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Request for Proposals- Risk Management Services 2026-2027 due 10-23-25
BID #: 261
ISSUED: 10/3/2025
DUE: 10/23/2025
VALUE: TBD
100
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Executive Summary
The City of Summit is soliciting proposals for Risk Management Services covering the calendar years 2026-2027. This informal Request for Information and Proposal (RFIP) aims to identify qualified consultants to manage the City's insurance programs, assess insurable exposures, coordinate coverages, assist with claims, and implement loss control objectives. Key responsibilities include comprehensive insurance plan administration, facilitating the annual renewal process, diligent claims management, and active participation in various risk management meetings.
Prospective vendors are required to submit detailed proposals outlining their company structure, qualifications of key personnel, experience with municipal government, and a pricing structure, including a commission percentage not exceeding 6% of the Municipality's annual assessment. Additionally, proposals must demonstrate compliance with New Jersey statutes regarding affirmative action, business registration, and disability acts, alongside adherence to specified insurance requirements for general liability, worker's compensation, employer's liability, automobile liability, and professional liability.
Proposals must be submitted to Megan Champney Kweselait by the submission deadline of October 23, 2025, at 4:00 PM. The City retains the right to either not award a contract from this RFIP or to initiate a formal public procurement process if the informal responses do not meet their requirements.
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Bid Postings • Request for Proposals- Risk Management Servic Skip to Main Content Create a Website Account - Manage notification subscriptions, save form progress and more. Website Sign In Search Government Services Community How Do I... Home Bid Postings Print Sign up to receive a text message or email when new bids are added! Print Bid Title: Request for Proposals- Risk Management Services 2026-2027 due 10-23-25 Category: City of Summit Status: Closed Publication Date/Time: 10/3/2025 3:30 PM Closing Date/Time: 10/23/2025 4:00 PM Related Documents: Request for Proposals- Risk Management Services 2026-2027 due 10-23-25 Return To Main Bid Postings Page Live Edit Smart911 Nixle Report a Concern FAQs Agendas & Minutes For Common Council and all boards and commissions Report a Concern For non-emergency service requests Notifications Sign up to get emergency and general information Make a payment Submit tax, sewer, parking and other payments online Get a permit For parking, Transfer Station, and more OPRA Request Request Open Public Records Act information Helpful Links Emergency Alerts Birth Certificates Report a Concern Construction Updates Employment Staff Directory Transit Schedules & Info City of Summit Webmail /QuickLinks.aspx Site Links Home Site Map Accessibility Copyright Notices Terms and Conditions /QuickLinks.aspx Contact Us City Hall 512 Springfield Avenue Summit, NJ 07901 Phone: 908-277-9400 Regular Hours: Monday through Friday 8:30 am to 4:30 pm Government Websites by CivicPlus® Loading Loading Do Not Show Again Close Arrow Left Arrow Right [] Slideshow Left Arrow Slideshow Right Arrow
Document Text
--- Document: Request for Proposals- Risk Management Services 2026-2027 due 10-23-25 --- THE CITY OF SUMMIT N E W J E R S E Y City Hall, 512 Springfield Avenue, Summit, NJ 07901 www.cityofsummit.org MEGAN L. CHAMPNEY KWESELAIT, MANAGER OF HUMAN RESOURCES / ASSISTANT TO THE CITY ADMINISTRATOR OFFICE OF THE ADMINISTRATOR TELEPHONE: 908 522-3600 FAX: 908 273-2977 E-MAIL: mchampney@cityofsummit.org October 1, 2025 INFORMAL REQUEST FOR INFORMATION AND PROPOSAL 2026-2027 RISK MANAGEMENT SERVICES The City of Summit is exploring options for the procurement of Risk Management Services for the January 1, 2026 through December 31, 2027 calendar years. The City will consider proposals from qualified consultants that satisfactorily respond to the criteria listed in the attached documents. Proposals should be submitted to Megan Champney Kweselait, Office of the City Administrator, 512 Springfield Avenue, Summit, NJ 07901 by the end of business Thursday, October 23, 2025. The City may or may not award a contract as a result of this Informal Request for Information and Proposal as an exception to bidding pursuant to N.J.S.A. 40A:11-5(m). In the event the City does not award a contract as a result of this Informal Request for Information and Proposal, it may opt to procure these services through a formal public process. If awarded, successful vendor will be required to comply with N.J.S.A. 19:44A-20.4 et seq. (Pay-to-Play); N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 (Affirmative Action); 42 USC S12101 et seq. (Americans w/ Disabilities Act); N.J.S.A. 52:32-44 (Business Registration), and any subsequent amendments thereto; and the City’s insurance requirements. THE CITY OF SUMMIT N E W J E R S E Y City