Item J2BOARD OF COUNTY COMMISSIONERS
County of Monroe A
Mayor Heather Carruthers, District 3
f (, S �� Mayor Pro Tem George Neugent, District 2
- Me Florida Keys t� ) � �` ��
�' Danny L. Kolhage, District 1
David Rice, District 4
Sylvia J. Murphy, District 5
County Commission Meeting
November 22, 2016
Agenda Item Number: J.2
Agenda Item Summary #2302
BULK ITEM: Yes DEPARTMENT: Fire & Ambulance District 1 Board of
Governors
TIME APPROXIMATE: STAFF CONTACT: James Callahan (305) 289 -6088
9:30 A.M. BOARD OF GOVERNORS
AGENDA ITEM WORDING: Approval to award proposal and enter into a Contract between the
Monroe County Board of County Commissioners, The Board of Governors Fire and Ambulance
District 1 of Monroe County, Florida, and Bound Tree Medical LLC furnishing specified medical
supplies and pharmaceuticals at set contract pricing, and provisional pricing on non - specified items
reflected as a 25% discounted percentage rate off list, and approval for Fire Chief to sign all
documents as needed to complete the transaction.
ITEM BACKGROUND: On September 7, 2016 at 3:00 pm, sealed proposals were opened to
furnish medical supplies and pharmaceuticals to Monroe County Fire Rescue for use at the Fire
Stations and on the ground and air ambulances. Per the RFP, the guidelines used for analyzing and
evaluating the various proposals were as follows: Pricing (30 points), Technology (30 points),
Required Services (30 points), References (10 points), and Local Preference (10 points). On
October 25, 2016, a Selection Committee Meeting was held at the Marathon Annex at 9:00 am.
Three members were present at the meeting with a fourth member previously completing and
providing review for public record on October 11, 2016.
Attachment A of the RFP mandated:
1. Set contract pricing on all 193 items
2. A discount off list (provisional pricing) for items not on Attachment A
Three (3) proposers were ranked:
1. Midwest Medical Supply — proposed 160 items — 28% off
2. Moore Medical LLC — proposed 179 items — 18% off
3. BoundTree Medical — proposed all 193 items — 25% off
In comparing the aforementioned companies, Bound Tree Medical LLC had more competitive
pricing on the most frequently purchased medical supplies. The Selection Committee recommends
accepting the Bound Tree Medical LLC proposal, and entering into a contract commencing on
December 1, 2016 and ending November 30, 2019; with two one -year options for renewal. Please
refer to the selection committee's individually attached score and ranking sheets.
PREVIOUS RELEVANT BOCC ACTION: On November 17, 2010, the Board approved a contract
used for medical supplies between Monroe County Board of County Commissioners, The Board of Governors
Fire and Ambulance District 1 of Monroe County, Florida, and Bound Tree Medical LLC commencing
December 1, 2010 thru November 30, 2013 with no renewal options. On November 17, 2013, the current
contract was approved for medical supplies between Monroe County Board of County Commissioners (Item
K3) and The Board of Governors Fire and Ambulance District 1 of Monroe County, Florida (Item G11) and
Bound Tree Medical LLC commencing December 1, 2013 thru November 30, 2016 with no renewal options.
CONTRACT /AGREEMENT CHANGES:
N/A
STAFF RECOMMENDATION: Approval
DOCUMENTATION:
Contract
FINANCIAL IMPACT:
Effective Date: December 1, 2016
Expiration Date: November 30, 2019
I" year renewal option December 1, 2019 — November 30, 2020
2 nd year renewal option December 1, 2020 — November 30, 2021
Total Dollar Value of Contract: Approximately $149,200
Total Cost to County: Approximately $149,200
Current Year Portion: $149,200
Budgeted: $149,200
Source of Funds: 141 -11500 and 101 -11001 and 404 -63100
CPI: N/A
Indirect Costs: N/A
Estimated Ongoing Costs Not Included in above dollar amounts: N/A
Revenue Producing: No If yes, amount:
Grant: No
County Match: N/A
Insurance Required: Attached
Additional Details:
11/22/16 141 -11500 FIRE & RESCUE CENTRAL $100,000.00
11/22/16 101 -11001 MEDICAL AIR TRANSPORT $42,000.00
11/22/16 404 -63100 - FIRE & RESCUE KW AIRPORT $7,200.00
Total: $149,200.00
REVIEWED BY:
Pedro Mercado Completed 11/06/2016 3:05 PM
James Callahan Completed 11/07/2016 8:22 AM
Kathy Peters Completed 11/07/2016 12:20 PM
Board of County Commissioners Pending 11/22/2016 9:00 AM
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BOARD OF COUNTY COMMISSIONERS
3 t
Co un ty Of M onr oe ; Mayor Heather Carruthers, District 3
lrl I J j Mayor Pro Tem George Neugent, District 2
- Me Florida. Keys Danny L. Kolhage, District 1
David Rice, District 4
Sylvia J. Murphy, District 5
Emergency Services Department
49063 rd Street Ocean
Marathon, FL 33050
Phone (305) 289 -6088 6
MEMORANDUM
DATE: October 28, 2016
TO: Jim Callahan, Fire Chief / Department Head
FROM: Holly Pfiester, Executive Administrator
RE: Request for Proposals (RFP), Medical Supplies and Pharmaceuticals, Selection Committee
Chief Callahan,
On September 7, 2016 at 3:00 pm, sealed proposals were opened to furnish medical supplies and
pharmaceuticals to Monroe County Fire Rescue for use at the Fire Stations and on the ground and air
ambulances.
On October 25, 2016, a Selection Committee Meeting was held at the Marathon Annex at 9:00 am. Present
at the meeting were Steve Hudson — Deputy Chief of Operations, Shannon Davis Weiner — Planner from
Emergency Management, and Robby Davis — Logistics. Gary Boswell — Deputy Chief of Administration
had previously completed and provided his review for public record on October 11, 2016.
Attachment A of the RFP mandated:
1. Set contract pricing on all 193 items
2. A discount off list (provisional pricing) for items not on Attachment A
Per the RFP, the guidelines used for analyzing and evaluating the various proposals were as follows: Pricing
(30 points), Technology (30 points), Required Services (30 points), References (10 points), and Local
Preference (10 points).
Three (3) proposers were ranked:
1. Midwest Medical Supply — proposed 160 items — 28% off
2. Moore Medical LLC — proposed 179 items — 18% off
3. BoundTree Medical — proposed all 193 items — 25% off
E 4�
Page 1 of 2
Each individual on the selection committee recommends accepting the Bound Tree Medical LLC proposal,
and entering into a contract commencing on December 1, 2016 and ending November 30, 2019; with two
one-year options for renewal. Please refer to the selection committee's individually attached score and
ranking sheets.
A
Gary Boswell — Deputy Chief of Administration
Steve Hudson — Deputy Chief of Operations
ILI"
Davis , Weiner — Planner from Emergency Management
— Logistics
:I 4�
Page 2 of 2
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CONTRACT BETWEEN
THE BOARD OF COUNTY COMMISSIONERS
AND
THE BOARD GOVERNORS
FIRE AND AMBULANCE DISTRICT 1
OF MONROE COUNTY, FLORIDA
AND
BOUND TREE MEDICAL, LLC
FOR THE PURCHASE OF MEDICAL SUPPLIES AND PHARMACEUTICALS
THIS CONTRACT, hereinafter "CONTRACT" or "AGREEMENT ", is made and entered into
this 1 st day of December, 2016 by and between the Monroe County Board of County
Commissioners and Board of Governors Fire and Ambulance District 1 of Monroe County,
Florida, hereinafter referred to as "COUNTY ", and Bound Tree Medical, LLC, hereinafter
referred to as "CONTRACTOR".
WITNESSETH:
WHEREAS, the COUNTY advertised a notice of request for proposals for medical supplies and
pharmaceuticals.
WHEREAS, the successful Proposer was Bound Tree Medical, LLC, and;
WHEREAS, this CONTRACTOR represents that it is capable and prepared to provide such
services, and;
WHEREAS, the COUNTY intends to enter into an agreement to furnish medical supplies and
pharmaceuticals at set pricing and;
WHEREAS, this contract is an "Agreement" between both parties,
NOW, THEREFORE, in consideration of the promises contained herein, the parties agree
as follows:
1. CONTRACT DOCUMENTS — This contract consists of the Agreement, the
CONTRACTOR'S response to the Request for Proposals (RFP), and the documents
referred to in the Agreement as a part of this Agreement. In the event of any conflict 0
between any of the contract documents, the one imposing the greater burden on the
CONTRACTOR will control.
E
2. CONTRACT PERIOD AND RENEWAL - The effective date of this Agreement shall be "
December 1, 2016 through November 30, 2019, with two one -year options for renewal,
subject to the approval of the Monroe County Board of County Commissioners and the
Board of Governors of Fire and Ambulance District 1.
3. CONTRACT TERMINATION - This Agreement may be terminated for any reason by
either party on 30 -day written notice without cause. If the CONTRACTOR fails to fulfill
the terms of this Agreement, or attachments, properly or on time, or otherwise violates
the provisions of the agreement or of applicable laws or regulations governing the use of
funds, the County may terminate the contract immediately by written notice. The notice
shall specify cause. All finished or unfinished supplies or services shall, at the option of
the County, become property of the County. The County shall pay the CONTRACTOR
fair and equitable compensation for expenses incurred prior to termination of the
agreement, less any amount or damages caused by the CONTRACTOR'S breach. If the
damages are more than compensation payable, the CONTRACTOR will remain liable
after termination and the County shall pursue collection for damages.
4. SUBJECT MATTER OF CONTRACT - This Agreement is to furnish medical supplies
and pharmaceuticals at set pricing to Monroe County Fire Rescue.
PRICING — is set forth in the Medical Supply Discount Off List and Pricing Worksheet
(Attachment A). This will be inserted in the contract, which outlines both a discount in
the form of a percentage off list, and pricing on specified numbered items.
6. QUALITY INSURANCE PROVISIONS
A. Quality and Quality Control. A system of test inspections shall be used to insure
receipt of the quality and quantity of material(s) /service(s) purchased.
Material(s) /Service(s) will be promptly inspected any discrepancies from the
purchase order and /or the supplier's invoice shall be reported immediately by the
Monroe County Logistics Specialist.
