Life Pricing Worksheet.xls
XLS spreadsheet 163 KB Posted
- Attached to
- Life Insurance Services - Pricing Only
- Solicitation number
- 20-416CMS-BENF4-B-14561
- Issued by
- Illinois
About this file
This document is the Financial Proposal for a Request for Proposal (RFP) issued by the State of Illinois for Group Term Life and Accidental Death and Dismemberment (AD&D) Insurances. The RFP seeks proposals for a group life and AD&D insurance program for the state's employees and annuitants. The Financial Proposal contains detailed pricing forms for various coverage options, including Basic Life, Optional Life, Spouse Life, Child Life, and AD&D. Offerors must provide monthly premium rates per $1,000 of coverage, as well as administrative fees and interest rates, which will be used to rank proposals from lowest to highest cost. The contract term is for a minimum of 3 years, with a potential 5-year rate guarantee.
The Financial Proposal requires offerors to submit firm, fixed, maximum pricing on a per-unit basis. There is no guarantee of enrollment, but all premiums must be guaranteed regardless of enrollment. The State will use the "Total Premium" and the difference between "Total Premium" and Current Premium to rank proposals in order of lowest cost and highest savings to state employees. The RFP does not mention any set-asides, incumbents, or specific funding sources, but it does state that no other amounts will be paid to the awarded vendor beyond the proposed pricing.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment - Notice of Electronic Submission Only v.20.2~1.pdf | ||
| Life Pricing Worksheet Revised 5-19-20.xls | XLS spreadsheet | |
| Vendor Instruction to Submit Pricing B-14561.docx | DOCX document |
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Listbox
| ListYesNoOnly | Yes |
| No with explanation | |
| ListYesNo | Yes |
| No | |
| ExpDev | Explanation |
| Deviation |
E-1 Proposal Instructions
| Request for Group Term Life and Accidental Death and Dismemberment (AD&D) Insurances |
| Proposal for The State of Illinois |
| Attachment E-1: Financial Proposal Instructions |
| RFP # |
| Instructions: |
| Complete all the attached financial exhibits for the proposed Group Term Life plan. |
Attachment E-2: Financial Proposal Basic Life, Participationg Attachment E-3: Financial Proposal Optional Life. Participating Attachment E-4: Financial Proposal Optional Life (alternate), Participating Attachment E-5: Financial Proposal Optional Life. Non-Participating Attachment E-6: Financial Proposal Optional Life (alternate), Non-Participating
| The Financial Proposal Form is used to calculate the Offeror’s TOTAL Proposal PRICE. Follow these instructions carefully when completing your Financial Proposal Form: | |
| A. | All Unit Prices must be clearly entered in dollars and cents, e.g., $24.15. Make your decimal points clear and distinct. |
| B. | All Unit Prices must be the actual price per unit the State will pay for the specific item or service identified in this RFP and may not be contingent on any other factor or condition in any manner. |
| C. | All calculations shall be rounded to the nearest cent, e.g., .344 shall be .34 and .345 shall be .35. |
| D. | Every blank in every Financial Proposal Form for the Service Category or Categories in which Offeror is proposing shall be filled out. Any changes or corrections made to the Financial Proposal Form by the Offeror prior to submission shall be initialled and dated. |
