318-22 Exhibit A-Coronis Health for Emergency Transport Third Party Billing - 2022.pdf

TOWNSHIP OF WEST ORANGE The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, labor unions, that it does not discriminate on the basis of age, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices. The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job-related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions. In conforming with the applicable employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court decisions of the State of New Jersey, and applicable Federal law and applicable Federal court decisions. The contractor shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents: Letter of Federal Affirmative Action Plan Approval Certificate of Employee Information Report Employee Information Report Form AA302 The contractor and its subcontractors shall furnish such reports or other documents to the Div. of Contract Compliance & BEO as may be requested by the office from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Div. of Contract Compliance & EEO for conducting a compliance investigation pursuant to Subchapter 10 of the Administrative Code at N.J.A.C. 17:27. 27

TOWNSHIP OF WEST ORANGE REQUIRED EVIDENCE AFFIRMATIVE ACTION REGULATIONS NJ. S.A. 10:5-31, et seq. (NLA. C. 17:27) If awarded a contract, the Bidder will be required to comply with the requirements of N.J.S.A. 10:531, e seq. and N.J.A.C 17:27. Within five (5) days after receipt of the notification of intent to award the contract, the Bidder shall present one of the following: 1. Appropriate evidence that the Contractor is operating under an existing federally approved or sanctioned affirmative action program; or 2. A Certificate of Employee Information Report Approval issued in accordance with N.J.A.C. 17:27-4; or 3. An initial Employee Information Report consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with NJAC. 17:27-4. The Bidder must submit no later than three (3) days after the signing of the Contract an Initial Project Manning Table consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with N.J.A.C. 17:27-7. Bidders are referred to the Bidder's Information Section of the Bid Packet for a further description of the above requirements. NO BIDDER MAY BE ISSUED A CONTRACT UNLESS THEY COMPLY WITH THE AFFIRMATIVE ACTION REGULATIONS OF NJ.S.A. 10:5-31, et seq. The following questions must be answered by all Bidders: 1. Do you have a federally-approved or sanctioned Affirmative Action Program? Yes (If yes, submit a copy of such approval.) GoD 2. Do you have a State Certificate of Employee Information Report approval? ¢ Yes_ ) {If yes, submit a copy of such approval.) No The undersigned Bidder certifies that he is aware of the commitment to comply with the requirements of N.].S.A. 10:5-31, ef seg., and agrees to furnish the requi‘ed documentation pursuant to the law. COMPANY: Carazns Le fA LPI) LL NAME: S#2c2-17 Coor tt SIGNATURE: < TITLE: ZA Siche ot NOTE: A bid ket as non-responsive if a Bidder fails to comply with requirements of N.J.S.A. 10:5-31, et seq., within the time frame stipulated. 28

ae, Certification 84660 CERTIFICATE OF EMPLOYEE INFORMATION REPORT This ie to cortily that the contractor: NIAC, 17:2744,5 a1 CORONIS GLopar 3953 EXCHANGE PR SYKEEVIDEE 1H 38 14,

TOWNSHIP OF WEST ORANGE AMERICANS WITH DISABILITIES ACT OF 1990 Equal Opportunity for Individuals with Disability The contractor and the Township of West Orange, (hereafter "Township") do hereby agree that the provisions of Title 11 of the Americans With Disabilities Act of 1990 (the "Act") (42 U.S.C. $121 01 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, and activities provided or made available by public entities, and the rules and regulations promulgated pursuant there unto, are made a part of this contract. In providing any aid, benefit, or service on behalf of the Township pursuant to this contract, the contractor agrees that the performance shall be in strict compliance with the Act. In the event that the contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the contractor shall defend the Township in any action or administrative proceeding commenced pursuant to this Act. The contractor shall indemnify, protect, and save harmless the Township, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages, of whatever kind or nature arising out of or claimed to atise out of the alleged violation. The contractor shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the Township's grievance procedure, the contractor agrees to abide by any decision of the Township which is rendered pursuant to said grievance procedure. If any action or administrative proceeding results in an award of damages against the Township, or if the Township incurs any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the contractot shall satisfy and discharge the same at its own expense. The Township shall, as soon as practicable after a claim has been made against it, give written notice thereof to the contractor along with full and complete particulars of the claim, If any action or administrative proceeding is brought against the Township or any of its agents, servants, and employees, the Township shall

ctor along with full and complete particulars of the claim, If any action or administrative proceeding is brought against the Township or any of its agents, servants, and employees, the Township shall expeditiously forward or have forwarded to the contractor every demand, complaint, notice, summons, pleading, or other process received by the Township or its representatives. It is expressly agreed and understood that any approval by the Township of the services provided by the contractor pursuant to this contract will not relieve the contractor of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the Township pursuant to this paragraph. It is further agreed and understood that the Township assumes no obligation to indemnify or save harmless the contractor, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the contractor expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the contractor's obligations assumed in this Agreement, nor shall they be construed to relieve the contractor from any liability, nor preclude the Township from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