Hall, 512 Springfield Avenue, Summit, NJ 07901 www.cityofsummit.org MEGAN L. CHAMPNEY KWESELAIT, MANAGER OF HUMAN RESOURCES / ASSISTANT TO THE CITY ADMINISTRATOR OFFICE OF THE ADMINISTRATOR TELEPHONE: 908 522-3600 FAX: 908 273-2977 E-MAIL: mchampney@cityofsummit.org October 1, 2025 INFORMAL REQUEST FOR INFORMATION AND PROPOSAL 2026-2027 RISK MANAGEMENT SERVICES The City of Summit (“the City”) is exploring options for the procurement of Risk Management Services for the January 1, 2026 through December 31, 2027 calendar years. The City is approximately 6 square miles with a population of approximately 22,000, and is a charter member of the Suburban Municipal Joint Insurance Fund (“JIF”). JIF Policies and Procedures Manual can be found online at: http://www.njmel.org/images/stories/mel_jifs/SubMuni/SubMuni_PolicyProcedures.pdf. The City will consider proposals from qualified consultants that satisfactorily respond to the following criteria including but not limited to a) through p) below and the duties outlined in the attached “Outline of Duties”: a) Assist the Municipality in identifying its insurable property and casualty exposures and to recommend professional methods to reduce, assume or transfer the risk or loss. b) Assist the Municipality in understanding the various coverages available from the JIF and Excess JIF. c) Coordinate the Municipality’s insurance programs as they apply to the various departments of the Municipality. d) Review with the Municipality any additional coverages that the Consultant feels should be carried but are not available from the JIF or Excess JIF and, subject to the Municipality’s authorization, place such coverages outside the JIF or Excess JIF. e) Advise the Municipality of the implications of special events insurance coverage that is required and available. f) Assist the Municipality in the preparation of applications, statements of values and similar documents requested by the JIF and Excess JIF, it being understood that this shall not require any appraisal work by the Consultant. g) Review Certificates of Insurance from contractors, vendors and professionals when requested by the Municipality. h) Review the Municipality’s assessment as prepared by the JIF and Excess JIF, assist the Municipality in the preparation of its annual insurance budget, and advise the Municipality of its annual insurance costs. i) Review loss and engineering reports and generally assist the Risk Management Committee of the City in its loss containment objectives, including the attendance at monthly Risk Management Committee meetings to assist and promote the safety objectives and goals of the Municipality and the JIF and Excess JIF. j) Assist where needed in the settlement of claims, with the understanding that the scope of the Consultant’s involvement does not include work normally done by a public adjuster. k) Communicate all important (deadline) dates to the Municipality to avoid surcharges and/or lapses in coverage. l) Attend meetings of the JIF and Excess JIF and keep the Municipality advised of their operations. m) Serve on the committees appointed by the Executive Committee of the JIF and Excess JIF. n) Formulate an understanding and working knowledge of the JIF and Excess JIF. o) Perform any risk management related services required by the Bylaws of the JIF and Excess JIF or by the Municipality. p) Prepare and present an annual report for the Municipality’s Mayor and Council outlining the financial performance and services of the JIF and Excess JIF as well as the Municipality’s summary claim experience, loss ratio and other pertinent performance standards, including a fair discussion and review of alternatives available outside of the JIF and Excess JIF both through self-insurance and commercial insurance. Written proposals should provide a detailed response addressing the above listed criteria, demonstrating knowledge of the service requirements, and include detailed narrative of: 1. Current company description, e.g. structure, key staff who will be assigned to the City’s account (number, job titles, licenses, qualifications, certifications, experience), company experience and specifically experience with municipal government, length of time providing insurance brokerage and consulting services to municipalities, references and specifically municipal government references, physical location, hours of availability and accessibility (phone, fax, email, etc.), history/establishment, and any other pertinent information. 2. A description of qualifications, experience and resources as they relate to undertaking Risk Management Services for the City of Summit. 