1.Your Company's Name

2.Your Company's Street address

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

AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of Columbia (DC)FloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

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

5.Your contact name / title.

6.What is your work email address?

7.What is your phone number?

8.What is your website address?

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

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

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

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

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.

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

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

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