| E. | Except as instructed on the Financial Proposal Form, nothing shall be entered on, or attached to, the Financial Proposal Form that alters or proposes conditions or contingencies on the prices. Alterations and/or other conditions may render the Proposal not reasonably susceptible to being selected for award. |
| F. | It is imperative that the prices included on the Financial Proposal Form have been entered correctly by the Offeror and that the respective total prices agree with the entries on the Financial Proposal Form. Any incorrect entries or inaccurate calculations by the Offeror may cause the Proposal to be rejected. |
| G. | All Financial Proposal prices entered are to be fully loaded prices that include all costs/expenses associated with the provision of services as required by the RFP. The Financial Proposal price shall include, but is not limited to, all labor, profit/overhead, general operating, administrative, and all other expenses and costs necessary to perform the work set forth in the solicitation. No other amounts will be paid to the awarded vendor. |
| H. | Unless indicated elsewhere in the RFP, sample amounts used for calculations on the Financial Proposal Form are typically estimates for evaluation purposes only. Unless stated otherwise in the RFP, the Department does not guarantee a minimum or maximum number of units or usage in the performance of the Contract. |
| I. | Failure to adhere to any of these instructions may result in the Proposal being determined not reasonably susceptible to being selected for award. |
| Attachment E-2 through E-6: Premiums | |
| All premuim rates are to be quoted on a firm, fixed, maximum basis for enrollees. | |
| Administrative Fee percentage is to be quoted on a firm, fixed, maximum basis for enrollees. | |
| Annual Interest Rate percentage is to be quoted on a firm, fixed, maximum basis for enrollees. | |
| The Financial price sheets are used for evaluation purposes only. There is no guarantee of enrollment for the plan and all premiums must be guaranteed regardless of enrollment. |
E-2 Basic Life (par)
| Request for Group Term Life Proposal for The State of Illinois, Basic Life | ||||
| Attachment E-2: Financial Proposal Basic Life | ||||
| Participating, Dividend Eligible, Deficit carry-forward | ||||
| RFP # | ||||
| The Offeror shall provide monthly cost per $1000 coverage for Basic Life insurance. Rate quoted in the table below shall apply to the entire term of the contract. Rate quoted should be guaranteed for a minimum of 3 years. | ||||
| For purposes of financial ranking, the State will use the “Total Premium” as the evaluated price to rank Offerors’ proposals in order of lowest to highest cost to the State. | ||||
| Basic Life Premium Rate | ||||
| # of Insured Employees/ Retirees (A) | Volume in $1,000 (B) | Monthly Rate (C) | # of Months (D) | Total Premium (E) [B×CxD] |
| 12 | $ - 0 | |||
| Total Premium | $ - 0 | |||
| Rate Guarantee | 5 Years | |||
| The Offeror shall quote the Administration Fee as a percent of the Basic Life Premium Rate. The Administration percent should be guaranteed for a minimum of 3 years. | ||||
| For purposes of financial ranking, the State will use the “Admin Fee %” as the evaluated price to rank Offerors’ proposals in order of lowest to highest cost to the State. | ||||
| Basic Life Administration Fee | ||||
| Admin Fee % | ||||
| Fee Guarantee | 5 Years | |||
