Proposal contact

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2000 NE 46th Street




Bob Charlesworth, CPCU, ARM, ALCM, AIS

Connie Sargent, ARM


Charlesworth Benefits, L.C.


P.O. Box 23588

Overland Park, Kansas 66283-0588

Overnight Mail Address

10950 W. 154th Street

Overland Park, Kansas 66221

Office Phone

(913) 851-4730


(913) 851-1993



INCEPTION DATE: January 1, 2016



PROCEDURE: ALL communication is to be with

Charlesworth Benefits, L.C.

SECTION A) General Data

B) Proposal Procedures

C) Proposal Requirements



The North Kansas City School District (NKC) hereby solicits qualified and interested licensed Group Benefit Broker/Consultants to submit proposals and statements of qualifications for providing all supervision, labor, services, equipment, hardware, software, materials, and any assistance necessary to provide the District with Group Benefit Broker/ Consulting services. The services are to be provided for the Human Resources/Benefits Department of the District. The District is interested in appointing a single brokerage source as their Broker of Record with a minimum of ten (10) years of local experience and a proven local service record with area governmental entities similar to the size and scope of the District.


A1. Location

North Kansas City Schools (hereinafter referred to as either NKC or the District), serves students in suburban Kansas City – North and is fully accredited by the state of Missouri.


The District has approximately 3,165 employees which include 1,600 certified staff (1,479 are teachers) of which are full time - thirty (30) hours or more per week active employees are eligible for group benefits. Approximately 2,550 employees enroll in the group health benefit program.

Student Enrollment

Estimated student enrollment for the current school year approximates 19,000 (k-12).

Staffed Facilities

The District consists of the following:

  1. 21 Elementary schools (grades k-5)

  2. 5 Middle Schools (grades 6-8)

  3. 4 High Schools (grades 9-12)

  4. 4 Alternative programs

  5. 2 Auto/Carpentry programs

  6. Administration & Warehouse

  7. Bus Services

  8. 3 Stadiums (Football; Activities Complex & Soccer)

Other information about the District can be found on their web site:

A2. Any premium contributions required are paid via payroll deduction. A Section 125 plan is used for health, dental and vision premium contributions, which includes a medical and dependent care component. Employees who choose to decline coverage do not obtain any monetary benefit. This service is currently provided by Tri-Star Systems. UMB administers the Health Savings Account.

A3. NKC’s Federal I.D.# 44-6003683
A4. The current benefit plans are as follows. Summaries may be found on the District’s web-site under their Careers / Benefits link found at their home page.

Health Insurance: BlueKC – Blue Care HMO (1 plan) and Preferred Care Blue QHDP (1 plan)

Employee Assistance Program (New Directions)

Dental Insurance: Delta Dental of Missouri (DPO program)

Vision: Vision Service Plan (voluntary)

Term Life: Guardian (plus voluntary)

Long Term Disability: Guardian (voluntary)

Accident/Whole Life/Critical Illness: Boston Mutual (voluntary)

Retirement Plan services are NOT included in the RFQ
A5. Claims, enrollment, contribution and various summaries are available upon specific request with the proposal contact and are to be handled on a confidential basis. This is not a solicitation for benefit plans – strictly benefit broker & consulting services.

A6. Except for the Open Enrollment Period in April, finalized in Early May of each year, life-changing events are the only other times during the Plan Year that you can apply to make changes to insurance benefit coverages. These events include: marriage, divorce, birth, adoption, death, or a change in employment status (part-time to full-time, full-time to part-time, or termination of employment) for either you or your spouse. These events open a 30-day window to make an application for changes in coverage. When enrolling or applying for coverage changes, all necessary forms are obtained and processed through the Benefits Department located at the District Office.

A7. Estimated annualized premiums for 2015:


Est. Annual Premiums




$ 1,320,000


$ 100,000

Group Life:

$ 250,000

Long Term Disability:

$ 160,000

A8. Broker History: Hays Companies: 01/01/2007 to 01/01/2010

Lockton Companies: 01/01/2010 to current
A9. North Kansas City Schools is insured on a Modified Cost Plus plan with BlueKC initially on 10/1/2013. The incumbent broker negotiated a renewal date for 7/1/2016 (negotiated from a 10/1/2014 inception for a 21-month rate period).  All other plans are fully insured.
A10. North Kansas City Schools is working with Benefit Ready currently provided by the incumbent Broker. This program will need to be changed effective 1/1/2016 or earlier with negotiated service fee pass-through overseen by the selected broker.

