E.2_-_Subcontractor_Proposal_Checklist.doc

HHSM-500-2016-RFP-0002-NCCI

Exhibit E.2

Proposal Checklist - Subcontractor You are requested to complete the following checklist to allow CMS to more readily identify various aspects of your proposal. Please check the appropriate items and provide an explanation, if necessary.

1) Prime Offeror’s Name: _________________________________

2) Type of contract entered into with the Prime (i.e. fixed price, Time and Materials):

3) Subcontractor company name, address, point of contact and telephone number

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

a. __________________ b.__________________

5) List of proposed subcontractors (if applicable):

a. _____________________________________

b. _____________________________________

c. _____________________________________

6) In accordance with the North American Industry Code 541511, indicate the business size of the subcontractor entity/company.

□ Large Business

□ Small Business – check additional categories as applicable:

____ Disadvantaged

____ Woman-owned

____ Veteran-owned

____ HUBZone

____8(a)

6) TIN # _______________

7) DUNS# _______________

8) Cage Code _____________

9) Productive Hours for Exempt and Non-Exempt Employees ________