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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, is so please explain.

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* 13. What is your Supplier Diversity Ownership Classification?

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* 14. Is your company a certified Diverse Supplier? If so, please attach a copy of your certification.

We accept certification from the following organizations and their regional affiliates:

The North American Industry Classification System
The Standard Industrial Classification (SIC)
National Minority Supplier Development Council
Women's Business Enterprise National Council
U.S. Small Business Administration and Office of Small Business
Service Disabled Veteran Owned Small Business and Disabled Veteran Business Enterprise
NGLCC Global - international division of the National LGBT Chamber of Commerce

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

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

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

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