A11. North KC School started the Blue Cross/Blue Shield's Wellness Program “A Healthier You” in 2008 and has been conducting these initiatives each year. The District provides a financial dis-incentive for employees who chose to not participate – a premium difference of $30 per month (currently about 90% participate). Participation doesn’t include spouses and/or other dependents at this time.

A12. The use of the District’s logo – found on their website – may be used in your presentation only and not for any other marketing services or any other uses.


B1. ALL questions are to be submitted no later than Tuesday, September 29, 2015, via e-mail to Bob Charlesworth – (verbal inquiries will not be acceptable).

Responses will be in the form of an e-mail. Verbal responses and/or representations shall not be binding on the District.

B2. NKC reserves the right to modify or cancel any part of this proposal after issuance in the form of an addendum, which will be e-mailed to each offeror.
B3. FOUR (4) copies of your proposal are required at the time of submittal. Proposals will not be accepted via Fax machine or internet e-mail. It is encouraged that the written responses to the questionnaire be provided on a Flash Drive for ease of distribution to the District’s review committee.
B4. Proposals shall be delivered to Charlesworth Benefits, L.C., by no later than 12:00 Noon, Central Time, Thursday, October 8, 2015. All proposals received after the deadline will NOT be considered. There will be no public opening of proposals. Full disclosure of all proposals will be made available after an award has been made.
B5. Confidentiality: Each proposal must be sealed and submitted in or under cover to provide confidentiality of the information prior to the submission date and time. All proposals and supporting documents become public information after the submission date and time, except such information that discloses propriety or financial information submitted in response to qualification statements, all in accordance with the Missouri Open Records Act.
Any premium and loss data information provided within these specifications or through subsequent addenda information provided through Charlesworth Benefits, L.C. is to be treated as confidential information.
B6. Proposals: Proposals are due by the date and time at the designated location noted on page one of these specifications. Proposals received after the date and time indicated on the cover sheet shall not be considered and returned unopened. Proposals will not be opened or reviewed until after the proposal due date and time.
B7. Signature Sheet: Any proposal submitted MUST include the Signature Sheet found in this RFQ which has been signed by an individual authorized to bind the Vendor. All proposals submitted without such signature may be deemed non-responsive.
B8. Proposals Binding: All proposals for service shall remain valid and be binding upon the respondent if accepted by the District within ninety (90) calendar days of the proposal submission date. All proposals shall be signed by an authorized representative of such company.
B9. Negotiation: NKC reserves the right to negotiate any and all elements of any proposal direct with the provider. No changes in or to the proposal submissions will be permitted subsequent to the proposed target date unless approved by the District. Charlesworth Benefits, L.C., may request clarifications on any portion of the proposal in order to develop a comprehensive assessment of the proposal. Proposed Fees are NOT to be disclosed at the due date of this RFQ and will be fully negotiated by the District and the preferred Benefit Broker/Consultant prior to any recommendation made to the Board of Education.
B10. Rights Reserved: NKC reserves the right to accept or reject any or all proposals, and to waive any technicalities or irregularities in any proposals, and to make award to the response which in the District's opinion is the most advantageous to the District. Each proposer agrees that the submission of a proposal constitutes an agreement by the proposing firm to waive any legal claim against the District and Charlesworth Benefits, L.C. should the District fail to select their proposal.
B11. Number of Plans: The employee benefit plan is to continue to include the renewal of the current benefit program. The benefit program is to be bid for a July 1, 2016 inception, with the possibility of objectively evaluating participation in a Cooperating School District of Greater Kansas City’s self-insurance pool which currently consists of Smithville R-II, Blue Springs, Grain Valley and Lone Jack school district.
B12. Contract Period: It is NKC’s desire to maintain the Broker/Consultant program on an annual contract year basis (January 1 through December 31), subject to annual approval by the District. NKC reserves the sole right to renew said contract as deemed in the best interest of the District for up to five (5) more consecutive periods of one year each. The agreed upon contract must include the Scope of Services proposed by the Broker/Consultant. All contracts must contain a non-discrimination provision.
B13. Termination: It shall be the sole right of the District to terminate any contract upon written notification to the Broker/Consultant and to award such commissions the date such change is effective to another Broker/Consultant, if any.
B14. Expenses: Neither NKC nor Charlesworth Benefits, L.C. will be responsible for any expenses incurred by a firm in preparing and submitting a proposal.
B15. Governing Law: Any accepted firm(s) shall comply with all local, state and federal laws and regulations related to the performance of the program being offered. The proposing firm(s) must be registered with and maintain good standing with the Missouri Department of Insurance, as may be required by law or regulation. All contractual agreements shall be subject to, governed by, and construed according to the laws of the State of Missouri.
B16. Assignment: Contractors are prohibited from assigning, transferring, conveying, subletting or otherwise disposing of this proposal or any resultant agreement or its rights, title, or interest therein or its power to execute such agreement to any other person, agent, broker, company, insurer or corporation without the previous written approval of the District.
B17. Selection Process: All proposals will be evaluated by the District's staff and consultants, anticipated to consist of at least the following people or their designees:

NKC Schools Executive Director, HR / Benefits

NKC Schools Benefits Specialist

NKC Schools Associate Superintendent – Administrative Services

NKC Schools Chief Financial Officer

CTTN Representative

Insurance Committee Representative

Charlesworth Benefits, L.C. (facilitator only)

B18: Rating Criteria:

  1. Quality & quantity of similar services provided for other public school entities in the Kansas City geographic area the size and/or complexity of this District;

  2. Firm Personnel (background; experience; in-house staff; etc.), including the ability of the key contact and internal support staff – both clerical and professional in a local office. This includes positive interaction between the District’s staff and assigned personnel of the proposing Broker.

  3. Overall creativity and quality of the responsiveness to this RFQ;

  4. Proposed scope of services in compliance with that requested;

  5. Stability of proposing broker of requested services;

  6. Access to the insurance market on a competitive basis;

  7. Objective position and evaluation of the area schools Cooperative self-insurance health benefit program;

  8. Enrollment capabilities, on-site enrollment assistance, benefits administration technology, and/or communication tools that may be provided or for which your firm has access;

  9. Ability to help guide the District to be ahead of cost and benefit issues as well as wellness initiatives, that can include experience with employee health clinics;

  10. Technical capabilities and resources of the broker itself as well as with support providers;

  11. Ancillary services and incentives provided by the Broker/Consultant;

  12. Internal cost of disruption to brokerage change (if any); and,

  13. Cost and fees are NOT to be included in your response and will be fully negotiated by the District with the preferred vendor prior to any recommendation being made to the Board of Education. Current “blue chip broker” status with BlueKC may be an important point of discussion as well as how compensation may be impacted if a change is made to the Cooperative self-insurance health benefit plan.

B19: Basis for Award: Information and/or factors gathered during interviews, negotiations, professional news articles and reference checks, in addition to the evaluation criteria contained herein, and any other information or factors deemed relevant by the District, shall be utilized in the final award.

B20. Interview: The District may decide to conduct an interview of any or all proposing brokers at the District’s discretion. This would be an oral presentation made to the selection committee and will include reference checks. The purpose of the interview is to develop a working dialog between the proposing broker and the direct contact personnel that the Broker would assign the District. This will form a significant part of the District’s selection process.
B21: Specifications: These specifications have been developed specifically for NKC and are the intelligent property of Charlesworth Benefits, L.C.
B22: Insurance: The Broker/Consultant shall purchase and maintain in full force, at its own expense, such insurance as will protect them from claims which may arise out of or result from the Broker/Consultant’s execution of the work, whether such execution be by an individual, employee, agent, subcontractor or by anyone whose acts any of them may be liable. The Broker/Consultant shall furnish a certificate of insurance with a minimum notification of 30 days should any policy be canceled before the expiration date.
The Broker/Consultant must maintain, as a minimum, the following coverages:

Commercial General Liability insurance with a limit of no less than $1,000,000 each occurrence and aggregate, including bodily injury, property damage and personal injury.

Business Automobile Liability with a limit of no less than $1,000,000 combined single limit each accident, bodily injury and property damage.
Statutory Workers’ Compensation and Employers Liability with a limit of no less than $100,000 / $500,000 / $100,000.
Professional Errors & Omission’s Liability with a limit of no less than $5,000,000 each claim and aggregate.
B23: No Contact Policy: ALL communication through this RFQ process is to be with Charlesworth Benefits, L.C. Any contact initiated by any proposing firm with any District representative concerning this RFQ is prohibited. Any such unauthorized contact may cause the disqualification of the proposing firm from this procurement transaction.
B24: Conflict of Interest: The successful Broker/Consultant shall not have conflicts of interest as to any decisions or revenues (other than that fully disclosed herein) from the results of any recommendation made on behalf of the Broker/Consultant. In addition, the Broker/Consultant shall fully disclose any potential conflicts of interest they may have with the District. No salaried officer or employee of the District and no member of the Board of Education shall have a financial interest, direct or indirect, in this proposal for services being solicited.
B25: Timeline: The estimated timeline for process. Nothing in this RFQ precludes the District from requesting additional information at any time during the procurement process.

