Intercare Holdings Insurance Services, Inc 5/8/2026

Page 17 of 22 F ORM 4.01 SUPPLIER COMMITMENT AND INFORMATION REQUEST FOR PROPOSAL #2026-001 THIRD PARTY CLAIMS ADMINISTRATOR (TPA) SERVICES Company Name: Company Address: City: State: ZIP: Tax ID #: UBI #: Legal status of supplier organization, i.e., corporation, partnership, sole proprietorship. Diversity Certification (if applicable): ☐ Disadvantaged Business Enterprise (DBE) ☐ Minority Business Enterprise (MBE) ☐ Women Business Enterprise (WBE) ☐ Minority Women Business Enterprise (MWBE) Certification number: Website: City of Everett Business License # Supplier Contact Name (if different from Authorizing Official): Supplier Contact Title: Supplier Contact Email: Supplier Contact Direct Phone: Supplier Contact Address (if different from above): City: State: ZIP: By responding to this solicitation, the Supplier understands and agrees to be bound by all requirements and contract terms and conditions contained in this solicitation. By signing this form, the Supplier acknowledges receipt and understanding of any and all addenda issued for this solicitation. This form, signed by an individual authorized to legally commit the Supplier, must be submitted as the cover page. The Supplier also certifies that: • I am authorized to commit my firm to this Proposal and that the information herein is valid for 120 days from this date. • That all information presented herein is accurate and complete and that the scope of work can be performed as presented in this proposal upon the City’s request. • That I have had an opportunity to ask questions regarding this Proposal and that those questions have been answered. • That this Proposal response is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting an offer for this Proposal and is in all respects fair and without collusion or fraud. This form may be signed by ink signature, copy of ink signature, copy of signature, e-signature or any other form of signature. By submitting this bid, the bidder agrees that its signature will have the same legal effect as an original ink signature. Authorizing Official Name: Authorizing Official Title: Authorizing Official Email: Authorizing Official Phone: Authorizing Official Signature and Date: City of Everett RFP #2026 001 for Third Party Claims Administrator (TPA) Services Supplier Commitment and InformationA. 5 Intercare Holdings Insurance Services, Inc. 11000 NE 33rd Place, Suite 300 Bellevue WA 98004 954465745 602 607 991 Corporation N/A www.intercareins.com N/A N/A N/A N/A 6020 West Oaks Blvd. Suite 100 Rocklin CA 95765 Agnes Hoeberling Chief Customer Officer ahoeberling@intercareins.com (818) 459-6742 March 25, 2026