BRIDGETON PUBLIC CHARTER SCHOOL
REQUEST FOR PROPOSALS
FOR THE PROVISION OF
INSURANCE BROKERAGE SERVICES
FOR
DISABILITY INSURANCE
RFP 15-04(re-issue)
ISSUE DATE: May 18, 2015
DUE DATE: June 1, 2015
Issued by:
Douglas McGarry, Board Secretary/Business Manager
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GLOSSARY
The following definitions shall apply to and are used in this Request for
Proposals:
"Board" - refers to the (Bridgeton Public Charter School Board of Trustees).
"Proposal Statement" - refers to the complete responses to this RFP submitted
by the Respondents.
“Proposed Respondent" - refers to those Respondents who (in the sole
judgment of the Board) have satisfied the proposal criteria set forth in this
RFP.
"RFP" - refers to this Request for Proposals, including any amendments thereof
or supplements thereto.
"Respondent" or "Respondents" - refers to the interested firm(s) that submit a
Proposal Statement.
2
SECTION 1
INTRODUCTION AND GENERAL INFORMATION
1.1
Introduction and Purpose
The Board is soliciting Proposal Statements from interested persons and/or
firms for the provision of consulting services, as more particularly described herein.
Through a Request for Proposal process described herein, persons and/or firms
interested in assisting the Board with the provision of such services must prepare and
submit a Proposal Statement in accordance with the procedure and schedule in
this RFP. The Board will review Proposal Statements only from those firms that submit
a Proposal Statement which includes all the information required to be included as
described herein (in the sole judgment of the Board).
The Board intends to accept proposals from person(s) and/or firm(s) that:
(a) Possess the professional, financial and administrative capabilities to provide the
proposed services; and
(b) Will agree to work under the compensation terms and conditions determined
by the Board of Trustees to provide the greatest benefit to the Bridgeton Public
Charter School Board of Trustees.
1.2
Procurement Process and Schedule
The selection of Proposed Respondents is subject to the “New Jersey Local
Unit Pay-to-Play” Law, N.J.S.A. 19:44A-20.4 et seq. The Board has structured a
procurement process that seeks to obtain the desired results described above,
while establishing a competitive process to assure that each person and/or firm is
provided an equal opportunity to submit a Proposal Statement in response to the
request and will be evaluated in accordance with the criteria set forth in Section 2
of this RFP.
Proposal Statements will be reviewed and evaluated by the Board and its
legal advisors. The Proposal Statements will be reviewed to determine if the
Respondents have met the minimum professional, administrative and financial
areas described in this RFP. Based upon the totality of the information contained in
the Proposal Statement, including information about the reputation and experience
of each Respondent, the Board will (in its sole judgment) determine which
Respondents are qualified (from professional, administrative and financial
standpoints). Each Respondent that meets the requirements of the RFP (in the sole
judgment of the Board) will be designated as a Proposed Respondent and will be
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given the opportunity to participate in the selection process determined by the
Board.
The RFP process commences with the issuance of this RFP. The steps involved
in the process are found on the Procurement Schedule. The Board reserves the
right to, among other things, amend, modify or alter the Procurement Schedule in
its sole discretion and in accordance with applicable law.
All communications concerning this RFP or the RFP process shall be directed
to the designated contact person, in writing.
Designated Contact Person(s):
Douglas McGarry, Board Secretary – 856-691-1611 OR
Christina Murphy, School Business Administrator – 856-497-8202, ext.301
Bridgeton Public Charter School Board of Trustees
2560 Industrial Way, Unit C.
Vineland, NJ 08360
Proposal Statements must be submitted to, and be received by, the Board,
via mail or hand delivery, by (10:00 AM) Prevailing Time on (June 1, 2015).
TABLE 1
ANTICIPATED PROCUREMENT SCHEDULE
1.
Issuance of Request for Proposals
2.
Receipt of Proposal Statements
3.
Opening of Proposals
4.
Analysis of Proposals
5.
Administrative Review
6.
Designation of Proposed Respondents deemed necessary or appropriate
by the Board.
4
Section 1.3 Conditions Applicable to RFP
Upon submission of a Proposed Statement in response to this RFP, the
Respondent acknowledges and consents to the following conditions relative to the
submission, review and consideration of its Proposed Statement:
•
The Board reserves the right to reject for any reason any and all
responses and components thereof and to eliminate any and all
Respondents responding to this RFP from further consideration for this
procurement.
•
The Board reserves the right to reject any Respondent that submits
incomplete responses to this RFP, or a Proposal Statement that is not
responsive to the requirements of this RFP.
•
The Board reserves the right, without prior notice, to supplement,
amend, or otherwise modify this RFP, or otherwise request additional
information.
•
All Proposal Statements shall become the property of the Board and
will not be returned.
•
All Proposal Statements will be made available to the public or the
other Respondents at the appropriate time, as determined by the
Board (in the exercise of its sole discretion) in accordance with law.
•
The Board may request Respondents to send representatives to the
Board for interviews.
•
Any and all Proposal Statements not received by the Board by
10:00 AM Prevailing Time on June 1, 2015 will be rejected.