| The Offeror shall quote the Annual Interest Rate percent in the table below. The quoted Annual Interest Rate should be guaranteed for a minimum of 3 years. | ||||
| For purposes of financial ranking, the State will use the “Interest Rate %” as the evaluated price to rank Offerors’ proposals in order of highest to lowest cost to the State. | ||||
| Basic Life Annual Interest Rate | ||||
| Interest Rate % | ||||
| Interest Rate Guarantee | 5 Years | |||
| Submitted By: | ||||
| Authorized Signature: ______________________________________________________Date: ___________ | ||||
| Printed Name and Title: | ||||
| Company Name: | ||||
| Company Address: | ||||
| Location(s):* | ||||
| FEIN: | eMM#: | |||
| Telephone: | Fax: | |||
| E-mail: | ||||
| * from which services will be performed (City/State) |
E-3 Optional Life (par)
| Request for Optional Group Term Life and Accidental Death and Dismemberment (AD&D) Insurances for The State of Illinois | |||||
| Attachment E-3: Financial Proposal Optional Life, Spouse Life, Child Life, and AD&D | |||||
| Employee & Retirees share same age banded rate table | |||||
| Participating, Dividend Eligible, Deficit carry-forward | |||||
| RFP # | |||||
| The Offeror shall provide monthly term life insurance rates per applicable unit of coverage. Same rate per $1,000 for employees as for for retirees in each age bracket indicated. A flat monthly rate per $1,000 of coverage shall be provided for spouse coverage, child(ren}) coverage and AD&D coverage. Enrollment and volume information is provided in the price sheet to assist Offerors with rate calculations. | |||||
| For purposes of financial ranking, for each Optional coverage, the State will use "Total Premium", as well as the difference between "Total Premium" and Current Premium, to rank Offerors' proposals in order of lowest to highest cost, and highest to lowest savings to State employees. | |||||
| Optional Life | |||||
| Age Bracket for Employees/ Retirees | # of Insured Employees/ Retirees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] |
| 0 to 24 | 0 | $0 | 12 | $ - 0 | |
| 25 to 29 | 0 | $0 | 12 | $ - 0 | |
| 30 to 34 | 0 | $0 | 12 | $ - 0 | |
| 35 to 39 | 0 | $0 | 12 | $ - 0 | |
| 40 to 44 | 0 | $0 | 12 | $ - 0 | |
| 45 to 49 | 0 | $0 | 12 | $ - 0 | |
| 50 to 54 | 0 | $0 | 12 | $ - 0 | |
| 55 to 59 | 0 | $0 | 12 | $ - 0 | |
| 60 to 64 | 0 | $0 | 12 | $ - 0 | |
| 65 to 69 | 0 | $0 | 12 | $ - 0 | |
| 70 to 74 | 0 | $0 | 12 | $ - 0 | |
| 75 to 79 | 0 | $0 | 12 | $ - 0 | |
| 80 to 84 | 0 | $0 | 12 | $ - 0 | |
| 85 to 89 | 0 | $0 | 12 | $ - 0 | |
| 90 to 94 | 0 | $0 | 12 | $ - 0 | |
| 95 and older | 0 | $0 | 12 | $ - 0 | |
| Total | 0 | $0 | $ - 0 | ||
| Optional Spouse Life | |||||
| # of Employees Insuring Spouse (A) | Benefit Amount (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [AxC×D] | |
| 0 | $5,000 | $0.00 | 12 | $ - 0 | |
| 0 | $10,000 | $0.00 | 12 | $ - 0 | |
| Total Premium | $ - 0 | ||||
| Optional Dependent Child(ren) Life | |||||
| # of Employees Insuring Dependent Children (A) | Benefit Amount (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [A×C×D] | |
| 0 | $10,000 | $0.00 | 12 | $ - 0 | |
| Optional AD&D | |||||
| # of Insured Employees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] | |
| 0 | $0 | $0.00 | 12 | $ - 0 | |
| Total Premium | $ - 0 | ||||
| Rate Guarantee | 5 Years | ||||
| Submitted By: | |||||
| Authorized Signature: ___________________________________________________ Date: _______________ | |||||
| Name and Title: | |||||