B. Material Safety Data Sheet (MSDS). Any items delivered must be accompanied
by a MSDS. The MSDS must be maintained by the user agency and must include
the following information:
1) The Chemical name and the common name of the toxic substance.
2) The hazards or other risks in the use of the toxic substance, including:
a) The potential for fire, explosion, corrosively and reactivity;
b) The known acute and chronic health effects of risk from exposure, F
including the medical conditions which are generally recognized as
being aggravated by exposure to the toxic substance; and
0
c) The primary routes of entry and symptoms of overexposure.
3) The proper precautions, handling practices, necessary personnel °P
protective equipment, and other safety precautions in the use of, or
exposure to, the toxic substances, including appropriate emergency
treatment in the case of overexposure.
4) The emergency procedure for spills, fires, disposal and first aid.
5) A description, in lay terms, of the known specific potential health risks
posed by the toxic substance intended to alert any person reading this
information.
6) The year and month, if available, that the information was compiled and
the name, address, and emergency telephone number of the
manufacturer responsible for preparing the information.
C. CONTRACTOR must be able to supply contracted requested supplies within a
three (3) business day time frame of normal request of supplies when the County
has made that request within normal working hours of 8 am to 5 pm Monday
through Friday. During emergency (natural or man -made emergencies) situations
CONTRACTOR must be able to supply requested supplies on a next day basis,
twenty -four (24) hours a day seven (7) days a week.
7. CONTRACTOR'S LIABILITY
A. Warranty. It shall be the CONTRACTOR'S responsibility to submit at the time of
shipment the original manufacturer's warranty for the materials supplied.
CONTRACTORS shall follow procedure(s) to accomplish supplying a
replacement product, if warranted. Replacements shall be finalized within five
working days of reporting the defect.
B. Guarantee. The material(s) supplied shall be guaranteed to be free from defect of
composition, conception and workmanship for a minimum period of 120 days
from the date of acceptance by the County. Any parts or portions found not in
accordance with this specification will be rejected by the County and returned to
the CONTRACTOR at the CONTRACTORS expense for immediate
replacement.
8. SPECIFICATIONS:
A. Substitutions. Items supplied shall be as ordered and specified. When
substitutions are recommended or necessary, the determination as to whether any
proposed substitution is or is not equal to the product specified as a standard shall
be made by the COUNTY, and such determination shall be final and binding.
B. Quality. The materials to be furnished shall be currently in production and shall
be of the manufacturer's standard or better quality.
0
C. Quantities. The quantities listed on the Medical Supply Discount Off List and
Pricing Worksheet (Attachment A) are estimated quantities for one (1) year. The
COUNTY shall not be required to purchase any minimum or maximum quantities E
during the term of any award resulting from this specification. The COUNTY
may purchase as little as zero percent (0 %) or exceed as much as one hundred
percent (100 %) of the forecasted or estimated quantities
D. Packaging. Only materials that are packaged in the original factory fresh
packaging shall be accepted. No materials that have been re- packaged or that are
in the adulterated or damaged packages shall be accepted at the receiving
location, nor shall after - market materials be accepted at the receiving location.
Any attempts by the CONTRACTOR to furnish the COUNTY with other than
first quality materials shall constitute default as outlined in this specification.
E. Refrigeration. Maintaining a specific temperature range throughout the shipping
process is essential to the quality of healthcare products. Only materials which
have been properly shipped in a temperature - controlled environment shall be
accepted by the COUNTY.
F. Expiration Dates. All merchandise shall have a minimum expiration date of 18
months from date of shipment, and date must be displayed on the package.
9. CONDITIONS:
A. Authorization. All orders shall be placed via Monroe County by individual
Purchase Orders generated by the County's electronic ordering software,
Operative IQ, or as "Open" Purchase orders, at the County's election.
B. Furnishing Items. Contract items are to be furnished on an "as needed, when
needed basis" during the life of the contract.
C. Delivery. Materials ordered shall be delivered within three (3) business days after
receipt of order. Failure to do same shall be considered breach of contract or
default, and the COUNTY shall utilize its options as stated within the proposal
specification.
D. Backorders. In the event an item is not immediately available at the time of an
order, or is not able to be delivered within three (3) days, the County shall have
the option of purchasing the item from another vendor.
E. Penalties. The COUNTY reserves the right to increase or decrease quantities
shown without penalty.
F. Addition /Deletion. The COUNTY reserves the right to add or delete any item N
from this proposal or resulting contract when deemed to be in the interest of the
COUNTY.
G. Samples. When required, samples shall be labeled with the CONTRACTORS' 0
name and item number and shall be furnished free of charge. Samples not
destroyed will be returned upon request at the CONTRACTOR'S expense.
E
H. Substitution. The CONTRACTOR shall not substitute items for like items "
without the approval of the COUNTY. Any violation of such procedure may
result in a possible cancellation of the contract. All approved substitutes shall be
annotated as such on the CONTRACTOR'S shipping document(s).
I. Contract Prices. Contract prices from Medical Supply Discount Off List and
Pricing Worksheet (Attachment A) shall be firm and shall not be amended after
the contract is executed. Any attempt by the CONTRACTOR to amend said
prices unilaterally shall constitute default as outlined in the contract.
Prices quoted shall include all shipping costs, shipped F.O.B Marathon, Florida or
to the facility location specified by the requestor or the purchase order.
All taxes of any kind and character payable on account of the work done and
materials furnished under the award shall be paid by the CONTRACTOR and
shall be deemed to have been included in the price. The COUNTY is exempt
from all state and federal sales, use, transportation, and excise taxes.
Contract prices shall include all royalties and costs arising from patents,
trademarks, and copyrights in any way involved in the work. Whenever the
CONTRACTOR is required or desires to use any design, device, material or
process covered by letters of patent or copyright, the CONTRACTOR shall
indemnify and save harmless the COUNTY, its officers, agents, and employees
from any and all claims of infringement by reason of the use of any such patented
design, toll, material, equipment or process, to be performed under the contract,
and shall indemnify the said COUNTY, its officers, agents and employees for any
costs, expenses and damage which may be incurred by reason of any infringement
at any time during the prosecution or after the completion of the work.
J. Contract Provisional Prices off List Price. Contract pricing for items not
included on Medical Supply Discount Off List and Pricing Worksheet
(Attachment A) and sold to the County at a discounted percentage rate off the list
price issued by CONTRACTOR shall be firm and shall not be amended after the
contract is executed. Any attempt by the CONTRACTOR to amend said prices
shall constitute default as outlined in the contract.
COUNTY will verify items by a printout from the CONTRACTOR's online
catalog showing both the "list price" and "your price ", the latter being the
COUNTY'S price.
K. Contract Changes. No changes, over the contract period, shall be permitted ..
unless prior written approval is given by the Monroe County Board of N
Commissioners and the Board of Governors of Fire and Ambulance District 1.
No CONTRACTOR shall assign the contract or any rights or obligations there
under to a subcontractor without the prior written approval of the Monroe County
Board of Commissioners and the Board of Governors of Fire and Ambulance
District 1.
L. Price Escalation. The County will allow a price escalation provision for items on
the Medical Supply Discount Off List and Pricing Worksheet (Attachment A) with
this award. The original CONTRACTOR prices on Medical Supply List Pricing <
Worksheet (Attachment A) shall be firm for a one (1) year minimum period. A
price escalation /de- escalation will be allowed one (1) year after the beginning of
the award period and at one (1) year intervals thereafter, provided the
CONTRACTOR notifies the COUNTY, in writing of any requested price changes
at least sixty (60) days prior to those changes taking effect. This request must be
accompanied by a certified letter from the CONTRACTOR'S supplier showing
the price increase to the contractor. The price increase to the County shall be
limited to the percentage increase to the CONTRACTOR as stated in this letter.
If, at the point of exercising the price escalation provision, market media
indicators show that the prices have decreased, and that the CONTRACTOR has
not passed the decrease on to the COUNTY, the COUNTY reserves the right to
place the CONTRACTOR in default, cancel the contract, and remove the
CONTRACTOR from the COUNTY's CONTRACTOR list for a period of time
deemed suitable to the COUNTY.
M. Invoicing. The CONTRACTOR shall furnish the COUNTY complete itemized
invoices for the goods received. Invoices are to reflect the prices stipulated on the
purchase order, and as outlined on the Medical Supply Discount Off List and
Pricing Worksheet (Attachment A). Invoices are also to reflect the provisional
price discount in the form of a percentage at which the CONTRACTOR will sell
these items off its list price.
The COUNTY will not accept an aggregate invoice. As part of the award
process, the COUNTY may request a sample invoice. Invoices shall contain, but
not limited to the following information:
• Invoice number
• Company name
• Purchase order number
• Location and dates of delivery
• Cost of items as stated on the contract and extended price to reflect total
cost for number of items received.
N. Payment. Full payment will be made by the COUNTY after receipt and
acceptance of materials /services and proper invoices in accordance with the
Florida Local Government Prompt Payment Act, Section 218.70 et al.
O. Ordering. CONTRACTOR will provide web -based online ordering website
designed specifically for service.
P. Disaster Recovery. CONTRACTOR must have a proven Disaster Support
Program in place and shall provide the COUNTY with emergency numbers for 0
these situations. These numbers will be updated immediately if the contact
number changes.
10. INDEMNIFICATION — CONTRACTOR shall indemnify and hold the COUNTY and "
Monroe County and Monroe County Fire and Ambulance District 1 harmless for any
negligence on its part or faulty or improper workmanship, for all work performed under
this contract, including all costs of collection, reasonable attorney fees, claim costs, and
as per "Attachment V. All property or equipment being directly maintained or repaired
by CONTRACTOR shall be considered in its care, custody, and control while such work
is in progress and until physical control of such property or equipment is restored to the
COUNTY.
1 1. INSURANCE — The Proposer will comply with the insurance requirements listed in
Attachi I to the RFR
12. ADDITIONAL REQUIRED STA / VERIFICATIONS
AFFIDAVI"I'S. Attached hereto in Attachments
Attachment A —
Medical Supply Discount Off List and Pricing Workshect
Attachment B —
Submission Proposal Response Form
Attachment C —
Non-ColklSion Affidavit
Attachment 1) — Lobbying and Conflict of Interest
Attachment E —
Drug Free Workplace
Attachment F —
Public Entity Crime Statement
Attachment G —
Local Preference (if applicable)
Attachment I I —
Scope of Set-vices Response Form
Attachment I —
Request for Waiver of Insurance Requirements (if applicable)
13. Monroe County's performance and obligation to pay Under this contract is contingent
upon an annual appropriation by the Board of County Cornmissionets of Monroe County,.
