E-TENDER ENQUIRY FOR RATE CONTRACT No. 175 FOR SUPPLY OF DRUGS/MEDICINES

Name of the Particiapting Pharmaceutical Firm ___________________

Tender Enquiry No:…………

Details Annexure A Annexure F

S.No. Name of the Particpating Pharmaceutical Firm Item No. Item Name and Description as per Drug Schedule Unit as per Drug Schdeule Item Name and Description of the product offered by the firm Brand Name, if any Packing Offered by firm Drug License No. and Date of issue for the product Date of Mfg. of 1st batch of the product S. No. in Annexure B/Page No. Was it in past Rate Contract. If yes, R.C. No Was the firm debarred in the past for the item if so, period of debarring as per Annexure - E NPPA Notified Ceiling Price OR write Not Applicable as the case maybe. (pls attach self certified copy of the NPPA order, if applicable) Manufactured by Marketed by Type of Drug License Self mfg. / loan license / 3rd party BMR document no. as per official record BMR finalization date Page no. of Document in uploaded technical bid (Pages in range) Remarks (Put NA if Not Applicable)

Warning: Any Bidder found to have quoted rate/s for any drug/s more than NPPA Notified Ceiling Price shall be construed to be in violation of Code of Integrity as per the Tender Enquiry and shall be liable for action as per clause 2(XV).

Signature of Authorized Signatory:

Name of the Particiapting Pharmaceutical Firm ___________________

Tender Enquiry No:…………

DETAILS OF LICENSES (to be uploaded in Excel)

· For Indigenous Items

Details of Licenses – quoted Items

S. No Item No. Drug License (fill no.) Site GMP/WHO-GMP GLP No Conviction Patent & Proprietary Drug Certificate New molecule/Drug Certificate

Number Valid Upto Page No. Valid Upto Page No. Valid Upto Page No. Date of Issue Page No. Number Date of Issue Valid upto Number Date of issue

· For Imported Items

Details of Licenses – quoted Items

S. No. Item No. Import License Form 10 Country of Origin COPP Form 20B/21B Form 41 No Conviction Patent Drug Certificate New molecule/Drug Certificate

Number Valid Upto Page No. Valid Upto Number Date of Issue Valid Upto Page No. Number Valid Upto Page No. Date of Issue Page No. Number Date of Issue Valid Upto Number Date of issue

Signature of Authorized Signatory:

Name of the Particiapting Pharmaceutical Firm ___________________

Tender Enquiry No:…………

Earnest Money Deposit Criteria

SNo. Item No. Name of the Drugs Drugwise EMD (in Rs.) as per the Drug Schedule

Sum total of EMD submitted in Rs.

NOTE: Correct Item No. & Name of the Drugs to be mentioned.

Signature of Authorized Signatory:

Name of the Particiapting Pharmaceutical Firm ___________________

Tender Enquiry No:…………

Turnover Criteria as per clause 7 of the tender For Financial Years 2022-23, 2023-24 and 2024-25

SNo. Item No. Name of the Drugs Drug wise Turnover (In Rs.) as per the Drug Schedule

Total number of items quoted

Sum total of Turnover for drugs quoted (in Rs.)

Total Annual Turnover of the firm from Pharmaceutical Products for Drug formulations only (excluding sale of Active Pharmaceutical Ingredients or Bulk Drugs) for the year 2022-23

Annual Turnover of the firm for the year 2022-23 from Trade/Market other than Govt. Institutions/ Sale to 3rd Party for drug formulations only (excluding sale of Active Pharmaceutical Ingredients or Bulk Drugs)

Total Annual Turnover of the firm from Pharmaceutical Products for Drug formulations only (excluding sale of Active Pharmaceutical Ingredients or Bulk Drugs) for the year 2023-24

Annual Turnover of the firm for the year 2023-24 from Trade/Market other than Govt. Institutions/ Sale to 3rd Party for drug formulations only (excluding sale of Active Pharmaceutical Ingredients or Bulk Drugs)

Total Annual Turnover of the firm from Pharmaceutical Products for Drug formulations only (excluding sale of Active Pharmaceutical Ingredients or Bulk Drugs) for the year 2024-25

Annual Turnover of the firm for the year 2024-25 from Trade/Market other than Govt. Institutions/ Sale to 3rd Party for drug formulations only (excluding sale of Active Pharmaceutical Ingredients or Bulk Drugs)

NOTE: Correct Item No. & Name of the Drugs to be mentioned.