RFQ Schedule


District Advertises RFQ

Wednesday, September 16, 2015

RFQ issued to Brokers(s) upon request; District to post on District Website

Friday, September 18, 2015

Broker submits clarification questions to Charlesworth by no later than:

5:00 p.m. Central Time, Tuesday, September 29, 2015

The District responds to Broker with responses to clarification questions by no later than this date

Thursday, October 1, 2015

Broker RFQ Proposal Due at Charlesworth Benefits, L.C.

Thursday, October 8, 2015 by 12:00 Noon Central Time

District reviews RFQ Proposal Summaries and Benefit Committee review, discussion and status of Proposals

Thursday, October 15, 2015

District conducts Proposal interviews at the District’s Office [Proposal interviews granted at the sole discretion of the District].

Tuesday, October 27, 2015

Summary report, findings and recommendation to the District Board of Education

November 4, 2015

District Board of Education Decision

November 10, 2015

Agreement Effective Date

January 1, 2016



It is important that your responses be as brief and to the point as possible.
The District seeks a qualified Benefits Broker/Consulting firm who shall provide group benefit broker/consulting services and shall have full access to the entire health and welfare insurance marketplace through a strong local office with a dedicated local service team with current capacity to be assigned to the District.
C1. Provide a brief history of your firm, including office location that is being proposed to service this District. A Kansas City regional office with significant executive authority is considered extremely important to the District. Identify who has the local executive authority.
C2. Identify the ONE designated local customer service representative that will assist either the District in its day-to-day benefit plan issues, or to assist a plan member on a claim dispute or a billing issue?

  • What specific experience does this individual have with local public entities as well as working directly with Human Resources Departments?

  • How many clients is this person directly responsible for currently?

  • Can the District make changes should the assigned representative not appear to work out with District personnel?

The purpose is to assist the human resources team in administering all employee benefit plans, responding to questions from and providing information to HR staff on a timely and ongoing basis.
C3. Who would be the designated local representative that would present information to Administrative Staff as well as the Board of Education?

  • What specific experience does this individual have with local public entities as well as working directly with senior administrative staff?

  • How many clients is this person directly responsible for currently?

  • Can the District make changes should the assigned representative not appear to work out with District personnel?

C4. Have you or any of your employees that will be assigned to the District participated in any conferences that pertain to governmental entities and benefit issues either as a presenter or member that you believe could highlight your experience with entities like the District?

C5. Core Broker Services are to include, as a minimum, the following. Confirm what is included in your proposed basic service model:

Service Description

Included / Not Included

Health & Welfare program assessment - short and long term planning


Voluntary Benefit evaluation


Financial impact of plan modifications


Develop strategic plans on benefits offered, cost and contributions


Coordinate all renewal activities with carriers


Financial impact of plans, including variances of projections by Broker


Detailed renewal analysis into a workable summary report for management


Prepare RFQ when necessary for each line of benefit


Coordinate all marketing activities with carriers


Make final recommendations for the District's consideration


Assist with any claim problems or other administrative issues


Assistance with any insurer billing errors


Strategize the employee communication process with the District


Review technology programs handled by the District and any improvement opportunities with current or future vendors, including vendor administrative systems


Seek possible third party funding of technology solutions


Provide insight into vendor and wellness service options


Discuss trends in health and productivity strategies and possible resources


Assist with communication ideas and implementation strategies with District's HR Department


Provide quantitative data analysis at a minimum on a quarterly basis - monthly on overall experiences


Provide direction on federal laws and regulations that can impact the District's benefit plans. (not as legal counsel to the District)


Assist in interpreting state laws that may impact the District's benefit plans.


Monitor case laws that could impact the District's benefit plans.


Provide annual trend study comparables for the District at time of renewal.


Assist with possible comparative plans/cost on an annual basis.


Be available to assist in any technical support regarding specific benefit issues.


Assist the District's HR Staff in developing agenda and goals for any Employee Health Committee, including attendance as needed, but not to exceed 6 times per year.


C6. How often do you anticipate providing claims analysis information to the management of the District? Are the reports strictly from the insurer? What service do you provide, as a broker/consultant, in regards to loss evaluations?