Florida.
14. Venue for any litigation arising under this contract must be in a court of competent
jurisdiction in Monroe County, Florida. This Agreement is not subject to arbitration.
IN WITNESS WHEREOF, each party hereto has caused this contract to be eXeCUted by its duly
ailthorized representative.
(SEAL) 130ARD OF COUNTY COMMISSIONERS
ATTEST: AMY HE AVILIN, OF MONROE COUNTY, FLORIDA
COUNTY CLERK
in
By:
Clerk of Court, Arriy Heavilin
13OUND TREE MEDICAL, LLC:
By:
Print Name and `Title
Mayor
BOARD OF GOVERNORS OF FIRE AND
AMBULANCE DISTRICT I OF MONROE
COUNTY, Ft.,
By:
Mayor / Chairperson
E 4�
Date.
"I ' /'1 -,
0,
SECTION FOUR: ATTACHMENTS AND FORMS
Attachment A Medical Supply Discount Off List and Pricing Worksheet
Attachment B Submission Proposal Response Form
Attachment C Non - Collusion Affidavit
Attachment D Lobbying and Conflict of Interest
Attachment E Drug Free Workplace
Attachment F Public Entity Crime Statement
Attachment G Local Preference
Attachment H Scope of Services Response Form
Attachment I Insurance Requirements, Indemnification/Hold Harmless, and Request for
Waiver of Insurance Requirements
Z 4�
FirmriarortmA
o 11ARTEMIENIBM-.1 LUMMIM
ITEM
CATEGORY
ITEM DESCRIPTION
1
AIRWAY
ENDOTRACHEAL TUBE CUFFED WITH STYLETTE 5.0 IO/BX FLEX]-SET
2
AIRWAY
ENDOTRACHEAL TUBE CUFFED WITH STYLETTE 5.5 IO/BX FLEXI-SET
3
AIRWAY
ENDOTRACHEAL TUBE CUFFED WITH STYLETTE 6.5 10/BX FLEXI-SET
4
AIRWAY
ENDOTRACHEAL TUBE CUFFED WITH STYLETTE 7.0 10/BX FLEX[-SET
5
AIRWAY
ENDOTRACHEAL TUBE CUFFED WITH STYLETTE 7.5 10/BX FLEXI-SET
6
AIRWAY
. . ...... . .... . ...
ENDOTRACHEAL TUBE CUFFED WITH STYLETTE 8.0 10/BX FLEXI-SET
7
AIRWAY
ENDOTRACHEAL TUBE CUFFED WITH STYLETTE 8.5 10/BX FLEXI-SET
8
AIRWAY
ENDOTRACHEAL TUBE CUFFED WITH STYLETTE 9.0 10/BX FLEXI-SET
9
10
AIRWAY
JAIRWAY
ENDOTRACHEAL TUBE HOLDER ADULT 100/CS THOMAS
ENDDTRACHEAL TU BE U NCU FFED WITH STYLETTE 2.5 ID/BX FLEX]-SET
II
AIRWAY
I ENDOTRACHEAL TUBE U NCU FFED WITH STYLETTE 3.0 10/BX F'
12
AIRWAY
ENDOTRACHEAL TUBE U NCU FFED WITH STYLETTE 3.5 10/BX FLEX]-SET
13
14
AIRWAY
AIRWAY
- - --- - ----- . ....
ENDOTRACHEAL TUBE UNCUFFED WITH STYLETTE 4.0 10/BX FLEX]-SET
ENDOTRACHEAL TUBE UNCUFFED WITH STYLETTE 4.5 10/BX FLEXI-SET
15
AIRWAY
ET TUBE DISP, INTRODUCER, BLUE STARIGHT TIP 15 FRENCH X 70 CM, ADULT
16
AIRWAY
IGEL 02 RESUS PAK ADULT SIZE 3 YELLOW HOOK RING BY INTERSURGICAL
17
AIRWAY
IGEL 02 RESUS PAK ADULT SIZE 4 YELLOW HOOK RING BY INTERSURGICAL
18
AIRWAY
IGEL 02 RESUS PAK ADULT SIZE 5 YELLOW HOOK RING BY INTERSURGICAL
19 JAIRWAY
KING VISION VIDEO LARYNGOSCOPE BLADE, CHANNELED, DISP, 18 MIA, W/WHITE LED, DIGITAL CIVICS CAMERAL 10EA/ BK
20
AIRWAY
KING VISION VIDEO LARYNGOSCOPE BLADE, STANDARD, DISP. 13 MM, W/WHITE LED, DIGITAL CMOS CAMERAL IDEA/ FIX
21
AIRWAY
LARYNGOSCOPE BLADE DISP. FIBEROPTIC STAINLESS STEEL MAC# I GREENLINE
22
AIRWAY
LARYNGOSCOPE BLADE DISP. FIBEROPTIC STAINLESS STEEL MAC N 2 GREENLINE
23
AIRWAY
jLARYNGOSCOPE BLADE DISP. FIBEROPTIC STAINLESS STEEL MAC 4 3 GREENLINE
24
IAIRWAY
LARYNGOSCOPE BLADE DISP. FIBEROPTIC STAINLESS STEEL MAC 04 GREENLINE
25
IAIRWAY
LARYNGOSCOPE BLADE DISP, FIBEROPTIC STAINLESS STEEL MILLER 4 0 GREENLINE
AttachmentA
Medical Supply Discount Off List and Pricing Worksheet
ITIM CATEGORY ITEM DESCRIPTION
It
26
AIRWAY
LARYNGOSCOPE BLADE DISP. FIBEROPTIC STA INLESS STEEL MILLER 4 1 GREENLIN
27
AIRWAY
LARYNGOS BLADE DISP, FIBEROPTIC STAINLESS STEEL MILLER # 2 GR
28
AI RWAY
iLAR BLADE DISP. FIBEROPTIC STAINLES STEE MILLER N 3 GREENUNE
29
AIRWAY
LARYNGOSCOPE BLADE DISP. FIBEROPTIC STAINLESS STEEL MIL 4 4 GREENUNE
30
AIRWAY 1 1-ARYNGOSCOPE
HANDLE, GREENLINE FIBER OPTIC, PENLITE CHROME PLATED BRASS 2 AA BAT'T'ERIES
31
AIRWAY
LUBRICATIN JELLY 23 GRAM, FOIL PACK, STERILE, WATER S OLUBLE, MINI PA 14 4/BX �-
32
AIRWAY
NASOGASTRIC TUBE 08FR RUSH LEVIN
33
AIRWAY
N ASOGASTRIC TUBE, 10FR RUSH LEVINE
34
AIRWAY
NAS OGASTRIC TUBE 12FR RUSH LEVI
35
AIRWAY
NASOGASTRIC TUBE, 14FR RUSH LEVINE
36
AIRWAY
NASOGASTRIC TUBE, 1 RU LEVINE
37
AIRWAY
NASOGASTRIC TUBE, 18FR RU LEVINE
38
AIRWAY
_
NASOPHARYNGE AIRWAY NPA LATEX FREE PVC 12 FRENCH 10/BX RUSC14 �
39
AIRWAY
NASOPHARYNGEAL AIRWAY - NPA - LATEX FREE. PVC 14 FRENCH 10/BX RUSCH
40
41
AI RWA Y
AIRWAY —
N AIRW - NP a L ATE X FREE P VC 16 FRENCH 1 0/B RUS
NASOPHARYNGEAL AIRWAY - NPA - LATEX FREE PVC 18 FRENCH 10/BX RUSCH � � �-
42
AIRWAY
NASOPHARYNGEAL AIRWAY - NPA - LATEX FREE PVC 20 FRENCH 1G/BX RUSCH
43
AIRWAY
NASOPHARYNGEAL AIRWAY - NPA - LATEX FREE PVC 22 FRENCH 10 /BX R USCH
44
AIRWAY
NAS OPHARYNG EAL AIRWAY - NP - LATEX FREE PVC 24 FRENCH 1€1 /BX RU SCH w
45
AIRWAY
NASOPHARYNGEALA]RWAY- NPA - LATEX FREE PVC 26 FRENCH 10 /BX RUSCH
46
AIRWAY
NASD PHARYNGEAL AIRWAY - NPA - LATEX FREE PVC 28 FRENCH 10/BX RUSCH
47
AIRWAY
NAS OPHARYNGEALAIRWAY - NPA - LATEX FREE PVC 30 FREN 10 /BX RUSC
48
49
AIRWAY
AIRWAY
ORAL AIRWAY, 100MM PURPLE BERMAN
ORAL AIRWAY, 50MM TURQUOISE BERMAN
50
AIRWAY
ORAL AIRWAY, 60MM BLACK BERMAN
51
AIRWAY
O RAL AIRWAY, 70MM WHITE BERMAN
52
AIRWAY
ORAL AIRWAY, 80MM GREEN BERMAN
53
AIRWAY
ORAL AIRWAY, 90MM YELLO BERMAN
54
AIRWA
SUCTION CANIS DIS POSABLE RED TOP 800cc
55
AIRWAY
ISUCTION CANISTER WITH PREATTACHED 6 FT TUBING GREEN 1200ce 48/CS
Attachwent
IT EM
CATEGOR
ITEM DESCRIPTION
56
AIRWAY
SUCTION CATHETER, 12FR, COILED, GRADUAT FROSTED SURFACE, KINK RESISTANT
57
AIRWAY
SUCTION CAT 1411, COILED, GRADUATED, FROSTED SUR KINK RES
SR
AIRWAY
SUCTION CATHETER, 16FR, COILED, GR ADUATED, FROSTED SURFACE, KINK RESISTANT
59
AIRWAY
SUCTION CATHETER, 18FR, C OILED, GRADUATED, FROSTED SURFACE, KINK RESISTANT
60
AIRWAY
