Exhibit_E.2__Prime_Proposal_Information_Checklist.doc

Provider Enrollment and Oversight

75FCMC18R0014

Exhibit E.2

PEO IDIQ PRIME Proposal Information Checklist The prime contractor shall complete the following checklist for the Provider Enrollment and Oversight (PEO) IDIQ and Site Verification Services (SVS) task orders as applicable. This submission will allow CMS to more readily identify various aspects of your proposal. Please check the appropriate items and provide an explanation, if necessary.

****COMPLETE ALL PAGES AS APPLICABLE****

1) Prime Company name and address*

*If financial records are maintained at some other location, also provide the address of the place where the records are kept

2) Prime Company point of contact, email address and telephone number for this solicitation

3) If a newly formed company, provide name and address of parent companies forming the new entity:

a. __________________ b.__________________

4) Proposing on SVS Eastern Region Task Order:

___ yes If yes, please complete Page 4 of this document

___ no

5) Proposing on SVS Western Region Task Order:

___ yes If yes, please complete Page 5 of this document

___ no

6) CAGE CODE _______________

7) Dun & Bradstreet, Data Universal Numbering System (DUNS) No. ________________

8) Sales – Please provide the following information with regard to your organization’s annual sales:

Prime Offeror’s fiscal period __________ to ______________ (i.e. January to December)

Work distribution for the last complete fiscal accounting period:

Government cost reimbursement (includes T&M) type prime contracts and subcontracts: $_______________

Government fixed price prime contracts and subcontracts: $____________

Commercial Sales: $_______________

Total Sales: $_______________

9) Separate Entity or Segment:

Is your organization a separate entity or separate segment of a parent corporation?

If a separate segment of a parent corporation, name parent company:

10) Manpower - Total number of organization employees:______________

11) Place of Performance:

The offeror shall perform the majority of work on this contract at the following location:

(Name of Facility, Street Address, City, State, Zip)

12) Estimating System: Has your cost estimating system been approved by any Government agency? Yes_____No_____

If yes, give name and address of agency that approved the system:

13) Accounting System – Has your accounting system been deemed adequate or acceptable for use on Government cost reimbursement contracts? Yes_____No_____

If yes, give name and address of agency that deemed the system adequate or acceptable:

14) Purchasing System - Has your purchasing system been approved by a Government agency? Yes_____No_____

If yes, give name and address of agency that approved the system:

15) Compensation System – Has your compensation system been approved by a Government agency? Yes____No____

If yes, give name and address of agency that approved the system:

Does your organization comply with the limitations of FAR 31.205-6 Compensation for Personal Services? Yes_____No_____. If no, please explain.

16) IF A LARGE BUSINESS:

____Fully CAS Covered ____Partially CAS Covered ____N/A

If Fully or Partially CAS covered, provide the following:

Date of Disclosure Statement: __________________

Name and Address of Cognizant ACO or Federal Official Where Filed: _________________________

PEO IDIQ - Site Verification Services Eastern Region Task Order

List of proposed subcontractors (if applicable):

(i.e. Large, SDVOSB, 8a)*

*If the NAICS above does not fit with the subcontract requirement, provide the appropriate NAICS and why it was chosen.

PEO IDIQ - Site Verification Services Western Region Task Order List of proposed subcontractors (if applicable):

(i.e. Large, SDVOSB, 8a)*

*If the NAICS above does not fit with the subcontract requirement, provide the appropriate NAICS and why it was chosen.