4-RFP 05 Verification of Authorized Offeror Form.pdf

This is a Verification of Authorized Offeror Form issued by the Incorporated County of Los Alamos Procurement Division in Los Alamos, New Mexico, for use in conjunction with the Employee Dental Benefits solicitation. The form serves to establish the authorized officer who can legally obligate the selected offeror in providing dental insurance benefit coverage services to the County. The solicitation seeks licensed and qualified offerors to provide comprehensive dental insurance benefits including Administrative Services Only (ASO), claims administration, provider network coverage, and customer service. The form requires offerors to submit detailed information identifying their authorized representative, including printed name, title, signature, and contact information along with organizational details.

The form collects essential business identification information required for contract execution, including the organization's legal name, state of incorporation, federal tax identification number, New Mexico BTIN for in-state vendors, and designated contract manager information. Offerors must provide both mailing and physical addresses along with telephone and email contact details. This standardized form ensures the County has verified points of contact and proper authorization documentation prior to contract award, enabling efficient contract administration and service delivery for the employee dental benefits program.