SUCTION CATHETER, 6FR, C OILE D, GRADUATED, FROSTED SURFACE, KINK RESIS
61
AIRWAY
SUCTION CATHETER, 8FR, COILED, GRADUATED, FROSTED SURFACE KINK RESIST
L6.2
AIRWAY
SUCTION TIP YANKAUER , BULB TIP WI CONTROL VENT STE C'URAPLEX ^
63
AIRWAY
SUCTIO TUBING ONLY 1/4 IN X £J FT 50/CS
64
AIRWAY
BAAM AIR FLOW M ONITOR
65
AIRWAY
EN TIDAL CO2 SMART CAPNOLI PLUS OXYG ORIDION ADULT `/ IN TERMEDIATE
66
AIRWAY
FILTERLINE SET, NON HUM IDIFIED, INTUBATED AD ULT /PEDIATR O RIDIO N MIC
67
BAN DAGES /DRESSING
BANDAGE ADHESIVE FLEXIBLE Latex free 1 IN X 3 IN, LF 100 /BX Johnson and Johnson
68
BANDAGES/DRESSINGS
B ANDAGE ELASTIC LATEX FREE 6 IN X 5 YARDS 1ORLS /BX
69
BANDAG /DRESSINGS
IBANDAGE T RIANGULAR WITH TWO PINS 51 IN X 36 IN X 36 IN 1 /BX
70
71
BANDAGES /DRESSINGS
BANDAGES /DRESSIN
BANDAGE, MULTI- TRUAMA DRESSING, 121N X 30IN, STERILE, 2SEA /CS
BURN DRE SSING WATER JEL 2 IN X 6 IN
72
BANDAGES /DRESSINGS
BURN DRESSING WATER JEL 4 IN X 4 IN
73
BANDAGES / DRESSINGS
BUR DRESSING WATER J'EL 8 IN X 18 IN
74
BANDAGES /DRESSINGS
BURN DRESSING WATER JEL BLANKET 3 X 2.5FT
75
BANDAGES /DRESSINGS
BU RN DRESSING WATER JEL FACIAL
76
BANDAGES /DRESSINGS
BURN S HEET, BLUE, 60IN X 96 IN, STERILE
77
BANDAGES /DRESSINGS
CO LD PACK INSTANT 55 IN X 10 IN 24 /CS RAPID COLI
78
BANDAGES /DRESSINGS
CONFORMING STRETCH BANDAGE, GA UZE'. 4 I N STERILE, 12 RL /BG
73
BAND AGES /DRESSINGS
DRESSING, ABDOMIN PADS STERILE SIN X 9IN 25 /BX
80
BANDAGES/DRESSINGS
GAU SPONGE NON STERILE 12 PLY 2 IN X 2 IN 2 00/BG
81
BANDAGES /DRESSINGS
GAUZE SPONGE, BASIC ECONOMY, 4 IN x 4 IN, 12 PLY, STERILE, 2 /PK, 25PK /BX
82
BANDAGES /DRESSINGS
GAUZE, CONFORMING STRETCH STERILE 4IN X 4A YD 12RLS /BG
83
84
BANDA GES/DRESSI NGS
BANDAGES /DRESSINGS
HY PEROXIDE 3% OZ
TAPE ADHESIVE CLOTH 1 IN X 10 YARDS 12/BX
85
BANDAGES /DRESSINGS
TAPE ADHESIVE CLOTH 2 IN X 10 YARDS 6 /BX
AttachmentA
r . . M
ITEI`iPl
CATEGORY
ITEM DESCRIPTION
8.0
BANDAGES /DRESSINGS
TRAUMA EMS SHEARS, BLACK 7 1,/4 in SAFETY BANDAGE TIP, FULLY AUTOCLAVABLE, SURGICAL STAINLESS STEEL BLADES
87
BANDAGES /DRESSINGS
TRIPL ANTIBIOTIC OINTMETN, UNIT DOSE 1/32 OZ 144/8X
88
89
BR EAT H ING
BREATHIN
BAG V A LV E. MAS NE /INFANT RESU SCITATOR SPU 11 WITH OXYGEN RESERVOIR TUBE
BACK VALV MASK W/ MEDIUM ADULT MASK SPUR II DISP, INDIVIDUALLY BOXE
94
BREATHING
BAG VALVE MASK,COLLAPSED SPUR II PEDIA DISP, WITH MASK AND EX HEPA FILTER, AM
91
BREATHING
C PAP OS BREATHING CIRCUIT W/ MEDI MASK
92
BREATHING
HE VENT FILTER, HIGH EFFICIENCY W/ P ORT, HYDR OPHOBIC PAPER. TIDAL VOLUME RANGE > 544 mL
93 IBRE ATHING
VEN TILATION CIRCUIT LISP KIT, W/ E XHAUST COLLECT/ PEEP VAL F OR DEM VE OF P / VENT I PAC
94
BREAT
VENTI LATION CIRUIT, SINGLE LI MB, PORTABLE, 6 F PATIENT TUBE, 1/8 I N AND 1/ IN I FOR USE WITH EA GLE UNIVENT�
95
DIAGNOSTIC
BLOOD PRESSUR CUFF D15P ADULT FOR USE WITH L MONITO
91
DIAGNOSTIC
BLOOD PRESSURE CUFF DISP CH ILD FOR USE WITH LIFEPAK MONITO
97
DIAGNOSTIC
BLOOD PRESSURE CUFF DISP INFANT FOR USE WITH LIFEPAK M ONITORS
98
DIAGNOSTIC
BLOOD PRE CUFF DISP LARGE ADU FOR USE WITH LIFEPAK MONITORS.
99
DIAGNOSTIC
BLOOD PRESSURE CUFF DISP SMALL ADULT FO USE WITH LIFEPAK MONITORS
1
DIA
D EFI B /PA CI N G( E CG PADS ADULT W /QU I,K -COMBO CONNECTOR 2FT LEAD, LifeP 1 2, LifePak 15
101 _
DIAGNOSTIC
DEFIB /PACING /ECG PADS PEDI W/ QUIK -COMBO CONNECTOR FOR LifePak 12 & LifePak 10 & LifePak 5
1172
DIAGNOSTIC
ELECTRODES 5 /STRIP 517 /BX 12BX /CS
103
DIAGNOSTIC
LELECTROD PEDIAT 3 /PK 14PK /B HUGGABLE
104
DIAGNOSTIC
GLUCOSE TEST S TRIPS, CAPILLARY, 54 /B PRECISION XTRA
1175
DIAGNOSTIC
LANC ETS, FINGE RSTI}C 240/BX
1176
DIAGNOSTIC
PAPER LP11,LP12, LP1S SIZE 108 MM X 23M ROLL, S ROLLS /B LIFE PAK
147
DIAGNOSTIC
PENLI DISPOSABLE Ci /PK
1178
DIAGNOSTIC
RAZOR PREPARATION 54 /BX GALLANT
1019
DIAGNOSTIC
T PR EA TH COVER
114
DIAGNOSTIC
TINCTURE OF BENZOIN SWABSTICKS INDIVIDUALLY WRAPPED SO /B
111.
IMMOBILIZATION
RESTRAINT DUAL LADDER LOCK 7 FT LOOPLOCK SAME LENGTH ORANGE PLASTIC DISP
112
IMMOBILIZATION
RESTRAINT STRAP SEAT BELT BUCKLE LOOP' END 2 PIECES 5 FT DISP
113
IMMOBILIZATION
EXTRICATION COLLAR, BABY NO -NECK
114
IMMOBILIZATION
EXTRICATION COLLAR ADJUSTABLE PEDIATRIC STIFNECK PEDI- SELECT LAERDAL
115
IMMOBILIZATION
EXTRICATION COLLAR AD.JU STAB LE,ADULT NASAL CANNULA HOOK STIFNECK SELECT LAERDAL
Medical Supply Discount Off List and Pricing Worksheet
ITIM I CATIG0111 JITIM DESCRIPTION
tr
1116
IMMOBILIZATION
HAND-E HAND HOLD DEVICE YELLOW
117
IMMOBILIZATION
HEAD BLOCKS STICKY FOAM - PAIR
118
IMMOBILIZATION
VACUUM SPLINT SET DISPOSABLE
119
INFECTION CONTROL
BIOHAZARD WASTE BAG, 1.2MIL, RED W/ BLACK PRINT, 23 IN X 23 IN 7-10 GAL
120
INFECTION CONTROL
BODY BAG BASIC VINYL STRAIGHT ZIPPER 6 GAUGE 36 IN X 90 IN 10/CS
121 1
INFECTION CONTROL
EMBAGS, EMESIS BAG 1500 mL, 50/pk
122
INFECTION CONTROL
GERMICIDAL WIPES EXTRA LARGE SA,NI-CLOTH HB
123
INFECTION CONTROL
GLOVES LATEX FREE POWDER FREE EXTENDED CUFF NITRILE EXTRA LARGE 50/BX 10BX/CS FREEFORM EC •
124
INFECTION CONTROL
GLOVES LATEX FREE POWDER FREE EXTENDED CUFF NITRILE LARGE 5018X 10BX/CS FREEFORM EC
1 125
INFECTION CONTROL
GLOVES LATEX FREE POWDER FREE EXTENDED CUFF NITRILE MEDIUM 50/BX 10BX/CS FREEFORM EC
126
INFECTION CONTROL
GLOVES LATEX FREE POWDER FREE EXTENDED CUFF NITRILE SMALL 50/BX 10BX/CS FREEFORM EC
127
INFECTION CONTROL
HAND CLEANSER FOAMING ALCOHOL BASED 9 OZ 24/CS ALCARE PLUS
128
INFECTION CONTROL
RESPIRATOR N95 REGULAR SIZE 20/B,X 6BX/CS 3M
129
INFECTION CONTROL
SLEEVE COVER 200/CS PPE Trauma sleeves
130
INFECTION CONTROL
TRANSPORTABLE SHARPS CONTAINER, SHUTTLE W/ LOCKING MECHANISM, 1 1/2 IN 0 X 6 1/2 IN L
131
INFECTION CONTROL
WASH BASIN, 6 QUART, ROSE 50 EA/CS
1.32.
