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EXHIBIT C <br />CITY OF SANTA ANA <br />REQUEST FOR PROPOSALS FOR MEDICAL SERVICES REVIEW PROGRAM <br />PROPOSERS CERTIFICATION and PROPOSAL ITEM PRICING <br />Certification - I certify that I have read, understand and agree to the terms and conditions of this Request for <br />Proposals. I have examined the Scope of Services (Exhibit A) and am familiar with the scope of work <br />locations. I am familiar with all the existing conditions and limitation that may impact work requests. I <br />understand and agree that I am responsible for reporting any errors, omissions or discrepancies to the City for <br />clarification prior to the submission of my proposal. <br />Proposal Item Price - Pricing shall be based on the services performed, for services described in Exhibit A. <br />Fee must be Inclusive of all costs, Including but not limited to, direct and indirect costs for labor, overhead, <br />Incidental supplies, travel, mileage, and fuel. Attach additional pages as needed. <br />ESTIMATED I COST PER I ESTIMATED <br />1i <br />See Attached Exhibit C Supplemental Fee Schedule <br />Occu -vied Ltd. 559,435.2800 Fax: 559.435.7200 <br />LEGAL NAME OF COMPANY PHONE AND FAX NUMBERS <br />2121 West Bullard Avenue Fresno, CA 93711 <br />BUSINESS ADDRESS <br />52- 2333519 <br />FEDERAL ID NUMBER (IF APPLICABLE) CONTRACTOR LICENSE NUMBER (IF APPLICABLE) <br />THIS FORM MUST BE COMPLETED AND INCLUDED WITH THE PROPOSAL. <br />PROPOSALS THAT DO NOT CONTAIN THIS FORM WILL BE CONSIDERED NONRESPONSIVE. <br />Medical Services Review — January 12, 2015 <br />Page 23 <br />25A -37 <br />