10-Vendor Information Form.pdf

PDF 1 MB Posted

Attached to
26P-040 Group Dental Insurance Services for Eligible Employees and Dependents
Solicitation number
26-040
Issued by
Marion County, Florida

About this file

Written by GovTribe AI ·

This is a Vendor Information Form for a Florida state and local contract opportunity seeking qualified and licensed insurance carriers to provide comprehensive group dental insurance services for eligible employees and their dependents. The Request for Proposals (RFP) identified as 26P-040 requires vendors to offer competitive dental plan options, administer benefits, provide customer service and claims processing, and ensure compliance with all applicable federal, state, and local regulations.

The form requests essential vendor information including the legal business name, Doing Business As (DBA) designation, Federal Employer Identification Number (FEIN), and details of the authorized signatory legally empowered to execute contracts on behalf of the vendor. Additional required information includes the primary business contact person (if different from the authorized signatory), complete company address information for both headquarters and legal address, and multiple points of contact with corresponding email addresses and phone numbers to facilitate communication throughout the procurement process.

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6-EXHIBIT D - Top 25 Providers.xlsx XLSX spreadsheet
7-EXHIBIT C - Past Three-Year Claims and Enrollment History.xlsx XLSX spreadsheet
1-Scope of Services.pdf PDF
11-Conflict of Interest Statement Form.pdf PDF
8-Questionnaire.docx DOCX document
5-EXHIBIT A - Current Plan Certificate.pdf PDF
2-EXHIBIT F - Current Schedule of Benefits.pdf PDF
3-EXHIBIT E - Current Rollover Balance.xlsx XLSX spreadsheet

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Vendor Information Form

Legal Business Information

Legal Business Name Doing Business As (DBA)

FEIN

Authorized Signatory This should be the person legally authorized to sign contracts on behalf of the vendor.

First Name Last Name Primary Email Address Secondary Email Address Phone Number

Primary Business Contact If different from signatory First Name Last Name Title/Position Phone Number Email Address

Company Address Information Headquarters or Legal Address Street City State Zip Code

Doing Business As DBA:
Secondary Email Address:
Primary Email Address 1:
First Name:
Last Name:
Legal Business Name:
FEIN:
Phone Number:
Primary First Name:
Primary Last Name:
Title or Position:
Primary Phone Number:
Primary Email Address 2:
Street:
City:
State:
Zip Code:

File details come from the government source that posted it. Updated .