3. Cost for services including but not limited to a) through p) above and attached outline of duties, including commission percentage not to exceed 6%, of the Municipality’s annual assessment as promulgated by the JIF and Excess JIF. 4. Any brokerage commission to be paid by an insurance company for any insurance coverages authorized by the City to be placed outside the JIF and Excess JIF. 5. Any hourly rate for services not outlined in this RFP, if applicable. Complete or provide proof of compliance with your submission the following: N.J.S.A. 19:44A-1 et seq. (Pay-to- Play); N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27 (Affirmative Action); 42 USC S12101 et seq. (Americans w/ Disabilities Act); N.J.S.A. 52:32-44 (Business Registration), and any subsequent amendments thereto; and the City’s minimum standard insurance requirements: CONTRACTOR shall maintain the insurance coverages as indicated by below issued by companies rated “A-” or better by A.M. Best Rating and shall furnish insurance certificates for such coverage upon execution of this Agreement. General Liability, including Premises Operations, Products/Completed Operations, Personal and Advertising Injury Liability, Contractual Liability and Property Damage Liability Combined Single Limit of $1,000,000.00 Each Occurrence and a $2,000,000.00 General Aggregate and a $2,000,000.00 Products-Completed Operations Aggregate, with City of Summit to be named as additional insured using Forms CG2010 and CG2037 or their equivalents (a blanket additional insured endorsement is not an equivalent). The General Liability Policy may not contain a “third-party over action” exclusion, therefore a copy of the vendor’s general liability policy may be requested for review. Property damage coverage shall be extended to cover damage to underground wires, ducts, pipes, conduits, etc. Statutory Limits of Workers' Compensation shall be maintained in full force during the life of the contract, covering all employees engaged in performance of the contract pursuant to N.J.S.A. 34:15-12(a) and N.J.A.C. 12:235-1.6. Each subcontractor shall provide Statutory Limits of Workers' Compensation and Employer's Liability Insurance for the latter’s employees, unless such employees are covered by the protection afforded by Contractor’s insurance. Employer’s Liability Insurance shall have limits not less than $500,000 per accident. Automobile Liability Insurance to include “Non-Owned and Hired Automobiles” with City of Summit to be named as additional insured by endorsement. One person in any one occurrence ..................................................... $500,000. Two or more persons in any one occurrence ............................................... $1, 000,000. Property damage in any one occurrence ............................................ $250,000. OR Combined Single Limit .................................................................................. $1, 000,000. Professional Liability Insurance in an amount (a) not less than $1,000,000 each claim and a $1,000,000 aggregate if CONTRACTOR is an individual or sole proprietorship, or those vendors that are described or offer services as tax appraisal services or construction inspection services on construction projects valued under $2 million; (b) in an amount not less than $2,000,000 each claim and a $2,000,000 aggregate if CONTRACTOR is a corporation, partnership, limited liability company, limited liability partnership or similar entity, or (c) in such amount as recommended by The City Department Head and authorized by resolution of the Common Council. The policies shall remain in effect until all work has been completed. The vendor shall ascertain the cost of all required insurance before preparing and submitting a bid or proposal as applicable. The certificate of General Liability insurance furnished by the vendor shall indicate that contractual liability is included. The certificate shall also state that the vendor’s insurance for general liability, public personal injury liability and property damage liability, and automobile liability names the City of Summit as an additional named insured. Vendor will indemnify and hold harmless the CITY, its officers, agents, and employees, from all claims, suits or actions and damages or costs of every name and description to which the CITY may be subjected or put by reason of injury to the person or property of another, or the property of the CITY, resulting from negligent acts or omissions on the part of the vendor, the vendor’s employees, agents, servants or subcontractors in the delivery of materials and supplies, or in the performance of the work under this Agreement. Certificates of the Required Insurance Certificates of Insurance for those policies required above shall be submitted to and accepted by the City of Summit before the contract can be fully executed. Such coverage shall be with an insurance company authorized to do business in the State of New Jersey and shall name the City of Summit as an additional insured. Self-insured contractors shall submit an affidavit attesting to their self-insured coverage and shall name the City of Summit as an additional insured. Insurance shall be issued on a primary and non-contributory basis; and a waiver of subrogation in favor of the City of Summit shall be included by endorsement. Proposals should be submitted to Megan Champney, Office of the City Administrator, 512 Springfield Avenue, Summit, NJ 07901 by October 23, 2025. Proposals received after this date will not be considered. The City may or may not award a contract as a