CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT 
CALIFORNIA HEALTH BENEFIT EXCHANGE 
 
I certify that I have no personal or financial interest and no present or past employment or activity that is incompatible with my participation in the procurement referenced below. I further certify that neither my spouse nor my dependent children has a personal or financial interest and no present employment that would be incompatible with these procurement activities. For the duration of my involvement with this procurement, I agree not to accept any gift, benefit, gratuity, or consideration, or obtain a personal or financial interest in any party who is bidding or associated with a bid on this procurement. I am able to give full, fair, and impartial consideration to this procurement. 
 
I certify that, except for purposes directly connected with the administration of the procurement process referenced below, I will keep confidential and secure and will not copy, give, or otherwise disclose to any person the subject matter or substance of any information or data, proposals, bids, e-mails, correspondence, memoranda, working papers, meeting results or notes, phone or conference call notes, or records, in any form, that contain any documentation related to this procurement. I understand that information to be kept confidential includes, but is not limited to, specifications, administrative requirements, and terms and conditions, and includes concepts and discussions as well as written or electronic materials. 
 
I understand that when my service with the California Health Benefit Exchange ends, I must continue to keep confidential all information that was made available to me as part of my duties and participation with this procurement. I agree to follow any instruction provided by the California Health Benefit Exchange respecting the confidentiality of procurement information. 
 
I fully understand that any unauthorized disclosure I make may be a basis for civil or criminal penalties and/or disciplinary action (including dismissal for State employees). I agree to advise the buyer immediately in the event that I either learn or have reason to believe that any person who has access to confidential information related to this procurement has disclosed or intends to disclose that information in violation of this agreement. 

 

Organization 
 California Health Benefit Exchange	Title 
	
Name 
	Signature 	Date 	
Project Name
 
Qualified Health Plan Certification	Procurement Title and # 

QHP Certification for Plan Year 2019 (Individual & Small Business Marketplaces) 
QDP Certification for Plan Year 2019 (Individual & Small Business Marketplaces)