APPENDIX G

DENTAL QUESTIONNAIRE

VENDORS MUST COMPLETE THE FOLLOWING CHART.

Please complete the following chart by responding in the right hand column. If you cannot meet these criteria, you may not be considered.

1 . Vendor Brand Name

2 . Parent Co. Legal Entity Name

3 . d/b/a (Name in Marketplace)

4 . Year Established/Incorporated

5 . NAIC Code

6 . Industry Classification

7 . Stock Ticker #

8 . FEIN (Federal Employer Identification Number)

9 . Tax Status

1 0 . Public or Privately Held 1 1 1 . Home Office Location

1 2 . Address Line #1

1 3 . Address Line #2

1 4 . City

1 5 . State

1 6 . Zip Code

1 7 . Web Address

1 8 . Name of Marketing Rep. (responding to this RFP)

1 9 . Title

2 0 . Address (Street, City, State, Zip) APPENDIX G

2 1 . Phone Number

2 2 . Fax Number

2 3 . Email Address

2 4 The vendor agrees to accept current Agree Disagree . enrollment forms and elections made by current participants.

2 5 . Indicate the length of the grace period you will permit for late payment of premiums.

2 There will be no restrictions or benefit Agree Disagree 6 limitations for pre-existing conditions applied . to any members enrolled in the plan at any time.

27. The vendor agrees to comply with the Department of Labor’s final claims procedure regulations, including appropriate timeframes for Agree Disagree adjudicating claims and notice of appeal decisions.

28. The vendor agrees to make internal practices, books and records relating to the use and disclosure of PHI received from, created or received by your organization available to the Agree Disagree Secretary of the Department of Health and Human Services for purposes of determining your organization’s compliance with the privacy rules.

3 29. The vendor agrees to mitigate, to the extent practicable, any harmful effect that is known to the organization of a use or disclosure of PHI by Agree Disagree the organization in violation of the requirements of the federal privacy rule.

30. The City shall have the right, in its sole and absolute discretion and without the payment of any penalty, to terminate the contract, in whole or in part, at any time during the term Agree Disagree thereof upon 60 days prior written notice to the vendor.

31. Do not contact any employee of The City, other that the assigned buyer, regarding this RFP or the Agree Disagree vendor selection process.

32. All costs associated with your proposal, including preparation and presentation, will Agree Disagree be borne by your organization and not The City.

33. The City will not be responsible for errors or omissions made in your proposal. You will Agree Disagree be permitted to submit only one proposal. Therefore, please take care to make your bid sound and competitive.

Please provide three references of clients currently using services that are similar in employee size and industry to the City. Reference #1 34. Company Name Contact Person Title Phone Number Fax Number Email Address Number of covered employees List coverages in place similar to those in the RFP APPENDIX G

Reference #2 3 Company Name 5 Contact Person . Title Phone Number Fax Number Email Address Number of covered employees List coverages in place similar to those in the RFP Reference #3 36. Company Name Contact Person Title Phone Number Fax Number Email Address Number of covered employees List coverages in place similar to those in the RFP

Questionnaire Acknowledged and Accepted as indicated above by:

Company

NOTE: Your typed name and date above will be considered a valid signature for this RFP.

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