C7. Describe the frequency in which you will review current benefits offered regarding plan design, funding and cost compared to the benefits offered to similar employers and retirees in the geographic area.

C8. How and when will your firm be analyzing the existing plan designs and identify insurer and funding alternatives for reducing annual costs to both the District and the employee?
C9. Does the proposing broker have the capability to run “what if” scenarios regarding possible plan design changes and the impact that would have had on the past claims year or Predictive Modeling for potential claims. Is this your system or a system to which you subscribe?

C10. The District currently handles all employee benefit communication. As such, what would be your proposed role in such an arrangement? Give an example of one communication piece you authored for a client. Note any employee newsletters, on-line booklets, etc. that would be provided within your normal basic fee structure.
C11. Should the District wish to have your firm assist in preparation or provide ideas in their communication pieces, would this be considered “core services” or would such need to be discussed in Compensation? Provide one example of an ongoing benefit education piece.
C12. Do you anticipate conducting any employee surveys and if so, what do you believe would be the main objective of this survey and is such included in your basic services? Could this include Retirees?
C13. With your experience with an account the size of NKC – exactly what is your involvement to be during the annual open enrollment process? Typically, how many of your employees do you anticipate to provide at enrollment meetings compared to the number of individuals sent by the insurer? The District does anticipate the Broker/Consultant to serve in a support role during open enrollment, new employee orientation meetings the end of each school year and any employee enrollment changes throughout the year.
C14. Does the proposing broker/consultant have the capability to provide this District with information (enrollment, changes, plan overviews, etc.) to be placed on the District's intranet service or is this service to be provided by the insurer? Note what is available to be provided. Current vendor is Benefit Ready. If by the Insurer or Broker/Consulting firm, is this service proprietary or may the District continue its use should those services terminate in the future? The District’s payroll vendor is SunGuard (Business Plus /B+), with Kronos time-keeping – would such a known system you work with have experience with this type system? Confirm that any new administrative service program will manage COBRA and Retiree communication and billing. Outline any fees for the service and how paid as a pass-through fee for the District.
C15. Identify any potential on-line benefit statement services or benefit calculators that may be available to the District, either as provided by the proposing Broker/Consultant or as a service that can be purchased by the District. The District currently has this available as on on-line template only, but time involvement with the District to input some of the data is limited for a District produced document.

C16. Are you able to provide update information to the District regarding current and pending legislative information that may impact either the District or their employees?

  1. Identify how your firm keeps abreast of compliance/ notification issues as well as reform issues with PPACA and how you would relay such information to the District.

  2. What role does your firm play in assisting/advising regarding 1095 IRS Reporting?

  3. Will you perform an ACA compliance review in 2016?

  4. Briefly list other ACA related services included?

C17. Provide a very basic summary time-line of services for renewals/marketing. It is anticipated that on an annual basis, all renewals should be finalized before the first day of March of each year. In addition, the Broker/ Consultant will provide the District with a written assessment of all insurance policies then in force for the benefit of the District and shall include recommendations for improved coverages. This should include the following:

  1. Complete list of in-force policies, carriers, renewal dates and rate

  2. Evaluation of overall insurance programs compared to similar employer

  3. Forecast of market conditions and expectations of renewals

  4. List of contract modifications and recommendations for each benefit

  5. Account history, by benefit, of claims and premiums

  6. Summary of activity on open, ongoing large claims as allowed by HIPAA

  7. Review of future goals and long-term strategy

  8. Provide innovative approaches to benefit challenges facing the District and recommendations for benefit plan design changes

  9. Service analysis and improvement areas

  10. National HealthCare Reform issues and impact on the District

C18. All negotiations with insurance carriers or other providers of insurance products, Broker/Consultant will act solely for the benefit of the District and its employees without regard for the benefit of the Broker/Consultant or any other person or entity. Confirm that the District’s Human Resources Executive Director or Assistant Superintendent will be in all negotiations involvement placing of the District’s insurance programs; and that all strong potential insurers will have an opportunity to meet with the District’s HR department prior to finalizing any RFQ process.

C19. When a decision is made by the District that the broker is to market health, dental, life and vision, as well as any other insurance or benefit service program provider, note if your annual fee would need to be negotiated changes during the years in which the program(s) are marketed.
C20. Should a partially self-funded or cost-plus product continue to be considered, confirm that the Broker/ Consultant will compare insurance provider discounts, analyze stop-loss quotations, health care provider network matching, first year immature funding issues, reserving practices, fiduciary risk, etc.
C21. Explain how your firm can remain objective in the evaluation of a Cooperative area school self-insurance health benefit plan (established by Mercer); and either still maintain as the District’s Consultant/Broker or if that role would be eliminated. If such a move were made in the future, what types of discussions do you anticipate regarding compensation? Identify your firm’s experience as a consultant working with a Cooperative plan.

C22. The District requires an all-inclusive cost structure, with the proposing broker’s plan on compensation for insurance placement and benefit consulting that are to be outlined in detail, along with any additional fees when negotiations begin by the District.
NKC understands that commissions or other fees can be payable from the insurer to the broker for the broker’s involvement. Be prepared to discuss and disclose all anticipated fees, commissions, contingencies, over-rides, bonuses, etc., to be paid with regard to or in connection with products sold to or through the District. It will be necessary to be very clear how future commissions or costs impact the District and its employees.
Any fees received that have not been previously disclosed to the District for any reason for products placed on behalf of the District by the Broker/Consultant will be cause for immediate termination and gross misconduct of a contractual relationship with the District.
C23. The District will NOT reimburse the broker for any expenses of any kind that are not fully disclosed and approved for by the District prior to incurring such expenses.
C24. Identify typical “pass through” of fees that the District may experience, i.e., enrollment fees; mass mailings; pre-approved travel; etc.

C25. Describe the firm’s view of the role wellness programs have on controlling healthcare costs. What resources and tools do you offer clients around wellness initiatives? Would the fees associated with these services need to be part of the negotiation process?
C26. Please describe any training, seminars or workshops that your firm provides for clients to attend. Do you anticipate any cost to the District and how many of the District employees could attend?
C27. Describe experience you have working with employee health committees, and what role your firm plays on the committee. Please provide a sample agenda for an employee health committee that your firm has been a part of. The District will be re-creating this committee once the decision is made on its Benefit Broker/Consultant.

C28. The District currently works with NKC Hospital/Meritas regarding the operation of a near-site clinic. Outline your involvement in evaluating such specialty clinic or other unique cost saving initiatives for clients and how that may translate into a benefit for the District. Specifically touch on your current working relationship with Meritas with any other clinic operations.

C29. Describe any other facets of your organization and your firm’s experience that are relevant to this proposal that have not been previously described.
C30. Provide at least three references for the broker services being proposed, including contact name and phone number. Local governmental entity references are preferred compared to the size and geographic of NKC Schools.
Provide at least one reference as to a recent client lost by your firm and the reason you believe you lost the account.
C31. What is the estimated percentage of clients that you have fully insured vs. partially self-funded in their group health benefit program?
C32. If the District made the decision to appoint your firm as its broker of record, how would the District rank either size (employees) or premium in proportion to the balance of your local business (estimates are acceptable).
C33. In 200 words or less, answer why the District should select your firm as its broker of record by using two specific objective reasons.


C34. Are you a current “blue chip” broker with Blue Cross / Blue Shield of Kansas City? Identify the importance of this distinction, if any. When the final discussion on compensation is held with the preferred Broker/Consultant – be ready to discuss “total compensation” regardless of which source it is derived.


My signature certifies that the proposal as submitted complies with all terms and conditions as set forth in North Kansas City School District’s RFQ for Benefit Broker/Consulting services.

My signature also certifies that the accompanying proposal is not the result of, or affected by, any unlawful act of collusion with another person or company engaged in the same line of business commerce, or any act of fraud.
My signature also certifies that this firm has no business or personal relationships with any other companies or persons that could be considered as a conflict of interest or potential conflict of interest to the North Kansas City School District, and that there are no principals, officers, agents, employees, or representatives of this firm that have any business or personal relationships with any other companies or persons that could be considered as a conflict of interest or a potential conflict of interest to the North Kansas City School District, pertaining to any and all work or services to be performed as a result of this request and any resulting contract with the North Kansas City School District.
I hereby certify that I am authorized to sign as a Representative for the Firm:
Complete Legal Name of Firm: __________________________________________
Address: ________________________________________________________


Federal I.D. #: _______________________
Name (print/type):________________________________________________________
Title: __________________________________________________________________
Telephone (_____) _____-________ Fax: (_____) _____-________
Date: ________________________
To receive consideration for award, this signature sheet MUST be returned as part of your response to this Request For Qualifications.

North Kansas City Schools, Benefit Broker RFQ for 01/01/2016

Facilitated by Charlesworth Benefits, L.C.


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