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City of Everett <br />RFP #2026 001 for Third Party Claims Administrator (TPA) Services <br />Page 18 of 22 <br />FORM 4.02 PRICE SHEET <br />REQUEST FOR PROPOSAL #2026-001 THIRD PARTY CLAIMS ADMINISTRATOR (TPA) <br />SERVICES <br />Supplier Name:_____________________________________________________________________________ <br />Provide a pricing rate sheet for services detailed in the Scope of Work. If there are options for different pricing <br />structures, such as Life of Claim, Life of Contract, or others, please clearly distinguish the different rate options. <br />The pricing rate sheet must be easy to understand and clearly laid out. <br />All fees must be disclosed and included in the pricing rate sheet. Do not include state or local sales tax in the <br />prices. Actual invoices must include proper WA state sales tax. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Price SheetB. <br />6 <br />Intercare Holdings Insurance Services, Inc.