3-Vendor Information Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-116
- Issued by
- Marion County, Florida
About this file
This Vendor Information Form is associated with Marion County Board of County Commissioners' solicitation for Third-Party Administration (TPA) services for the County's self-insured Workers' Compensation Program in Florida. The form requires vendors to submit comprehensive legal business information, including the legal business name, Doing Business As (DBA) designation, Federal Employer Identification Number (FEIN), and details of an authorized signatory who is legally empowered to execute contracts on behalf of the vendor. Additionally, vendors must provide primary business contact information if different from the authorized signatory, including name, title, phone number, and email address, along with complete company address information for both the headquarters or legal address and any secondary DBA locations.
The form serves as a standardized submission requirement for firms seeking to provide claims administration and management, medical and indemnity payment processing, litigation support, regulatory compliance, reporting, data conversion and transition services, and Risk Management Information System (RMIS) access to support the County's Workers' Compensation Program. Vendors must supply both primary and secondary email addresses, phone numbers, and complete street addresses with city, state, and zip codes to facilitate communication throughout the procurement and contract administration process.
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Other files
| File | Type | Posted |
|---|---|---|
| 5-Scope of Work.pdf | ||
| 2-RFx - General Terms and Conditions.pdf | ||
| 6-Evaluation Process and Scoring Criteria.pdf | ||
| 7-3 year WC claim history.xlsx | XLSX spreadsheet | |
| 4-PaymentWorks Onboarding Letter.pdf | ||
| 1-Conflict of Interest Statement Form.pdf |
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Text version
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 .