CAA 2021 Broker Compensation Disclosure

THE WHOLE PERSON
Benefits Broker Request for Proposal (RFP)
CAA 2021 BROKER COMPENSATION DISCLOSURE FORM
This form must be completed by all bidders as part of the RFP response. The Consolidated Appropriations Act of 2021 (CAA 2021) requires brokers and consultants who provide services to group health plans to disclose all direct and indirect compensation. Failure to complete this form will result in disqualification of your proposal.
SECTION 1: BROKER/CONSULTANT INFORMATION
Broker/Firm Name:*
Contact Person:*
Address:*
Phone / Email:*
Contract Period:*

MonthDayYear
Date
through*

MonthDayYear
Date
SECTION 2: SERVICES TO BE PROVIDED
Provide a detailed description of all services you will provide to The Whole Person under this contract:*
YesNo
SECTION 3: DIRECT COMPENSATION
Direct compensation includes commissions, fees, or other payments paid directly to you by The Whole Person, insurance carriers, or vendors for the placement and servicing of group health plan coverage.

SECTION 3: DIRECT COMPENSATION*

Rows	Coverage Type	Payor (Carrier/Client)	Compensation Type	Amount/Formula
1

Compensation Type Examples: Base Commission %, PEPM Fee, Flat Fee, Per Transaction Fee
SECTION 4: INDIRECT COMPENSATION
Indirect compensation includes any payments or benefits received from sources OTHER than The Whole Person that are related to services provided for The Whole Person's group health plans. This includes:
- Contingent commissions, bonuses, or profit-sharing from carriers
- Volume bonuses, growth bonuses, or retention bonuses
- Overrides or commissions from downstream providers (TPAS, PBMs, vendors)
- Service fees, consulting fees, or finder's fees from vendors
- Non-monetary compensation (trips, gifts, awards, sponsorships, training)
- Marketing fees, advertising allowances, or co-op funds

Rows	Source (Carrier/Vendor/Third Party)	Type of Compensation	Method of Receipt	Amount/Formula/Range
1
2
3
4
5

Rows	Source (Carrier/Vendor/Third Party)	Type of Compensation	Method of Receipt	Amount/Formula/Range
1
2
3

Check here if NO indirect compensation is expected to be received.
SECTION 5: CONTINGENT OR VARIABLE COMPENSATION
Describe any compensation that cannot be calculated as of this disclosure date because it is contingent on future events (e.g., profitability, growth, retention, volume thresholds). Include the conditions that must be met and the estimated range of compensation:*
SECTION 6: TERMINATION COMPENSATION
Describe any compensation you or your affiliates/subcontractors expect to receive in connection with the termination of this contract:*
Check here if NO termination compensation is expected.
SECTION 7: CONFLICTS OF INTEREST
Identify any actual or potential conflicts of interest that may exist as a result of compensation arrangements with carriers, vendors, or other third parties:*
Check here if NO conflicts of interest exist.

SECTION 8: AFFILIATES AND SUBCONTRACTORS
List any affiliates or subcontractors who will provide services under this contract and describe their compensation:*
Check here if NO affiliates or subcontractors will be used.
SECTION 9: CERTIFICATION AND ACKNOWLEDGMENT
I certify that the information provided in this disclosure is accurate and complete to the best of my knowledge as of the date below. I understand that:
1. This disclosure is required by the Consolidated Appropriations Act of 2021 for all brokers and consultants who expect to receive $1,000 or more in compensation.
2. I must update this disclosure within 60 days of any material change in compensation.
3. I must correct any inadvertent errors or omissions within 30 days of discovery.
4. I must respond to any written request for information from The Whole Person within 90 days.
5. Failure to provide accurate disclosure may result in disqualification and may constitute a prohibited transaction under ERISA.
Authorized Signature:*

Clear
Printed Name:*
Title:*
Date:*

MonthDayYear
Date
This form must be completed and submitted as part of your RFP response. Failure to provide this disclosure will result in automatic disqualification of your proposal.
Should be Empty:

THE WHOLE PERSON