8.Att.H-Respondent & Sub Info-FINAL 4.25.22.pdf

RFP No.: DMS-21/22-027 Attachment H: Respondent and Subcontractor Information Page 1 of 5

ATTACHMENT H: RESPONDENT AND SUBCONTRACTOR INFORMATION

The Respondent’s response to this section will not be scored and is for informational purposes.

Instructions: The Respondent is to provide a response to each requested item below.

Additional tables may be added by Respondent as needed.

1. Respondent General Information

Company Information Response

Respondent’s Legal Name

Address of Headquarters City State ZIP Code Date Established Web address Corporate Tax Status Federal Employer Identification Number (FEIN)

2. Contact Information

For solicitation purposes, the Respondent’s contact person will be:

Name

Title

Company Name

Address

Telephone

Fax

E-mail

FEID #

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

Attachment H: Respondent and Subcontractor Information Page 2 of 5

3. Account Manager Provide the following information regarding the Account Manager that will be assigned to the State’s account, if Respondent is awarded a Contract under this RFP. This individual provides oversight of account services for the State. In addition, submit a resume or curriculum vitae for the Account Manager below (include as Tab 7 Attachment R&S-3: Account Manager Resume).

Account Manager Response

Name Title Address City State ZIP Code Telephone number Email address Years of dental plan experience

Years with the organization Years in the current position Proposed percent of time dedicated the Department

Number of Clients and size of accounts

4. Implementation Manager Provide the following information regarding the Implementation Manager that will be assigned to the State’s account, if Respondent is awarded a Contract under this RFP. In addition, submit a resume or curriculum vitae for the Implementation Manager below (include as Tab 7 Attachment R&S-4: Implementation Manager Resume).

Implementation Manager Response Name Title Address City State ZIP Code Telephone number Email address Years of industry experience Years with the organization Years in the current position Proposed percent of time dedicated to the State of Florida Plan

Number and size of other accounts

Attachment H: Respondent and Subcontractor Information Page 3 of 5

5. Subcontractors Instructions: Provide responses below for each proposed Subcontractor that will perform any of the required Services, or provide services to the Respondent to meet the requirements of the resultant contract, should the Respondent be awarded. Submission of this form does not indicate the Department’s approval but provides the Department with information on proposed subcontractors for review.

Complete a separate sheet for each subcontractor. If additional subcontractors are proposed, copy and insert the applicable tables and update the header (i.e. Subcontractor #11).

There will be subcontractors for this solicitation YES ____ NO ____ (place a checkbox where applicable). If no, Respondents are not required to complete the remainder of this form.

Subcontractor Questionnaire (SQ) Form

Question Response

Subcontractor #1

SQ-1 Subcontractor Name

SQ-2

Corporate address, telephone number and website of Subcontractor.

SQ-3

Office address, telephone number and website of Subcontractor that will be performing any of the required Services under the Contract.

SQ-4

Federal Employer Identification Number (Employer ID or Federal Tax ID, FEID).

SQ-5

Occupational license number (if applicable)

SQ-6

Is this Subcontractor currently registered as a certified woman, veteran, or minority-owned small business enterprise certified by the State of Florida’s Office of Supplier Diversity?

SQ-7

Does this Subcontractor currently have a Form W-9 registered by the Internal Revenue Service (IRS)?

SQ-8

Primary contact person’s name, address, email address and phone number, at the Subcontractor’s company, related to the performance of the Contract.

SQ-9

Brief summary of the history of the Subcontractor's company and information about the growth of the organization on a national level and within the State of Florida.

Attachment H: Respondent and Subcontractor Information Page 4 of 5

SQ-10

Describe any significant government action or litigation taken or pending against the Subcontractor or any entities affiliated with the Subcontractor during the most recent five (5) years.

SQ-11

List and describe the Services the Subcontractor will be responsible for in the performance of the Contract.

Specifically, what roles (duties, tasks, administrative services, etc.) will the Subcontractor have in the performance of the Contract?

SQ-12

List the locations where all Services will be provided (e.g., city, state, country)

SQ-13

Explain the process for monitoring the performance of the Subcontractor and measuring the quality of its results.

SQ-14

a.) Is the Subcontractor compliant with all applicable HIPAA administrative simplification rules?

b.) What procedures does Respondent have in place to ensure Subcontractor compliance?

SQ-15

Describe the process the Respondent will implement during the Contract term to ensure that background checks (as described in the Contract) will be completed on the Subcontractor.

Attachment H: Respondent and Subcontractor Information Page 5 of 5

6. References Instructions: Provide at least four (4) references in accordance with the instructions in the Contents of Proposal section and Form 4 of the RFP, and as follows:

a. The two (2) largest public sector Clients for whom the Respondent currently provides similar services to those sought in this RFP, each having an enrollment count equal to or greater than 50,00 Participants.

b. The two (2) largest former Clients (public or private sector) for whom the Respondent provided similar services to those sought in this RFP, each having had an enrollment count equal to or greater than 50,00 Participants.

References will not be accepted from:

a. Current employees of DMS.

b. Former employees of DMS within the past three (3) years.

c. Persons currently or formerly employed by the respondent’s organization.

d. Board members of the Respondent’s organization.

e. Relatives.

f. Corporations based solely in a foreign country.

g. A member of the Respondent’s organization, who has written, completed and submitted the form on behalf of the reference.

h. Subcontractors of the Respondent.

i. Entities having an affiliation with the Respondent (i.e. currently parent, subsidiary having common ownership, having common directors, officers or agents or sharing profits or liabilities).

The same Client may not be listed for more than one (1) reference and confidential Clients shall not be included.

In the event the Respondent has had a name change since the time work was performed for a listed reference, the name under which the Respondent operated at that time must be provided in the space provided for Respondent’s name.

The Respondent shall include with its response a completed Form 4 –Client References for at least four (4) separate and verifiable references. Each reference must be provided in accordance with the instructions contained therein, in this RFP, and in this Attachment. The Department will not accept any references that are not included with the Respondent’s Proposal in the manner specified.

The Department reserves the right to contact references other than those identified by the Respondent to obtain additional information regarding past performance. Any information obtained as a result of such contact may be used to determine whether or not the Respondent is a responsible vendor, as defined in section 287.012(25), F.S.