19GE5026Q0053_Attachment2-PriceSchedule.xlsx
XLSX spreadsheet 21 KB Posted
- Solicitation number
- 19GE5026Q0053
About this file
This is a Price Schedule template for a health insurance solicitation for Locally Employed Staff (LES) at U.S. Embassy Ashgabat, Turkmenistan under Solicitation Number 19GE5026Q0053. The document establishes the pricing structure for a single-award firm-fixed-price Blanket Purchase Agreement (BPA) issued by the Regional Procurement Support Office (RPSO) Frankfurt, Department of State Office of Acquisition Management.
The price schedule requires offerors to submit firm-fixed monthly and annual premium rates for three coverage categories: Self Only (one individual), Self Plus One (two individuals), and Family (three or more individuals). Pricing is requested across five performance periods, with estimated premiums of 55, 65, and 130 respectively for each coverage tier. Offerors must enter proposed unit prices in the designated yellow-highlighted fields, specify applicable currency (defaulting to USD), and provide monthly retention amounts for each coverage category across all five periods. The template includes sections for calculating period totals and a grand total, with the pricing structure supporting the establishment of health insurance coverage for LES employees and their eligible dependents.
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Sheet1 Combined Synopsis/Solicitation 19GE5026Q0053 Health Insurance for Locally Employed Staff (LES), U.S. Embassy Ashgabat, Turkmenistan Attachment 2 - Price Schedule
Instructions: Offerors shall complete the Price Proposal Breakdown by entering their proposed unit firm-fixed prices in the yellow-highlighted fields and specifying the applicable currency in the designated area.
| CLIN | Category | Estimated Number of Premiums* | Monthly Premium | Annual Premium | Total |
| 1001 | FIRST PERIOD | ||||
| 1001A | Self Only (one individual) | 55 | - 0 | - 0 | |
| 1001B | Self Plus One (two individuals) | 65 | - 0 | - 0 | |
| 1001C | Family (three or more individuals) | 130 | - 0 | - 0 | |
| FIRST PERIOD TOTAL | - 0 | ||||
| 2001 | SECOND PERIOD | ||||
| 2001A | Self Only (one individual) | 55 | - 0 | - 0 | |
| 2001B | Self Plus One (two individuals) | 65 | - 0 | - 0 | |
| 2001C | Family (three or more individuals) | 130 | - 0 | - 0 | |
| SECOND PERIOD TOTAL | - 0 | ||||
| 3001 | THIRD PERIOD | ||||
| 3001A | Self Only (one individual) | 55 | - 0 | - 0 | |
| 3001B | Self Plus One (two individuals) | 65 | - 0 | - 0 | |
| 3001C | Family (three or more individuals) | 130 | - 0 | - 0 | |
| THIRD PERIOD TOTAL | - 0 | ||||
| 4001 | FOURTH PERIOD | ||||
| 4001A | Self Only (one individual) | 55 | - 0 | - 0 | |
| 4001B | Self Plus One (two individuals) | 65 | - 0 | - 0 | |
| 4001C | Family (three or more individuals) | 130 | - 0 | - 0 | |
| FOURTH PERIOD TOTAL | - 0 | ||||
| 5001 | FIFTH PERIOD | ||||
| 5001A | Self Only (one individual) | 55 | - 0 | - 0 | |
| 5001B | Self Plus One (two individuals) | 65 | - 0 | - 0 | |
| 5001C | Family (three or more individuals) | 130 | - 0 | - 0 | |
| FIFTH PERIOD TOTAL | - 0 |
| FIRST PERIOD TOTAL | - 0 |
| SECOND PERIOD TOTAL | - 0 |
| THIRD PERIOD TOTAL | - 0 |
| FOURTH PERIOD TOTAL | - 0 |
| FIFTH PERIOD TOTAL | - 0 |
| GRAND TOTAL | - 0 | ||
| CURRENCY | USD | ||
| *estimated number of premiums does not include any Riders | |||
| **does not include any premiums for Riders. | |||
| Monthly Retention Amounts per separate premium paid per Self Only (one individual), Self Plus One (two individuals) and Family (three or more individuals) | |||
| Period of Performance | Self Only (one individual) | Self Plus One (two individuals) | Family (three or more individuals) |
| FIRST PERIOD | |||
| SECOND PERIOD | |||
| THIRD PERIOD | |||
| FOURTH PERIOD | |||
| FIFTH PERIOD |
_x000D_&1#&"Calibri"&14&K000000 SBU - CONTRACTING AND ACQUISITIONS
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