall be sealed.
1.2 Sealed proposals shall be received no later than:
m. on the day of , 200_
MARK ENVELOPE: Employee Ber-efrts
1.3 Kerr County appreciates your time and effort in preparing this RFP. Please note that all proposals must
be received at the designated location by the deadline shown. Proposals received after deadline will be
returned unopened and shall be considered void and unacceptable. Opening is scheduled to beheld in the
Commissioners County Courtroom, Kerr County Courthouse, Kerrville, Texas 78028.
1.4 If Proposer does not wish to submit an offer at this time, but desires to remain on the list for this service,
please submit a "No Offer" by the same time and at the same location as stated above. Kerr County is
always very conscious and extremely appreciative of the time and effort you must expend to submit an
offer. We would appreciate your indicating on a~ "No Offer" response any requirements of the RFP
which may have influenced your decision to "No Offer".
I.5 The Kerr County Commissioners' Court is requesting sealed proposals for Emp}oyee Benefits for Kerr
County. It is desired that this RFP will result in a contract for cone-year term, with an option to renew
for two additional one-year terms.
The second- and third-year terms should reflect in the proposal a percent cap increase. Prior to each
renewable option term the percent cap increase must be negotiated between the respective parties and
approved by the Commissioners' Court. The Court desires for this service to begin
200
1.6 Hereinafter Kerr County will be refereed to as "County", the Kerr County Commissioners' Court will be
referred to as "Court''.
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REQUEST FOR PROPOSAL
E1t~IPLOi'EE BENEFITS FOR KERR COUNTY
2.d PROPOSAL INSTRUCTIONS
2.1 It is understood that the County reserves the-right to accept or reject ar~y and/or all proposals as it shall
deem to be in the best interest of the County. Receipt of any RFP shall under no circumstances obligate
the County to accept the lowest RFP. The award of the contract shall be made to the responsible
Proposers) whose RFP is determined to be the lowest and best evaluated offer resulting from
negotiation, taking into consideration the relative importance of price and other evaluation factors set
forth in the RFP.
2.2 Costs and expenses relating to the preparation of the RFP and its submissions are to be borne solely by
the Proposer. The County shall not be responsible for any such costs or expenses.
2.3 Late Proposals: Proposals received in the County Auditor's Office after submission deadline shall be
returned unopened and will be considered void and unacceptable. The County is not responsible for
lateness of mail, carrier, etc., and time/date stamp clock in the Purchasing Office shall be the official time
of receipt.
2.4 Altering Proposals: Arty alteration or erasure made before receiving time must be initialed by the signer
of the RFP, guaranteeing authenticity.
2.5 No oral, telegraphic, teiephorric or facsimile proposals will be considered.
2.6 Proposals will be received and publicly acknowledged at the location, date and time stated above.
Proposers, their representatives, and interested persons may be present. Proposals shall be received and
acknowledged only, and kept secret during the negotiation/evaluationpmcess, so as to avoid disclosure
of the contents to competing Proposers. However, all proposals shall be open for public inspection after
the contract is awarded. Trade secrets and confidential information contained in the RFP, so identified
by the- Proposer as such, will be treated as confidential by the County to the extent allowable in the Open
Records Act.
2.7 Contract: This RFP, submitted documents, and any negotiations, when properly accepted by the County,
shall constitute a contract equally binding between the successful Proposer and the County. No different
or additional terms will become a part of this contract with the- exception of a Change Order.
2. $ Change Order: No oral statement of any person shall modify or otherwise change or affect the terms,
conditions or specifications stated in the resulting contract. All change orders to the contract shall be
made in writing and approved by the Court.
2.9 Contract Negotiations: The County will negotiate a contract with the selected Proposer. The Proposer is
requested to have its RFP completed by in-house personnel. Negotiations may include an oral
presentation by Proposers) prior to award. If an oral presentation is requested; Proposer must use
company officers and/or employees.
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REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
2.10 Funding: Any contract awarded pursuant to this RFP shall be contingent on sufficient funding and
authority being made available in each fiscal period by the appropriate officials of the County. If
sufficient funding or authority is not made available, the contract shall become null and void.
2.11 Conflict of Interest: No public official shall have interest in this contract, in accordance with Vernon's
Texas Codes Annotated, Local Government Code, Title 5, Subtitle C, Chapter 171.
2.12 Ethics: The Proposer shall not accept or offer gifts, or anything of value, nor enter into any business
arrangement with any employee, official or agent of the County.