Signature of Authorized Signatory:

Name of the Particiapting Pharmaceutical Firm: ___________________

Tender Enquiry No:…………

Name of the Particiapting Pharmaceutical Firm

Name of the Authorised Signatory

Email Address of Authorised Signatory

Mobile Number of Authorised Signatory

Address of firm for correspondence:

Telephone No. (landline if any):

Working Fax No (Must be provided):

E-mail address for all Correspondences including placing of Supply order :

I hereby undertake timely and efficient supply of the quoted drugs as per the tender in all the locations where ESIC / ESIS Hospitals and State ESI Directorates are located. The details are as under:

S. No. Zone States Postal Address of Registered Office in zone Postal Address of Depot in zone Name of Reg. office/Depot Incharge along with telephone No. ,E-mail etc. of the Zone GST No. Manufacturing Drug Licenses or Wholesale Drug Licenses

1 Zone 1 Kerala, Karnataka, Tamil Nadu, Pudducherry, Andhra Pradesh, Telangana

2 Zone 2 Maharashtra, Goa, Madhya Pradesh,Chhattisgarh, Gujarat, Rajasthan

3 Zone 3 Jammu & Kashmir, Punjab, Himachal Pradesh , Delhi & Haryana, Uttar Pradesh, Uttrakhand

4 Zone 4 Odisha, Jharkhand, West Bengal, Bihar, North East States including Sikkim.

Note :Valid documentary evidence for Annexure L has to be submitted along with the bid.(Valid Manufacturing Drug Licenses or Wholesale Drug Licenses or GST Certificate only)

Signature of Authorized Signatory:

S.No. Name of the Bidder Tender Enquiry No. Mode of EMD Submitted(DD/BG/FDR) DD/BG/FDR No. Amount (value in Rs.) Date of Issue Date of Expiry/ Maturity Date Date of Claim expiry Name of the Bank

Select, Excess (+), Less (-)

Tender Inviting Authority: DIRECTOR GENERAL, EMPLOYEES' STATE INSURANCE CORPORATION

Name of Work: SUPPLY OF DRUGS/MEDICINES

Contract No: E-TENDER ENQUIRY FORM FOR RATE CONTRACT NO – 175

Name of the Bidder/ Bidding Firm / Company :

Sl. No. Item Description Item Code / Make Quantity Units Estimated Rate in Rs. P Addition / Deduction Addition / Deduction Values Currency Convertion against each Item Quoted Currency in INR / Other Currency Net Rates / Unit ** offered without GST (in figures) Net Rates offered/ Unit (in words ) Applicable GST Brand Name If Price is Notified by NPPA, Enter the Order No. & Ceiling Price otherwise Enter NA *Retail Sale Price IIIrd Party i.e DGS&D / RITES etc Inspection Charges @0.34%+Service Tax in Rs. P Less for Cenvat Credit,if any respect of Supplies Under full Excise Duty Category in Rs. P

1 5-aminosalicylic acid (Mesalazine/ Mesalaine) Retention Enema: Each 60ml unit of rectal suspension contains Mesalazine/mesalamine 4.0 grams Packing:60ml Bottle Item No.: NLEM001 0.000 1ml Excess(+) Full Conversion INR

48 CarbamazepineTab- Each Tab to contain: Carbamazepine 100mg Item No.: NLEM070 0.000 1 Tab Excess(+) Full Conversion INR

113 Ferrous Salt and Folic acid Tab- Each tablet to contain 45 mg elemental iron and 400mcg Folic acid. Item No.: NLEM155 0.000 1 Tab Excess(+) Full Conversion INR

160 Linezolid Tab- Each Tablet to contain: Linezolid 300mg Item No.: NLEM219 0.000 1 Tab Excess(+) Full Conversion INR

184 Midazolam Nasal Spray- Each actuation to release Midazolam 1.25mg Packing: 25 Metered Dose Item No.: NLEM248 0.000 1 Dose Excess(+) Full Conversion INR

253 Tenecteplase Inj- Each Vial to contain: Tenecteplase 30mg Packing: 1 Vial Item No.: NLEM338 0.000 1 Vial Excess(+) Full Conversion INR

Total in Figures

Quoted Rate in Figures Select %

Quoted Rate in Words

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