| Company Name: | |||||
| Company Address: | |||||
| Location(s):* | |||||
| FEIN: | eMM#: | ||||
| Telephone: | Fax: | ||||
| E-mail: | |||||
| * from which services will be performed (City/State) |
E-4 Optional Life (alt, par)
| Request for Optional Group Term Life and Accidental Death and Dismemberment (AD&D) Insurances for The State of Illinois | |||||
| Attachment E-4: Financial Proposal Optional Life, Spouse Life, Child Life, and AD&D | |||||
| (alternate) Employee & Retirees have separate age banded rate table | |||||
| Participating, Dividend Eligible, no Deficit carry-forward | |||||
| RFP # | |||||
| The Offeror shall provide monthly term life insurance rates per applicable unit of coverage. Separate rate per $1,000 for employees from rate per $1,000 for retirees in each age bracket indicated. A flat monthly rate per $1,000 of coverage shall be provided for spouse coverage, child(ren}) coverage and AD&D coverage. Enrollment and volume information is provided in the price sheet to assist Offerors with rate calculations. | |||||
| For purposes of financial ranking, for each Optional coverage, the State will use "Total Premium", as well as the difference between "Total Premium" and Current Premium, to rank Offerors' proposals in order of lowest to highest cost, and highest to lowest savings to State employees. | |||||
| Optional Life - Active Employees | |||||
| Age Bracket for Employees/ Retirees | # of Insured Employees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] |
| 0 to 24 | 12 | $ - 0 | |||
| 25 to 29 | 12 | $ - 0 | |||
| 30 to 34 | 12 | $ - 0 | |||
| 35 to 39 | 12 | $ - 0 | |||
| 40 to 44 | 12 | $ - 0 | |||
| 45 to 49 | 12 | $ - 0 | |||
| 50 to 54 | 12 | $ - 0 | |||
| 55 to 59 | 12 | $ - 0 | |||
| 60 to 64 | 12 | $ - 0 | |||
| 65 to 69 | 12 | $ - 0 | |||
| 70 to 74 | 12 | $ - 0 | |||
| 75 to 79 | 12 | $ - 0 | |||
| 80 to 84 | 12 | $ - 0 | |||
| 85 to 89 | 12 | $ - 0 | |||
| 90 to 94 | 12 | $ - 0 | |||
| 95 and older | 12 | $ - 0 | |||
| Total | 0 | $0 | $ - 0 | ||
| Optional Life - Retirees | |||||
| Age Bracket for Employees/ Retirees | # of Insured Retirees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] |
| 0 to 24 | 12 | $ - 0 | |||
| 25 to 29 | 12 | $ - 0 | |||
| 30 to 34 | 12 | $ - 0 | |||
| 35 to 39 | 12 | $ - 0 | |||
| 40 to 44 | 12 | $ - 0 | |||
| 45 to 49 | 12 | $ - 0 | |||
| 50 to 54 | 12 | $ - 0 | |||
| 55 to 59 | 12 | $ - 0 | |||
| 60 to 64 | 12 | $ - 0 | |||
| 65 to 69 | 12 | $ - 0 | |||
| 70 to 74 | 12 | $ - 0 | |||
| 75 to 79 | 12 | $ - 0 | |||
| 80 to 84 | 12 | $ - 0 | |||
| 85 to 89 | 12 | $ - 0 | |||
| 90 to 94 | 12 | $ - 0 | |||
| 95 and older | 12 | $ - 0 | |||
| Total | 0 | $0 | $ - 0 | ||
| Total Premium | $ - 0 | ||||
| Optional Spouse Life | |||||
| # of Employees Insuring Spouse (A) | Benefit Amount (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [AxC×D] | |
| $5,000 | 12 | $ - 0 | |||
| $10,000 | 12 | $ - 0 | |||
| Total Premium | $ - 0 | ||||
| Optional Dependent Child(ren) Life | |||||
| # of Employees Insuring Dependent Children (A) | Benefit Amount (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [A×C×D] | |
| $10,000 | 12 | $ - 0 | |||
| Optional AD&D | |||||
| # of Insured Employees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] | |
| 17,794 | 12 | $ - 0 | |||
| Total Premium | $ - 0 | ||||
| Rate Guarantee | 5 Years | ||||
| Submitted By: | |||||
| Authorized Signature: ___________________________________________________ Date: _______________ | |||||