result of this Informal Request for Information and Proposal as an exception to bidding pursuant to N.J.S.A. 40A:11-5(m). In the event the City does not award a contract as a result of this Informal Request for Information and Proposal, it may opt to procure these services through a formal public process. OUTLINE OF DUTIES As the insurance broker and risk manager, the following outline of duties lists the minimum requirements for managing the City of Summit’s Commercial Insurance Program. ❖ Insurance Plan Administration ➢ Manage all phone call and email requests as they are received from the City. ➢ Preparation of binders of insurance for policies as they renew, as needed. ▪ Prepare and process. ▪ Renewal Policies. ▪ Automobile ID cards. ➢ Review vendor certificates of insurance ➢ Generate Certificates of Insurance that the City must provide to its vendors. ➢ Prepare City’s documents from the Suburban Municipal JIF. ➢ Provide surveys of insurance to public auditors and others upon request. ➢ Prepare allocations of premium as needed. ➢ Process invoices & monitor all billing arrangements. ➢ Check and review coverages as provided. ➢ Analyze policies and remand terms and conditions as necessary. ➢ Coordinate audit process on auditable policies. ➢ Check and process audits. ➢ Manage all change requests. ▪ Process all endorsements as received and forward copies to City. ▪ Meet with City representatives, as needed, in order to review documents, contracts, hold harmless agreements and certificate of insurance requests. ▪ Prepare all proposals for City’s review, as needed. ❖ Renewal Process ➢ Meet with the City representatives and review all renewal documents. ➢ Finalize and complete all renewal applications and schedules. ➢ Process all underwriting requests prior to the renewal. ➢ Update all schedules for City’s renewal for review at the effective date. ➢ Process all underwriting requests from the carriers and the City. ➢ Prepare the renewal proposal and meet with the City to review all renewal quotations & options. ❖ Claims ➢ Report & file all claims as received to the appropriate claim contact. ➢ Review and follow up with the City on all claim activities. ➢ Track, review and amend the claim activity on the Statistical Claim Report. ➢ Maintain computerized diary system of open pending items. ➢ Prepare quarterly claim report on activities and reported claims. ❖ Risk Management ➢ Attend, in-person, the monthly (5) loss control meetings at Scotch Plains, NJ. ➢ Attend, in-person, the monthly (10) Suburban Municipal JIF at Scotch Plains, NJ. ➢ Attend the quarterly (4) risk management meetings held by the City at their offices. ➢ Review and follow up on all loss control reports and inspections. ➢ Meet with the loss control engineer for all site visits, as necessary. ➢ For training session or seminars that do not require a certified technician. ▪ Create a power point presentation as needed. ▪ Secure an appropriate video for the presentation. ▪ Schedule and manage the training session for the City’s employees. ❖ Other Activities ➢ Stewardship Reports - provide City with a stewardship/activity report at the end of each year that will include a breakdown of all activities for the policy term. ➢ Property Appraisals – assist City with developing property valuations for real and personal properties BUSINESS ENTITY DISCLOSURE CERTIFICATION FOR NON-FAIR AND OPEN CONTRACTS Required Pursuant To N.J.S.A. 19:44A-20.8 CITY OF SUMMIT – 2025 Part I – Vendor Affirmation The undersigned, being authorized and knowledgeable of the circumstances, does hereby certify that the (name of business entity)__________________________________ has not made and will not make any reportable contributions pursuant to N.J.S.A. 19:44A-1 et seq. that, pursuant to P.L. 2023, c. 30 would bar the award of this contract in the one year period preceding (date of scheduled award DO NOT COMPLETE; TO BE COMPLETED BY CITY) ________________, 2025, to any of the following named candidate committee or joint candidates committee as defined pursuant to N.J.S.A. 19:44A-3 (q) and (r). ELECTED OFFICIALS CAMPAIGN COMMITTEES Mayor: Elizabeth Fagan Councilmembers: Together for Summit Jamel Boyer Toth for Summit Delia Hamlet Delia Hamlet Summit First Michelle Kalmanson Bob Pawlowski for Summit Council Michael McTernan SmallzforSummit Robert Pawlowski Kalmanson for Council Kevin Smallwood Claire Toth Part II – Ownership Disclosure Certification I certify that the list below contains the names and addresses of all owners holding ownership or control of more than 10% of the profits or assets of the undersigned or, in the case of a business entity that is a corporation for profit, 10% or more of the issued and outstanding stock of the undersigned. Check the box that represents the type of business entity: Partnership Corporation Sole Proprietorship Subchapter S Corporation Limited Partnership Limited Liability Company Limited Liability Partnership Name of Stock or Shareholder Home Address Part 3 – Signature and Attestation: The undersigned is fully aware that if I have misrepresented in whole or part this affirmation and certification, I and/or the business entity, will be liable for any penalty permitted under law. Name of Business Entity: ___________________________________________ Signed: ________________________________ Title: __________________________________ Print Name: ____________________________ Date: __________________________________ BUSINESS ENTITY DISCLOSURE CERTIFICATION FOR NON-FAIR AND OPEN CONTRACTS Required Pursuant To N.J.S.A. 19:44A-20.8 CITY OF SUMMIT The following is statutory text related to the terms and citations used in the Business Entity Disclosure Certification form. “Local Unit Pay-To-Play Law” (P.L. 2004, c.19, as amended by P.L. 2005, c.51) 19:44A-20.6 Certain contributions deemed as contributions by business entity. 