REQUEST FOR PROPOSAL AMBULANCE BILLING SERVICES & DATA CAPTURE AND REPORTING SOFTWARE

Transcription

1 REQUEST FOR PROPOSAL AMBULANCE BILLING SERVICES & DATA CAPTURE AND REPORTING SOFTWARE The Township of Redford, is seeking proposals from experienced and qualified firms to provide AMBULANCE BILLING SERVICES AND NEMSIS GOLD CERTIFIED, WEB- BASED ELECTRONIC FIELD DATA CAPTURE SOFTWARE AS A TURN-KEY, SOLE SOURCE SOLUTION. Sealed proposals will be received by the Township of Redford Clerk no later than: 3:00 EST, February 21, 2013 at which time the name of submitting proposers will be publicly read. CHARTER TOWNSHIP OF REDFORD RESERVES THE RIGHT TO REJECT ANY AND ALL PROPOSALS. Any deviation from the specifications must be noted on the proposal. Proposal packets are available at the Charter Township of Redford, Clerk s Office, on the Redford Township website at and on Bidnet (Michigan International Trade Network MITN). Please submit proposal on or before the date and time given above to: Charter Township of Redford Clerk s Office Beech Daly Rd. Redford Twp MI, All proposals (3 copies) must be submitted in a Sealed Envelope marked RFP AMBULANCE BILLING AND ELECTRONIC DATA CAPTURE SERVICES. Direct all questions to: Fire Chief Tom Graham, (313) The Township of Redford is seeking to provide the community with a billing and data capture function that is efficient and effective. The Township of Redford wishes to enter into a contractual agreement with a firm to provide medical billing and reporting services for ambulance and other related services. The Township of Redford is seeking an initial three (3) year contract with options to renew for up to five (5) additional years. With a view to obtaining the most acceptable services, these specifications cover the general requirements. Recommendations from proposers are encouraged and will be reviewed and evaluated based on the best interests of Redford Township. This document is a Request for Proposal (RFP). It differs from a request for Bid/Quotation in that the Township of Redford is seeking a very specific fully integrated, turn-key, sole source web based NEMSIS Gold Certified field data capture, reporting and EMS medical Claims Management solution. 1

2 The Proposal Solution which in the assessment of the Township of Redford offers and demonstrates past experience and success, will be best positioned to be awarded a contract, rather than on pricing alone. The Township of Redford is interested in streamlining data capture, reporting and billing activities with a sole source, fully accountable vendor. Background The Charter Township of Redford of is located in the Wayne County, Michigan, USA is a form of government with legislative power vested in a Supervisor, Clerk, Treasurer and Board of Trustees. The Township of Redford Fire Department provides rapid pre-hospital emergency medical service. We strive to deliver the highest quality Advanced Life Support for the citizens we serve. Scope of Work The Township of Redford is seeking to provide the community with a sole source billing and electronic data capture function that is efficient and effective. The Township of Redford believes that leading-edge technology and relative experience are the key elements to ensure a successful billing and data capture solution. The Township of Redford desires to enter into a contractual agreement with a governmental or private sector ambulance billing and data capture service, as a sole source contractor. It is the Township s objective to select: A reputable firm to provide ambulance billing, accounts receivable and data capture functions, as a sole source for patient services rendered. A reputable firm that within the last five years has been responsible for at least fifteen concurrently active public sector ambulance billing and collection projects of similar size as the Twp. A reputable firm to provide complete and thorough financial reports to be presented to the Fire Chief, EMS Coordinator, Chief Accountant or Finance Director upon request The selected firm shall comply with the privacy obligations applicable to them under the Health Insurance Portability and Accountability Act of 1996 and the regulations issued pursuant thereto, as amended, (HIPAA) to protect the privacy of Personal Health Care Information (PHI) as delivery, collected, processed or obtained. The selected firm shall be able to provide direct deposit of funds into the Township s bank account. The Fire Chief or his designee shall have the ability to review and authorize all accounts, prior to billing and again before being sent to collections if applicable. 2