| Name and Title: | |||||
| Company Name: | |||||
| Company Address: | |||||
| Location(s):* | |||||
| FEIN: | eMM#: | ||||
| Telephone: | Fax: | ||||
| E-mail: | |||||
| * from which services will be performed (City/State) |
E-5 Optional Life (nonpar)
| Request for Optional Group Term Life and Accidental Death and Dismemberment (AD&D) Insurances for The State of Illinois | |||||
| Attachment E-5: Financial Proposal Optional Life, Spouse Life, Child Life, and AD&D | |||||
| Employee & Retirees share same age banded rate table | |||||
| Non-Participating | |||||
| RFP # | |||||
| The Offeror shall provide monthly term life insurance rates per applicable unit of coverage. Same rate per $1,000 for employees as for for retirees in each age bracket indicated. A flat monthly rate per $1,000 of coverage shall be provided for spouse coverage, child(ren}) coverage and AD&D coverage. Enrollment and volume information is provided in the price sheet to assist Offerors with rate calculations. | |||||
| For purposes of financial ranking, for each Optional coverage, the State will use "Total Premium", as well as the difference between "Total Premium" and Current Premium, to rank Offerors' proposals in order of lowest to highest cost, and highest to lowest savings to State employees. | |||||
| Optional Life | |||||
| Age Bracket for Employees/ Retirees | # of Insured Employees/ Retirees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] |
| 0 to 24 | 0 | $0 | 12 | $ - 0 | |
| 25 to 29 | 0 | $0 | 12 | $ - 0 | |
| 30 to 34 | 0 | $0 | 12 | $ - 0 | |
| 35 to 39 | 0 | $0 | 12 | $ - 0 | |
| 40 to 44 | 0 | $0 | 12 | $ - 0 | |
| 45 to 49 | 0 | $0 | 12 | $ - 0 | |
| 50 to 54 | 0 | $0 | 12 | $ - 0 | |
| 55 to 59 | 0 | $0 | 12 | $ - 0 | |
| 60 to 64 | 0 | $0 | 12 | $ - 0 | |
| 65 to 69 | 0 | $0 | 12 | $ - 0 | |
| 70 to 74 | 0 | $0 | 12 | $ - 0 | |
| 75 to 79 | 0 | $0 | 12 | $ - 0 | |
| 80 to 84 | 0 | $0 | 12 | $ - 0 | |
| 85 to 89 | 0 | $0 | 12 | $ - 0 | |
| 90 to 94 | 0 | $0 | 12 | $ - 0 | |
| 95 and older | 0 | $0 | 12 | $ - 0 | |
| Total | 0 | $0 | $ - 0 | ||
| Optional Spouse Life | |||||
| # of Employees Insuring Spouse (A) | Benefit Amount (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [AxC×D] | |
| 0 | $5,000 | $0.00 | 12 | $ - 0 | |
| 0 | $10,000 | $0.00 | 12 | $ - 0 | |
| Total Premium | $ - 0 | ||||
| Optional Dependent Child(ren) Life | |||||
| # of Employees Insuring Dependent Children (A) | Benefit Amount (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [A×C×D] | |
| 0 | $10,000 | $0.00 | 12 | $ - 0 | |
| Optional AD&D | |||||
| # of Insured Employees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] | |
| 0 | $0 | $0.00 | 12 | $ - 0 | |
| Total Premium | $ - 0 | ||||
| Rate Guarantee | 5 Years | ||||
| Submitted By: | |||||
| Authorized Signature: ___________________________________________________ Date: _______________ | |||||
| Name and Title: | |||||
| Company Name: | |||||
| Company Address: | |||||
| Location(s):* | |||||
| FEIN: | eMM#: | ||||
| Telephone: | Fax: | ||||
| E-mail: | |||||
| * from which services will be performed (City/State) |
E-6 Optional Life (alt, nonpar)
| Request for Optional Group Term Life and Accidental Death and Dismemberment (AD&D) Insurances for The State of Illinois | |||||
| Attachment E-6: Financial Proposal Optional Life, Spouse Life, Child Life, and AD&D | |||||
| (alternate) Employee & Retirees have separate age banded rate table | |||||
