As we approach the FY21 contract year, our goal is to ensure that all FY21 contracts are executed timely and efficiently. To that end, we will need the documents below submitted to the Office of Provider Management by close of business on February 7, 2020. The deadline cannot be extended for any reason.
All documents should be submitted electronically to Brenda Jones at Brenda.Jones@dhs.ga.gov or faxed to 678-747-6881. If faxing, please include your organization's name, address and contact information on the cover page. If you have questions or concerns, contact either Brenda Jones at Brenda.Jones@dhs.ga.gov or 404-232-7860.
- Georgia Secretary of State Corporations Divisions (Print document showing Active/Compliance for year 2020- http://cgov.sos.state.ga.us)
- Corporate Resolution Letter (Not-for-Profit-Only) See attached sample. (Include contract period beginning July 1, 2020 and ending June 30, 2021).
- Criminal Background Form
- Security & Immigration Compliance Form
- Tax Compliance Form
- Void Business Check with Agency name
- W-9 (This form may change for FY21 – pending updated form from the accounting office).
- Vendor Management Form and Instructions (This form may change for FY21 – pending updated form from the accounting office).
- Vendor-Provider Request Form (fillable) (This form will hold 3 different site locations).
- Please note: A separate Vendor Request Form (VRF) is required for all changes to the contract. Select and complete the appropriate attached Vendor Request Form for all changes. Please email the VRF to Brenda Jones, Brenda.Jones@dhs.ga.gov to be considered for change request approval.
- Certificate of Liability Insurance – Single page only listing required coverage below. (Please do not send the entire policy package).
- Malpractice/Professional Liability Policy (Claims Based) with Electronic Data processing (EDP), Errors and Omissions Coverage. $1 million per occurrence/$3 million aggregate policy limits.
- Commercial General Liability Policy (Occurrence) to include contractual liability. $1 million per occurrence/$3 million dollar aggregate policy limits.
- Business Auto Policy (Occurrence) to include but not be limited to liability coverage on any owned, non owned and hired vehicle used by Contractor or Contractor’s personnel in the performance of this Contract. $1 million per occurrence/$3 million dollar aggregate policy limits.
- Commercial Umbrella Policy (Occurrence). An umbrella policy may cover the aggregate policy limits required herein. There must be no gap between the $1 million and $3million dollar policy limits and the umbrella policy must follow the form of the underlying $1 million primary policy.
- Workers Compensation Insurance (Occurrence) in the amounts of the statutory limits established by the General Assembly of the State of Georgia in Title 34, Chapter 9 of the O.C.G.A. (A self-insurer must submit a certificate from the Georgia Board of Workers Compensation stating that Contractor qualifies to pay its own workers compensation claims). Contractor shall require all subcontractors that are required by stature to hold workers compensation insurance and that occupy the premises or perform work under this Contract to obtain an insurance certificate showing proof of Worker Compensation Coverage.
Thanks in advance,
The Office of Provider Management