5. When a business entity is a natural person, a contribution by that person's spouse or child, residing therewith, shall be deemed to be a contribution by the business entity. When a business entity is other than a natural person, a contribution by any person or other business entity having an interest therein shall be deemed to be a contribution by the business entity. 19:44A-20.7 Definitions relative to certain campaign contributions. 6. As used in sections 2 through 12 of this act: “business entity" means any natural or legal person, business corporation, professional services corporation, limited liability company, partnership, limited partnership, business trust, association or any other legal commercial entity organized under the laws of this State or of any other state or foreign jurisdiction; “interest" means the ownership or control of more than 10% of the profits or assets of a business entity or 10% of the stock in the case of a business entity that is a corporation for profit, as appropriate; ~~~~~~~~~~~~~~~~~~~~~ The New Jersey Campaign Contributions and Expenditures Reporting Act (N.J.S.A. 19:44A-1 et seq.) 19:44A-3 Definitions. In pertinent part… q. The term "candidate committee" means a committee established pursuant to subsection a. of section 9 of P.L.1973, c.83 (C.19:44A-9) for the purpose of receiving contributions and making expenditures. r. the term "joint candidates committee" means a committee established pursuant to subsection a. of section 9 of P.L.1973, c.83 (C.19:44A-9) by at least two candidates for the same elective public offices in the same election in a legislative district, county, municipality or school district, but not more candidates than the total number of the same elective public offices to be filled in that election, for the purpose of receiving contributions and making expenditures. For the purpose of this subsection: …; the offices of member of the board of chosen freeholders and county executive shall be deemed to be the same elective public offices in a county; and the offices of mayor and member of the municipal governing body shall be deemed to be the same elective public offices in a municipality. 19:44A-8 and 16 Contributions, expenditures, reports, requirements. While the provisions of this section are too extensive to reprint here, the following is deemed to be the pertinent part affecting amounts of contributions: “The $200 limit established in this subsection shall remain as stated in this subsection without further adjustment by the commission in the manner prescribed by section 22 of P.L.1993, c.65 (C.19:44A-7.2) C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Contractor Instructions Business entities (contractors) receiving contracts from a public agency that are NOT awarded pursuant to a “fair and open” process (defined at N.J.S.A. 19:44A-20.7) are subject to the provisions of N.J.S.A. 19:44A-20.26. This law provides that 10 days prior to the award of such a contract, the contractor shall disclose contributions to (see next page for listing): • any continuing political committee (a.k.a., political action committee) • any candidate committee of a candidate for, or holder of, an elective office: o of the public entity awarding the contract o of that county in which that public entity is located o of another public entity within that county o or of a legislative district in which that public entity is located or, when the public entity is a county, of any legislative district which includes all or part of the county The disclosure must list reportable contributions to any of the committees that exceed $200 per election cycle that were made during the 12 months prior to award of the contract. See N.J.S.A. 19:44A-8 and 19:44A-16 for more details on reportable contributions. N.J.S.A. 52:34-25(b) itemizes the parties from whom contributions must be disclosed when a business entity is not a natural person. This includes the following: • individuals with an “interest:” ownership or control of more than 10% of the profits or assets of a business entity or 10% of the stock in the case of a business entity that is a corporation for profit • all principals, partners, officers, or directors of the business entity or their spouses • any subsidiaries directly or indirectly controlled by the business entity • IRS Code Section 527 New Jersey based organizations, directly