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9. In the past five years, has any claim against your firm concerning your firm's work on a medical services <br />review program, been filed in court or arbitration? ❑ Yes ❑ No <br />if "yes," on a separate page identify the claim(s) by providing the project name, date of the claim, name of <br />the claimant, the name of the entity the claim was filed against, a brief description of the nature of the claim, <br />the court and case number, and a brief description of the status of the claim (pending or, if resolved, a brief <br />description of the resolution.) <br />10. In the past five years, has your firm made any claim against a government Department concerning services <br />provided, and filed that claim in court or arbitration? ❑ Yes ❑ No <br />If `yes,"on a separate page identify the claim(s) by providing the project name, date of the claim, name of <br />the claimant, the name of the entity the claim was filed against, a brief description of the nature of the claim, <br />the court and case number, and a brief description of the status of the claim (pending or, if resolved, a brief <br />description of the resolution.) <br />11. At any time during the past five years, has any surety company made any payments on your firm's behalf <br />as a result of a default, to satisfy any claims made against a performance or payment bond issued on your <br />firm's behalf in connection with a project, either public or private? ❑ Yes ❑ No <br />12. In the last five years, has any insurance carrier, for any form of insurance, refused to renew the insurance <br />policy for your firm? ❑ Yes ❑ No <br />13. Has your firm or any of its owners, officers, or partners ever been liable in a civil suit, or found guilty in a <br />criminal action, for making any false claim or material misrepresentation to any public Department or entity? <br />❑ Yes ❑ No <br />14. Has your firm or any of its owners, officers or partners ever been convicted of a federal or state crime of <br />fraud, theft, or any other act of dishonesty? ❑Yes ❑No <br />If "yes," identify on a separate page, the person or persons convicted, the court case and number, the <br />crimes and the year convicted. <br />15. During the last five years, has your firm ever been denied bond credit by a surety company, or has there <br />ever been a period of time when your firm had no surety bond in place during a project when one was <br />required? ❑ Yes ❑ No <br />THIS FORM MUST BE COMPLETED AND INCLUDED WITH THE PROPOSAL. <br />PROPOSALS THAT DO NOT CONTAIN THIS FORM WILL BE CONSIDERED NONRESPONSIVE. <br />i�:cirf��❑ <br />of Santa Ana Human Resources Department <br />for Medical Services Review—August 27, 2018 <br />2tr=E32 <br />