AttachMENT D

RFP No.: 15-0023CLAIMS LEGAL Services

RESPONSIBLE VENDOR REVIEW FORM

Contractspursuant to this RFP will be awarded only to Firms that are both responsible and responsive. A “responsible vendor” is a Firmthat has the capability in all respects to fully perform the contract requirements and the integrity and reliability that will assure good faith performance.

  1. Definitions. For this document, the terms listed below shall have the following meanings:
  1. Partner – means any person having an equity interest or management role in the Firm.
  2. Associate – means any licensed attorney employed by the Firm other than a Partner.
  3. Paralegal–means any person performing paralegal services for the Firm.
  4. Firm – meansthe entity submitting a responseto this RFP.
  1. Due Diligence Review. To determine if a Firm is “responsible” to receive a contract award, as required in Section 287.057, Florida Statutes, Citizens will review theinformation Firm submits on this form and elsewhere(“Due Diligence Review”). A Due Diligence Reviewwill generally cover a Firm’s soundness, operational capability, integrity, fitness, trustworthiness and reliability.
  1. Size of Firm. Does the Firm currently employ at least three (3) Florida licensed attorneys (Partners and/or Associates) on a full-time basis whoprovide legal services in at least one of the five (5) Service Areas included in this RFP and are located in the State of Florida? [Except for the Appellate Service Area, a “NO” answer will result in the disqualification of the Firm for this RFP. This minimum size requirement does not apply to Firms in the Appellate Service Area.]

 YES  NO

  1. Financial Stability. Does the Firm (i) have sufficient financial resources to pay its immediate, short-term and long-term obligations over the life of the Contract, (ii) generate operating income in excess of its operating expenses, and (iii) have the financial capacity to provide the legal services as specified in the Contract? [A “NO” answer will result in the disqualification of the Firm for purposes of this RFP.]

 YES  NO

  1. Other Required Information. For each “YES” answer below,Firm must provide a detailed written explanation and attach copies of any relevant documents.
  1. Within the past ten (10) years, has Firm(or any current Partner, Associate or Paralegal) been the subject of anydisciplinary actionsby any state bar association?

 YES  NO

  1. Within the past ten (10) years, has Firm(or any current Partner, Associate or Paralegal) been subject to any criminal charges, judgments, convictions, plea agreements, withholding of adjudication, or pre-trial interventions?

 YES  NO

  1. Within the past ten (10) years, havethere been any civil judgments or settlements for any actions against Firm(or any current Partner, Associate or Paralegal) related to fraud?

 YES  NO

  1. Has Firmor any Partner ever had a contract with Citizens terminated for cause?

 YES  NO

  1. Within the past two (2) years, has Firm or any Partner represented a party adverse to Citizens in any litigation?

 YES  NO

SIGNATURE: By my signature below, I certify that I am an authorized representative of the Firm named below and that all of the information provided above is true and complete to the best of my knowledge.

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