3 SELECTION PROCESS The selection process will be based on the responses to this Request for Proposal. The Township of Redford reserves the right to select the proposal that best meets its needs. A committee comprised of members from the Fire Department, Finance Department and Township of Redford Clerks office will judge each proposer's response as determined by meeting the following criteria: Criteria Qualification of personnel assigned to this account; Capacity of firm to provide a full scope of services and to meet the requirements outlined within this proposal (Proposal Completeness) Relevant prior experience with similar engagements and References (Comparable Projects/References) Presentation best addresses the needs as described by the goals and objectives identified in the RFP (Experience/Qualifications) Presentation of a detailed, comprehensive and realistic work project approach (Work Program/Methodology) Reporting Capabilities Contingency Fee (Cost) Total possible rating Points 0-20 points 0-25 points 0-25 points 0-15 points 0-5 points 0-10 points 100 Points Proposal Completeness All Request for Proposal conditions and miscellaneous instructions as outlined herein are included in the proposal. The proposal is clear, complete and comprehensive. Comparable Projects/References Proposal provides references verifying exemplary service levels for similar services from firebased EMS agencies. References will be contacted to verify service levels and capability of the proposer to provide a thorough solution. Proposers shall provide a list of fifteen (15) concurrent projects of comparable scope and size (integrated billing and electronic data capture) to this request within the last two years in providing ambulance billing and accounts receivable services similar to those described in this document. Include a contact person (name, address, title, responsibility and telephone number). Experience/Qualifications The ambulance billing service and accounts receivable function which will best address the Cities goals and objectives as set forth in this document. This shall include: Years and capacity of the business The number of claims you currently process, in total, that make up your business portfolio; number of clients 3

4 Business locations and staffing Relative municipal provided ambulance billing, collection; reporting and electronic data capture experience. Education and training Identify any subcontracted firms that will be utilized to fulfill the Twp s requirements. Provide scope of work to be performed by the subcontracted firm as well as information relative to experience and qualifications of the proposed company. Provide a summary of all services provided by your company, or any of its affiliates, including collection or ambulance services. Provide corporate compliance plan that includes: policies and procedures to ensure compliance with all regulatory entities including Medicare/Medicade and commercial insurance carriers Work Program/Methodology As part of this Request for Proposal, the consultant shall provide a work program that will address the objectives as discussed herein. Your work program shall identify the tasks to be performed by your company and the timeframe to complete them. It must also identify who on the company s team will be performing the tasks and related experience. Proposals shall include implementation (start-up) strategies, communication and coordination procedures/recommendations and a complete description of the billing, reporting and collection processes utilized by the company. Provide within your proposal the methodology for utilization of electronic programs to streamline the processes, enhance reporting capabilities and increase communication. Identify software programs you currently utilize and those that integrate with your systems. Reporting Capabilities The following is a list of reports desired by the Twp.: Charge Detail Report (Trip Date) Displays charge details, including trip date, run number, customer name (Last name, First name), incident number, charge description, quantity, price per unit, and total charge amount. Charges are included based on the trip date. Charge Type Summary Report Displays a count of all charges in each charge type and the total dollars. Charges are included based on trip date. Credit as Type Summary Report (deposit date) Displays a count of credits and total amount, grouped by Credit As category. Credits are included based on the deposit date. 4

5 User Activity Report Credits Displays the credits posted by each user, and sorted by Credit As category. Includes trip date, run number, customer name (Last name, First name), credit description, deposit date, check #, and total credit amount. Credits are included based on the post date. Trip Detail (Current Payor) displays a trip list, grouped by trip date and sorted by current payor. All charges and credits are displayed for each trip, regardless of the actual payor. Payor is defined as the person or persons responsible for paying for all or part of the EMS services provided to the patient. Aging Detail Report (Patient/Aging Date) Displays aging, grouped by customer (Lname, Fname), and sorted in alphabetical order. Amounts are listed in the aging categories based on the aging date. Trips are included based on trip date and are listed. Aging Summary By Current Payor Displays aging, grouped by current payor. Amounts are listed in the aging categories (Current, 31-60, 61-90, , , over 180) based on the aging date. Trips are included based on trip date. Payment Credits by User (Deposit Date) Displays the credits posted by each user, and included trip date (date of service), run number, customer name (Last name, First name), credit description, and check #, amount and deposit date. Credits are included based on the deposit date. Payer Summary (Credit as Type/Deposit Date) Displays a count of credits and total amount, grouped by Credit As category and payor (for whom the credit was posted). Credits are included based on the deposit date. Other reports as requested by the Fire Chief, Finance Director or their designee. Reports may include but not limited to: Contractual Write Offs, Charity Cases, Bad Debt and Uncollectable Accounts Cost Sole source Cost Proposal for ambulance billing, accounts receivable, reporting and data capture services are believed to be the most advantageous to the Twp. Proposal shall provide a percentage fee based on an amount equal to a percentage of the amount collected each month for medical billing services. Any additional amounts for set-up, hardware, software, reports, collection fees or other fixed or percentage based fees must be included in the cost proposal. The Township of Redford requires a complete cost proposal for all applicable services. The review committee will evaluate and rank the proposals on the basis of the apparent greatest benefit to the Twp. Shortlisted proposers may be asked to provide a presentation to the review committee during the evaluation period. No negotiations, decisions, or actions shall be initiated by any firm as a result of any verbal discussion with any Township of Redford employee prior to the opening of responses to this document. The Township of Redford reserves the right to select, 5

