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Request for Qualification - Health Benefits Consultant
BID #: 5
ISSUED: 1/21/2020
DUE: 2/27/2020
VALUE: TBD
100
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Green Risk
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Executive Summary
The Township of East Brunswick is seeking Qualification Statements from interested parties for the provision of Health Benefits Consultant services. The selected consultant will need to be licensed to sell insurance to public entities in New Jersey, possess extensive knowledge of municipal medical insurance, and be familiar with New Jersey medical insurance carriers. The consultant is expected to serve as an effective advocate and negotiator with medical insurance providers. Qualification Statements must be received by February 27, 2020, at 10:00 A.M.
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Document Text
--- Document: Request for Qualification - Health Benefits Consultant (PDF) ---
REQUEST FOR QUALIFICATIONS
HEALTH BENEFITS CONSULTANT
ISSUE DATE: January 21, 2020
DUE DATE: February 27, 2020 at 10:00 a.m.
I s s u e d b y :
T o w n s h i p o f E a s t B r u n s w i c k
1 J e a n W a l l i n g C i v i c C e n t e r
E a s t B r u n s w i c k , N e w J e r s e y 0 8 8 1 6
T e l . ( 7 3 2 ) 3 9 0 - 6 8 5 0
F a x . ( 7 3 2 ) 2 3 8 - 8 8 4 5
w w w . e a s t b r u n s w i c k . o r g
L e g a l P u b l i c a t i o n D a t e : E a s t B r u n s w i c k T o w n s h i p w e b s i t e
J a n u a r y 2 1 , 2 0 2 0
2 | R e q u e s t f o r Q u a l i f i c a t i o n s
GLOSSARY
The following definitions shall apply to and are used in this Request for Qualifications:
•
“Township” – refers to the Township of East Brunswick, its officers and elected and appointed
officials, employees and advisors and consultants.
•
"Due Date" - refers to the date and time by which Qualification Statements must be received by the
Township in order to be considered for award of the contract or position.
•
"Qualification Statement" - refers to a Respondent’s complete response to this RFQ.
•
"Qualified Respondent" - refers to those Respondents who (in the sole judgment of the
Township) have satisfied the qualification criteria set forth in this RFQ.
•
"RFQ" - refers to this Request for Qualifications, including any amendments thereof or
supplements thereto.
•
"Respondent" or "Respondents" - refers to the interested individuals and firms that submit
Qualification Statements.
•
“Services” – refers to the professional services the Township seeks in this RFQ process.
•
“Successful Respondent” – refers to the Respondent selected by the Township to perform the
Services.
SECTION 1
INTRODUCTION AND GENERAL INFORMATION
1.1
Introduction and Purpose.
The Township is soliciting Qualification Statements from interested persons and/or firms for the
provision of the professional services described herein. Through a Request for Qualification process,
persons and/or firms interested in assisting the Township with the provision of such services must prepare
and submit a Qualification Statement in accordance with the procedure and schedule in this RFQ. The
Township will review only Qualification Statements that include all the required information as described
herein. The Township intends to qualify persons and/or firms that (a) possess the professional capabilities
to provide the proposed services; (b) will agree to work under the compensation terms and conditions set
forth; and (c) have demonstrated the capability and willingness to provide high quality services to the
Township.
1.2
Procurement Process and Schedule.
The selection of Qualified Respondents is subject to the New Jersey Local Unit Pay-to-Play Law,
N.J.S.A. 19:44A-20.4 et seq. The Township has structured a competitive procurement process which
insures that anyone interested in providing the services sought has an opportunity to submit a Qualification
Statement in response to this RFQ. The Township will evaluate responses to this RFQ in accordance with
the criteria set forth in Section 5. Based upon the totality of the information contained in the
Qualification Statement, and from the Respondents’ references, the Township will determine which
Respondents are qualified. Each Respondent that meets the requirements of the RFQ (in the sole
judgment of the Township) will be designated as a Qualified Respondent, and will be considered for
selection by the Township.
3 | R e q u e s t f o r Q u a l i f i c a t i o n s
The RFQ process commences with the issuance of this RFQ. The steps involved in the process and
the anticipated completion dates are stated in the Anticipated Procurement Schedule. The Township
reserves the right to, among other things, amend, modify or alter the Procurement Schedule upon notice to
all potential Respondents who have provided contact information to the Clerk upon receipt of this RFQ.