IV ADM I NISTRATION
ALCOHOL PREP PADS LARGE 100/BX
13,3
IV ADMINISTRATION
BD ECLIPSE SAFETY NEEDLE 18 G 100/BX
134
IV ADMINISTRATION
INTRAVENOUS (IV) ADMINISTRATION SET NEEDLE FREE I Y SITE I VALVE 10 DROP 83 IN SO/CS
135
IV ADMINISTRATION
INTRAVENOUS (IV), ADMINISTRATION SET NEEDLE FREE 1 Y SITE 1 VALVE 60 DROP 83 IN 50/CS
136
IV ADMINISTRATION
INTRAVENOUS (IV) DRESSING TRANSPARENT ADULT 100/BX 5BX/CS VENI-GARD
137
IV ADMINISTRATION
INTRAVENOUS (V) EXTENSION SET NEEDLE FREE WITH 2 Y SITES 43 IN 48/CS INTERLINK
138
IV ADMINISTRATION
IV EXTENSION set WITH AMSAFE NEEDLELESS INJECTION SITE 9 IN 100/CS
139
IV ADMINISTRATION'
PRESSURE INFUSOR, 1000 CC INFUSION CUFF W/THUMBWHEEL VALVE AND ANEROID GAUGE
140
IV ADMINISTRATION
SALINE FLUSH 0,9%, 10 ML PREFILLED 12 ML LUER LOCK SYRINGE, 100EA/BX
141
IV ADMINISTRATION
SYRINGE ONLY LUER LOCK 10CC 100EA/BX
142
IV ADMINISTRATION
SYRINGE ONLY LUER LOCK 60CC 40/BX BECTON DICKINSON
143
IV ADIVIMISTRATION
SYRINGE ONLY, BD, 5 CC, LUER-LOK TIP, STERILE, 125/BX
144
IV ADMIN 15TRATION
,TOURNIQUET, LATEX FREEE, I IN X 18 IN ,PRE ROLLED 250/EG 108G/CS
145
IV CATHETERS
CATHETER INTRAVENOUS (IV) LATEX FREE 16 GAUGE X 1.25 IN SO/BX PROTECTIV
AttochmentA
Medical Supply Discount Off List and Pricing Worksheet
ITEM
CATEGORY 1
ITEM DESCRIPTION
146
IV CATHETERS
CATHETER INTRAVENOUS (IV) LATEX FREE 18 GAUGE X 1.25 IN SO/BX PROTECTIV
147
IV CATHETERS
CATHETER INTRAVENOUS IIV) LATEX FREE 20 GAUGE X 1.25 IN SO/BX PROTECTIV
148
IV CATHETERS
CATHETER INTRAVENOUS (IV) LATEX FREE 22 GAUGE X I IN 50/BX PROTECTIV
149
IV CATHETERS
CATHETER INTRAVENOUS (IV) LATEX FREE 14 GAUGE X 1.25 IN SO/BX PROTECTIV
150
IV COMPONENTS
STOPCOCK 4 WAY W/ SWIVAL AND MALE LUER LOCK
151
IV SOLUTIONS
SODIUM CHLORIDE 0,91 1000ML 14EA/CS
152
IV SOLUTIONS
SODIUM CHLORIDE 0.9% 100ML SINGLES 96EA/CS
153
1 IV SOLUTIONS
SODIUM CHLORIDE 0,9% 500ML 24EA/CS BAXTER
154
IMEDICATIONS
ADENOCARD 12MG 4ML ANSYR SYRINGE
155
MEDICATIONS
ADENOCARD 6MG/2ML ANSYR SYRINGE
156
157
MEDICATIONS
MEDICATIONS
ALBUTEROL 0.083% 2.5MG/3ML 25VIALS/BX
AM] DAT E/ETO MI DATE UfeshieId prefilled Byrn 40MG/20 ML
158
MEDICATIONS
AMIODARONE 150MG 3ML VIAL
159
MEDICATIONS
AMMONIA INHALANTS 10/BX
160
161
MEDICATIONS
MEDICATIONS,
ANECTINE 200 MG, 10 ML VIAL *REFRIGERATE* 10EA/BX . ..... . . ......
ASPIRIN CHILDREN'S CHEWABLE ORANGE FLAVOR 81MG 36/BT
1.62
MEDICATIONS
. ......
ATROPINE 1MG/10ML ANSYR PREFILLED SYRN.
163
IMEDICATIONS
CALCIUM CHLORIDE IGM 10ML ANSYR SYRINGE
164
MEDICATIONS
DEXTROSE 505/a 50ML ANSYR SYRINGE
165
MEDICATIONS
DIAZEPAM 5MG/ML 2ML LUER LOCKING CARPL)JECT 10/BX
166
MEDICATIONS
DILTIAZEM 100MG ADD•VANTAGE VIAL, NOWREFMG, ADD-VANTAGE DILUENT REQUIRED- SOLD SEPERATELY)
167
MEDICATIONS
DIPHENHYDRAMINE 50MGYML IML BENADRYL
168
MEDICATIONS
DOPAMINE 400MG/D5W 250ML 12/CS
169
MEDICATIONS
EPINEPHRINE 1:1000 1MG IML AMPULE
170
MEDICATIONS
EPINEPHRINE 1:10000 1 MG 10 ML LIFESHIELD SYRINGE
171
MEDICATIONS
PENTANYL,CLASS 11, 0.05MG/ML, 2ML VIAL
172
IMEDICATIONS
FLU MAZEN IL 0.5 MG, 5M L VIAL 10 VIALS/BX ROMAZICON
173
174
MEDICATIONS
MEDICATIONS
. . .....
HYDROMORPHONE, DILAUDID CLASS 11, 2 MG/ML, 1ML CARPUJECT
INSTA-GLUCOSE 31GM, 12/CS
!175
MEDICATIONS
LORAZEPAM 2MG 1ML VIAL 10/BOX *REFRIGERATE**
AttochmentA
176
MEDICATIONS
M ETOP ROLOL, 5MGISM L VIAL
177
MEDICATIONS
MIDAZOLAM "VERSED" 5MG/ML 2ML VIAL 10/BOX
178
MEDICATIONS
MORPHINE IDMG/ML IML Carpuiet 10/BX
179
MEDICATIONS
NALOXONE 2MG 2ML LUER JET
180
1
INITROGLYCERIN 50MG/DSW 25 STI,
181
MEDICATIONS
IOGLYCERIN LINGUAL SPRAY, 400MCG/ SPRAY, 60 DOSES '2EA CS
182
MEDICATIONS
ONDANSETRON, 4 MG, 2ML VIAL 25 EA/BX
183
MEDICATIONS
. ......
PANCURONIUM 1MG/10ML VIAL
1,84
MEDICATIONS
QU E LIC[N 200MG 10M L VIAL* R EFRIGE RATION REQUIRED
185
MEDICATIONS
SODIUM BICARBONATE 4.2% 10ML INFANT LIFESHIELD
186
187
MEDICATIONS
MEDICATIONS
SODIUM BICARBONATE 8.49" LIFESHIELD SYRINGE
— — -- — -------- — - . . ....
SOLU-MEDROL, 125 MG, 2 ML VIAL 25EA/BX
188
IMEDICATIONS
SALINE,UNIT DOSE MODUDOSE, 3ML, 0.9% NACL INHALER, EASY OPEN TWIST AND PULL 100 EA/BX
189
MEDICATIONS
VECURONtUM 10MG/10MLVIAL 10EA/BX
190
OXYGEN DELIVERY
TUBING CONNECTOR FITS TUBING FROM 7/32 TO 7/16 IN DIAMETER 5 IN 1 50/PK
191
OXYGEN DELIVERY
INEBULIZER, SMALL VOLUME, HAND HELD WITH TEE, MOUTHPIECE, FLEXTUBE, 7FT TUBING SOEA/Cs
1.92
OXYGEN DELIVERY
IOXYGEN MASK, ADULT, ELONGATED, HIGH CONCENTRATION, PARTIAL NON-REBREATHING METAL NOSE CLIP 50 EA/CS
193
OXYGEN DELIVERY
IOXYGEN NASAL CANNULA, ADULT, CONV,STYLE, CLEAR FLARED NASAL PRONGES, 7 FT TUBING, SOEA/CS
Attachment B
Proposer's NaTne and Mailing Address: Bound Tree
Medical, LC
5000 FutLle
Crossing Blvd
Dublin, 0th
43016
Telephone and Fax Numbers:
I have included:
Proposal/1"abbed Sections
Medical Supply Discount Off List and pricing Worksheet
(Attachment A)
Submission Proposal Response Form (Atlachnient 13)
• Non-Collusion Affidavit (AttachmentQ
• Lobbying and Conflict of Interest Clause Lorin (Attachment D)
AL
• Drug Free Workplace Form (Attachment E)
• Public Entity Crime Statement (attachment F)
• Local Preference Form (Attachment G)
• Scope of Sei-vices Response Forni (Attaclinient 14)
• Insurance Requireinems, Indemnification/Hold Harmless,
and Request for Waiver of Insurance Requirements (Attachment l) IL
(Check in ark items obove, os a reminder treat they are includeol.
I state that I am authorized to subinit this proposal.
S'l"A Ohio
(Signature of Proposers)
COUNTYOF Frank!' VI-ce President:
--= - - -- 1D ---.
Date 9 / o / 2 o 1, 6
Attochiwnt C
NON-COLLUSION AFFIDAVIT
1, ('..,'reene
larn Vice P.residerO'.. ofthefirrnof Bound Tree !-1-dical, L.LC
the bidder/responder making the proposal fbr the project described in the Notice of Request for Competitiv
Solicitations fbr:
Tv-' Supplies and Pharmace'at =cais
and I executed the said proposal with full authority to do so.
according to law, on my oath, and under penalty of pe j ury, depose and say that:
2. The prices in this proposal have been arrived at independently without collusion, consultation, communication or agreerne
for the purpose of restricting competition, as to any matter relating to such prices with any other bidder/responder or with aj
competitor.
Unless otherwise required by law. the prices which have been quoted in this proposal have not been knowingly disclosed I
the bidder/responder and will not knowingly be disclosed by the bidden'responder prior to the opening of the respons(
directly or indirectly, to any other bidder/respondet to any competitor.
4 No attempt has been made or will be made by the bidder/responder to induce any other person, partnership or corporation
submit, or not to submit, a proposal for the purpose of restricting competition.
5. I'lig—siatements contained in this affidavit are true and COITeCt, and made with full knowledge that Monroe County relies up(
t truth of ti statements contained in this affidavit in awarding contracts for said project.