6 and subsequently recommend for award, the proposal which best meets its required needs, quality levels, and budget constraints. The Township of Redford reserves the right to reject any and all proposals, to make an award based directly on the proposals, or to negotiate further with one or more firms. The Township of Redford further reserves the right to make the final determination of actual equivalency or suitability of proposals with respect to requirements outlined herein. The Township of Redford may award a contract based on initial offers received, without discussion of such offers. Proposer s initial offer should therefore be based on the most favorable terms available from a price and technical standpoint. The Township of Redford may, however, have discussions with those proposers that it deems in its discretion to fall within a competitive range. All proposals shall be opened publicly at the date and time specified. Each shall be recorded with the name of the proposer. All proposals shall be in accordance with the Purchasing ordinance and the requirements of this notice in order to be deemed responsive. CONTRACT PERIOD & PAYMENT TERMS A formal contract (submit sample copy with proposal) will be used and shall be subject to specifications, requirements, and conditions contained herein. A contractual period will begin following the Township of Redford Board approval of the recommended proposal, of a Three (3) year contract with options to renew for up to an additional 5 years. Payment shall be made on a monthly percentage collection basis. The percentage of the collection fee will be based on actual revenue received less refunds on overpayments. Payment will be made to vendor within thirty days from receipt of invoice. Mandatory Requirements These guidelines are provided to assist consultants submitting in response to this Request for Proposal in formulating a thorough response. The successful firm ensures and understands that: All licenses required by the State of Michigan are to be maintained by the firm during the course of the contract. The consultant will comply with the regulations, laws, ordinances and requirements of all levels of government applicable to this project. The company will represent that all tasks will be performed in accordance with generally acceptable professional standards. All required insurances are to be maintained by the firm during the course of the contract. The company will ensure completion of the work in accordance with the proposed time line as proposed. 6

7 General Conditions All inquiries from interested firms regarding this proposal must be directed to the attention of: Charter Township of Redford Fire Chief Tom Graham Beech Daly Rd. Redford Twp MI, All inquires will be made in writing in order that a written response in the form of an addendum can be processed before the proposals are opened: Inquires received after 12:00 pm EST on February 18, 2013 will not be considered. Additional information to this proposal from prospective firms may be requested. No proposal will be accepted from, or contract awarded to any person, firm, or corporation that is in arrears or is in default to the Township of Redford upon any debt or contract, or that is in default as surety or otherwise, or failed to perform faithfully any previous contract with the Twp.. No proposal may be withdrawn after it has been deposited with the Township of Redford except as provided by law. All costs incurred in the preparation, submission, and presentation of this proposal, in any way whatsoever, will be wholly absorbed by the prospective firm. All supporting documentation will become the property of the Township of Redford unless requested otherwise at the time of submission. The Township of Redford reserves the right to reject any and all proposals, to waive any informality in the proposal received, and to accept any proposal (or part thereof) which it will deem to be most favorable to the interests of the Township of Redford or to award to multiple proposers. The Township of Redford reserves the right to modify the scope of services during the course of the contract. Such modification may include adding or deleting any tasks this project will encompass and/or any other modifications deemed necessary. Any changes in pricing or payment terms proposed by the consultant resulting from the requested changes are subject to acceptance by the Twp.. Changes may be increases or decreases. The Township of Redford is exempt from all sales, excise, and transportation taxes. The selected firm must maintain for the life of the agreement insurance coverage meeting the minimum limits of liabilities as outlined in Appendix A. 7

8 No faxed proposals will be accepted. All information requested herein must be submitted with the proposal; failure to do so may result in rejection of the proposal as non-responsive and/or incomplete. All proposals must be in accordance with the Purchasing Ordinances of the Township of Redford and the requirements of this notice to be deemed responsive. Any deviation from the specifications must be noted in the proposal. Ownership of all data, materials and documentation originated and prepared for the Township of Redford pursuant to the Request for Proposals and the subsequent contract shall belong exclusively to the Twp.. The proposer will provide competent, suitable and qualified personnel to perform the work as required by the specifications. The proposer will designate a representative who will be the point of contact and will have the authority to act on behalf of the company. The proposer s representative will not be replaced without prior written notice to the Twp.. All communications given the proposer s representative will be as binding as if given to the company. The proposer shall not subcontract any or all portions of the work unless the Township of Redford grants prior written approval. Any subcontractor, so approved, shall be bound by the terms and conditions of this contract. The proposer shall be fully liable for all acts and omissions of its subcontractor(s) and shall indemnify the Township of Redford for such acts or omissions. All work shall meet with the approval of the Township of Redford Fire Chief, or his authorized representative, as conforming to the provisions and requirements of this contract. Advanced payments will not be authorized. Payments will be made on a time and materials basis and acceptance of services rendered. Correct invoices will be paid net 30 days, following the Cities schedule for payment of invoices. The Township of Redford reserves the rights to waive any informalities, or immaterial omissions or defects not involving price, time or changes in the work and to reject any or all proposals, if to do so is deemed in the best interest of the Twp.. In no event will an award be made until all necessary investigations are made as to the responsibility and qualifications of the consultant to whom it is proposed to make such award. Any contract awarded to a person or company who is discovered to have been in default or disqualified at the time of the awarding of the contract shall be voidable at the discretion of the Twp. Proposers are advised that the RFP is considered to be under evaluation from the opening date until contract award. The Fire Department staff and Township of Redford staff is restricted from giving any information relative to the progress of the evaluation during this time, except as described in this RFP and as required to administer the evaluation process Payment Terms Payment will be remitted net 30 days following receipt and authorization of a monthly invoice that includes the following detailed information: 8

9 Information for each discipline on each individual project: Amount of monthly payment Itemization of all additional services performed Number of hours spent on additional services Fees associated with these hours Balance of costs remaining Instructions to Proposers 1. Submit Three (3) COPIES, one original and two copies of your proposal. Proposers not responding to any of the specifications may be classified as unresponsive. The response must follow the format outlined in this proposal. Supplemental information may be attached. 2. Any significant explanation desired by a proposer, regarding the meaning or interpretation of the Request for Proposals must be requested with sufficient time allowed for a reply to reach all prospective proposers before the submission of their proposals. Any information given to a prospective proposer concerning the RFP will be furnished to all prospective proposers as an amendment or an addendum to the RFP, if such information would be of significance to uninformed proposers. The Township of Redford will make the sole determination as to the significance to uninformed proposers. Inquires regarding the proposal will not be accepted after 12:00 (Noon) EST, on February 18, 2013, Proposer shall be responsible to insure that he/she has all significant information prior to submitting a proposal. 3. All proposals shall be directed to the attention of: Charter Township of Redford Clerk s Office Beech Daly Rd. Redford Twp MI, APPENDIX A INSURANCE REQUIREMENTS Submit a Certificate of Insurance prior to the issuance of a purchase order meeting the minimum limits of liabilities as outlined. Certificate of Insurance shall have language the same as that shown in example. All insurance carriers must be acceptable to the Township of Redford and licensed in the State of Michigan. A new certificate of insurance shall be provided to the Township of Redford each year at the time of policy renewal. New certificates shall be delivered to the Township of Redford in the same format as outlined in the SAMPLE certificate attached. The Vendor shall not allow for any lapse of insurance coverage in the amounts shown below. Failure of the Vendor to maintain the required insurance shall be grounds for contract cancellation. 9