Qualification Statements must be received by the Township’s Designated Contact Person,
via mail or hand delivery, by 10:00 A.M. prevailing time on the Due Date. Qualification Statements
received after 10:00 A.M. on the Due Date will be returned unopened.
All communications concerning this RFQ or the RFQ process shall be directed to the Township’s
Designated Contact Person, in writing. The Designated Contact Person is:
Nennette Perry, Municipal Clerk
Township of East Brunswick
1 Jean Walling Civic Center Drive
East Brunswick, New Jersey 08816-1081
ANTICIPATED PROCUREMENT SCHEDULE
ACTIVITY
DATE
1.
Issuance of Request for Qualifications
January 21, 2020
2.
Receipt of Qualification Statements/ Due Date
February 27, 2020
3
Completion of Evaluation of Qualification Statements
March 6, 2020
4.
Award of Professional Services Agreements
March 23, 2020*
*Or Next Available Council Meeting
1.3
Conditions Applicable to RFQ.
Upon submitting a Qualification Statement in response to this RFQ, the Respondent
acknowledges and consents to the following conditions:
•
This document is an RFQ and does not constitute an RFP.
•
This RFQ does not commit the Township to issue an RFP.
•
All costs incurred by the Respondent in connection with responding to this RFQ shall be
borne solely by the Respondent. There shall be no claims whatsoever against the
Township, its staff or consultants for reimbursement or payment of costs or expenses
incurred in the preparation of the Qualification Statement or other information required
by the RFQ.
•
The Township reserves the right to reject for any reason any and all responses and
components thereof.
•
The Township reserves the right to reject any Respondent that submits incomplete
responses to this RFQ, or a Qualification Statement that is not responsive to the
requirements of this RFQ.
4 | R e q u e s t f o r Q u a l i f i c a t i o n s
•
The Township reserves the right, without prior notice, to supplement, amend, or modify
this RFQ, or to request additional information.
•
All Qualification Statements shall become the property of the Township and will not be
returned.
•
All Qualification Statements will be made available to the public at the appropriate time,
as determined by the Township in accordance with law.
•
Any Qualification Statements not received by the Township timely will be rejected.
•
The Township shall not be liable for any claims or damages alleged to have been incurred
as a result of this RFQ process, including the Township’s review of Qualification
Statements and its award of contracts.
1.4
Rights of Township.
The Township reserves the following rights with regard to this RFQ and the procurement process
in accordance with the provisions of applicable law:
•
To determine that any Qualification Statement received complies or fails to comply with
the terms of this RFQ.
•
To supplement, amend or otherwise modify the RFQ through issuance of addenda to all
prospective Respondents who have received a copy of this RFQ.
•
To waive any technical non-conformance with the terms of this RFQ.
•
To change or alter the schedule for any events called for in this RFQ upon the issuance of
notice to all prospective Respondents who have received a copy of this RFQ.
•
To conduct investigations of any or all of the Respondents, as the Township deems
necessary or convenient, to clarify the information provided as part of a Qualification
Statement, and to request additional information to support the information included in
any Qualification Statement.
•
To suspend or terminate the procurement process described in this RFQ at any time,
commence a new procurement process, or exercise any other rights provided under
applicable law without any obligation to the Respondents.
The Township shall be under no obligation to complete all or any portion of the procurement
process described in this RFQ.
1.5
Addenda or Amendments to RFQ.
After the issuance of the RFQ, but no later than five (5) business days prior to the Due Date, the
Township may issue addenda, amendments or answers to written inquiries. Addenda will be noticed by
the Township and will constitute a part of the RFQ. All responses to the RFQ shall be prepared with full
consideration of any addenda issued.
5 | R e q u e s t f o r Q u a l i f i c a t i o n s
1.6
Proposal Format.
Responses should cover all information requested in Section 3 of this RFQ. Responses that do
not meet the requirements of the RFQ or which are in any way conditional, incomplete, obscure, contain
additions or deletions from requested information, or contain errors may be rejected.
SECTION 2
SCOPE OF SERVICES
The Township seeks Qualification Statements from Respondents that have expertise in the
provision of services as outlined in the Notice of Solicitation. Refer to Appendix A for Scope of
Services by particular profession.
SECTION 3
SUBMISSION REQUIREMENTS
3.1
General Requirements.
Respondent’s Qualification Statement must meet or exceed the professional,
administrative and financial qualifications set forth in this Section 3 and shall incorporate the
information requested below.
In addition to the information described below, Respondents are invited to submit supplemental
information that may be useful to the Township in evaluating the Qualification Statement. This
information may include, for example, a firm profile or brochure. Respondents are encouraged to be clear,
factual, and concise in their presentation of information.
3.2
Administrative Information Requirements.
The Respondent shall, as part of its Qualification Statement, provide the following
documentation and information:
1.
An executive summary (not to exceed two (2) pages) of the information contained in all
the other parts of the Qualification Statement.
2. An executed Letter of Intent (See Exhibit A).
3.
Name, address and telephone number of the individual or firm submitting the
Qualification Statement and the name of the key contact person.
4.
A statement that the Respondent has complied with all applicable affirmative action (or
similar) requirements with respect to its business activities (e.g. N.J.S.A. 10:5-31 et seq.
and N.J.A.C. 17:27 as amended) and evidence of such compliance. (See Exhibit B)
5.
The number of years Respondent has been in practice.
6.
Any judgments within the last three years in which Respondent has been adjudicated liable
for professional malpractice. If any, please provide the docket numbers.
6 | R e q u e s t f o r Q u a l i f i c a t i o n s
7.
Whether Respondent or its firm is now or has been involved in any bankruptcy or re-
organization proceedings in the last ten years. If so, please provide the docket
numbers.
8.
A statement that principals have no immediate relatives who are Township employees or
elected officials.
3.3
Professional Information Requirements.
1.
Respondent shall submit a description of its overall experience in providing the same or
similar Services. At a minimum, the following information should be included as
appropriate:
a.
Description and scope of Respondent’s work experience.
b.
Three business references, including contact information.
c.
Explanation of perceived relevance of Respondent’s experience to the RFQ.
2.
Describe those portions of the Respondent’s services, if any, that are sub-contracted.
Identify all subcontractors the Respondent anticipates using in connection with the
Services.
3.
Resumes of key employees who will be assigned to provide the Services.
3.4
Services Fees.
1.
Refer to Scope of Services.
2.
Respondents should take careful note of the following:
a.
Respondent shall be reimbursed for out-of-pocket expenses that shall include, but
not be limited to:
(i)
Faxes and conference calls;
(ii)
Payment of filing, application fees, review fees and similar charges;
(iii)
Outside printing, reproduction, binding, collating, graphic services;
(iv)
Messenger service and overnight mail.
Charges incurred under (iii) and (iv) must be pre-approved by the Township.
b.
Respondent shall send monthly invoices to the Township detailing the Services
performed.
c.
The Township shall require that upon performing Services totaling 70 percent of
the encumbered amount, whether or not all Services have been invoiced to the
Township, the Respondent shall provide the Township with an estimate of
additional funds that may be necessary to conclude the matter. Additional funds
must be approved by resolution of the Township Council. The Township expects
its professional service providers to maintain time-management control systems
to ensure compliance with this RFQ requirement.
7 | R e q u e s t f o r Q u a l i f i c a t i o n s
SECTION 4
INSTRUCTIONS TO RESPONDENTS
4.1
Submission of Qualification Statements.
Respondents must submit an original and two copies of its Qualification Statement to the
Designated Contact Person:
Nennette Perry, Municipal Clerk
Township of East Brunswick
1 Jean Walling Civic Center Drive
East Brunswick, New Jersey 08816-1081
To be responsive, Qualification Statements must provide all requested information, and must be in
strict conformance with the instructions set forth herein:
1.
Qualification Statements must be received by the Township no later than the Due Date,
and must be mailed or hand-delivered. Qualification Statements forwarded by facsimile
or email will not be considered. Qualification statements received after the designated
time on the Due Date will be returned, unopened, to the sender. The Respondent is
solely responsible for delays in delivery.
2.
Qualification Statements and all Forms (Exhibits A through J) and other related information
must be stapled or bound, and signed by the Respondent. If Respondent is other than a
natural person, the Qualification Statement must be signed by an individual with power
to bind the Respondent.
3.
The name of the Respondent and the position or contract for which the submission is
being made must be printed on the outside of the package containing Respondent's
submission. The Township will, in its sole discretion, determine whether to qualify more
than one Respondent for the Services.
4.
Respondents are reminded that the forms attached to this RFQ must be completed and
submitted with their Qualifications Statements. See also, Exhibit C for a list of
documents that must be submitted with the proposal and those that that successful
Respondents must present to the Township prior to the Township’s executing a contract
for services with the Respondent.
4.2
Legislation Compliance
Respondents are to submit a Certification of Political Contribution pursuant to N.J.S.A. 19:44A-
20.4 et seq. with their proposals. A Certification form is provided as Exhibit G.
8 | R e q u e s t f o r Q u a l i f i c a t i o n s
SECTION 5
EVALUATION
The Township's objective in soliciting Qualification Statements is to enable it to select a firm,
individual, or organization that will provide high quality and cost effective services to the taxpayers of
the Township. The Township will consider Qualification Statements only from firms, individuals, or
organizations that, in the Township's judgment, have demonstrated the capability and willingness to
provide high quality services to the taxpayers of the Township in the manner described in this RFQ.
The Township will consider all relevant factors, including, but not limited to:
1.
Qualifications of firm, specifically as they relate to this Project.
2.
Related project experience of the firm(s) and the individuals who would be assigned to
the Project.
3
Familiarity with the Township.
4.
Available resources to complete project. This criterion would include the analytical,
design tools, personnel, resources or methodologies commonly used by the firm that may
be applicable to the project categories.
5.
Other factors determined to be in the best interest of the Township.
9 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit A
LETTER OF INTENT
(To be prepared on Respondent's Letterhead. No modifications may be made to this letter)
Date:
Nennette Perry, Municipal Clerk
Township of East Brunswick
1 Jean Walling Civic Center Drive
East Brunswick, New Jersey 08816-1081
Re: Letter of Intent
Dear Ms. Perry:
The undersigned, as Proposer, has (have) submitted the attached Proposal in response to a Request for
Proposals\Qualifications
(RFP\RFQ),
issued
by
the
Township
of
East
Brunswick
dated_______________________________ in connection with the “Scope of Services”. The undersigned hereby
states:
1. The Proposal contains accurate, factual and complete information to the best of our knowledge and belief.
The Proposal is submitted in good faith. I/we understand that any false statement may result in my/our
disqualification.
2. Proposer agrees to participate in good faith in the procurement process described in the RFP and to adhere
to the Township's procurement schedule.
3. Proposer acknowledges that all costs incurred by it (them) in connection with the preparation and
submission of the Proposal, amendments thereto, and any other documents prepared and submitted in
response to the RFP, or any negotiation which results therefrom shall be borne exclusively by the Proposer
4. Proposer hereby declares that the only persons anticipated by Proposer to perform the professional services
for which this Proposal is submitted are named herein and that no person other than those herein named
participated in this Proposal or will participate in any contract to be entered into between Proposer and the
Township. Proposer declares that this Proposal is made without connection with any other person, firm or
parties who has submitted a Proposal, except as expressly set forth below, and that it has been prepared and
submitted in good faith and without collusion or fraud.
5. Proposer acknowledges and agrees that the Township may modify, amend, suspend and/or terminate the
procurement process (in its sole judgment).
6. Proposer acknowledges that if it becomes the Successful Proposer and is awarded a contract to provide the
Services, it shall comply with all applicable affirmative action and equal employment opportunity laws
Signed: _________________________________
Printed: _________________________________
Title: _________________________________
*If a joint venture, partnership or organization other than a natural person is submitting a Proposal, this Letter of
Qualification must be signed by an individual with the authority to bind the organization.
10 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit B
EXHIBIT A - MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE PER
N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27-1.1 et seq.
GOODS, PROFESSIONAL SERVICE AND GENERAL SERVICE CONTRACTS
During the performance of this contract, the contractor agrees as follows:
The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant
for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual
orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual
orientation and gender identity or expression, the contractor will take affirmative action to ensure that such
applicants are recruited and employed, and that employees are treated during employment, without regard to their
age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or
expression, disability, nationality or sex. Such action shall include, but not be limited to the following: employment,
upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other
forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in
conspicuous places, available to employees and applicants for employment, notices to be provided by the Public
Agency Compliance Officer setting forth provisions of this nondiscrimination clause.
The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees
placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment
without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation,
gender identity or expression, disability, nationality or sex.
The contractor or subcontractor, where applicable, will send to each labor union or representative or workers
with which it has a collective bargaining agreement or other contract or understanding, a notice, to be provided by
the agency contracting officer advising the labor union or workers' representative of the contractor's commitments
under this act and shall post copies of the notice in conspicuous places available to employees and applicants for
employment.
The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the
Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans
with Disabilities Act.
The contractor or subcontractor agrees to make good faith efforts to employ minority and women workers
consistent with the applicable county employment goals established in accordance with N.J.A.C. l7:27-5.2, or a
binding determination of the applicable county employment goals determined by the Division, pursuant to N.J.A.C.
17:27-5.2.
The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including,
but not limited to, employment agencies, placement bureaus, colleges, universities, labor unions, that it does not
discriminate on the basis of age, creed, color, national origin, ancestry, marital status, affectional or sexual
orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any
recruitment agency which engages in direct or indirect discriminatory practices.
The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all
personnel testing conforms with the principles of job-related testing, as established by the statutes and court
decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court
decisions.
11 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit B, Continued
In conforming with the applicable employment goals, the contractor or subcontractor agrees to review all
procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without
regard to age, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity
or expression, disability, nationality or sex, consistent with the statutes and court decisions of the State of New
Jersey, and applicable Federal law and applicable Federal court decisions.
The contractor shall submit to the public agency, after notification of award but prior to execution of a goods
and services contract, one of the following three documents:
Letter of Federal Affirmative Action Plan Approval
Certificate of Employee Information Report
Employee Information Report Form AA302
The contractor and its subcontractors shall furnish such reports or other documents to the Div. of Contract
Compliance & EEO as may be requested by the office from time to time in order to carry out the purposes of these
regulations, and public agencies shall furnish such information as may be requested by the Div. of Contract
Compliance & EEO for conducting a compliance investigation pursuant to Subchapter 10 of the Administrative
Code at N.J.A.C. 17:27-1.1 et seq.
12 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit C
CHECKLIST FOR ITEMS TO BE SUBMITTED WITH QUALIFICATIONS
STATEMENT
Read,
Acknowledged,
Signed & Submitted
Respondent’s Initial
FAILURE TO SUBMIT ANY OF THESE ITEMS IS MANDATORY CAUSE
FOR REJECTION OF RFP\RFQ
1
Letter of Intent (Ex. A)
2
Affirmative Action Letter, Certificate or Employee
Information Report AA-302 (Ex. B) (Submit Copy of State
Certificate of Employee Information Report Prior to
Contract Award)
3
Disclosure Statement (Ex. D)
4
Non-Collusion Affidavit (Ex. E)
5
Certification of Political Contributions (Ex. G)
6
Proposal Form (Ex. H)
7
Acknowledgement of Receipt of Addenda (Ex. I)
8
Disclosure of Investment Activities in Iran (Ex. J)
DOCUMENTS REQUIRED PRIOR TO CONTRACT EXECUTION
1
Business Registration Certificate (BRC) from the State of New
Jersey Department of Treasury, Division of Revenue) (N.J.S.A.
52:32-44) (SUBMISSION OF CERTIFICATE WITH
RESPONSE PREFERRED)
2
Certificate of Insurance Evidencing Comprehensive Liability,
Property/Casualty ($2 million aggregate/$1million per occurrence)
(or less if Umbrella coverage is present); Workers Compensation
(statutory limits); and Professional Malpractice (if applicable) ($2
million aggregate/$1 million per occurrence) naming Township as
additional insured.
READ ONLY
1
Americans With Disability Act of 1990 Language (Ex. F)
Signature: The undersigned hereby acknowledges that he/she has submitted
the required documents with the Qualifications Statement and will submit
the remaining required documents prior to execution of a contract with the
Township.
Name of Respondent/ Firm: ____________________________________________
Print Name and Title: _________________________________________________
Signature: __________________________________________________________
Date: __________________________
13 | R e q u e s t f o r Q u a l i f i c a t i o n s
EXHIBIT D
STATEMENT OF OWNERSHIP DISCLOSURE
N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43)
This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure
to submit the required information is cause for automatic rejection of the bid or proposal.
Name of Organization: _________________________________________________________
Organization Address: __________________________________________________________
Part I - Check the box that represents the type of business organization:
□Sole Proprietorship (skip Parts II and III, execute certification in Part IV)
□ Non-Profit Corporation (skip Parts II and III, execute certification in Part IV)
□ For-Profit Corporation (any type) □Limited Liability Company (LLC)
□ Partnership □ Limited Partnership □ Limited Liability Partnership (LLP)
□ Other (be specific): __________________________________________
Part II
□ The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or
more if its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest
therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the
case may be. (COMPLETE THE LIST BELOW IN THIS SECTION)
OR
□ No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual
partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability
company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV)
(Please attach additional sheets if more space is needed):
Name of Individual or Business Entity
Home Address (for Individuals) or Business
Address
Part III - DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS
OR LLC MEMBERS LISTED IN PART II
14 | R e q u e s t f o r Q u a l i f i c a t i o n s
If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent
or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and
Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to
the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign
equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the
publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on
each such person. Attach additional sheets if more space is needed.
Website (URL) containing the last annual SEC (or foreign equivalent) filing
Page #’s
Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest
in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for
any publicly traded parent entities referenced above. The disclosure shall be continued until names and
addresses of every non-corporate stockholder, and individual partner, and member exceeding the 10 percent
ownership criteria established pursuant to N.J.S.A. 52:25-24.2 has been listed. Attach additional sheets if more
space is needed.
Stockholder/Partner/Member and Corresponding
Entity Listed in Part II
Home Address (for Individuals) or Business Address
Part IV - Certification
I, being duly sworn upon my oath, hereby represent that the foregoing information and any
attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am
authorized to execute this certification on behalf of the bidder/proposer; that the Township of
East Brunswick is relying on the information contained herein and that I am under a continuing
obligation from the date of this certification through the completion of any contracts with
Township of East Brunswick to notify the Township of East Brunswick in writing of any
changes to the information contained herein; that I am aware that it is a criminal offense to make
a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal
prosecution under the law and that it will constitute a material breach of my agreement(s) with
the, permitting the Township of East Brunswick to declare any contract(s) resulting from this
certification void and unenforceable.
Full Name (Print):
Title:
Signature:
Date:
15 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit E
NON-COLLUSION AFFIDAVIT
I, ________________________________ of the City of ___________ _____,
In the County of _______________________, and the State of _________________, of full age, being duly sworn
according to law on my oath depose and say that:
I
am
____________________________________________________________of
the
firm
of
_____________________________________________________________, the Proposer herein, and I executed the
Proposer with full authority to do so; that the Proposer has not directly or indirectly, entered into any agreement,
participated in any collusion, or otherwise taken any action in restraint of free, competitive proposing in connection
with the above-named Vendor, and that all statements contained in the Proposal and in this affidavit are true and
correct, and made with full knowledge that the Township of East Brunswick relies upon the truth of the statements
contained in the Proposal and the statement in this affidavit in awarding the contract.
I further warrant that no person or selling agency has been employed or retained to solicit or secure a
contract upon an agreement or understanding for a commission, percentage, brokerage or contingent fee, except
bona
fide
employees
or
bona
fide
established
commercial
or
selling
agencies
maintained
by
__________________________________. (Name of Vendor)
____________________________
Signature
____________________________
Print or Type Name and Title
16 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit F
AMERICANS WITH DISABLITIES ACT OF 1990
EQUAL OPPORTUNITY FOR INDIVIDUALS WITH DISABLITY
The RESPONDENT and the TOWNSHIP OF EAST BRUNSWICK (herein referred to as the
TOWNSHIP) do hereby agree that the provisions of Title 11 of the Americans With Disabilities Act of 1990 (the
“Act”) (42 U.S.C. S12101 et seq.), which prohibits discrimination on the basis of disability by public entities in all
services, programs and activities provided or made available by public entities, and the rules and regulation
promulgated pursuant thereunto, are made a part of this contract. In providing any aid, benefit, or service on behalf
of the TOWNSHIP pursuant to this contract, the RESPONDENT agrees that the performance shall be in strict
compliance with the Act. In the event the RESPONDENT, its agents, servants, employees, or subcontractors violate
or are alleged to have violated the Act during the performance of this contract, the RESPONDENT shall defend the
TOWNSHIP in any action or administrative proceeding commenced pursuant to this Act. The RESPONDENT shall
indemnify, protect, and save harmless the TOWNSHIP, its agents, servants, and employees from and against any
and all suits, claims, losses, demands, or damages of whatever kind or nature arising out of the alleged violation.
