Market Conduct Property Casualty Examination Sup

ATTACHMENT D
INSTRUCTIONS FOR NONCOLLUSION AFFIDAVIT
1. This Noncollusion Affidavit is material to any contract/purchase order awarded pursuant to
this bid. According to Section 4507 of Act 57 of May 15, 1998, 62 Pa. C.S. 4507,
governmental agencies may require Noncollusion Affidavits to be submitted with bids.
2. This Noncollusion Affidavit must be executed by the member, officer, or employee of the
bidder who makes the final decision on prices and the amount quoted in the bid.
3. Bid rigging and other efforts to restrain competition, and the making of false sworn
statements in connection with the submission of bids are unlawful and may be subject to criminal
prosecution. The person who signs the affidavit should examine it carefully before signing and
assure himself or herself that each statement is true and accurate, making diligent inquiry, as
necessary, of all other persons employed by or associated with the bidder with responsibilities
for the preparation, approval or submission of the bid.
4. In the case of a bid submitted by a joint venture, each party to the venture must be identified
in the bid documents, and an affidavit must be submitted separately on behalf of each party.
5. The term "complementary bid" as used in the affidavit has the meaning commonly associated
with that term in the bidding process, and includes the knowing submission of bids higher that
the bid of another firm, any intentionally high or noncompetitive bid, and any other form of bid
submitted for the purpose of giving a false appearance of competition.
6. Failure to submit an affidavit with the bid proposal in compliance with these instructions may
result in disqualification of the bid.

NONCOLLUSION AFFIDAVIT
Contract/Requisition No. ________________
State of _____________________ :
County of _____________________ : s.s.
I state that I am (Title) of (Name of Firm) and that I am
authorized to make this affidavit on behalf of my firm, and its owners, directors, and officers. I am the person
responsible in my firm for the price(s) and the amount of this bid.
I state that:
(1) The price(s) and amount of this bid have been arrived at independently
and without consultation, communication or agreement with any other contractor, bidder or potential bidder.
(2) Neither the price(s) nor the amount of this bid, and neither the approximate price(s)
nor approximate amount of this bid, have been disclosed to any other firm or person who is a bidder or
potential bidder, and they will not be disclosed before bid opening.
(3) No attempt has been made or will be made to induce any firm or person to refrain
from bidding on this contract, or to submit a bid higher than this bid, or to submit any intentionally high or
noncompetitive bid or other form of complementary bid.
(4) The bid of my firm is made in good faith and not pursuant to any agreement or
discussion with, or inducement from, any firm or person to submit a complementary or other noncompetitive
bid.
(5) (Name of Firm) its affiliates, subsidiaries, officers, directors, and
employees are not currently under investigation by an governmental agency and have not in the last four years
been convicted or found liable for any act prohibited by state or federal law in any jurisdiction, involving
conspiracy or collusion with respect to bidding on any public contract, except as follows:
I stated that (Name of Firm) understands and acknowledges that the above
representations are material and important, and will be relied on by (Name of Purchasing Agency)
in awarding the contract(s)/purchase order (s) for which this bid is submitted. I understand and my firm
understands that any misstatement in this affidavit is and shall be treated as fraudulent concealment from the
Purchasing Agency of the true facts relating to the submission of this bid.
_______________________________ _______________________________
(Signature) (Signatory's Name)
_______________________________
(Signatory's Title)
SWORN TO AND SUBSCRIBED
BEFORE ME THIS _________DAY
OF ___________________ 20 _____
______________________________My Commission Expires ___________________
Notary Public