All Proposal Statements shall remain firm for a period of sixty (60) days
after the date specified for the receipt of proposals and must stipulate
that commissions are guaranteed for sixty (60) days following receipt.
•
Neither the Board, nor its respective staffs, consultants or advisors shall
be liable for any claims or damages resulting from the solicitation or
preparation of the Proposal Statement, nor will there be any
reimbursement to Respondents for the cost of preparing and
submitting a Proposal Statement or for participating in this
procurement process.
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Section 1.4 Rights of Board
The Board reserves, holds and may exercise, at its sole discretion, the
following rights and options with regard to this RFP and the procurement process in
accordance with the provisions of applicable law:
•
To determine that any Proposal Statement received complies or fails to
comply with the terms of this RFP.
•
To supplement, amend or otherwise modify the RFP through issuance
of addenda to all prospective Respondents who have received a
copy of this RFP.
•
To waive any technical non-conformance with the terms of this RFP.
•
To change or alter the schedule for any events called for in this RFP
upon the issuance of notice to all prospective Respondents who have
received a copy of this RFP.
•
To conduct investigations of any or all of the Respondents, as the
Board deems necessary or convenient, to clarify the information
provided as part of the Proposal Statement and to request additional
information to support the information included in any Proposal
Statement.
•
To suspend or terminate the procurement process described in this RFP
at any time (in its sole discretion.) If terminated, the Board may
determine to commence a new procurement process or exercise any
other rights provided under applicable law without any obligation to
the Respondents.
The Board shall be under no obligation to complete all or any portion of the
procurement process described in this RFP.
1.5
Addenda or Amendments to RFP
During the period provided for the preparation of responses to the RFP, the
Board may issue addenda, amendments or answers to written inquiries. Those
addenda will be noticed by the Board and will constitute a part of the RFP. All
responses to the RFP shall be prepared with full consideration of the addenda
issued prior to the proposal submission date.
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1.6
Cost of Proposal Preparation.
Each proposal and all information required to be submitted pursuant to the
RFP shall be prepared at the sole cost and expense of the respondent. There shall
be no claims whatsoever against the Board, its staff or consultants for
reimbursement for the payment of costs or expenses incurred in the preparation of
the Proposal Statement or other information required by the RFP.
1.7
Proposal Format
Responses should cover all information requested in the Questions to be
answered in this RFP.
Responses which in the judgment of the Board fail to meet the requirements
of the RFP or which are in any way conditional, incomplete, obscure, contain
additions or deletions from requested information, or contain errors may be
rejected.
1.8
Term
The Broker for Disability will be subject to a one-year contract. The Board
reserves the right to exercise an annual renewal thereafter.
The length of term for the Broker for Disability Contract is as follows: January
1, 2015 to June 30, 2015 and July 1, 2015 to June 30, 2016.
1.8
Cost
The Broker shall provide a description of the compensation structure
proposed by the brokerage firm. The description shall include all bases for
remuneration proposed by the firm, i.e., commission, fee, other. Broker shall
complete the Letter of Intent (Attachments), providing all rates, commissions, fees
and other expenses for a total proposal price.
The Broker shall describe all available fee structures offered by your firm;
including travel charges and any other cost that may be passed on to the
Bridgeton Public Charter School.
Successful bidders shall fully disclose the commissions or other compensation
received from anyone in the performance of brokerage services on behalf of the
District.
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1.9
Compliance
A proposal will not be a valid proposal and will not be read unless the
following items are included in the proposal documents:








Firm’s Certificate of Insurance;
Affirmative Action Questionnaire;
Stockholders Disclosure Statement;
Vendor Questionnaire/Certification;
New Jersey Business Registration Certificate;
Chapter 271 Political Contribution Disclosure Form;
Non-Collusion Affidavit;
Disclosure of Investment Activities in Iran.
8
SECTION 2
SCOPE OF SERVICES
It is the intent of the Board to solicit Proposal Statements from Respondents
that have expertise in the provision of consulting services regarding the evaluation
and obtaining of insurance coverage for the position of Disability Insurance
Consultant.
Firms and/or persons responding to this RFP shall be able to
demonstrate that they will have the continuing capabilities to perform these
services.
The services detailed below are those services expected to be provided
by the Broker pertaining to disability benefits. Actual work will be directed by
Bridgeton Public Charter School and may involve other consulting services that
are not listed below.
1. Conduct strategic planning meetings to establish goals, priorities and
identify areas of concern.
2. Financial underwriting and claims analysis, including renewal analysis and
negotiations, budget projections, funding levels and alternatives, large
claims analysis and quarterly reporting of the plan’s financial
performance.
3. Evaluate plan design in light of industry trends and labor market
conditions, claims cost trends, alternative delivery systems and legal
requirements. Evaluate eligibility, cost-sharing and benefit structure and
network savings.
4. Prepare Requests for Proposals for insurance services or other employee
benefit programs; analyze and make appropriate recommendations.
5. Apprise Bridgeton Public Charter School of local and national trends and
innovative ideas, and recommend new products, programs and services
to ensure a competitive benefits plan.
