Applications for New Vendors Interested in The Wesley Community

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General Information

This form must be submitted with a completed IRS W‐9 form from the vendor/individual. If a completed W-9 is not received, you and/or your company will not be added to the Wesley database.

Max. file size: 25 MB.

Vendor/Professional Documents - submit your contract/proposal for services, licenses, and any other necessary documentation here.

Max. file size: 25 MB.

Payment Terms are Net 30, unless otherwise stated and agreed to by The Wesley Community
All invoices should be emailed to accountspayable@thewesleycommunity.org

Printed Name:*

Name Title

Date:*

I Certify that I have carefully examined this form and I determined that to the best of my knowledge and belief, the Information provided is complete and accurate.

Electronic Signature:*

First Last

Terms of Acceptance*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Business Contact Information

Legal Name of Company or Business:*

(Name that is used on your Federal Tax Return. If you are a Sole Proprietor of a business, the name of the owner of the business is required.)

DBA:

Vendor Contact Name:*

First Last

Vendor Phone:*

Vendor Fax:

Vendor Email Address:*

Vendor Mailing Address:*

Street Address Address Line 2 City State ZIP Code

Payment/Remit Contact Name:*

First Last

Payment/Remit Phone:*

Payment/Remit Fax:

Payment/Remit Email Address:*

Payment/Remit Mailing Address:*

Street Address Address Line 2 City State ZIP Code

Wesley Contact Information

Name of person or department from Wesley with whom you anticipate doing business once approved

Contact Name:*

First Last

Department:

Phone:

Fax:

Commodities/Services Offered:

Conflict of Interest Information

Are you or any Officer, Owner or Partner in this company an employee of The Wesley Community?*

Yes

Are any family members employees of The Wesley Community?*

Yes

If yes, please state who:*

Note to Vendors:

The performance of vendors on the approved vendor list is routinely monitored. If a vendor is found to be in violation of The Wesley Community (TWC) policy in regards to its business relationship with TWC, or, is unable to maintain the required level of service, the vendor will be removed from the approved list. Reinstatement is subject to successful application and re-evaluation. You must provide a valid Social Security Number (SSN) or Federal Employer Identification Number (FEIN) in order for the TWC to process your payment(s). The Wesley Community is required by Federal law where applicable to report such payments along with the SSN/FEIN to Federal and State agencies where required by law. Your failure to provide a correct name and Taxpayer Identification Number may subject your payments to a 30% federal income tax withholding.

General Information

Dear Wesley Vendor,

United Methodist Health and Housing, Inc., (UMHH) a New York not-for-profit corporation, is the parent entity for Wesley Health Center, Inc. ("Wesley"), a licensed not- for-profit skilled nursing facility, adult day care, outpatient therapies, subsidized senior housing, and assisted living.

As part of its commitment to providing quality health care services in accordance with ethical standards and in compliance with applicable laws, United Methodist Health and Housing, Inc. has adopted a Corporate Compliance Program ("Compliance Policy"). UMHH strives to conduct its business operations in accordance with the policies and standards of its Compliance Policy and expects that its business partners and their employees will comply with such policies and standards in conducting business with United Methodist Health and Housing, Inc.

Federal legislation requires UMHH to establish policies for its employees, and those of its contractors, vendors and business associates which or who, on behalf of a UMHH entity, furnish or otherwise authorize the furnishing of health care items or services, perform billing or coding functions, or are involved in monitoring of health care provided by a UMHH entity, which provide detailed information about:

(A) The Federal False Claims Act;
(B) Federal administrative remedies for false claims and statements:
(C) State laws pertaining to civil and criminal penalties for false claims and statements;
(D) Federal and state whistleblower protections under such laws; and
(E) UMHH's policies and procedures for detecting and preventing fraud, waste and abuse.

UMHH has incorporated such information in its Compliance Policy. To provide its contractors, vendors and business associates with ready access to this information, UMHH has placed its Compliance Policy on its website. The Compliance Policy can be found at www.TheWesleyCommunity.org (Corporate Compliance Link) located at the bottom of the home screen.