AFFIDAVIT OF NON-COLLUSION ‘The undersigned bidder of full age, being duly sworn according to law depose and hereby specifically certifies that: A. _ to the best of the bidder's knowledge and belief, the annexed bid proposal for this project has not been prepared in collusion with any other bidder of like item or services and the prices, discounts, terms and conditions thereof have not been directly ot indirectly communicated by or on behalf of the bidder to any person other than the recipient of the bid and will not be communicated to any person prior to the official opening of the bid. B. the bidder fully understands that no premiums, rebates, or gratuities are permitted cither with, prior to, o after signing of contract. Any violation will result in cancellation and removal ftom the bid list. C. _ the bidder further certifies that the undersigned has the necessary authority, to sign this stipulation stating that the bidder has not entered into any agreement, or otherwise taken any action in restraint of free competitive bidding in connection with this bid. All references to the bidder are understood to include the undersigned and all principals, partners and officers of the bidder. Dated: Signa) CF Sheer Lure [Fai of, t (Name and Title) (Company Name\__€2 72777 & # aL) Lh, ELT? . LL oC. (Address, FD -2L y Leen AL EL B ia WA / (Ci, Si 2 Cod hu, wile AL 2775] (Corporate Seal) Subscribed and sworn to before me this —§$ A 7 ayo __/Voventser 20a Notary Public of the State of New Jersey eo My Commission expires 6%-g4- 900+ StoteR NT Cons of Morne.

TOWNSHIP OF WEST ORANGE DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN Proposer Covers Malle KEIM, LEC Pursuant to Public Law 2012, c. 25, any person or entity that submits a bid or proposal or otherwise proposes to enter into or renew a contract must complete the certification below to attest, under penalty of perjury, that the person or entity, or one of the person or entity’s parents, subsidiaries, or affiliates, is not identified on a list created and maintained by the New Jersey Department of the Treasury as a person or entity engaging in investment activities in Iran. If the Director finds a person or entity to be in violation of the principles which are the subject of this law, s/he shall take action as may be appropriate and provided by law, rule or contract, including but not limited to, imposing sanctions, secking compliance, recovering damages, declaring, declaring the party in default and seeking debarment or suspension of the person or entity. I certify, pursuant to Public Law 2012, c. 25, that the person or entity listed above for which I am authorized to submit a proposal: {Is not providing goods or services of $20,000,000 or more in the energy sector of Iran, including a person or entity that provides oil or liquefied natural gas tankers, or products used to construct or maintain pipelines used to transport oi] or liquefied natural gas, for the energy sector of Iran, and PX Is nota financial institution that extends $20,000,000 or more in credit to another person or entity, for 45 days, or more, if that person or entity will use the credit to provide goods or services in the energy sector in Iran. In the event that a person or entity is unable to make the above certification because it or one of its parents, subsidiaries, or affiliates has engaged in the above referenced activities, a detailed, accurate and precise description of the activities must be provided in part 2 below to the New Jersey Turnpike Authority under penalty of perjury. Failure to provide such will result in the proposal being rendered as non-responsive and appropriate penalties, fines and/or sanctions will be assessed as provided by law. Part 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN You must provide a detailed, accurate and precise description of the activities of the proposer, or one of its parents, subsidiaries or affiliates,

INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN You must provide a detailed, accurate and precise description of the activities of the proposer, or one of its parents, subsidiaries or affiliates, engaging in the investment activities in Iran outlined above by completing the boxes below. Name: Relationship to Proposer: Description of Activities: Duration of Engagement: Anticipated Cessation Date: Proposer Contact Name: Contact Phone Number: Certification: I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I attest that I am authorized to execute this certification on behalf of the above referenced person or entity. I acknowledge that the Township of West Orange, State of New Jersey is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the Township to notify the Township in writing of any changes to the answers of information contained herein. I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I recognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the Township of West Orange, Continued... State of New Jersey and that the Township at its option may declare am (s) xesy}ting from this certification void and unenforceable. Full Name (Print): Shute Loc? Signature: nites Le Sibert pare LL aw a

TOWNSHIP OF WEST ORANGE Political Contribution Disclosure Statement Pursuant to Chapter 2, Section 68 of the Revised General Ordinances of the Township of West Orange Pursuant to Section 2-68.1 of the Revised General Ordinances of the Township of West Orange, please set forth below all political contributions in cash or in kind of two hundred ($200.00) dollars or more made within five (5) years of the date of acceptance of a proposal for a negotiated contract with the Township of West Orange, or within five (5) years of the notice of award for a bid contract with the Township of West Orange, either directly or indirectly, by the individuals or any of the principals of the business entity completing this form or by the business entity itself, to any elected official of the Township of West Orange currently in office or any political organization affiliated with an elected official of the Township currently in office.’ Name of Amount of Recipient of Date of Contribution Individual/Entity Contribution Contribution Making Contribution NONE If you have NOT made any contributions within the scope of Section 2-68.1, as set forth above, please X the line to the right. ~ I hereby certify under penalty of perjury that the information provided herein is true and accurate to the best of my knowledge, information and belief. The current elected officials of the Township include the following: Mayor Robert D. Parisi; Councilwoman Cindy Matute-Brown, Councilman Bill Rutherford; Councilwoman Susan McCartney, Councilwoman Michelle Casalino; and Councilwoman Tammy Williams. Coes 12 lb A LEM, ae Axthori iQnature SK 0 (fa Yh G Printed Name LL (7 -P-P~ Date

TOWNSHIP OF WEST ORANGE TOWNSHIP OF WEST ORANGE ACKNOWLEDGMENT OF RECEIPT OF ADDENDA The undersigned Bidder hereby acknowledges receipt of the following addenda: Please assign the number, date and initial. Addendum Number Dated Acknowledge Receipt (Initial) 0 No addenda was received. Acknowledged for: C, COLE ; kh AL, KE G7 CLE (Company Name) By: SS U4 (Sifmataré opethorized Representative) Name: Shivers Les pt E (Print) Title: [Fes Oe all