2.13 Addenda: Airy interpretations, corrections and changes to this RFP, specifications, and/or extension to
the opening/receipt date will be made by Addenda. Sole issuing authority of Addenda shall be vested in
the County Auditor as entrusted by the Court. Addenda will be mailed to all who are l.-nown to have
received a copy of the RFP. Proposer shall acknowledge receipt of all Addenda.
2.14 Assignment: The successful Proposer shall not sell, assign, transfer, or convey an contract resulting
from this RFP, in whole or in part, without prior written consent of the County.
2.15 Venue: This agreement will be governed and construed according to the laws of the State of Texas. This
agreement is performable in Kerrville, Ken County, Texas.
2.16 Indemnification: Successful Proposer shall defend, indemrrify and save harmless the Coumy and all its
officers, agents, and employees from all suits, actions, or other claims of any character, name, and
description brought for, or on account of, arty injuries or damages received or sustained by arty person(s),
or property on account of any negligent act or fault of the successful Proposer, or of any agent, employee,
subcontractor or supplier in the execution of, or performance under, any contract which may result from
RFP award. Successful Proposer shall pay any judgment with cost which may be obtained against the
County growing out of such injury or damages.
2.17 Sales Tax: The County is by statute exempt from State Sales Tax and Federal Excise Tax; therefore, the
RFP prices shall not include- taxes.
2.18 Practices and Procedures: Quality of services must conform to the highest standards of professional
services.
2.19 Proposers Must Comply with: All Federal, State, County and local laws governing or covering this type
of service.
2.20 Termination of Contract:
A. This contract shall remain in effect until contract expires or is in default.
B. Either party may terminate this contract with a 60-day written notice to the other party prior to
cancellation. The termination notice must state the reasons for such cancellation.
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REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERB COUNTY
C. The County reserves the right to terminate the contract immediately in the event the successful
Proposer fails to perform in accordance with the accepted RFP.
Should the successful Proposer default, the sum of $250.00 per calendar day will be deducted
from the monies due the Proposer or charged to the Proposer until a new service has been
implemented, not to exceed 120 days. This sum will not be considered as a penalty, but rather
as reasonable liquidated damages, since it would be impractical or extremely difficult to fix the
actual damages. An extension of time may be allowed for delays beyond the control of the
Proposer at the discretion of the County.
2.21 Performance of Contract: The County reserves the right to enforce the performance of this contract in
any manner prescribed by law or deemed to be in the best interest of the County in the event of breach or
default of resulting contract award.
2.22 In accordance with the State of Texas Prompt Payment Act, Article 601f, V.T.C.S., payment will be
made after receipt and acceptance by the County of all completed services and receipt of a valid invoice.
2.23 Information/Questions: Requests for information related to the RFP should be directed to:
*Insurance Manager Kerr County Auditor
Kerr County Courthouse Kerr County Courthouse
Kerrville, Texas 78028 Kerrville, Texas 78028
830-792- 830-792-2235
3.0 BACKGROUND INFORMATION
3.1 Kerr County is requesting a proposal for the following:
EMPLOYEE BENEFITS COMPONENTS
A. Healthcare Provider Network Access
B. Claims Administration
C. Utilization Review
D. Large Case Management
E. Prescription Program -Pharmacy and Mail-in
3.2 Ken County presently has a self insured, (with re-insurance) health plan with a decfd~bie
The County is interested in maintaining a self insured, with re-insurance, or fully insured plan, along
with any discounts which are available. The County plan could be modified to facilitate discounts. The
County is also willing to enter into agreement with multiple hospitals and/or physician groups to
maximize these discounts, as stated in this RFP. The County may select individual sections of a
proposal to best meet the County requirements and needs.
7
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
3.3 For the purpose of this RFP, a network may be a single hospital, or a group of hospitals, as well as a
single physician, or a group of physicians.
3.4 Provide a brief description of the proposed provider, including the provider's name, state of
incorporation (if incorporated), location of the headquarters' office, location of offices that would serve
the County's account, and identity of executives that would service the County's account.
3.5 All proposals submitted by agents must affirmatively state that they are so submitted, and the agent shall
disclose the commission or sales fee expected to be earned, as well as the nature and scope of services to
be rendered by the agent to the County. Third-Party Administrators will be expected to disclose fees,
commissions or other remuneration made to any party in connection with the proposed program offered
to the County.
3.6 The County prefers fees be quoted on aper-employee, per-month basis. For comparison purposes,
Proposers should state separate fees for each service area, rather than consolidated fee. To the extent
that service options or add-ons are available, please explain in detail the difference in fees. Upon
expiration or termination of its contract the selected provider maw be effected to process the runoff
claims incurred prior to the expiration or termination date and provide cost containment services for
admissions in progress. Please quote runoff cost. The County may request that the selected finn handle
run-in claims. Quote additional cost for this service, if any.
3.7 We have attempted to include sufficient information to allow you to generate a competitive proposal.
Additional information may be requested or clarification regarding the RFP.
3.8 You may propose one or all of the components. You must clearly identify any components that can only
be purchased in combination with one or more other components. Any difference in component versus
package cost must be clearly identified.
3.9 You must use employee count for proposal purposes, although actual enrollment and final cost may vary
at enrollment and each thereafter.
4.0 EVALUATION CRITERIA
The award of the contract shall be made to the responsible Proposer whose RFP is determined to be the
best evaluated offer resulting from negotiations, taking into consideration the relative importance of price
and other factors set forth in the RFP.
8
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
5.0 PROPOSAL SUBMITTAL REQUIREMENTS
5.1 Proposals submitted must address each section (5.0 - 13.0) as stated herein, and include the following
information numbered to correspond to the items listed below for proper comparison and evaluation by
the County.
52 Minimum Standards for Proposer:
A. A Proposer must affirmatively demonstrate their responsibility. The Proposer must meet the
following requirements:
1.) have adequate fmancial resources, or the ability to obtain such resources as required;
2.) be able to comply with the required schedules;
3.) have a satisfactory record of performance;
4.) have a satisfactory record of integrity and ethics;
6.0 SCOPE OF SERVICES REQUIRED
6.1 General Conditions:
A. The Kerr County Commissioners' Court is requesting sealed proposals for Employee Benefits
for Kerr County. It is desired that this RFP will result in a contract for cone-year term, with an
option to renew for two additional one-year terms.
The second- andthird-year terms should reflect in the proposal a percent cap increase. Prior to
each renewable option term, the percent cap increase must be negotiated between the respective
parties and approved by the Commissioners' Court.
The Court desires for this service to begin , 200_.
B. On the following sections 6.2 - 6.6, answer only those questions applicable to your proposal.
1.) Proposals must address each question in sections 6.2 - 6.6. Proposer may answer the
questions using the forms provided or may re-type and answer each question on their
letterhead. Additional information maybe added if needed. Answers to the questions
in sections 6.2 - 6.6 include the following information numbered to correspond to the
items listed below for proper comparison and evaluation by the County.
6.2 HEALTHCARE PROVIDER NETWORK ACCESS
A. For the purpose of this RFP, a network may be a single hospital, or group of hospitals, as well
as a single physician, or group of physicians.
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REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
C. Projected savings must be backed up by documentation. Discounts, fee schedules, and/or per
diems must be provided. Any Network participation percentage required to achieve savings
must be specified. Some level of projected savings should be guaranteed--please specify that
level.
D. Will your Network Providers utilize current medical files? Yes No
1.) Or will they require a new patient set-up charge with the first office visit?
Yes No
a.) Will new testing be required? Yes No
E. Do you provide a monthly savings report?Yes No
l.) Does it include Network utilization? Yes No
2.) Dces it include Non-Network utilization? Yes No
3.) Does it include Network versus Non-Network utilization? Yes No
F. Do you provide a Network Director? Yes No
1.) If yes, include a sample.
a.) Confirm copy is attached. Yes No_
2.) Do you provide printed Network updates on a monthly basis?
Yes No
3.} How often do you provide new directories?
4.) Is there any charge to the County? Yes No
5.) If so, how much per directory?
G. Do you provide a customer service number for Network information?
Yes No
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REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
1.) If yes, is it toll-free? Yes No
2.) What hours does it operate?
H. If you are proposing Claims Administration, do you utilize an integrated system for re-pricing
and adjudication? Yes No
I. What is the average turn-around time for re-pricing?
J. Specify any other important aspects of your Network you feel should have an impact on the
County.
K. Will you assist in negotiating discounts at out-of--state or out-of-network providers incase of
emergency or out-of-county residency or illness? Yes No
L. List your proposed rates/discounts:
6.3 CLAIMS ADMINISTRATION '
a. Do you provide benefit booklets and claim forms as a part of your basic service?
Yes No
1.) If yes, how soon will they be provided?
B. Do you furnish your explanation of benefits with the payment check?
Yes No
1 _) Please provide a copy of E.O.B.
a.) Confirm copy is attached. Yes No
11
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
C. Do you furnish the County a copy of the E.O.B.'s? Yes No
D. Will you produce and timely file IRS Form 1099's for providers?
Yes No
E. Estimate your minimum startup time from date of contract award to date you could commence
processing claims. days
F. Do your monthly reports include:
1.) Paid Claims Listing Yes No
2.) Paid Claims Summary Yes No
3.) Monthly Enrollment Yes No
4.) Monthly Check Register Yes No
G. Turnaround time for clean claims averages working days.
H. What is the average error rate for claims payments?
I. Do you provide COBRA services? Yes No
If yes, describe:
J. Do you have a quality assurance program? Yes No
If yes, describe:
12
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
K. Do you have a fraud detection program? Yes No
If yes, describe:
L. Do you provide a Medical Director for claim review and disputed claims?
Yes No
M. The County requires specific banking arrangements. You must have the capability to print
checks for the County's signature. Yes No
N. Describe your claims system. Specimen reports, including lag-time report, would be beneficial.
Confirm copy(s) are attached. Yes No
Please described system:
O. If proposal is from a T.P.A., provide copy of license.
Confum copy is attached. Yes No_
P. A certificate of insurance indicating Professional Liability limits is included?
Yes No
1.) Confirm copy is attached. Yes No
2.} If no, explain:
13
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
Q. Please describe your Customer Service procedures and staffmg:
R Do you utilize voicemail? Yes No.
S. Is it possible to speak directly with the claims examiner for problem resolution?
Yes No
T. What is your claims load per examiner?
U. Will you devote an examiner to Kerr County? Yes No
V. Would you consider on-premises processing in the County? Yes No
l.) Would you utilize County staff or TPA staff?
a.) County staff? Yes No
b.) TPA staff? Yes No
2.) What kind of fee reduction would you allow if County staff were utilized?
3.) Would you provide training and oversight if County staff were utilized?
Yes No
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REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
W. Will you assist with enrolhnent meetings and provide materials for enrollment? (The County
utilizes * 14-20 departmental meetings over a period of 4-5 days.)
Yes No
1.) If yes, specify charge, if any:
2.) How soon will ID cards be available after enrollment?
X. Do you utilize any mechanisms to identify and follow up on subrogation opportunities?
Yes No Please explain:
Y. Please explain any cost savings features you have which you feel will have an impact on the
County's healthcare costs:
15
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
Z. Do you administer medical, dental, and prescription claims? Yes No
AA. Please explain your procedures to assure timely and accurate filing of stop loss claims, both
specific and aggregate:
6.4 UTILIZATION REVIEW
A. Please explain your procedures:
B. What hours are phones answered?
C. What are after-hours and weekend procedures?
16
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
D. How many employee lives are served?
17
REQUEST FOR PROPOSAL
EMPLOYEE BENEFiT5 FOR KERR COUNTY
E. What is the caseload for the U.R_ nurses?
F. What are your qualifications for U.R. nurses?
G. Are potentially serious cases reported to the T.P.A. immediately for implementation of Large
Case Management? Yes No
H. Is a toll-free number provided? Yes No
I. All calls are returned within hours.
6.5 LARGE CASE MANAGEMENT
A. Please explain your procedures:
B. Please provide three references:
1.)
2.)
3.)
18
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
C. Explain your fee schedule and length of involvement:
6.6 PRESCRIPTION CARD PROGRAM
A. Specify time required to issue cards:
B. Is a mail-in service available? Yes No
l.) What kind of cost savings are available through mail-in?
C. Is a toll-free Customer Service number available? Yes No
D. Provide copy of management reports. Confnm copy is attached.
Yes No
E. Are formulary rebates available? Yes No
1.) If yes, when are rebates calculated and when are rebates paid?
19
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
F. Is literature encouraging use of generics provided? Yes No
I .) If yes, at what cost to the County?
2.} Confirm copy is attached. Yes No
G. What is the cost basis to your card?
7.0 REFERENCES
Please provide three governmental references where Proposer is providing employee benefits and length
of time that each contract has been in effect. Include the name of the firm, address, telephone number
and name of representative.
8.0 OTHER PROJECTS INVOLVED WITH
Proposer shall provide a list of other projects that you are currently involved with or will be involved
with.
9.0 PROPOSAL SUMMARY
Found on page * , must be included with the RFP.