or indirectly controlled by the business entity and filing as continuing political committees, (PACs). When the business entity is a natural person, “a contribution by that person’s spouse or child, residing therewith, shall be deemed to be a contribution by the business entity.” [N.J.S.A. 19:44A-20.26(b)] The contributor must be listed on the disclosure. Any business entity that fails to comply with the disclosure provisions shall be subject to a fine imposed by ELEC in an amount to be determined by the Commission which may be based upon the amount that the business entity failed to report. The enclosed list of agencies is provided to assist the contractor in identifying those public agencies whose elected official and/or candidate campaign committees are affected by the disclosure requirement. It is the contractor’s responsibility to identify the specific committees to which contributions may have been made and need to be disclosed. The disclosed information may exceed the minimum requirement. The enclosed form, or a content-consistent facsimile, or an electronic data file containing the required details (along with a signed cover sheet) may be used as the contractor’s submission and is disclosable to the public under the Open Public Records Act. The contractor must also complete the attached Stockholder Disclosure Certification. This will assist the agency in meeting its obligations under the law. C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Required Pursuant To N.J.S.A. 19:44A-20.26 This form or its permitted facsimile must be submitted to the City of Summit no later than 10 days prior to the award of the contract. Part I – Vendor Information Vendor Name: Address: City: State: Zip: The undersigned being authorized to certify, hereby certifies that the submission provided herein represents compliance with the provisions of N.J.S.A. 19:44A-20.26 and as represented by the Instructions accompanying this form. _________________________ _________________________ _________________________ Signature Printed Name Title Part II – Contribution Disclosure Disclosure requirement: Pursuant to N.J.S.A. 19:44A-20.26 this disclosure must include all reportable political contributions (more than $200 per election cycle) over the 12 months prior to submission to the committees of the government entities listed on the form provided. Contributor Name Recipient Name Date Dollar Amount $ Check here if the information is continued on subsequent page(s) DOUBLE SIDED DOCUMENT Continuation Page C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Required Pursuant To N.J.S.A. 19:44A-20.26 Page ___ of ______ Vendor Name: ___________________________________ Contributor Name Recipient Name Date Dollar Amount $ Check here if the information is continued on subsequent page(s) List of Agencies with Elected Officials Required for Political Contribution Disclosure N.J.S.A. 19:44A-20.26 County Name: Union State: Governor Legislative District #s: 20, 21, & 22 State Senator and two members of the General Assembly per district. County: County Commissioners County Clerk Sheriff Surrogate Municipalities (Mayor and members of governing body, regardless of title): Berkeley Heights Township Clark Township Cranford Township Elizabeth City Fanwood Borough Garwood Borough Hillside Township Kenilworth Borough Linden City Mountainside Borough New Providence Borough Plainfield City Rahway City Roselle Borough Roselle Park Borough Scotch Plains Township Springfield Township Summit City Union Township Westfield Town Winfield Township Boards of Education (Members of the Board): Berkeley Heights Township Clark Township Cranford Township Elizabeth City Garwood Borough Hillside Township Kenilworth Borough Linden City Mountainside Borough New Providence Borough Plainfield City Rahway City Roselle Borough Roselle Park Borough Scotch Plains-Fanwood Regional Springfield Township Union Township Westfield Town Winfield Township Fire Districts (Board of Fire Commissioners): None 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 of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS SECTION) OR No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV) (Please attach additional sheets if more space is needed): Name of Individual or Business Entity Address Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART II If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed. 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 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 City of Summit 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 the City of Summit to notify the City of Summit 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 City of Summit to declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): Title: Signature: Date:
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Megan L. Champney Kweselait
Manager of Human Resources / Assistant to the City Administrator · Office of the Administrator
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Timeline
First Discovered
Apr 28, 2026
Last Info Update
Apr 30, 2026
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