Enter Basic Contract Information
Administrative Information
Basic Contract Details
| Vendor Name |
Healthcare in Action
|
| Vendor Number (3____ for AP and 00___ for AR) |
330011
|
| Vendor Contact Name |
Michael Hochman
|
| Vendor Contact Email |
[email protected]
|
| Contract / Amendment Title |
Contract for healthcare services
|
| Contract / Amendment Amount |
$556,193.00
|
| Is this a new agreement or an amendment to an existing agreement? |
New Agreement
|
| Supplemental Insurance (for Risk team only) |
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|
Upload Contract Documents
Upload Documents
| Upload Contract or Amendment Authorization Form |
HIA Contract Authorization1.pdf
|
| Upload Agreement or Amendment |
HIA Contract1.pdf
|
| Upload Insurance Documents (COI, Endorsements, WOS, etc.) |
Insurance Requirements.pdf
|
| Describe changes to Insurance Requirements, if any (if no insurance is required, type "None required") |
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|
| Describe changes to Contract Template, if any (If none, type "None required") |
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|
| Upload other supporting documents here, if necessary (e.g. staff reports, etc.) |
HIA Scope.pdf, HIA Budget.pdf, W-9 Form - HIAMG.pdf
|
Supplemental Risk Information
General Liability Details
| Policy Effective Date |
07/01/2022
|
| Policy Expiration Date |
07/01/2023
|
| Policy Amount |
$1,000,000.00
|
| Endorsements |
PNC, AI, WOS
|
Automobile Policy Details
| Effective Date |
07/01/2022
|
| Expiration Date |
07/01/2023
|
| Policy Amount |
$1,000,000.00
|
| Endorsements |
Includes SA and Molestation
|
Workers Comp Policy Details
| Effective Date |
07/01/2022
|
| Expiration Date |
07/01/2023
|
| Policy Amount |
$1,000,000.00
|
| Endorsements |
WOS
|
Professional Liability Policy Details
| Effective Date |
08/01/2022
|
| Expiration Date |
08/01/2023
|
| Policy Amount |
$1,000,000.00
|
| Waived |
includes medical malpractice
|
Other Policy Details
| Other Policy Name 1 |
Crime
|
| Effective Date 1 |
07/01/2022
|
| Expiration Date 1 |
07/01/2023
|
| Policy Amount 1 |
$2,000,000.00
|