The RESPONDENT shall, at its own expense, appear, defend, and pay any and, all charges for legal services and
any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection
therewith. In any and all complaints brought pursuant to the TOWNSHIP’S grievance procedure, the
RESPONDENT agrees to abide by any decision of the TOWNSHIP, which is rendered pursuant to, said grievance
procedure. If any action or administrative proceeding result in an award of damages against the TOWNSHIP or if
the TOWNSHIP incurs any expense to cure a violation of the ADA which has been brought pursuant to its grievance
procedure the RESPONDENT shall satisfy an discharge the same at its own expense.
The TOWNSHIP shall, as soon as practicable after a claim has been made against it, give written notice
thereof to the RESPONDENT along with full and complete particulars of the claim. If any action or administrative
proceeding is brought against the TOWNSHIP or any of its agents, servants, and employees, the TOWNSHIP shall
expeditiously forward or have forwarded to the RESPONDENT every demand, complaint, notice, summons,
pleading, or other process received by the TOWNSHIP or its representatives.
It is expressly agreed and understood that any approval by the TOWNSHIP of the services provided by the
RESPONDENT pursuant to this contract will not relieve the RESPONDENT of the obligation to comply with the
Act and to defend, indemnify, protect, and save harmless the TOWNSHIP pursuant to this paragraph.
It is further agreed and understood that the TOWNSHIP assumes no obligation to indemnify or save
harmless the RESPONDENT, its agents, servants, employees and subcontractors for any claim which may arise out
of their performance of this Agreement. Furthermore, the RESPONDENT expressly understands and agrees that the
provisions of this indemnification clause shall in no way limit the RESPONDENT’S obligations assumed in this
Agreement, nor shall they be construed to relieve the RESPONDENT from any liability, nor preclude the
TOWNSHIP from taking any other actions available to it under any other provisions of this Agreement or otherwise
at law.
17 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit G
CERTIFICATION OF POLITICAL CONTRIBUTIONS
Name of Business Entity:
___________________________________________________
(Proposer)
___________________________________________________
___________________________________________________
___________________________________________________
Contact Person:
___________________________________________________
(Name and Title)
Proposal Submitted for:
____________________________________________________
(i.e., Township Engineer; Labor Counsel, etc.)
Date of Proposal:
____________________________________________________
STATE OF NEW JERSEY
)
ss:
COUNTY OF __________
)
_______________________., being duly sworn, upon his/her oath deposes and says:
I am _________________________ of the Proposer referenced above.
(title)
I have read Township of East Brunswick Ordinance No. 06-13 Establishing Restrictions on the Award of
Contracts to Professional Entities and Certain Other Entities Who Make Certain Political Contributions, and
pursuant to Section 3 (a) thereof, and I state that the Proposer has not made any contributions in violation of Section
1 of Ordinance No. 06-13 and amended by Ord. 19-23.
______________________________________
.
18 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit H
PROPOSAL FORM
COMPLETE IF REQUIRED BY SCOPE OF SERVICES
To the Municipal Clerk of the Township of East Brunswick:
The Proposer whose signature is below declares that he/she has reviewed the RFP\RFQ. In the
event this Proposal is accepted, and the Township awards a contract to this Proposer for the
Services, Proposer agrees to perform the Services as set forth under Section 2 of the RFP\RFQ
following total amount:
$ _________________________________________
(Proposal amount in numbers)
$__________________________________________
(Proposal amount in words)
Name of Proposer (Print)
Title
Signature
Date
19 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit I
ACKNOWLEDGEMENT OF RECEIPT OF ADDENDA
The undersigned hereby acknowledges receipt of the following Addenda:
Addendum Number
Dated
_________________________
___________________
_________________________
___________________
Acknowledged for ___________________________________
Name of Proposer
By_________________________________________________
Signature of Authorized Representative
Name_______________________________________________
(Print)
Title________________________________________________
20 | R e q u e s t f o r Q u a l i f i c a t i o n s
Exhibit J
TOWNSHIP OF EAST BRUNSWICK
DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN
BID/RFP/RFQ Solicitation: _______________________________ Bidder/Offeror: _______________________________
Part 1: Certification
BIDDERS ARE TO COMPLETE PART 1 BY CHECKING EITHER BOX
Failure to check one of the Boxes will render the Proposal Non-Responsive.