| Non-Participating | |||||
| RFP # | |||||
| The Offeror shall provide monthly term life insurance rates per applicable unit of coverage. Separate rate per $1,000 for employees from rate per $1,000 for retirees in each age bracket indicated. A flat monthly rate per $1,000 of coverage shall be provided for spouse coverage, child(ren}) coverage and AD&D coverage. Enrollment and volume information is provided in the price sheet to assist Offerors with rate calculations. | |||||
| For purposes of financial ranking, for each Optional coverage, the State will use "Total Premium", as well as the difference between "Total Premium" and Current Premium, to rank Offerors' proposals in order of lowest to highest cost, and highest to lowest savings to State employees. | |||||
| Optional Life - Active Employees | |||||
| Age Bracket for Employees/ Retirees | # of Insured Employees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] |
| 0 to 24 | 0 | $0 | 12 | $ - 0 | |
| 25 to 29 | 0 | $0 | 12 | $ - 0 | |
| 30 to 34 | 0 | $0 | 12 | $ - 0 | |
| 35 to 39 | 0 | $0 | 12 | $ - 0 | |
| 40 to 44 | 0 | $0 | 12 | $ - 0 | |
| 45 to 49 | 0 | $0 | 12 | $ - 0 | |
| 50 to 54 | 0 | $0 | 12 | $ - 0 | |
| 55 to 59 | 0 | $0 | 12 | $ - 0 | |
| 60 to 64 | 0 | $0 | 12 | $ - 0 | |
| 65 to 69 | 0 | $0 | 12 | $ - 0 | |
| 70 to 74 | 0 | $0 | 12 | $ - 0 | |
| 75 to 79 | 0 | $0 | 12 | $ - 0 | |
| 80 to 84 | 0 | $0 | 12 | $ - 0 | |
| 85 to 89 | 0 | $0 | 12 | $ - 0 | |
| 90 to 94 | 0 | $0 | 12 | $ - 0 | |
| 95 and older | 0 | $0 | 12 | $ - 0 | |
| Total | 0 | $0 | $ - 0 | ||
| Optional Life - Retirees | |||||
| Age Bracket for Employees/ Retirees | # of Insured Retirees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] |
| 0 to 24 | 0 | $0 | 12 | $ - 0 | |
| 25 to 29 | 0 | $0 | 12 | $ - 0 | |
| 30 to 34 | 0 | $0 | 12 | $ - 0 | |
| 35 to 39 | 0 | $0 | 12 | $ - 0 | |
| 40 to 44 | 0 | $0 | 12 | $ - 0 | |
| 45 to 49 | 0 | $0 | 12 | $ - 0 | |
| 50 to 54 | 0 | $0 | 12 | $ - 0 | |
| 55 to 59 | 0 | $0 | 12 | $ - 0 | |
| 60 to 64 | 0 | $0 | 12 | $ - 0 | |
| 65 to 69 | 0 | $0 | 12 | $ - 0 | |
| 70 to 74 | 0 | $0 | 12 | $ - 0 | |
| 75 to 79 | 0 | $0 | 12 | $ - 0 | |
| 80 to 84 | 0 | $0 | 12 | $ - 0 | |
| 85 to 89 | 0 | $0 | 12 | $ - 0 | |
| 90 to 94 | 0 | $0 | 12 | $ - 0 | |
| 95 and older | 0 | $0 | 12 | $ - 0 | |
| Total | 0 | $0 | $ - 0 | ||
| Total Premium | $ - 0 | ||||
| Optional Spouse Life | |||||
| # of Employees Insuring Spouse (A) | Benefit Amount (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [AxC×D] | |
| 0 | $5,000 | 12 | $ - 0 | ||
| 0 | $10,000 | 12 | $ - 0 | ||
| Total Premium | $ - 0 | ||||
| Optional Dependent Child(ren) Life | |||||
| # of Employees Insuring Dependent Children (A) | Benefit Amount (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [A×C×D] | |
| 0 | $10,000 | 12 | $ - 0 | ||
| Optional AD&D | |||||
| # of Insured Employees (A) | Volume in $1,000 (B) | Monthly Rate per $1,000 (C) | # of Months (D) | Total Premium (E) [B×C×D] | |
| 0 | 17,794 | $0 | 12 | $ - 0 | |
| Total Premium | $ - 0 | ||||
| Rate Guarantee | 5 Years | ||||
| Submitted By: | |||||
| Authorized Signature: ___________________________________________________ Date: _______________ | |||||
| Name and Title: | |||||
| Company Name: | |||||
| Company Address: | |||||
| Location(s):* | |||||
| FEIN: | eMM#: | ||||
| Telephone: | Fax: | ||||
| E-mail: | |||||
| * from which services will be performed (City/State) |
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