6. Review and analyze claims experience data, claims service, efficiency
and accuracy of claims administration to ensure that Bridgeton Public
Charter School is receiving optimum service and benefits from all carriers
and vendors.
7. Review on-going employee communications program, including a review
of booklets, announcement materials and benefit statements.
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8. Manage carrier/vendor relationships, review and advise on master
contracts, review carrier service levels and compare to performance
guarantees, resolve administrative issues, conduct periodic meetings as
necessary.
9. Act as a technical resource and provide periodic updates on legislative
developments and emerging trends.
10. Evaluate in-house administration procedures including recommendations for
improving services and efficiency through the use of technology.
Additional Information:
Insurance Plan Administration: For all coverage written, timeliness is essential and the
selected broker shall agree to place coverage and issue binders prior to the
expiration of each policy. Policies and/or endorsements are expected to be
provided as soon as practicable after inception or renewal of the contract.
Access to Records: The selected broker must agree to provide full and free access
to those records maintained with respect to the insured, as well as other books,
records, and information reasonably related to the scope of services provided by
the producer to the Bridgeton Public Charter School Board of Trustees.
Expenses: The selected broker will agree that they are responsible for their own
expenses including travel and meals incurred in servicing the insured’s account.
Any extraordinary expenses that the producer expects to incur as the result of
providing such special services to the insured should be delineated and agreed to
in advance.
Schedule of Insurance: On an annual basis, the selected producer will provide the
Board of Education with a schedule detailing the coverages placed through the
firm. Allocation of premium should be provided as required by the School System.
Additional schedules must also be provided as needed by the School System.
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SECTION 3
SUBMISSION REQUIREMENTS
Section 3.1 General Requirements
The Proposal Statement submitted by the Respondent must meet or exceed
the professional, administrative and financial Proposals set forth in this Section and
shall incorporate the information requested below.
In addition to the information required as described below, a Respondent
may submit supplemental information that it feels may be useful in evaluating its
Proposal Statement. Respondents are encouraged to be clear, factual, and
concise in their presentation of information.
Section 3.2 Administrative Information Requirements
The Respondent shall, as part of its Proposal Statement, provide the following
information:
1. An executive summary (not to exceed two (2) pages) of the information
contained in all the other parts of the Proposal Statement.
2. An executed Letter of Proposal (See Appendix A to this RFP).
3. Name, address and telephone number of the firm or firms submitting the
Proposal Statement pursuant to this RFP, and the name of the proposed key
contact person who would manage the Board’s account.
4. A description of the business organization (i.e., corporation, partnership, joint
venture, etc.) of each firm, its ownership and its organizational structure:
a) Provide the names and business addresses of all Principals of the firm or firms
submitting the Proposal Statement. For purposes of this RFP, "Principals" mean
persons possessing an ownership or interest in the company. If the
Respondent is a corporation, "Principals" shall include each investor who
would have any amount of operational control over the Respondent and
every stockholder having an ownership interest of 10% or more in the firm.
b) If a firm is a partially owned or a fully-owned subsidiary of another firm,
identify the parent company and describe the nature and extent of the
parents' approval rights over the activities of the firm submitting a Proposal
Statement. Describe the approval process.
11
c) If the Respondent is a partnership or a joint venture or similar organization,
provide comparable information as required in (b) above for each member
of the partnership, joint venture or similar organization.
d) A statement that the Respondent has complied with all applicable
affirmative action (or similar) requirements with respect to its business
activities, together with evidence of such compliance.
5. An executed Letter of Intent (See Appendix B).
6. The number of years the business organization has been under the current
management.
7. Confirm appropriate federal and state licenses to perform activities.
8. Insurance Consultant must have a minimum of ten (10) years of experience in
insurance consulting/brokerage with a demonstrated focus on boards of
education.
9. Insurance Consultant should demonstrate representation of other boards of
education of a similar size (in terms of premium sizes, number of covered
employees, claims experience, etc.), and must submit a list of all references.
10. Disclose number of employees who are former employees of health
insurance companies, and list the health insurance companies.
11. The education, qualifications, experience, and training of all persons who would
be assigned to provide services along with their names and titles. The consultant
MUST possess both an Agency License and Individual Licenses for those persons
who would be assigned to provide services to the Bridgeton Public Charter
School Board of Trustees from the New Jersey Department of Banking and
Insurance.
12. A listing of all other engagements where services of the types being proposed
were provided in the past five (5) years. This should include other boards of
education and other levels of government. The following information, with
regards to other clients, must be submitted for review: premium sizes, number of
employees at other clients, claims experience, experience with negotiations in
other districts, preliminary and final settlement figures.
13. A description of all other areas of insurance consulting/brokerage activities,
with emphasis on a description of those services of interest to a Board of Trustees
client.
12
14. Must disclose or confirm the absence of relationships with any ancillary or
complimentary health benefit service or offering. “Relationships” shall
include any financial arrangements, joint ownership, joint employment or
other similar affiliation.
15. Any judgments, claims or suits pending or outstanding against company. If
yes, please explain.
16. Whether the business organization is now or has been involved in any
bankruptcy or re-organization proceedings in the last ten (10) years. If yes,
please explain.
17. List all immediate relatives of Principal(s) of Respondent who are Board
employees or elected officials of the Board. For purposes of the above,
“immediate relative” means a spouse, parent, stepparent, brother, sister, child,
stepchild, direct-line aunt or uncle, grandparent, grandchild, and in-laws by
reason of relation.
18. The successful insurance consultant shall be able, when necessary, to meet
with the Head of School, Business Administrator, Business Manager, Board or
designee and attend Board meetings, as necessary. Evidence of
compliance with this request, as provided to other districts, must accompany
this request for proposals.
19. The successful insurance consultant must provide documentation and
financial information, as requested by the Board of Trustees.
20. The successful insurance consultant shall list a principal representative
assigned to service the district. If the insurance consultant intends to
designate an individual who is not an employee, such sub-contractor shall
be named and shall provide all of the information required of the ICE as
listed in the request for proposal, including but not limited to the financial
agreement between the ICE and subcontractor.
21. The successful insurance consultant shall provide a list of ratings/proof of
access to all major insurance companies servicing New Jersey.
13
SECTION 4
INSTRUCTIONS TO RESPONDENTS
4.1
Submission of Proposal Statements.
Respondents must submit an original and two (2) copies of their Proposal
Statement to the Designated Contact Person(s):
Douglas McGarry, Board Secretary – 856-691-1611 OR
Christina Murphy, School Business Administrator – 856-497-8202, ext.301
Bridgeton Public Charter School Board of Trustees
2560 Industrial Way, Unit C.
Vineland, NJ 08360
Proposal Statements must be received by the Board no later than 10:00 AM
prevailing time, on June 1, 2015, and must be mailed or hand-delivered. Proposal
Statements forwarded by facsimile or e-mail will not be accepted. Proposal
statements received after this time will not be considered. The Board will not bear
responsibility for delays in delivery for any reason.
To be responsive, Proposal Statements must provide all requested
information, and must be in strict conformance with the instructions set forth herein.
Proposal Statements and all related information must be bound, and signed and
acknowledged by the Respondent.
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SECTION 5
EVALUATION
The Board’s objective in soliciting Proposal Statements is to enable it to select
a firm or organization that will provide high quality and cost effective services to the
citizens of Bridgeton Public Charter School. The Board will consider Proposal
Statements only from firms or organizations that, in the Board’s judgment, have
demonstrated the capability and willingness to provide high quality services to the
employees of the Board in the manner described in this RFP.
Proposals will be evaluated by the Board on the basis of the most
advantageous submission, all relevant factors considered. The evaluation will
consider:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Experience and reputation in the field as evidenced by references
given.
Prior experience with the Board and the subject matter addressed
under the contract.
Availability to accommodate the required meetings of the Board, as
well as other factors demonstrated to be in the best interest of the
Board.
Reasonableness of the fees for the services.
Familiarity with Boards of Education of similar size of employees,
budget and health benefits budget.
History of success with cost savings for Boards of Educations.
Evaluation will consider the outcome of reference checks, from the
references listed above.
Satisfaction of requirements listed in Section 3.
Experience working with professionals of the district assigned to
administer the health benefits.
15
APPENDIX A
LETTER OF PROPOSAL
(Note: To be typed on Respondent's Letterhead.
may be made to this letter)
No modifications
[insert date]
Attn: (INSERT CONTACT NAME)
(INSERT ENTITY NAME)
(INSERT ADDRESS)
Dear (INSERT CONTACT NAME):
The undersigned has/have reviewed my/our Proposal Statement submitted in
response to the Request for Proposals (RFP) issued by the (Insert Entity
Name)("Board"), dated (INSERT DATE), in connection with the Board’s need for an
Insurance Consultant.
I/We affirm that the contents of my/our Proposal Statement (which Proposal
Statement is incorporated herein by reference) is accurate, factual and complete
to the best of our knowledge and belief and that the Proposal Statement is
submitted in good faith upon express understanding that any false statement may
result in the disqualification of (Name of Respondent).
(Respondent shall sign and complete the spaces provided below. If a joint
venture, appropriate officers of each company shall sign.)
(Signature of Chief
Executive Officer)
(Signature of Chief
Financial Officer)
(Typed Name and Title)
(Typed name and Title)
(Type Name of Firm)*
(Type Name of Firm)*
Dated: ___________________
*
Dated: ______________________
If a joint venture, partnership or other formal organization is submitting a Proposal Statement,
each participant shall execute this Letter of Proposal.
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APPENDIX B
LETTER OF INTENT
(Note:
To be typed on Respondent's Letterhead.
modifications may be made to this letter)
No
[insert date]
Attn: (INSERT CONTACT NAME)
(INSERT ENTITY NAME)
(INSERT ADDRESS)
Dear:
The undersigned, as Respondent, has (have) submitted the attached
Proposal Statement in response to a Request for Proposals (RFP), issued by the
(Insert Entity Name)("Board"), dated (INSERT DATE), in connection with the
Board’s need for an Insurance Consultant.
(Name of Respondent) HEREBY STATES:
1.