4 1
09/06/2016
(SigiiatureofBidder/Rcsl)otider) (Date)
r , ' hi.annon 'Greene, Vice 1
IrintNarne/Title
0 ,
STA OF:
COUNTY OF: —ran klin
W t
PERSON ALILY APPEARED B EFORE ME, the undersigned authority, '01" A
(name of individual signing Affidavit), who, after first being sworn by rne, affixed his/her signature in the space provided above
on this
— 6 t lr, day of September 20 !6
Mycommi
may Rkk am d "
Camftlm M#9z Apo 18, 22M
Attochm,ent D
NOEW- W41
ETHICS CLAUSE
Rhian��('m Gre r, ',"ice P-reside
warrants that he/it has riot employed, retained o
otherwise had act oil his/its behalf any foriller County officer or employee in violation of Section 2 of Ordinance No, 10
1990 or any County officer or employee in violation of Section 3 ) of Ordinance V), 10-1990, For breach or violation
this provision, the County may, ill its discretion, terminate this contract vithout liability and may also, in its discretio
deduct froin the contract or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, is
or consideration paid to the former County officer or employee.
(Signature)
Mae: 9 / C "S f J I f,
STATE OF: Ohio
COUNTYOF: !'ranklin
rr
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
(name of individual signing Affidavit), who, after First being sworn by me, of his/her signature in the spac
r-
provided above oil this h da y. of ---- ,'-; , aLem e� 20 16 0
0
E
j I
My Commission Expires: `0
Do'd zteb 11 'RY PUBLIC
No" Pubk SWW d ONO
C E*es A924 18, 20
A tlachinei?t E
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that:
ound Txee Medicaj,,, LLC
(Name of Business)
1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of
controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees I
violations of such prohibition.
2. Informs employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-fr
workplace, any available drug counseling, rehabilitation, and employee assistance prograrns., and the penalties that play
imposed upon employees for drug abuse violations.
I
Gives each employee engaged in providing the commodities or contractual services that are Linder bid a copy iof the staterne.
specified in subsection (1).
4, In the statement specified in subsection (1), notifies the employees that, as a condition of working on the commodities
contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer
any conviction of or plea of guilty or nolo contendere to, any violation of Chapter 893 (Florida Statutes) or of any controll
substance law of the United States or any state, For a violation occurring in the wworkplace no later than five (5) days after su
conviction.
5. Imposes a sanction on, or requires the satisfactory participation in, a drug abuse assistance or rehabilitation program if such
available in the employee's community, for any employee who is so convicted,
6, Makes a 'Mood faith effort to continue to maintain a drug free workplace through implementation of this section.
I
As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements.
z:1 U
C
0
66'(
- — — -------- C
Bidder's Signature 0
E
R a. n n c n Tree e, V i c e 'i' r e ,, i d e ri'c
Date
Dam"d Zltdo 11
Allachment F
PUBLIC ENTITY CRIME STATEMENT
' person or affiliate who has been placed on the convicted vendor list following a conviction for public, enti
crime may not submit a bid on a contract to provide any goods or services to a public entity, may not submit
bid on a contract with a public entity for the construction or repair of a public building or public work, may n
submit bids on leases of real property to public entity, may not be awarded or perform work as a contract(
supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transa
business with any public entity in excess of the threshold arnount provided in Section 287.017, Florida Statutc
for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list."
I have read the above and state that neither T (Proposer's nam(
- -- J
nor any Affiliate has been placed on the convicted vendor list within the last 36 months.
Ohio
Frl k 1i n
r
Subscribed and sworn to (or affirmed) before me on the p E day of bs? 20 16 —. b,
,,
F 111 UP r, (name of individual signing Affidavit). He/She is personally known
-.,— " �. � � i j o% I
rase or has produced
(type of identification) as identification.
My Corrunission Expires
David M110 11
Kfty Mk ma of Ohio
kukkkbm""V,�"
NOTARY K.)BLIC
(Sign�ture)
Date: 9 PC`
6 0 ', 6
Ohio
Frl k 1i n
r
Subscribed and sworn to (or affirmed) before me on the p E day of bs? 20 16 —. b,
,,
F 111 UP r, (name of individual signing Affidavit). He/She is personally known
-.,— " �. � � i j o% I
rase or has produced
(type of identification) as identification.
My Corrunission Expires
David M110 11
Kfty Mk ma of Ohio
kukkkbm""V,�"
NOTARY K.)BLIC
A t1achiverit G
"Not Appl-icable
LO CAL PRE TERENCE FORM * %.
A. Vendors claiming a local preference according to Oi 0- 7 3-2009 must completethis form.
Nante of Bidder Responder
mm
I Does the vendor have a valid receipt for the business tax paid to the Monroe County Tax Collector dated at
least one year prior to the notice or request for bid or proposal? furnish copy.)
2; Does the vendor have a physical business address located within Monroe County from which the
vendor operates or performs business on a day to day basis that is a substantial component of the goods or
services being offered to Monroe Co unty?,
List Address:
Tel ephone N umber:
B. Does the vendor/prinie contractor intend to subcontract 50% or more of the goods, services or construction to local
businesses meeting the criteria above as to licensing and location'
If yes, please provide:
Copy of Receipt of the business lax paid to the Monroe CrullIty, " fax Collector by the
subcontractor dated at least one year prior to the notice or request for bid or proposal.
2. Subcontractor Address within Monroe County from which the subcontractor operates:
Address
Address
Signature and'I'itle of Authorized Signalorylbr
Bidder/Responder
STATE OF
C01-jN'T'V OF
Telephone Number
Pri n r N an"i e:
On this - - day of , 20 , before me, the undersigned notary public,
personally appeared known to me to be the person whose name is subscribed
above or who produced as identification, and acknowledged that lie/she is the person
who executed the above Local Preference Form fear the purposes therein contained.
W co mission expires:
Notary Public
(Seal)
Print Name
** This Form is only required if Local Preference is applicable pursuant to See. 2-349, Monroe County Code.
Attachment H - Scope of Services Response Form
proposal, the Proposer agrees that these provisions will be part of the agreement between the
parties.
YES
NO
YES
SERVICE REQUIREMENT
can
cannot
Can comply,
but with specified deviations
comply
comply
(please detail devictions below)
QUALITY ASSURANCE PROVISIONS
Ordered Supplies / Receiving
A system of test inspections shall be used to assure
quality and quantity of materials received by County.
Materials will be promptly inspected and any
discrepancies from the purchase order and/or the
supplier's invoice shall be reported immediately by the
Monroe County Logistics Specialist to the Supplier and
X
shall be corrected within a two (2) business day time
frame when the County has made that report within
normal working hours of 8 am to 5 pm Monday through
Friday.
Material Safety Data Sheet (MSDS):
Any items delivered must be accompanied by a MSDS.
The MSDS will be maintained by the County and must
include the following information:
1. The Chernical name and the cornmon name of the
toxic substance.
2. The hazards or other risks in the use of the toxic
substance, including:
a) The potential for fire, explosion, corrosively
X
and reactivity,
b) The known acute and chronic health effects
of risk from exposure, including the medical
X
conditions which are generally recognized as
being aggravated by exposure to the tonic
substance; and
c) The primary routes of entry and symptoms of
X
overexposure.
3. The proper precautions, handling practices,
necessary personnel protective equipment, and
X
a
Attachment H - Scope of Services Response Form OW
'I
YES
NO
YES
SERVICE REQUIREMENT
can
1 comply
cannot
Can comply,
bLA with specified deviations
comply
(piease de,� oil de viat io ns be lo vv)
Defects-
Upon un-packaging and discovering defects to materials
shipped by Supplier, any medical supplies and/or
pharmaceuticals requiring replacement shall be
finalized within five (5) working days of reporting the
defect.
(See also information required behind Talc 2 regarding
warranties and replacements.)
. . .......................................
Guarantee
.......... .
— -----
The material(s) supplied shall be guaranteed to be free
from defect of composition, conception and
workmanship for a minimum period of 120 days from
the date of acceptance by the County. Any parts or
portions found not in accordance with this specification
will be rejected by the County and returned to the
Proposer at the Proposer's expense for immediate
replacement.
. .. ...... ...... .. . ... . .... . .....
Quality:
The materials to be furnished shall be currently in
production and Shall be of the manufacturer's standard i
or better quality.
Quantities:
+
The quantities listed on the Medical Supply Discount Off
List and Pricing Worksheet (Attachment A) are
estimated quantities for one (1) year and are for cost
comparison only. Any reference to forecasted or
estimated quantities within the proposal documents is
intended to inform the proposers of approximate
annual requirements. The County shall not be required
to purchase any minimum or maximum quantities
during the term of any award resulting from this
specification. The County may purchase as little as zero
percent (0%) or exceed as much as one hundred
percent (100%) of the forecasted or estimated
quantities.
'I
Attachment H - Scope of Services Response Form 2016
... ........ "" . .. . . ..... ..
YES
YES NO Can comply,
,y
SERVICE REQUIREMENT i can cannot
c comply j but with specified deviations
(please detail deviations below)
Packaging:
Only materials that are packaged in the original factory
fresh packaging shall be accepted. No materials that
have been re-packaged or that are in the adulterated or
damaged packages shall be accepted at the receiving
location nor shall after-market materials be accepted
at the receiving location. Any attempts by the j j
Proposers to furnish the County with other than first
quality materials shall constitute default as outlined in
this specification,
Refrigeration:
Maintaining a specific temperature range throughout
the shipping process is essential to the quality of
healthcare products. Proposer has the ability to ship
products in a proper temperature-controlled
environment. Only materials which have been properly
shipped in a temperature-controlled environment shall
be accepted by the COUNTY.
Expiration Dates:
Where applicable, all merchandise shall have a
minimum expiration date of 18 months from date of
shipment, and date must be displayed on the package.
CONDITIONS
uthori
t
ion.
Proposer has the ability to handle orders placed by the
electronic ordering software Operative IQ. (All orders
shall be placed via Monroe County by individual
Purchase Orders generated by the County's electronic
ordering software, Operative 10, or as "Open" Purchase
orders.)
-- - ---------------- --------- - -------
Furnishing Proposalltems
Contract items are to be furnished on an "as needed,
when needed basis" during the life of the contract.
........... . ... .................... ...................
V_
�Ll
A ttachment
SERVICE REQUIREMENT
Materials ordered shall be delivered within three (3)
business days after receipt of order. Failure to do same
shall be considered breach of contract or default, and
the County shall utilize its options as stated within the
contract.