Pursuant to Public Law 2012, c. 25, any person or entity that submits a bid or proposal or otherwise proposes to enter into or
renew a contract must complete the certification below to attest, under penalty of perjury, that neither the person or entity, nor
any of its parents, subsidiaries, or affiliates, is identified on the Department of the Treasury’s Chapter 25 list as a person or
entity engaging in investment activities in Iran. The Chapter 25 list is found on the Division’s website at
http://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf. Bidders must review this list prior to completing the below
certification. Failure to complete the certification may render a bidder’s proposal non-responsive. If the Director finds a person
or entity to be in violation of the law, s/he shall take action as may be appropriate and provided by law, rule or contract,
including but not limited to, imposing sanctions, seeking compliance, recovering damages, declaring the party in default and
seeking debarment or suspension of the party.
PLEASE CHECK THE APPROPRIATE BOX:
I certify, pursuant to Public Law 2012, c. 25, that neither the bidder listed above nor any of the bidder’s
parents, subsidiaries, or affiliates is listed on the N.J. Department of the Treasury’s list of entities determined
to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c. 25 (“Chapter 25 List”). I further certify
that I am the person listed above, or I am an officer or representative of the entity listed above and am
authorized to make this certification on its behalf. I will skip Part 2 and sign and complete the Certification
below.
OR
I am unable to certify as above because the bidder and/or one or more of its parents, subsidiaries, or affiliates
is listed on the Department’s Chapter 25 List. I will provide a detailed, accurate and precise description of the
activities in Part 2 below, sign and complete the Certification below.
PART 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN
IRAN
You must provide a detailed, accurate and precise description of the activities of the bidding person/entity, or one of its parents,
subsidiaries or affiliates, engaging in the investment activities in Iran on additional sheets provided by you.
Certification: I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any
attachments thereto to the best of my knowledge are true and complete. I attest that I am authorized to execute this
certification on behalf of the above-referenced person or entity. I acknowledge that East Brunswick Township is relying
on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of
this certification through the completion of any contracts with the Township to notify the Township in writing of any
changes to the answers of information contained herein. I acknowledge that I am aware that it is a criminal offense to
make a false statement or misrepresentation in this certification, and if I do so, I recognize that I am subject to criminal
prosecution under the law and that it will also constitute a material breach of my agreement(s) with East Brunswick
Township, New Jersey and that the Township at its option may declare any contract(s) resulting from this certification
void and unenforceable.
Full Name (Print)___________________________________ Signature: ______________________________________
Title _____________________________________________ Date:____________________
*This form need not be submitted. It is provided for use in assuring compliance with all required documentation.
21 | R e q u e s t f o r Q u a l i f i c a t i o n s
TOWNSHIP OF EAST BRUNSWICK
SEALED SUBMISSION LABEL FOR REQUEST FOR QUALIFICATIONS
Please Tape This Label To The Front Of Your Sealed Submission
DO NOT OPEN
IMPORTANT - SEALED SUBMISSION ENCLOSED
NAME COMPANY: _______________________________________
ADDRESS: _______________________________________
_______________________________________
_______________________________________
TO: TOWNSHIP OF EAST BRUNSWICK
ATTN: MUNCIPAL CLERK
1 CIVIC CENTER DRIVE
EAST BRUNSWICK, NJ 08816-1081
TITLE OF SUBMISSION:
____________________________________________________________
____________________________________________________________
APPENDIX A – SCOPE OF SERVICES – HEALTH BENEFITS
CONSULTANT
The Township seeks Qualification Statements from Respondents that have expertise in the provision of
Health Benefits Consultant.
Respondents must state in their responses which of the Services they are interested in providing.
Respondents should be able to demonstrate that they have and will continue to have the capabilities to
perform the Services.
The Health Benefits Consultant shall be a person licensed to sell insurance to public entities in
the State of New Jersey and shall hold all other necessary licenses. The consultant shall have
knowledge, training and experience in all forms of municipal medical insurance. The Consultant
shall have a working knowledge and familiarity with New Jersey medical insurance carriers. The
Consultant shall have experience and possess the demonstrated capability of serving as an
effective advocate and negotiator with providers of medical insurance.
Fee to be determined after review of all RFQs and then Proposals.
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Contacts
Nennette Perry
Municipal Clerk · Township of East Brunswick
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Timeline
First Discovered
Mar 31, 2026
Last Info Update
Apr 30, 2026
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