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1. Your Company's Name

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2. Your Company's Street address

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3. In what state or U.S. territory is your company currently headquartered?

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4. Is your company U.S.A. based?  If not, what country are you located in?

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5. Your contact name / title.

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6. What is your work email address?

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7. What is your phone number?

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8. What is your website address?

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9. If your company operates under any other names (d/b/a), please indicate the other name(s) here.

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10. Has your company done work for Lifetime Healthcare Co. / Excellus or any of its subsidiaries in the past? Please explain.

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11. Have you recently met with anyone at Lifetime Healthcare Co. / Excellus, if so whom and for what reason?

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12. Is your organization currently doing business with any other BlueCross/BlueShield Plans, if so please explain.

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13. If your company has any certifications you would like to share, please attach them here.

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14. Describe the primary types of products/services your company offers.

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15. Briefly explain why your company is uniquely qualified. What differentiates you from your competitors?

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16. Please feel free to attach one file with relevant case studies and/or appropriate promotional materials.

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