YE
ca n
comply
Av
1
cannot
comply
YE
��� comply,
but with specified deviations
(please detail ia`eviatrons below)
Backorders: _
In the event an item is not immediately available at the
time of an carder, and able to be delivered within three
(3) days, the County shall have the option of purchasing
the item from another vendor.
The County reserves the right to increase or decrease
quantities shown without penalty.
:x
Samples (Medical Supplies only):
1
From time to time, either at the stage of the proposal
or subsequently while the contract is in force, the
Proposer may wish to recommend an alternative to an
item listed Can Medical Supply Discount Of � Ust and
Pricing Worksheet (Attachment A). In those situations,
the County may require the Proposer or the Proposer
may elect to submit a sample for inspection, to ensure
„-
that the alternative is of .similar quality. Sucl°i samples
shall be labeled with the Proposer "s name and item
number and shall be furnished free of charge. The
vendor can determine whether the sample should be
returned or destroyed. Samples not destroyed will be
returned upon request at the Proposers expense
within ten days following receipt of the sample.
Substitution:
_
No items will be' substituted without the prior written
i
approval of the County. Any violation of such
procedure may result in a possible cancellation of the
contract. All approved substitutes shall be annotated
as such on the Proposer's shipping document(s).
a
Attachnient H - Scope of Services Response Form 'EM
YES
NO
YES
SERVICE REQUIREMENT
L can
cannot'
Can comply,
but with specified deviations
,,y
,r
comply
(,Tease detail deviations below)
......
. ... . . ......
Proposal Prices:
..... .
Proposal prices quoted on Medical. upply Discount Off
List and Pricing Worksheet (Attachment A) shall be firm
and shall not be amended after the dates and time of
the proposal opening. Any attempt by the Proposer to
amend said proposal prices shall constitute default as
outlined in this specification.
----------
Shipping Costs:
Prices quoted in the Proposal and Proposal Response
form shall include all shipping costs, shipped F.0.13
Marathon, Florida or to the facility location specified by
the requester or the purchase order.
Taxes:
All taxes of any kind and character payable on account
of the word done and materials furnished under the
award shall be paid by the Proposer and shall be
deemed to have been included in the proposal, The
County is exempt from all state and federal sales, use,
transportation, and excise taxes.
. .. . ............
Infringement,
Proposal prices must include all royalties and costs
arising from patents, trademarks, and copyrights in any
way involved in the work. Whenever the Proposer is
required or desires to use any design, device, material
or process covered by letters of patent or copyright, the
Proposer shall indemnify and save harmless the County,
its officers, agents, and e m ployees from any and all
X
claims of infringement by reason of the use of any such
patented design, toll, material, equipment or process,
to be performed under the contract, and shall
indemnify the said County, its officers, agents and
employees for any costs, expenses and damage which
may be incurred by reason of any infringement at any
time during the prosecution or after the completion of
the work.
- --- - - - - - --
Attachment H - Scope of Services Response Form I=
YES
NO
YES
SERVICE REQUIREMENT
can
cannot
Can comply,
but with specified deviations
comply
comply
please detail deviations below)
Award Changes:
Flo changes, over the contract period, s ha 1] be
permitted unless prior written approval is given by the
County and, where applicable, confirmed by the
Monroe County Board of Commissioners.
Assignment',
No Proposer shall assign the contract or any rights or
obligations thereunder to a subcontractor without the
X
written consent of the County and approval of the
Monroe Cou nty Board of Co m missioners..
Price Escalation
The County will allow a price escalation provision with
this award. The original proposal prices quoted on
Medical Supply Discount Off List and Pricing Worksheet
�Attachment A) shall be firm for a one k l) year
minimurn period. A price escalation/de-escalation will
be allowed one (1) year after the beginning of the
award period and at one (1) year intervals thereafter,
provided the Proposer notifies the County, in writing of
any requested price changes at least sixty (60) days
prior to those changes taking effect. This request must
be accompanied by a certified letter from the
Proposer's supplier showing the price increase to the
contractor. The price increase to the County shall be
limited to the percentage increase to the Proposer as
stated in this letter.
if, at the point of exercising the price escalation
provision, market media indicators show that the prices
have decreased, and that the Proposer has not passed
the decrease on to the County, the County reserves the
right to place the Proposer in default, cancel the
contract, and remove the Proposer frorn the County's
proposer list for a period of time deemed suitable to
the County.
Attachment H � Scope of Services Response Form IBM
. ........ . ........
YES
NO
YES
SERVICE REQUIREMENT
can
cannot
Can comply,
but with specified deviations
comply
comply
(please detail deviations below)
Invoicing:
The Proposer shall furnish the County complete
itemized invoices forthe goods received. Invoices are
to reflect the prices stipulated on the purchase order
and as outlined on the Medicol Supply Discount Off List
and Pricing Worksheet (Attachment A). Invoices are
X
also to reflect the provisional price discount in the form
of a percentage at which the Proposer will sell these
items off its list price. The County will not accept an
aggregate invoice. As part of the award process, the
County may request a sample invoice. Invoices shall
contain, but not limited to the following information:
• Invoice number
• Company name
• Purchase order number
• Location and dates of delivery
• Cost of items as stated on Proposal Response
and extended price to reflect total cost for
number of items received.
Prompt Payment Act:
The Proposer agrees to accept payment per the terms
of the Florida Local Government Prompt Payment Act.
Normal processing time is approximately 30 days from
presentation of the invoice.
Ordering:
Proposers will provide web-based online ordering
website designed specifically for service.
Disaster Recovery:
Proposers have a proven Disaster Support Program in
place and can demonstrate previous experience in
disaster recovery supply chain management and shall
provide the County with emergency numbers for these
situations. These numbers will be updated immediately
if the contact number changes.
Attachment Services ra Air r =
a
'DES
NO
SERVICE REQUIREMENT
can
cannot
Can comply,
but with specified deviations
comply
comply
(please detail deviations below)
l
Indemnification and Insurance Requirements;.
The Proposer can comply with the insurance
requirements outlined in Attachment I to the RFF, or
has submitted a Request for Waiver (also found in
x.
Attachment I), Also, the Proposer can comply with the
indemnification and hold harmless requirements (also
found in Attachment 1'). p,
a
DATCtMWQOMYY)
CERTIFICATE OF LIABILITY INSURANCE
larzsrePia
THIS CERTIFICA TETTJSsurl) AS A MATTER OF INFORMATION ONLY AND IDONFERS HO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TNE COVERAGE AFFORDED BY THE POLICIES
BEI-W THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING WSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: If the wilficale holder Is an ADDITIONAL INSURED, the pottoy(les) inust be ondorsed. If SUBROGATION IS WAIVED, subjWCito
the terms and conditlom of 1ho polloy, cortaln policies may roqwlre an andorserneaf. A staternarit an ifils cerflflcalo daes not confer rights to the
cartificaw holder In Ileu of such ondorsernant(g).
PRODUCER
Aon Risk Services t4artheast, inc,
r
Columbus alf Office
NAME-
Pli FAX
N�,Haj-x t1m) m-M? - . CS00) 30-005
jl,. --- pvc, NrJ:
rz-lw�,
ADORE531
445 riutchimon Avenue
Suite 900
INSUIIER(S) MTORNNG COVERAGIE
RAIC 0
Colufft$ 04 43235 U-SA
6I81fRE4
10110R[RNI mednmrc casualty ins to
22241 Samova,
Inc
Bound Tree Medical LLC
5000 Tuttle Crossing Blvd.
ciublin off 43016 USA
WURERO� sentirwl Imurance Ca1!P�r7T
tzACHQCGUTAR
MSURERC-. Hartford Fire Insurance m
19682
IMURERO: P.artford Casualty I115,urallce CO
25424
ET
f04URERF:
IL"Offlaw-M �;IVLIII]aLwila;at"illtlii:iRZW"I&ikLolvffT-ut;mx K4NLmib
THIS IS TO CEPxTtFYTI1A7 THE POLICIEG OF INSURANCE LISTFI)SELOW I IAVE BEEN ISSUED TO 1HE: WSUREDNAMEDABOVE FOR THE POLICY PERIOD
NDICATED. NOTWITHSTANDING ANY REQWREMENT, TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THQ
CERTIFICATE MAY BE ISSUED OR WNY PERTAIN, TH INSURANCE AFFORDED BYT148 POLICIES DESCRIBED I IEP)EIN 13 SUBJECT TO ALL THE TERMS,
EXCLUSIMNS AND CONDITIONS OF SUCH POLICIES, LIMN SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, Wailes shown ale 05 roque5llid
W51i
TwIr OF [00PARCE
AM
KSP
PaLlcyrRAIMA
FULMYLFF
MWODA
POOGYEP
NKNDWYyy
LVANTS
X
tzACHQCGUTAR
wmq,I,=E Efl OCCUR
$300,000
PFR$0UAL&ADVR1JURV
sl,000,0001
sENERALAGCRE0ATE
S2,001),00DI
POLICY RO Los
CT
- ]J P El
F�
PRODUCTS - COMNOP ACG
rxcludod
C,
OVUM,
A UTom oa�,E UABiLn Y
33 U04 VG3435
1.2101/2014
12/01/2015
CMMINEDNIG(ELMAIT
S110001000
BODILY hNJURY I P.r Pamm)
a
z
x ARYAUro
BOOtLY MURY (Clay acdJfl nil
x ALL WlmE[)
AaIG
PROPERTYDAVACIF
AUTOa
Par fiedd+n
0
LIA8
X
OCCUR
E,� OCCURRENCE
[X
E 'Ss
XCL
tU1..fl7LrqtI.LA. LEAS
CLAIMS-MADE
GGOl
LG& F
R
10 OU0,000
'I) x
DSO X RETCV MAO
C Tto�
WORKERS COMMMAVONMID
PER STATUTE
EMPLOyrR S" VAVIL11 V YV N
jNyPRcP
0FFJCEPJ'ME?A0CR "QWOR�'Q?
wA
EL, D1 SFAS E EM1 UYEE
(VandalaritnHH)
Irm.45alboundar
0
'55 —
L,D1 - POLICYLI M It
----
A
Products Liab
14riN3fIb022
1' /01/2014
12/01/2015
Ago regite Linit
Claires mada
SIR Aggregate
112 5,000
SIR applies Per policy ter
is & condi I
ions
Per Occuvreoca Limi
SIO
rividei1rp of coverage. All i3oupid TI Medical Wat"P-house locations aT'e Covered,
CERTIFICATE HOLDER
(01900.2014 ACORD CORPORATION. All rights reserved.