The Proposal Statement contains accurate, factual and
complete information.
2.
(Name of Respondent) agrees (agrees) to participate in good
faith in the procurement process as described in the RFP and to adhere to
the Board's procurement schedule.
3.
(Name of Respondent) acknowledges (acknowledge) that all
costs incurred by it (them) in connection with the preparation and submission
of the Proposal Statement and any proposal prepared and submitted in
response to the RFP, or any negotiation which results there from shall be
borne exclusively by the Respondent.
4.
(Name of Respondent) hereby declares (declare) that the only
persons participating in this Proposal Statement as Principals are named
herein and that no person other than those herein mentioned has any
participation in this Proposal Statement or in any contract to be entered into
with respect thereto. Additional persons may subsequently be included as
participating Principals, but only if acceptable to the Board. (Name of
17
Respondent) declares that this Proposal Statement is made without
connection with any other person, firm or parties who has submitted a
Proposal Statement, except as expressly set forth below and that it has been
prepared and has been submitted in good faith and without collusion or
fraud.
5.
(Name of Respondent) acknowledges and agrees that the
Board may modify, amend, suspend and/or terminate the procurement
process (in its sole judgment). In any case, the Board shall have any liability
to the Respondent for any costs incurred by the Respondent with respect to
the procurement activities described in this RFP.
6.
(Name of Respondent) acknowledges that any contract
executed with respect to the provision of [insert services] must
comply with all applicable affirmative action and similar laws.
Respondent hereby agrees to take such actions as are required in
order to comply with such applicable laws.
(Name of Respondent) submits a proposal containing a fee
schedule/summary and associated costs for the following benefit
areas:

Disability Insurance
(Respondent shall sign and complete the space provided below. If a
joint venture, appropriate officers of each company shall sign.)
(Signature of Chief Executive Officer)
(Typed Name and Title)
(Type Name of Firm)*
Dated: ________________
*
If a joint venture, partnership or other formal organization is submitting a Proposal
Statement, each participant shall execute this Letter of Intent.
18
Appendix Forms:






Affirmative Action Questionnaire;
Vendor Questionnaire/Certification;
Non-Collusion Affidavit;
Stockholders Disclosure Statement;
Chapter 271 Political Contribution Disclosure Form;
Disclosure of Investment Activities in Iran.
Please also include:


New Jersey Business Registration Certificate;
Certificate of Insurance
19
EXHIBIT A
MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE
N.J.S.A. 10:5-31 et seq., N.J.A.C. 17:27
GOODS, PROFESSIONAL SERVICES 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 ensure that
equal employment opportunity is afforded to such applicants in recruitment and employment, 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 equal employment opportunity shall include, but not 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 afford equal employment opportunities to minority and women workers
consistent with Good faith efforts to meet targeted county employment goals established in accordance with N.J.A.C. 17:27-5.2, or Good
faith efforts to meet targeted 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 personal 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.
In conforming with the targeted 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 subcontractor shall furnish such reports or other documents to the Division of Public Contracts Equal Employment
Opportunity Compliance as may be requested by the Division 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 Division of Public Contracts Equal Employment Opportunity
Compliance for conducting a compliance investigation pursuant to Subchapter 10 of theAdministrative Code at N.J.A.C. 17:27.
20
To be completed and returned with the proposal form.
AFFIRMATIVE ACTION QUESTIONNAIRE
This form is to be completed and returned with the proposal. However, the
Board will accept in lieu of this Questionnaire, Affirmative Action Evidence
stapled to this page.
1.
Our company has a federal Affirmative Action Plan approval.
______ YES
______ NO
A. If yes, please attach a copy of the plan to this questionnaire.
2.
Our company has a New Jersey State Certificate of Employee Information
Report.
______ YES
______ NO
A. If yes, please attach a copy of the certificate to this questionnaire.
3.
If you answered NO to both questions above, an affirmative action
Employee Information Report (AA-302) will be mailed to you. Complete the
form and forward it to:
Department of Treasury
Division of Public Contracts/EEO Compliance
P.O. Box 209
Trenton, N.J. 08625-0002
All fees for this application are to be paid directly to the Division. A copy
shall be submitted to the Board of Education within seven (7) days of the
notice of the intent to award the contract or the signing of the contract.
I certify that the above information is correct to the best of my knowledge.
NAME ___________________________________________________________
SIGNATURE ___________________________________________________
TITLE ___________________________________________________________
DATE ___________________________________________________________
NAME OF COMPANY
ADDRESS
CITY, STATE, ZIP
21
To be completed and returned with the proposal form.
Vendor Questionnaire/Certification
Name of Company _____________________________________________________________
Street Address ________________________________________ PO Box ________________
City, State, Zip ________________________________________________________________
Business Phone Number (____)_________________________ Ext. ___________________
Emergency Phone Number (_____)______________________________________________
FAX No. (____)________________________ E-Mail _________________________________
Years in Business
Number of Employees __________________
References – Work previously done for School Systems in New Jersey
Name of District
Address
Contact Person/Title
Phone
1.
2.
3.
Vendor Certification
Direct/Indirect Interests
I declare and certify that no member of the Bridgeton Public Charter School, nor any officer
or employee or person whose salary is payable in whole or in part by said Board of Trustees
or their immediate family members are directly or indirectly interested in this bid or in the
supplies, materials, equipment, work or services to which it relates, or in any portion of
profits thereof. If a situation so exists where a Board member, employee, officer of the
board has an interest in the bid, etc., then please attach a letter of explanation to this
document, duly signed by the president of the firm or company.
Gifts; Gratuities; Compensation
I declare and certify that no person from my firm, business, corporation, association or
partnership offered or paid any fee, commission or compensation, or offered any gift,
gratuity or other thing of value to any school official, board member or employee of the
Bridgeton Public Charter School.
Vendor Contributions
I declare and certify that I fully understand N.J.A.C. 6A:23A-6.3(a1-4) concerning vendor
contributions to school board members.
I certify that I am not an official or employee of the Bridgeton Public Charter School.
I further certify that I understand that it is a crime in the second degree in New Jersey to
knowingly make a material representation that is false in connection with the negotiation,
award or performance of a government contract.
President or Authorized Agent
Signature
22
NON-COLLUSION AFFIDAVIT
Re: Proposal for the Bridgeton Public Charter School.
STATE OF NEW JERSEY)
:ss:
COUNTY OF
)
Date:
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 ____________________________________________________________________
Position in Company
Of the firm of ________________________________________________________________
and the bidder making the Proposal for the above names contract, and that I
executed the said Proposal with full authority so to do; that I have not, directly or
indirectly, entered into any agreement, participated in any collusion, discussed
any or all parts of this proposal with any potential bidders, or otherwise taken any
action in restraint of free, competitive bidding in connection with the above named
bid, and that all statements contained in said Proposal and in this affidavit are
true and correct, and made with full knowledge that the Bridgeton Public Charter
School relies upon the truth of the statements contained in said Proposal and in
the statements contained in this affidavit in awarding the contract for the said bid.
I further warrant that no person or selling agency has been employed or retained
to solicit or secure such contract upon an agreement or understanding for a
commission, percentage, brokerage or contingent fee, except bona fide employees of
bona fide established commercial or selling agencies maintained by
______________________________________________________________________________
(Print Name of Contractor/Vendor)
Subscribed and sworn to:
__________________________________________________________
(SIGNATURE OF CONTRACTOR/VENDOR)
before me this _______ day of _______________________,
Month
_______________________________________
Print Name of Notary Public
Year
.
NOTARY PUBLIC SIGNATURE
My commission expires ______________________ _________________, ________.
Seal –
Month
Day
Year
23
–
STOCKHOLDER/PARTNERSHIP DISCLOSURE AND STATEMENT OF OWNERSHIP
Re: Proposal for the Bridgeton Public Charter School.
Proposal Date:
Please check one type of Ownership, complete the form, and execute where provided.


Corporation-Partnership--


Limited Partnership-Limited Liability Corp.--


Sole Proprietorship-Sub Chapter S Corp.--


Limited Liability Partnership-Other-__________________________
No corporation “or partnership” shall be awarded any contract nor shall any agreement be
entered into for the performance of any work or the furnishing of any material or supplies, the
cost of which is to be paid with or out of any public funds, by the State or any county,
municipality or school district, or any subsidiary or agency of the State, or by an authority,
board or commission which exercises governmental functions, unless prior to the receipt of the
bid or accompanying the bid of said corporation or said partnership, there is submitted a
statement setting forth the names and all individual partners in the partnership who own a
10% or greater interest therein, as the case may be.” If one or more such stockholder “or
partner” is itself a corporation “or partnership”, the stockholder holding 10% or more of that
corporation “or partnership” the individual partners owning 10% or greater interest in that
partnership, as the case may be, shall also be listed. The disclosure shall be, continued until
names and addresses of every non-corporate stockholder, and individual partner, exceeding
the 10% ownership criteria established in this act, has been listed.
IT IS MANDATORY THAT THIS FORM BE COMPLETED AND SUBMITTED WITH
PROPOSAL. In the event that there are no persons who own ten percent or more of the stock
or ownership of the bidder, then such fact should be certified below as part of this disclosure.
Name of Company _______________________________________________
Address _________________________________________________________
City, State, Zip __________________________________________________
List of Owners with Ten Percent (10%) or More Interest
Owner’s Name
Home Address
Title/Office Held
NOTE: If you need more space than that provided above, please use an extra sheet for furnishing the above
required information for any remaining persons or entities.
____________________________________________
______________________
Signature
Date
(form continued on next page) 
To be completed and signed below.
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Percent (%) of
Partnership
Shares Owned
STOCKHOLDER/PARTNERSHIP DISCLOSURE AND STATEMENT OF OWNERSHIP
(con’t)
If your firm is not a corporation and/or partnership, please explain below how your firm
is organized and include a list of the various principals.
Our firm, ____________________________________________________________ , is organized
___________________________________________________________________________________
___________________________________________________________________________________
Names of Principals
Title
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Use additional paper if needed.
Check here
if additional sheets are attached.
