COST PROPOSAL WORKSHEET

Incorporated County of Los Alamos Procurement Division 101 Camino Entrada, Building 3 Los Alamos, NM 87544

Offeror Company Name:

Name and Title of the Person Completing this Form

INSTRUCTIONS:

1. Using this form, or Offeror’s own similarly formatted document, propose costs for all services, defined clearly in individual line items. If more space is needed, Offerors may add rows to clearly describe all costs or may provide more information separately.

2. All costs proposed must be in the currency of the United States of America.

3. Describe costs for reimbursable expenses, if any. If travel costs are proposed as direct reimbursable costs, Offerors should note the County’s *Travel Guidelines provided below and note any deviations or exceptions proposed by Offeror.

4. Describe costs for any additional and optional services Offeror may propose that are not already clearly described.

5. In accordance with County Code, the use of a cost-plus-a-percentage-of-cost contract is prohibited. Rates shall not include commissions.

6. Provide costs for all services (including additional, optional, and future services) for all years of an agreement. County will consider, but is under no obligation to accept proposed future year unit prices or price escalations, which may include but are not limited to price escalations based on:

a. a specified dollar amount;

b. a specified percentage;

c. a capped not-to-exceed dollar amount or percentage (e.g., annual increases will never exceed the lesser of $1,000.00 or 3%, per year over the prior year’s fee amounts);

d. or some other formula (e.g., a specific Producer Price Index or Consumer Price Index).

7. If proposing a price escalation mechanism for future years of an agreement where a specified dollar amount or specified percentage has not been proposed (e.g., if using a CPI), Offerors should also clearly describe the process and timing for Offeror to notify County of any such increase and the process by which County would approve such an increase in future years. County, at its sole discretion, reserves the right to accept any given proposed fees and price escalation mechanism and process for any agreement term length.

8. Provide a quote for the current plan design. Provide cost impact for plan design enhancement as outlined in RFP, as well as any plan design alternatives you wish to propose. ASO fees must be quoted on a PEPM basis. ASO Fees must be guaranteed for a minimum of two (2) years with level rates for Years 1 and 2 (i.e., there can be no increase in rates in Years 1 and 2). Rate caps or guarantees in years 3-7 will receive additional points as reference in the Proposal Evaluation Criteria Number 8 of the RFP.

COST PROPOSAL WORKSHEET: DENTAL SELF-FUNDED ASO FEES

COST CATEGORY

Monthly ASO Fee (PEPM)

Current Plan Design:

Current Plan Design with Evidence-Based Dentistry:

Alternative Plan Design, if you are offering:

Alternative Plan Design, if you are offering, with Evidence-Based Dentistry:

If you are awarded multiple lines of coverage, what, if any, is the impact to the Dental ASO Fees quoted above?

*Travel Guidelines:

If Offeror’s travel costs are proposed as direct reimbursable costs, copies of all travel expenses must accompany invoices submitted to County and shall only include the following:

1. The most economical means of transportation shall be used, commercial airlines coach fare rates;

2. Business-related tolls and parking fees;

3. Rental car, taxi service or shuttle services;

4. Mileage shall be reimbursed at the standard mileage rate for business miles driven as established from time to time by the Internal Revenue Service or a minimum of $0.45 per mile;

5. Hotel or motel lodging, not to exceed $250.00 base rate per night excluding tax;

6. Meals, per Los Alamos County Travel Policy, currently $90.00 per diem daily for multi-day travel, or up to $40.00 daily for one day travel;

7. Internet connectivity charges;

8. Any other reasonable costs directly associated with conducting business with County.

9. If reimbursement for lodging or airfare is sought and no receipt is furnished by Contractor showing the actual cost, the travel expense shall be deemed unreasonable and un-reimbursable.

Travel Expenses not allowed are as follows:

1. Entertainment; in-room movies, games, etc. and

2. Alcoholic beverages, mini bar refreshments or tobacco products.

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