10.0 SUBMITTAL OF SIGNATURE PAGE
Found on page * , must be included with the RFP.
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REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
11.0 SUBMITTAL OF INSURANCE REQUIREMENT AFFIDAVIT
Insurance Requirement Affidavit found on page * ,must be included with the RFP.
12.0 SUBMITTAL OF PROPOSAL AFFIDAVIT
Found on page * ,must be included with the RFP.
13.0 SUBMITTAL OF BIDDER RESIDENCY CERTIFICATE
Found on page * ,must be included with the RFP.
14.0 SUPPLEMENTAL INFORMATION PACKET
Found on page
21
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
9.0 PROPOSAL SUMMARY
Coverage/Service Rate Units Projected Monthl~t
Claims Administration Emp. x =
Utilization Review Emp. x =
COBRA Administration Emp. x =
Prescription Card fee Emp. x =
Network Access Emp. x =
Extra Cost(s), if any, must be shown:
Large Case Management:
Hospital Audits:
Booklets/Fonms, Printing Cost:
Setup Fee:
Other (please describe):
22
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
SIGNATURE OF ENTIRE PROPOSAL AND SUBMITTALS
FIRM/PROPOSER:
BY:
Signature
Title
Print or type name and title
ADDRESS:
Street address and/or P. O. box
Ciry State Zip Code
A/C and phone number A/C and phone number
Proposer must also complete, sign, and return the insurance and proposal affidavit found on page * and
* as part of this RFP.
RETURN ENTIRE PACKAGE AND ALL DOCUMENTATION
REQUIRED BY THIS REQUEST FOR PROPOSAL
23
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
INSURANCE REQUIREMENT AFFIDAVIT
To be completed by appropriate Insurance Agent.
STATE OF TEXAS }
COUNTY OF KERR }
I, the undersigned agent, certify that the insurance requirements contained in this bid docwnent have been
reviewed by me with the below identified bidder. if the below identified bidder is awarded this contract by the
County, I will be able, within 10 days after bidder is notified of such award, to furnish a valid insurance certificate
to the County meeting all of the requirements contained in this IFB.
Agent (Signature) (Print Name)
Name of Insurance Carrier
Address of Agency
City/State
Phone number where Agent may be contacted
Bidder's Name (Print or Type)
SUBSCRIBED AND SWORN TO before me by the abovenamed person on this day of
200
Notary Public in and for the State of
NOTE TO AGENT:
ffthis time requirement is not met, the County reserves the right to declare this Proposer non-responsible and award the contract to the next
best evaluated Proposer. if you have any questions concerning these requirements, please contact the Purchasing Agent at *830-792-
24
REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
STATE OF TEXAS
COUNTY OF KERB
AFFIDAVIT
BEFORE ME, the undersigned authority, on this day personally appeared
known to me to be the person whose name is subscribed to the following, who, upon oath, says:
I am the Manager, Secretary, or other agent or officer of the principal of the Bidder in the matter of the
bids to which affidavit is attached, and I have full knowledge of the relations of the Bidder with the other fines in
this same line of business, and the Bidder is not a member of any trust, pool or combination to control the price of
supplies bid on, or to influence any person to bid or not bid thereon.
I further affum that the Bidder has not given, offered to give, nor intends to give at anytime hereafter any
economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public
servant in connection with the submitted bid.
Affiant
SWORN TO AND SUBSCRIBED BEFORE ME by the above Affiant, who, on oath states that the facts
contained in the above are true and correct, this day of , 200_.
Notary Public in and for the State of
Name of Bidder
Signed by.
(Sign name in writing) (Title)
Address
(Zip Code)
Telephone Number.
Date
NOTE: BIDS NOT ACCOMPANIED BY THIS AFFIDAVIT WILL BE
CONSIDERED.
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REQUEST FOR PROPOSAL
EMPLOYEE BENEFITS FOR KERR COUNTY
BIDDER RESIDENCY CERTIFICATION
I hereby certify the following information to be true and correct:
In accordance with the Standard Terms and Conditions of the RFP, I certify the following (check applicable
statements):
^ Proposal is from aState-of-Texas-resident bidder.
^ Proposal is from anon-resident bidder.
The following is further certified by non-resident bidder:
^ Copy ofnon-resident current state statute is attached which specifies the amount that aTexas-
resident bidder would be required to underbid anon-resident bidder to obtain a comparable
contract in the non-resident state in which principal place of business is located.
^ No such statute exists in non-resident state.
Signature
Name and Title
Company
26