10 1. Workers Compensation Insurance. The Vendor shall procure and maintain during the life of this contract, Workers Compensation Insurance, including employers Liability Coverage, in accordance with all applicable statutes of the State of Michigan. 2. Commercial General Liability Insurance. The Vendor shall procure and maintain during the life of the blanket purchase order, Commercial General Liability Insurance on an Occurrence Basis with limits of liability not less than $1,000,000 per occurrence and/or aggregate combined single limit, Personal Injury, Bodily Injury, Bodily Injury and Property Damage. Coverage shall include the following extensions: (A) Contractual Liability; (B) Products and Completed Operations Liability; C) Independent Contractors Coverage; (D) Broad Form General Liability Extensions or equivalent; (E) Deletion of all Explosion, Collapse and Underground (XCU) Exclusions, if applicable. 3. Motor Vehicle Liability. The Vendor shall procure and maintain during the life of this contract Motor Vehicle Liability Insurance, including No-Fault coverage with limits of liability of not less than $1,000,000 per occurrence combined single limit Bodily Injury and Property Damage. Coverage shall include all owned vehicles, all non-owned vehicles, and all hired vehicles. 4. Umbrella Liability Insurance. The Vendor shall procure and maintain during the life of this contract, Umbrella Liability Insurance with limits of liability of not less than $1,000,000 per occurrence. 5. Additional Insured. Commercial General Liability Insurance, as described above, shall include an endorsement stating the following: Additional Insured s: The Township of Redford MI, 48239, all elected and appointed officials, all employees and volunteers, all boards, commissions and/or authorities and board members including employees and volunteers thereof. This coverage shall be primary to the Additional Insured s and not contributing with any other insurance or similar protection available to the Additional Insured s, whether other available coverage is primary, contributing or excess. 6. Cancellation Notice. Compensation Insurance, Commercial General Liability Insurance and Motor Vehicle Liability Insurance, as described above, shall include an endorsement stating the following: It is understood and agreed that Sixty (60) days Advance Written Notice of Cancellation, Non-Renewal, Reduction and/or Material Change shall be sent to the Twp. If any of the above coverage s expires during the term of the contract, the Vendor shall deliver renewal certificates and/or policies to the Township of Redford at least ten (10) days prior to the expiration date MINIMUM FIRM QUALIFICATIONS Please provide documents or evidence of the following: Proposer is certified/licensed for the types of services specified. Copies of all applicable certifications or licenses are included with this proposal. 10

11 Proposer has the capacity to acquire all required permits. Proposer has the capacity to coordinate with necessary approving/monitoring agencies; Proposer has provided services similar to those specified herein for a minimum of five (5) years. Does proposing firm have any previous or current billing violations (i.e., upcoding, incomplete signature requirements, etc.) with any regulatory entity or carrier? If the answer is yes, please include the detail of each. Has proposing firm undergone a comprehensive independent audit within the last 12 months? If so, please provide written documentation from the auditing agency detailing the results of same. Is, or at any time has, the proposing firm been a defendant in litigation or regulatory enforcement action? If the answer is yes, please include the detail of each. Demonstrate your understanding of local, state and federal billing laws and requirements. MANDATORY SERVICE SPECIFICATIONS AND REQUIREMENTS The Township of Redford desires the most thoroughly engineered and acceptable service available. The following specifications outline the minimum requirements of the proposed service. They are provided to assist proposers in understanding the objectives of the Township of Redford and submitting a thorough response. Proposals received must reflect in detail their inclusion and the degree provided. Vendors may propose methodologies which meet the spirit of the listed requirements, but shall note that the proposed service which meets all, or most closely meets the specifications will be recommended for award within the listed selection criteria. The successful proposer shall provide the following: Proposer has the ability to provide a Certificate of Insurance as described herein. Proposer has software that is ambulance billing compliant. Software is capable of immediate updates and changes from state and national agencies, as well as other industry organizations. Proposer guarantees daily claim filing with an electronic billing capacity, utilizing Medicare, Blue Cross/Blue Shield, Medicaid and commercial clearing house networks. Proposer is able to receive and edit reports immediately for clean claim transmissions. Proposer will provide on-site training for Fire Department administration staff on the software utilized. What is the name of the software that will be utilized? Describe its capacity. 11

12 Privacy and Security Explain your company s policy on the Township of Redford dismissing any charges. Provide details of pre-collection activities on accounts to significantly reduce accounts being turned over to collection or an outside collection agency if applicable (please specify) and describe process, fees, etc., (if utilizing the services of an outside collection agency). Provide details of handling bad debt, uncollectable and deceased patients accounts. Proposer will accept responsibility for all Fire Department EMS consumer billing inquiries and retrieval of medical records on normal business days from 8:00 am to 4:00 pm. Proposer accepts responsibility for all EMS consumer complaints and compliments by providing this information to the Fire Department administration (hard copy) no later than the following work day or by computer media. Proposer ensures responsibility for maintaining all software necessary to fulfill this agreement as well as the computer hardware to the extent that it owns such hardware. Proposer will supply the Fire Department administration with financial reports on a monthly basis. What custom reports are available? Provide the cost, if any. Monthly percentage of collection fee schedule is inclusive of all business costs including, but not limited to, the following: personnel, statements, envelope and return mail envelopes, HCFA 1500 claim forms, electronic clearinghouse service fees and postage. Describe in detail how the Fire Department would recover from a default by the successful proposer during the contractual period using the medical accounts receivable software. PRICING INFORMATION We, the above identified and signed, propose to provide the ambulance billing service and accounts receivable activity described herein for a monthly percentage of the amount collected of: Proposal shall include costs for any additional services Please state and detail any charges for start-up, installation and conversion of existing accounts receivable and all new business commencing with this contract. Please state and detail any other fees/charges, not stated above. Do you charge an administrative overhead fee for subcontracted services? Please explain. 12

13 State the amount of time required for completion of the proposed services, and provides a time line. TECHNICAL INFORMATION Please provide a detailed overview of the services to be provided in performance of this contract. List of credentials of legal services used for over site of operations and regulatory compliance Please indicate project manager/primary consultant for ambulance billing services, accounts receivable activities and data capture and reporting software. List credentials of project manager for EMS ambulance billing services, accounts receivable activities and data capture and reporting software. List ambulance billing, accounts receivable experience(s) of project manager for EMS billing services and data capture and reporting software List the individuals in the office that are certified coders. Also, indicate the number of employees focused on EMS billing. Describe any characteristics or capabilities which may make the Proposer uniquely qualified to provide the Fire Department EMS medical billing service, accounts receivable activities, and data capture and reporting software. Identify at least ten (10) clients who have direct knowledge of the proposer's medical billing service and electronic patient care reporting system. Please provide a description of the firm, its organization, size and nature of general services. Please provide a description of any special equipment, which will assist in fulfilling the services solicited herein. Specify the software supplier used and its version. What percentage of resources is associated with EMS billing clients? Describe the hardware to be used, the safeguards and protections, and the backup process. Describe the generation of patient statements, including a description of what the patient receives. Discuss the on-site training to be provided to Fire Department EMS staffing. Describe the composition of your firm s commitments, including the volume and size, number of transactions. List the percentage of total volume of each. List the capabilities of your firm to receive data from the Township of Redford electronically. 13

14 List the capabilities of your firm to send data to insurance companies for payment electronically. Submit samples of your reports, including patient data reports or screen prints. Include any reports, which show the effectiveness of your firm. How is your ad-hoc reporting data base language capabilities accessed, Microsoft Access, SQL, etc? What is the agency s average collection rate for ambulance clients? Does your company offer credit card payment as an option? If so, please describe the program and the involvement and costs affecting the Twp.. Does your company accept electronic run reports? If so, which software programs integrate with your system(s)? Describe your company s ability to submit the required electronic Gold certified XML file to the State of Michigan and all other stakeholders Please attach a copy of your standard contract. Conclusion The undersigned hereby declares that he/she has carefully examined the general conditions and specifications and will provide consulting services for Ambulance Billing Services as described herein for the price set forth in this proposal. Any changes to the specifications and its impact on the final cost will be discussed and mutually agreed upon before the delivery of the services. It is understood that all proposed prices shall remain in effect for at least one hundred twenty (120) days from the date of the proposal opening to allow for the award and that, if chosen the successful vendor, the prices will remain firm through invoice. The proposer affirms that he/she is duly authorized to execute this proposal, that this company, corporation, firm, partnership or individual has not prepared this proposal in collusion with any other proposer and that the contents of this proposal as to prices, terms or conditions have not been communicated by the undersigned, nor by any employee or agent, to any competitor, and will not be, prior to the award and the proposer has full authority to execute any resulting contract awarded as the result of, or on the basis of the proposal. The Proposer certifies that this proposal is submitted without collusion, fraud or misrepresentation as to the other proposers, so that all proposals for this project will result from free, open and competitive proposing among all vendors. By submission of a response, the Proposer agrees that at the time of submittal, he/she: (1) has no interest (including financial benefit, commission, finder s fee, or any other remuneration) and shall not acquire any interest, either direct or indirect, that would conflict in any manner or degree with the performance of Proposer s services, or (2) benefit from an award resulting in a Conflict of Interest. A Conflict of Interest shall include holding or retaining membership, or employment, on a board, elected office, department, division or bureau, or committee sanctioned by and/or governed by the Twp.. Proposers shall identify any interests, and the individuals 14

15 involved, on separate paper with the response and shall understand that the Twp., at its discretion may reject their proposal. The submission of a proposal hereunder shall be considered evidence that the proposer is satisfied with respect to the conditions to be encountered and the character, quantity and quality of the work to be performed. Representative s Name: SIGNED: PRINTED NAME: TITLE: FIRM NAME: 15