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2. <br />EXHIBIT G <br />CITY OF SANTA ANA <br />REQUEST FOR PROPOSALS FOR MEDICAL SERVICES REVIEW PROGRAM <br />I <br />RESPONSIBLE PROPOSER — SUPPLEMENTAL QUESTIONNAIRE <br />How many years has your organization been in business in California under your present business <br />If you performed same business under a different business name with same ownership and operation <br />management and changed name due to, but not limited to, bankruptcy, loss, or license, please complete <br />an additional and separate questionnaire. <br />Is your firm currently the debtor in a bankruptcy case? ❑Yes ❑No <br />i <br />If "yes," indicate the case number, bankruptcy court, and the date on which the petition was filed. <br />Case Number Bankruptcy Court <br />Date Filed <br />3. Was your firm in bankruptcy any time during the last five years? (This question refers only to a <br />bankruptcy action that was not described in answer to Question 2, above.) ❑Yes [:]No <br />If "yes," indicate the case number, bankruptcy court, and the date on which the petition was filed. <br />Case Number Bankruptcy Court Date Filed <br />4. Has any California State License Board license held by your firm or its responsiblemanaging employee or <br />responsible managing officer been suspended within the last five years? ❑Yes ❑No <br />5. At any time in the last five years, has your firm been assessed and paid liquidated damages after <br />completion of a medical services review program contract with either a public or private owner? <br />Dyes ❑No <br />Has your firm ever defaulted on a contract? ❑ Yes ❑ No <br />If "yes, " explain on a separate page. <br />8. In the last five years has your firm, or any firm with which any of your company's owners, officers or partners <br />was associated, been debarred, disqualified, removed, or otherwise prevented from bidding on, or <br />completing, any government Department project for any reason? ❑ Yes ❑ No <br />If "yes, " explain on a separate page. State the name of the organization debarred, the year of the event, <br />the owner of the project, and the basis for the action. <br />EXHIBIT G "RESPONSIBLE PROPOSER SAP' CONTINUES ON NEXT PAGE <br />City of Santa Ana Human Resources Department <br />RFP for Medical Services Review—August 27, 2018 <br />26T231 <br />