Name of Company
Address
City, State, Zip
Authorized Agent
Title
SIGNATURE OF AUTHORIZED AGENT
25
Bridgeton Public Charter School
Business Office
Chapter 271
Political Contribution Disclosure Form
(Contracts that Exceed $17,500.00)
Ref. N.J.S.A. 52:34-25
The undersigned, being authorized and knowledgeable of the circumstances, does
hereby certify that ______________________________________________________(Business
Entity) has made the following reportable political contributions to any elected official,
political candidate or any political committee as defined in N.J.S.A. 19:44-20.26 during
the twelve (12) months preceding this award of contract:
Reportable Contributions
Date of
Contribution
Amount of
Contribution
Name of Recipient
Elected Official/
Committee/Candidate
Name of
Contributor
The Business Entity may attach additional pages if needed.
________________________________________________________________________________________
 No Reportable Contributions (Please check () if applicable.)
I certify that _______________________________________(Business Entity) made no
reportable contributions to any elected official, political candidate or any political
committee as defined in N.J.S.A. 19:44-20.26.
Certification
I certify, that the information provided above is in full compliance with Public Law
2005—Chapter 271.
Name of Authorized Agent ____________________________________________________________
Signature _________________________________ Title ____________________________________
Business Entity______________________________________________________________________
26
P.L. 2005, c.271
(Unofficial version, Assembly Committee Substitute to A-3013, First Reprint*)
AN ACT authorizing units of local government to impose limits on political
contributions by contractors and supplementing Title 40A of the New Jersey Statutes and
Title 19 of the Revised Statutes.
BE IT ENACTED by the Senate and General Assembly of the State of New Jersey:
40A:11-51 1. a. A county, municipality, independent authority, board of education, or
fire district is hereby authorized to establish by ordinance, resolution or regulation, as may
be appropriate, measures limiting the awarding of public contracts therefrom to business
entities that have made a contribution pursuant to P.L.1973, c.83 (C.19:44A-l et seq.) and
limiting the contributions that the holders of a contract can make during the term of a
contract, notwithstanding the provisions and parameters of sections 1 through 12 of
P.L.2004, c.19 (C. 19:44A-20.2 et al.) and section 22 of P.L.1973, c.83 (C.19:44A-22).
b. The provisions of P.L.2004, c.19 shall not be construed to supersede or preempt any
ordinance, resolution or regulation of a unit of local government that limits political
contributions by business entities performing or seeking to perform government contracts.
Any ordinance, resolution or regulation in effect on the effective date of P.L.2004, c.19 shall
remain in effect and those adopted after that effective date shall be valid and enforceable.
c. An ordinance, resolution or regulation adopted or promulgated as provided in this
section shall be filed with the Secretary of State.
52:34-25 2. a. Not later than 10 days prior to entering into any contract having an
anticipated value in excess of $17,500, except for a contract that is required by law to be
publicly advertised for bids, a State agency, county, municipality, independent authority,
board of education, or fire district shall require any business entity bidding thereon or
negotiating therefor, to submit along with its bid or price quote, a list of political
contributions as set forth in this subsection that are reportable by the recipient pursuant to
the provisions of P.L.1973, c.83 (C.19:44A-l et seq.) and that were made by the business
entity during the preceding 12 month period, along with the date and amount of each
contribution and the name of the recipient of each contribution. A business entity
contracting with a State agency shall disclose contributions to any State, county, or
municipal committee of a political party, legislative leadership committee, candidate
committee of a candidate for, or holder of, a State elective office, or any continuing political
committee. A business entity contracting with a county, municipality, independent
authority, other than an independent authority that is a State agency, board of education,
or fire district shall disclose contributions to: any State, county, or municipal committee of a
political party; any legislative leadership committee; or any candidate committee of a
candidate for, or holder of, an elective office of that public entity, of that county in which
that public entity is located, of another public entity within that county, 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, or any continuing political
committee.
The provisions of this section shall not apply to a contract when a public emergency
requires the immediate delivery of goods or services.
27
b. 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. When a business entity is other than a natural person, a contribution by:
all principals, partners, officers, or directors of the business entity or their spouses; any
subsidiaries directly or indirectly controlled by the business entity; or any political
organization organized under section 527 of the Internal Revenue Code that is directly or
indirectly controlled by the business entity, other than a candidate committee, election fund,
or political party committee, shall be deemed to be a contribution by the business entity.
c. As used in this section:
"business entity" means a 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; and
"State agency" means any of the principal departments in the Executive Branch of the State
Government, and any division, board, bureau, office, commission or other instrumentality
within or created by such department, the Legislature of the State and any office, board,
bureau or commission within or created by the Legislative Branch, and any independent
State authority, commission, instrumentality or agency.
d. Any business entity that fails to comply with the provisions of this section shall be
subject to a fine imposed by the New Jersey Election Law Enforcement Commission in an
amount to be determined by the commission which may be based upon the amount that the
business entity failed to report.
19:44A-20.13 3. a. Any business entity making a contribution of money or any other thing
of value, including an in-kind contribution, or pledge to make a contribution of any kind to a
candidate for or the holder of any public office having ultimate responsibility for the
awarding of public contracts, or to a political party committee, legislative leadership
committee, political committee or continuing political committee, which has received in any
calendar year $50,000 or more in the aggregate through agreements or contracts with a
public entity, shall file an annual disclosure statement with the New Jersey Election Law
Enforcement Commission, established pursuant to section 5 of P.L.1973, c.83 (C.19:44A-5),
setting forth all such contributions made by the business entity during the 12 months prior
to the reporting deadline.
b. The commission shall prescribe forms and procedures for the reporting required in
subsection a. of this section which shall include, but not be limited to:
(1) the name and mailing address of the business entity making the contribution, and the
amount contributed during the 12 months prior to the reporting deadline;
(2) the name of the candidate for or the holder of any public office having ultimate
responsibility for the awarding of public contracts, candidate committee, joint candidates
committee, political party committee, legislative leadership committee, political committee or
continuing political committee receiving the contribution; and
28
(3) the amount of money the business entity received from the public entity through
contract or agreement, the dates, and information identifying each contract or agreement
and describing the goods, services or equipment provided or property sold.
c. The commission shall maintain a list of such reports for public inspection both at its
office and through its Internet site.
d. 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. When a business entity is other than a natural person, a contribution by:
all principals, partners, officers, or directors of the business entity, or their spouses; any
subsidiaries directly or indirectly controlled by the business entity; or any political
organization organized under section 527 of the Internal Revenue Code that is directly or
indirectly controlled by the business entity, other than a candidate committee, election fund,
or political party committee, shall be deemed to be a contribution by the business entity.
As used in this section:
"business entity" means a 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; and
"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.
e. Any business entity that fails to comply with the provisions of this section shall be
subject to a fine imposed by the New Jersey Election Law Enforcement Commission in an
amount to be determined by the commission which may be based upon the amount that the
business entity failed to report.
---
4. This act shall take effect immediately.
* Note: Bold italicized statutory references of new sections are anticipated and not final as of
the time this document was prepared. Statutory compilations of N.J.S.A. 18A:18A-51 is
anticipated to show a reference to N.J.S.A. 40A:11-51 and to N.J.S.A. 52:34-25.
29
List of Agencies with Elected Officials Required for Political
Contribution Disclosure
N.J.S.A. 52:34-25
County Name: Cumberland
State: Governor, and Legislative Leadership Committees
Legislative District #:
State Senator and two members of the General Assembly per district.
County:
Freeholders
County Clerk
Sheriff
Surrogate
Municipalities (Mayor and members of governing body, regardless of title):
Bridgeton City
Boards of Education (Members of the Board):
Bridgeton City
Fire Districts (Board of Fire Commissioners):
Bridgeton City Fire Districts (all)
30
DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN
Solicitation Number: ____________________ Name of Company: ____________________________________________
Pursuant to Public Law 2012, c.25, any person or entity that submits a Proposal or proposal or otherwise proposes to enter into or
renew a contract must complete the certification below to attest, under penalty of perjury, that the person or entity, or one of the
person or entity’s parents, subsidiaries, or affiliates, is not identified on a list created and maintained by the Department of the
Treasury as a person or entity engaging investment activities in Iran. If the Director finds a person or entity to be in violation of the
principles which are the subject of this 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 person or entity.
I certify, pursuant to Public Law 2012, c.25, that the person or entity listed above for which I am authorized to Proposal/renew:


is not providing goods or services of $20,000,000 or more in the energy sector of Iran, including a person or entity that
provides oil or liquefied natural gas tankers, or products used to construct or maintain pipelines used to transport oil or
liquefied natural gas for the energy sector of Iran, AND
is not a financial institution that extends $20,000,000 or more in credit to another person or entity, for 45 days or more,
if that person or entity will use the credit to provide goods or services in the energy sector in Iran.
In the event that a person or entity is unable to make the above certification because it or one of its parents, subsidiaries, or
affiliates has engaged in the above-referenced activities, a detailed, accurate and precise description of the activities must be
provided in part 2 below to the Passaic Board of Education under penalty of perjury. Failure to provide such will result in the
proposal being rendered as non-responsive and appropriate penalties, fines and/or sanctions will be assessed as provided by law.
PART 2 – ONLY COMPLETE IF ENGAGING IN INVESTMENT ACTIVITIES IN IRAN
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 Proposing person/entity, or one of its parents,
subsidiaries or affiliates, engaging in the investment activities in Iran outlined above by completing the box below.
Name: _____________________________________ Relationship to Proposer/Offeror ______________________________
Description of Activities _______________________________________________________________________________
__________________________________________________________________________________________________
Duration of Engagement ___________________________ Anticipated Cessation Date ____________________________
Proposer/Offeror Contact Name _______________________ Contact Phone Number _______________________________
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 the State of New Jersey 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 State to notify the State 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 the State of New Jersey and that the State at its option may declare any contract(s) resulting from this
certification void and unenforceable.
Full Name (Print):___________________________________ Signature __________________________________________
Title: _____________________________________________ Date: _____________________________________________
Name of Company: __________________________________ City/State/Zip: _____________________________________
31