We request that you familiarize yourself with our Compliance Policy and the information contained therein regarding state and federal false claims laws and whistleblower protections. In addition, to assist UMHH in meeting these federal requirements, you are requested to notify your employees that information pertaining to state and federal false claims laws and whistleblower protections can be accessed through UMHH's Compliance Policy located at www.TheWesleyCommunity.org. Lastly, please read and sign the enclosed document.

If you have any questions concerning the United Methodist's Compliance Policy or the federal requirements, please contact me at compliance@theWesleycommunity.org . Thank you for your attention and cooperation in this matter.

Sincerely,

Dutch Hayward, COO
Compliance Officer
COMPLIANCE

Compliance Program

Pursuant to The Wesley Community Compliance Program:

Before entering into any vendor or professional service contract, each vendor and professional provider is required to sign a certification to the effect that the vendor or professional provider has not been convicted of a criminal offense relating to health care or been debarred, excluded or otherwise found ineligible to participate in a federal health care program.

This certification will also be required to be updated on an annual basis. In addition, The Wesley Community will access any applicable state or federal data base to determine whether a prospective or current vendor or professional provider has been excluded or otherwise found ineligible to participate in federal health care programs, including the database operated by the General Services Administration containing a monthly listing of debarred contractors.

Thank you in advance for your cooperation with program requirement.

I certify that I/Company have not been convicted of a criminal offense relating to health care or been debarred, excluded or otherwise found ineligible to participate in a federal health care program. I further certify that if I/Company become convicted of a criminal offense relating to health care or become debarred, excluded or otherwise found ineligible to participate in a federal health care program that I/Company will immediately notify the Corporate Compliance Officer of The Wesley Community.

Date:*

Title:*

Company:*

Electronic Signature:*

First Last

Terms of Acceptance:*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Certificate of Insurance

Dear Vendor:

The Wesley Community requires that any vendor, prior to performing services at any of our locations, provide a Certificate of Insurance as evidence of the following coverage and minimum limits:

Commercial General Liability (Occurrence Form)

Occurrence $1,000,000
Aggregate $3,000,000

Workers’ Compensation and Employer’s Liability (applicable if there are employees)

Bodily Injury by Accident $100,000 each accident
Bodily Injury by Disease $500,000 policy limit
Bodily Injury by Disease $100,000 each employee

Automobile Liability: $1,000,000 each accident

Umbrella Liability:

*Each Occurrence and Aggregate: $5,000,000

Optional coverage dependent on what the vendor would be doing, this is usually determined during the application process:

Damage to rented premises: $50,000 per each occurrence.
Medical Expenses: $5,000
Professional Liability (personal & adv injury): $1,000,000
Sexual Abuse: $3,000,000
Cyber/PHI Breach Liability: $1,000,000

*Umbrella coverage must be increased dependent on exposure up to $10,000,000

Additional Insured: Insert Insureds Name- is to be listed as additional insured

Non contributory language: Coverage shall be primary to any similar insurance carried by the Insert Insureds Name whose insurance shall be considered excess and non-contributory with insurance maintained by [Contractor/Sub-contractor/Permitee – ie. client providing the certificate].

Waiver of Subrogation: Contracts should include waiver of subrogation language. Waiver of subrogation must be agreed to contractually prior to the loss. In such an agreement, the subcontractor will not pursue recovery from INSERT NAMED INSURED. Sample certificate wording – always refer to an attorney for specific contractual language:

Insureds Name and their respective directors, officers, agents and employees are named as additional insured on all above policies and waiver of subrogation in favor of the insert NAMED INSURED , and their respective directors, officers, agents and employees applies as required by written contract.”

Conditions: The above coverages must be placed with an insurance company admitted in NYS with an A.M. Best rating of A-:VII or better; provide 30 days notice of cancellation.

[Contractor/Sub-contractor/Permitee] acknowledges that failure to obtain such insurance on behalf of the INSERT Named Insured, constitutes a material breach of contract and subjects it to liability for damages, indemnification and all other legal remedies available to the INSERT Named Insured [Contractor/Sub-contractor/Permitee] is to provide the INSERT Named Insured with a certificate of insurance, evidencing the above requirements have been met, prior to the commencement of work or use of facilities.

Please upload your certificate of insurance.

Max. file size: 25 MB.

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