[INSERT TRANSMITTAL LETTER ON THIS PAGE]

Tobe considered, a proposalmustbe accompanied bya transmittallettersigned ininkbythe bidder. Thetransmittallettermustinclude the followingstatements:

  • RFP terms areaccepted
  • Thepricewasarrived atwithoutconflictofinterest.
  • A statementthatthebidderagreesto thestandardStatecontractrequirementsin AttachmentsC,Eand F.
  • A statementofanylimitations onthe numberofhours,days oftheweek, orweeks inthe yearthatthe bidderwould beavailabletoperformthe abovescope ofwork.
  • A statementofanyotherconsiderationsorlimitations,ifany,related tothescopeofworkthebidderwillbe expectedto perform.

BIDDER INFORMATION SHEET

FULL NAME OF BIDDER / INDIVIDUAL

MAILING ADDRESS

Street

City

State

Zip Code

STREET ADDRESS (for FedEx or other mail delivery service)

Street

City

State

Zip Code

SOCIAL SECURITY NUMBER

TELEPHONE NUMBER

FAX NUMBER (if available)

E-MAIL ADDRESS

REGION FOR WHICH BIDDER IS APPLYING (see application for region explanations)

DESCRIPTION OF BIDDER’S EXPERIENCE

ClinicalExperience andOrientation

EXPERIENCE:

SKILLS:

ProfessionalSkills

EXPERIENCE:

SKILLS:

Quality Improvementand Systems Thinking

EXPERIENCE:

SKILLS:

TechnologyProficiency

EXPERIENCE:

SKILLS:

Effective UtilizationofData to Drive Change

EXPERIENCE:

SKILLS:

[INSERT PROFESSIONAL RESUME AND REFERENCES ON THIS PAGE]

Bidsshallincludeaprofessionalresumeofthebidder/individual whowill performtheconsultativeservices.Bidsshallalsoincludereferencesasfollows:

  • A listofthreereferences,includingrelationship,address andtelephone contactnumber.
  • Names oforganizationsforwhich you have donerelated workand contactinformationforaperson atthe organizationwho can speakaboutyourpastsuccessincludingtheirprofessionaltitle, address, emailaddressand telephonecontactnumber

[INSERT FINANCIAL PROPOSAL ON THIS PAGE]

Budget Submittal Form For Region I

Business Name:
Contact Name and Number:
Line # / Budget Category / PAID HOURS / COST PER PANEL / TOTAL COSTS
DIRECT PROGAM COSTS – 2017-Q2
1 / [Insert number of panels supported in region] / [Insert cost per panel] / ###
DIRECT OPERATING COSTS – 2017-Q2
2 / CONTRACTED - PERSONNEL / [Insert paid hours] / ###
3 / TRAVEL / [Insert paid hours] / ###
INDIRECT ALLOCATIONS – 2017 – Q2
3 / IT EQUIPMENT / [Insert paid hours] / ###
DIRECT PROGAM COSTS – 2017-Q3
2 / [Insert number of panels supported in region] / [Insert cost per panel] / ###
DIRECT PROGAM COSTS – 2017-Q4
3 / [Insert number of panels supported in region] / [Insert cost per panel] / ###
2017 TOTAL COSTS

Budget Submittal Form For Regions II, III, IV, V, and VI

Business Name:
Contact Name and Number:
Line # / Budget Category / PAID HOURS / COST PER PANEL / TOTAL COSTS
DIRECT PROGAM COSTS – 2017-Q2
1 / [Insert number of panels supported in region] / [Insert cost per panel] / ###
DIRECT PROGAM COSTS – 2017-Q3
2 / [Insert number of panels supported in region] / [Insert cost per panel] / ###
DIRECT PROGAM COSTS – 2017-Q4
3 / [Insert number of panels supported in region] / [Insert cost per panel] / ###
2017 TOTAL COSTS

[IDENTIFY ALL RELATED PARTY RELATIONSHIP AND CONFLICTS OF INTEREST ON THIS PAGE]

Please identify all related party relationships and conflicts of interest including cost purpose and approval process.

[INSERT CURRENT CERTIFICATES OF INSURANCE ON THIS PAGE]

As partofthe proposalpacketthe Biddermustprovide currentcertificates ofinsuranceofwhich mayormaynotmeetthe minimumrequirementslaid outinthe section15 ofthis document. Anyquestions a biddermayhave concerningthe necessaryinsurance coveragemustbe raisedduringthequestionand answerperiodsetoutin section 8ofthisdocument. Inthe absence ofa question, and upon contractnegotiations the apparentlysuccessfulbiddermustprovide acertificate ofinsurance thatmeetsthe minimumcoverage specifiedinAttachment C and D ofthisdocument.

CERTIFICATE OF COMPLIANCE

This form must be completed in its entirety and submitted as part of the response for the proposal to be considered valid.

TAXES: Pursuant to 32 V.S.A. § 3113, bidder hereby certifies, under the pains and penalties of perjury, that the company/individual is in good standing with respect to, or in full compliance with a plan to pay, any and all taxes due to the State of Vermont as of the date this statement is made. A person is in good standing if no taxes are due, if the liability for any tax that may be due is on appeal, or if the person is in compliance with a payment plan approved by the Commissioner of Taxes.

INSURANCE: Bidder certifies that the company/individual is in compliance with, or is prepared to comply with, the insurance requirements as detailed in Section 8 of Attachment C: Customary Provisions for Contracts and Grants. Certificates of insurance must be provided prior to issuance of a contract and/or purchase order. If the certificate(s) of insurance is/are not received by the Department of Vermont Health Access within five (5) days of notification of award, the State of Vermont reserves the right to select another vendor. Please reference the RFP and/or RFQ # when submitting the certificate of insurance.

CONTRACT TERMS: The undersigned hereby acknowledges and agrees to Attachment C: Customary Provisions for Contracts and Grants.

TERMS OF SALE: The undersigned agrees to furnish the products or services listed at the prices quoted. The Terms of Sales are Net 30 days from receipt of service or invoice, whichever is later.

Insurance Certificate: Attached

Will provide upon notification of award:

Delivery Offered:

Days After Notice of Award:

Terms of Sale:

Quotation Valid for ______Days Date: ______

Name of Company/Individual: ______

Address:

Telephone Number:

Fed ID or SS Number:

E-mail:

Signature (Bid Not Valid Unless Signed):

Printed Name:

[INSERT W-9 FORM ON THIS PAGE]

As partofthe proposalpacketthe Biddermustprovide a completed, signed w9 form must be submitted. A blank w-9 can be found on the IRS website: