Specimen tender form
OFFER IN TENDER PROCEDURE APP/487/ABM05/2024
ORDERING PARTY:
Medical University of Warsaw
ul. Żwirki i Wigury 61
02-091 Warszawa
REGON: 000288917
NIP: 525-00-05-828

CONTRACTOR:
This tender is submitted by:
Contractor:		
Registered office address:		
TAX ID:		
Name and surname of contact person:		
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in response to the Invitation to Submit Price Bids No. APP/487/ABM05/2024 for the service of investigator's and sponsor's liability insurance in connection with the conduct of the clinical trial: "EMpagliflozin and daPAgliflozin in patients hospiTalized for acute decompensated Heart failure (EMPATHY trial)"; - a Phase III study within the scope specified in Annex 1 to the Request for Proposal I submit the following offer under the following conditions:

1. submitting my offer in the public procurement procedure entitled Service of researcher's and sponsor's liability insurance in connection with the conduct of a clinical trial in Turkey, case no: APP/487/ABM05/2024, I offer to perform the contract for the price:  
- net PLN:.................. (in words PLN.......................................................................................)
- VAT - exempt
- gross PLN ..................(in words PLN:.....................................................................................)
2. we offer the price of insurance for each additionally registered patient (in the case of exercising the option right by the Ordering Party):
- net PLN:.................. (in words PLN..................................................................................) per 1 patient
- VAT tax - exempt
- gross PLN ..................(in words PLN:.....................................................................................) per 1 patient

CONTRACTOR'S STATEMENTS:
1. I declare that the total gross price includes all costs related to the execution of the subject matter of the order, including the Contractor's risk for estimating all costs related to its execution. Underestimation, omission and failure to recognise the scope of the subject matter of the order shall not be the basis for requesting a change in the remuneration specified in pt. 1. Any change in risk during the policy period resulting from a change to the clinical trial protocol may require a reassessment of risk and may result in a change to the terms of the policy.
2) I declare that I have familiarised myself with the contents of the Request for Quotation and all appendices and I do not raise any objections thereto and I have obtained all information necessary to prepare an offer and to properly execute the order.
(3) I declare that I am bound by this tender for the period specified in the Request for Quotation, i.e. 60 days, counting from the deadline for submission of tenders. 
4) The data contained in the statements attached to the offer, are up-to-date as of the date of the offer submission.
5. I declare that I have fulfilled the information obligations provided for in Article 13 or Article 14 of GDPR.e. Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data and repealing Directive 95/46/EC (General Data Protection Regulation) (Dz. Urz. EU L 119, 04.05.2016, p. 1) in relation to natural persons from whom I have directly or indirectly obtained personal data for the purpose of applying for a contract in this procedure. 

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Place and date		(legible signature of person(s) authorised to represent the Contractor in the registration documents or in the relevant authorisation)

DECLARATION OF NO RELATIONSHIP WITH THE ORDERING PARTY

I declare that I have no personal or capital relations with the Ordering Party. A capital or personal relationship means a mutual relationship between the Ordering Party or persons authorised to incur liabilities on behalf of the Ordering Party, or persons performing activities on behalf of the Ordering Party connected with the execution of the procedure for selecting the Contractor and the Contractor, consisting in particular of the following:
a) participation in the company as a partner in a civil partnership or partnership,
b) holding at least 10% of shares or stocks, 
c) performing the function of a member of a supervisory or managerial body, proxy, attorney,
d) being married, in a relationship of kinship or affinity in a straight line, second degree of kinship or affinity in a side line, or in a relationship of adoption, custody or guardianship.

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Place and date	(legible signature of person(s) authorised to represent the Contarctor in the registration documents or in the relevant authorisation)

STATEMENT BY THE CONTRACTOR CONCERNING SANCTIONING PROVISIONS RELATED TO THE WAR IN UKRAINE
I.	In connection with Article 7(1) of the Law of 13 April 2022 on special solutions to prevent support for aggression against Ukraine and to protect national security, I declare that:
1. the Contractor is* / is not* included in the lists set out in Regulation 765/2006 and Regulation 269/2014 or included in the list on the basis of a decision on inclusion in the list determining the application of the measure referred to in Article 1(3) of the aforementioned Act;
2. the Contractor's ultimate beneficial owner within the meaning of the Act of 1 March 2018 on the prevention of money laundering and terrorist financing (Journal of Laws of 2022, item 593 and 655) is* / is not* a person listed in the lists set out in Regulation 765/2006 and Regulation 269/2014 or included in the list or being such an ultimate beneficial owner as of 24 February 2022, provided that it has been included in the list on the basis of a decision on inclusion in the list conclusive of the measure referred to in Article 1(3) of the aforementioned Act;
3. the parent undertaking of the Contractor, within the meaning of Article 3 (1) (37) of the Accounting Act of 29 September 1994 (Journal of Laws of 2021, item 217, 2105 and 2106), is* / is not* an entity listed in the lists set out in Regulation 765/2006 and Regulation 269/2014 or listed or being such a parent entity as of 24 February 2022, insofar as it has been included in the list on the basis of a decision on inclusion in the list ruling on the application of the measure referred to in Article 1(3) of the aforementioned Act.
II.	In connection with Article 5k(1) of Council Regulation (EU) No 833/2014 of 31 July 2014 concerning restrictive measures in view of Russia's actions destabilising the situation in Ukraine as amended by Council Regulation (EU) 2022/576 of 8 April 2022, I declare that:
1. I am* / am not* a Russian citizen or a natural or legal person, entity or body based in Russia,
2. I am* / am not* a legal person, entity or body whose ownership rights directly or indirectly in more than 50% belong to the entity referred to in point 1),
3. I am* / am not* a natural or legal person, entity or body acting on behalf of or at the direction of an entity referred to in point 1) or 2).

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Place and date 	(legible signature of person(s) authorised to represent            the Contractor in the registration documents or in the relevant authorisation)