IV. RFP Response Form (A)

(Submit one form per quote for RFP #12-008)

  1. Proposer/Agent Name:______
  2. Address:______
  3. CSZ:______
  4. Description of Agent services to be provided:______

______

  1. Licensed to do business in Texas: Yes______No______
  2. Copy of license enclosed: Yes______No______
  3. E&O and/or Professional Liability Insurance : Yes______No______
  4. Copy of E&O, Professional Liability Insurance Certificate enclosed: Yes______No______
  5. Agent name:______Estimated annual amount of commissions:______
  6. Insurance Carrier Name:______
  7. Address:______
  8. CSZ:______
  9. Description of Insurance Carrier services to be provided:______

______

  1. Licensed to do business in Texas: Yes______No______
  2. Copy of license enclosed: Yes______No______
  3. E&O and/or Professional Liability Insurance with $2,000,000 minimum: Yes______No______
  4. Copy of E&O, Professional Liability Insurance Certificate enclosed: Yes______No______
  5. A.M. Best Rating for Insurance Carrier: Financial Strength______Financial Size______
  6. Schedule of BenefitsRate per $1,000Max Level of $ Coverage
  1. Group Life Only$______$______
  2. AD&D Only$______$______
  3. Group Life and AD&D$______$______
  1. Effective Dates of Coverage:______to______
  1. _____Three years (36 months rate guarantee) ______B. Two Years (24 months rate guarantee)
  1. _____One year (12 months rate guarantee) w/option to renew 2nd and 3rd years
  1. Guaranteed Issue for Amount selected by District:
  1. Yes_____ No______
  2. If no, what is maximum “Guaranteed Issue” amount: $______
  1. Is coverage based on a “no loss/no gain” basis:
  1. Yes_____ No______
  2. If no, what is coverage based on:______
  1. May individuals request and obtain additional coverage in excess of Employer selected amount:
  1. Yes_____ No______
  2. If yes, what is the minimum/maximum amount: $______
  3. If yes, what is the insurability requirement:______
  1. Minimum % of premium cost by Employer Provision Requirement:______%
  2. Employee Eligibility:
  1. Eligibility Definition:______
  2. Minimum % of eligible employee enrollment requirement:______%
  1. Actively at Work Provision Requirement*:
  1. Yes_____ No______Waived______
  2. Definition:______
  3. If absent, enrollment/coverage begins:______
  1. Does quote include accelerated death benefit for terminal illness?
  1. Yes______No______
  2. Definition:______*Please note that the district defines all employees still on payroll as “actively at work,” whether they’re physically at work or not due to sick leave, medical leave, extended leave, workers’ compensation leave, non-contracted days, holidays, spring/Easter/summer breaks, etc.
  1. Benefit Reduction and/or Termination Schedule (percent of original amount)
  1. Life

1.Reduction

  1. Age______
  2. Reduction %______

2.Termination

  1. Age______
  2. Termination %______
  1. AD&D

1.Reduction

  1. Age______
  2. Reduction %______

2.Termination

  1. Age______
  2. Termination %______
  1. Waiver of Premium Provision for Disability:
  1. Yes______No______
  2. Definition:______
  3. Qualifying Age:______
  1. Proposed Premium Quote:

Basic Life Only:
Coverage Amount / Basic Life per 1,000 (Rate) / Basic Life Total: (Est. Monthly) / Basic Life Total: (Est. Yearly) 1st Year / Basic Life Total: (Est. Yearly) 2nd Year / Basic Life Total: (Est. Yearly) 3rd Year
10,000
15,000
20,000
25,000
AD&D Only:
Coverage Amount / AD&D per 1,000 (Rate) / AD&D Total: (Est. Monthly) / AD&D Total: (Est. Yearly) 1st Year / AD&D Total: (Est. Yearly) 2nd Year / AD&D Total: (Est. Yearly) 3rd Year
10,000
15,000
20,000
25,000
Basic Life & AD&D (Combined):
Coverage Amount / Basic Life & AD&D (Combined) (Rate) / Basic Life & AD&D Total: (Est. Monthly) / Basic Life & AD&D Total: (Est. Yearly) 1st Year / Basic Life & AD&D Total: (Est. Yearly) 2nd Year / Basic Life & AD&D Total: (Est. Yearly) 3rd Year
10,000
15,000
20,000
25,000

IV. RFP Response Forms Checklist (B)

If applicable, please acknowledge or confirm compliance with and/or provided documentation, for all conditions and requirements listed in all sections of the Request for Proposal for each proposed plan.

1.Required Forms & General Conditions:_____ Yes_____ No_____ NA

2.Scope of Work:_____ Yes _____ No_____ NA

3.Specifications:_____ Yes_____ No_____ NA

4.RFP Response Form (A):_____ Yes_____ No_____ NA

5.RFP Response Forms Checklist (B): _____ Yes_____ No_____ NA

6.Proposal:_____ Yes_____ No_____ NA

7.One Year Guaranteed Rate_____ Yes_____ No

8.Two Year Guaranteed Rate _____ Yes_____ No

9.Three Year Guaranteed Rate_____ Yes_____ No

Please list, identify and briefly explain any “No/NA” responses and/or deviations from RFP.

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

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Confirmation/Authorization of Proposal: