Att.F - Respondent and Subcontractor Info.pdf

RFP No.: DMS-22/23-174 Attachment F: Respondent and Subcontractor Information Page 1 of 4

ATTACHMENT F: 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, City, Zip Code

Telephone

Fax

E-mail Address

FEID #

Attachment F: Respondent and Subcontractor Information Page 2 of 4

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).

Title Address City State Zip Code Telephone Number Email Address Years of life insurance experience Years with the organization

Years in 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).

Title Address City State Zip Code Telephone Number Email Address Years of life insurance experience Years with the organization

Years in current position

Proposed percent of time dedicated the Department

Number of Clients and size of accounts

Attachment F: Respondent and Subcontractor Information Page 3 of 4

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

Subcontractor #1

Question Response

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 (FEID) (Employer ID or FEID Tax ID).

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)?

Attachment F: Respondent and Subcontractor Information Page 4 of 4

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

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.

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 location(s) 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.

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.