ACORD E25 1[1014101) 'rho ACORD name and logo are registered marks o(ACORD
$AQVI-0 ANY Of TflE PROVE VESCRIVED POOVER BE CAMELLEO BEFORE THE
rwPIBATIOA PATE THEREOF, NOTICE VALL BE DELIVFRED IN ACCORDANCE WVTfl rk,-z
POUGYPROV'3roils.
Bound Tree Medical , LLc
5000 Tuttle Crossing alvd.
Dublin OR 43016 USA
OWTHORZEDREPPEEVNTAINE
ell
(01900.2014 ACORD CORPORATION. All rights reserved.
ACORD E25 1[1014101) 'rho ACORD name and logo are registered marks o(ACORD
AGENCY CUSTOMER IM 570000037575
LOC 9:
k--- ADDITIONAL REMARKS SCHEDULE Page � of
AGVNCY
AOri Risk Services Northeast, Inc.
sarnova, lllc.
Pou
See certificate wmber: 570OSS948231
rMIRIER
see certificate Number: 570055948231
ADDITIONAL REMARKS
Tfie ACORD name q Rd iogo Rio rugtzhupd in a rks of AGO RD
SARNINC-M ArlICKSON
CERTIFICATE OF LIABILITY INSURANCE
ATE (MIAMMM)
1112612014
MIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLUM THIS
CERTIFICATE DOES NOT ArFIRMATWELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT EETWSEN THE ISSUING INStJRER(S),AUTf*RfZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT.* If the certificate holder Is an ADDITIONAL INSURED, the policy(fes) m,ust be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and oondillons of the policy, cor(aln policies may require an endongernwit, A statement on this certificate does not confer rights to the
conificato holder In flau of such ondorserriont(s).
PROOLICER
Then son Flanagan Executive Liability Group
626 Macksop Blvd, 5th Floor
Chicago, IL 60661
CO TACT Daniel R. Gunter
NAI 5�
EB('Nr djt2) 239-2800 (3 2 2S3 -15 6
- 1
IZA I
AeDncss: d g u n ter tht rTt s �Onf la n a
T9_ah-c�om -
IuSd M(j) AFFORI)MG COVERAG F
EAC9 O=RRENCE
5
MURERAXHUE313 &SONS . CHICAGO
INSURER r -
Sarneva, Inc. Bound Tree Medical, LLC
6006 Tuftle Crosstria Blyd.
P.O. Box 6 D23
INSURER D
MN S kr€* E R
aALA,5-hfAM OCCUR
Dublin, OF 43016
Ww*1T1_:M_T ," $1 t"WrOTA NJ
d. - - ........ ..... - - - - - - -
_74 6 IS TO CERTIFY THAT THE POLICIES OF iiiSURANCE LI BELOW HAVE BEEN ISSUED TO THE msuRb NAMED ABOVE FOR THE POECYPERO15
INDICATED. NOTVATHSTANDING ANY RMUMEMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENTWTH RESPECT TO MIMITHIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED MOMS SUBJECT TO ALL 7HETEIRMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES, LIMITS MIOVM MAY HAVE BE E14 REDUCED BY PAM CLAIMS,
L10 -- . ..... . ... ...
110, R INUITIMY1 LI
MR F ia MPT6
A JM
COM K MA L GEMM UA MU TY
EAC9 O=RRENCE
5
WKPIXG r; YORE R t L D
aALA,5-hfAM OCCUR
K.D LVP (Any 0.,o rd a
PfRRrJtd
)' ... ..... .. . ... .
GFNILACGREGATELiWAPPLIFSPER
GENERALAGISREGATE
POLICY E I to
PROM P 'C P A Ge
OT HER'
AUTOMORILELIAGIL117
am-90-95MGLEOIRT
_Ma's danIL,
ANYAUTO
2WO% ULED
BODILY INJURY (Per kcddul)
AMOS
1
,P RTC DANIA' G E
S
HIRECAUTC AUT03
uM9 BELLA LIAO (KCIAR
EXCESSMAS CLAJJ.J"LrJArq
AGARWAIE
JI PIF TE NT 113 r J $
S
WORRIERS COMPERS411014
AND EMPLOYERS'LIAM11,11Y YIN
A
--.8CUTtVE
At;YPROPP.EETOWPARTPIr,'�r-Y,
44319
12)0112014
1210112015
P,L� EACH ACC. KANT
e(CLUM?
NIA
F1- DISIASE PO LICV I MIT
(ACORD Jul, Addjt�oMewmlks
,;amp Cc Mi f [c a le.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL Bt 1312t.tVERED IN
Samplo Certificate ACCORDANCEWITH THE POLICY PROVISIONS.
AUTHORREOMPRESEN'ThM9
0
Q 1966 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks. of ACORD
AGENCY CUSTOMER ID: SARNING-01 BDICKSON
Lac If:
"Wifflyino M-1051 I'll -5 -'-
Page I I
AG&JCy
_Lh2Lnyson F
NAMED INSURED
Samova Inc, Bound Troe Medical, LLC
6000 Tuttle Crossing Blvd.
P.O. Box 8023
POUCYNUMPER
SEE PAGE 1
Dub11r, OH 43016
CARRIER
NAM CODF
SEE PAGE1 ISEE
P 1
FFFF;071V4 DATE! SEE PARE I
ACORD 101 (2008101) 0 200B ACORD CORPORATION, All rights reserved.
The ACORD name and logo are registered marks of ACORD
Formw_9
(Rev. Derernber2014)
department l
on ihaTreasviy
uo SaMoo
I
1 Name Jas shown on your moon
Bound Tree Medical ILLC
Request for Taxpayer 903UMMMU3
1.1dentificati o n Number ad n Certi fi cati o ,,: rAmliwwg pill #
1=11rill, "MIN
on IhIs line: do not leave
erill ty name, It d 11 lore nt from above
3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to
El IndivkluairsoleproprIelor or El 0 Corporation 0 S Corp oration El Partnership 0 Tru$tlaslef a certain e nl Ities, no Individuals, see
single - member LLC Instructions on page 3):
Limited liability company, Enter the tax classification (C=C corporation, S-S corporation, P--partnershlp) � P Exempt payee we 0 any
Note. For a single- m ember LLC I h at Is disregarded, do not check LLC: check the appropriate box In the line above for Exemption from FATCA reporting
I he tax cfasslficatfon of the single - member owner. code Of any)
F1 Other Inee Instructionsl 0 (AV&j I* a:c�rdi ffmWael owsida Ma V.SJ
5 Address (number, street, and apt. or
P.O. Box 8023
6 City, state, and ZIP code
Dublin, OH 43016-2023
7 List account numboy(sli here toationa
gig=
T wentitication NUMber I FIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line I to avoid
Social socurityrrumber
backup Withholding. For individuals, this Is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other
La
T
entities, it Is your employer Identification number (ON). If you do not have a number, see How to gel a
TIN on page 3.
or
Note. If the - account Is In more than one name, see the Instructions for line 1 and the chart on page 4 for
I Employer ldentiff 11 c 11 allon number
g uidelines on whose nu mb a r to enter.
r
1 3 1
=
11
-1
11
71
3
1 9
1 4
18
17
1
Under p enalties of perjury, I certl fy that:
1, The number shown an this form is my correct taxpayer identification number (or I am wailing for a number to he Issued to me); and
2, 1 am not subject to backup withholding because. (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS ties notified me that I am
no longer subject to backup withholding; and
3, 1 am a U.S, citizen or other US. person (defined below); and
4. The FATCA code(s) entered on this form (f any) Indicating that I am exempt from FATCA reporting Is correct,
Certification Instructions. You must cross out Item 2 above If you have been notified by the (83 that you are currently subject to backup withholding
because you have failed to report all Interest and dividends on your tax return. For real estate transactions, Item 2 does not apply, For mortgage
interest paid, acquisition or abandonment of Secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN, See the
Instructions on page 3.
Sign Signature of
Here I U.S. person 0- 0: -) vo, Date 1►
Section references are to the Internal Revenue Code unless olherwl8a noted.
Future developments. Information about devefopments affecting Form W-9 (such
as legislation anacted after we release 11) is at ivwWJrsgov1Av9.
Purpose of Form
An Individual or entity (Form; 41t -9 requester) who Is required to file an Information
return with the IRS must obtain your correct taxpayer kfentIfIcallon number (TIN)
which may be your social security number (SSN), Individual taxpayer Identification
number (ITIN), adoption taxpayer Identification number (ATIN), or employer
fdonlificallon number (EIN), to report on an Inform-alien return the amount paid to
you, or other amount reportable on an Information return, Examples of Information
returns Include, but are not Umiled to, the followfng:
- Form 10!39-INT(lnlero5t earned or paid)
- Form 1090-DIV (dividends, Including those from stocks or mutual funds)
v Form 1099 -MSC (various types of Income, prizes, awards, or gross proceeds)
- Form 1099-B (slacker mutual fund sales and certain other firansaclions by
brokers)
• Form 1099-8 (proceeds from real estate transartlons)
- Form 1099 -K (merchant card and third party network transactions)
name
- Farm 1098 (Roma mortgage Interest), 1098-E (student foan Interest), 1098-T
(tuition)
- Form 1099-C (carioeled debt)
* Farm 1099-A (acquisition or obandonmentof secured property)
Use Form W-9 only If you are a U,S. person ( Including a resident allen), to
provide your correct TIN,
11you do not return Forra W-9 to the requester will( a TIN, you m4ght be subject
to backup withholding. See What 1,3 backup withholding? on page 2.
By signing the tilled-out form, y=
1„ Certify that the TIN you are giving Is correct (at you are waiting for a number
to be Issu ad),
2. Certify [fiat you are not subject to backup withholdin or
S. Claim exemption from backup withholding It you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership Income from a U,S. trade or business Is not subject to the
withholding tax on foreign partners" share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) Indicating that you are
exempt from the FATCA reporting, Is correct. See MatIs FATGA repodingtr on
p age 2 for further informa
Cal. No. 10231X Form. W-9 (Rev, 12-201[4)