HMO RFP Response — ProvidusUnity Harmonised Scheme

Please complete this response in full. Your answers are used to assess your proposal against the published selection criteria. When finished, download your response as a PDF and email it to HealthFusion with the checklist documents attached. Figures should be your most recent available. Add rows to any list as needed.

HMO name *

Contact person

Contact email

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Unity Scheme Data

Total premium on the Unity portfolio (NGN)

NGN

Total number of employees covered

Total number of lives covered

Years on the Unity Bank scheme

Submission checklist

Attach the following documents to the email you send with your completed response. Tick each item to confirm it is attached. This checklist is included in your downloaded PDF.

Email your completed PDF and all attachments to the address provided by HealthFusion.

Authorisation & Declaration

This response must be submitted by an officer authorised to act on behalf of the HMO named above. Fields marked * are required.

Authorised officer — full name *

Title / position *

Date

* I confirm that I am duly authorised to submit this response on behalf of the named HMO, that the information provided is true and accurate to the best of my knowledge, and that I understand any false, misleading or impersonated submission will lead to disqualification and may constitute fraud.

HMO RFP Response — ProvidusUnity Harmonised Scheme

Your response is ready