HomeMy WebLinkAboutExhibit7Certification Statement
Please quote on this form, if applicable, net prices for the item(s) listed. Return signed original
and retain a copy for your files. Prices should include all costs, including transportation to
destination. The Cite reserves the right to accept or reject all or any part of this submission.
Prices should be firm for a minimum of 120 days following the time set for closing of the
submissions.
In the event of errors in extension of totals, the unit prices shall govern in determining the quoted
prices.
We (1) certify that we have read your solicitation., completed the necessary documents, and
propose to furnish and deliver, F.A.B. DESTINATION, the items or services specified herein.
The undersigned hereby certifies that neither the contractual party nor any of its principal owners
or personnel have been convicted of any of the violations, or debarred or suspended as set in
section 18-107 or Ordinance No. 12271.
ALI exceptions to thi5. submission have been documented in the section below (refer to paragraph
and section).
EXCEPTIONS: CIGNA Voluntary does not provide hardcopies of the Provider Directory.
This information can be obtained through our website. The Getting Started packet also will
include a Geo Report of 10 providers in the insureds area sent with the ID Cards. CIGNA
Voluntary's Customer Service line is also equipped to assist any insured in locating a
participating provider.
We (I) certify that any and all information contained in this submission is true; and we (I) further
certify that this submission is rnade without prior understanding, agreement, or connection with
any corporation, firm, or person submitting a submission for the same materials, supplies,
equipment, or service, and is in all respects fair and without collusion or fraud. We (I) agree to
abide by all terms and conditions of this solicitation and certify that I am authorized to sign this
submission for the submitter. Please print the following and sign your name:
SUPPLIER NAME: CIGNA Voluntary
ADDRESS: 2222 W. Dunlap Ave., Suite 350, Phoenix, AZ 85021
PHONE: 860-226- 73 86 FAX: 860-226-8854
EMAIL: jenettg.fctznerc'•na.com BEEPER: nfa
SIGNED BY:
TITLE: D.
FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM SHALL DISQUALIFY THIS BID.
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