Enter Basic Contract Information
Administrative Information
Basic Contract Details
| Vendor Name |
Brentview Medical
|
| Vendor Number (3____ for AP and 00___ for AR) |
324140
|
| Vendor Contact Name |
Amanda Pagliari
|
| Vendor Contact Email |
[email protected]
|
| Contract / Amendment Title |
Brentview Medical
|
| Contract / Amendment Amount |
$74,900.00
|
| 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 |
EdenContractAuthorizationForm.pdf, Brentview_Medical_-_Procurement_Memo_09-26-22.pdf
|
| Upload Agreement or Amendment |
Brentview Medical Contract - 07-01-22 updated (signed).pdf
|
| Upload Insurance Documents (COI, Endorsements, WOS, etc.) |
WC WOS 2023.pdf, WC COI.pdf, Med Mal 1.1.22 to 2023.pdf, AI PNC WOS.pdf, Brentview Medical COI 2022-2023 Work comp.pdf, BRENT-City of West Hollywood 22-23 COI (1).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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|
Supplemental Risk Information
General Liability Details
| Policy Effective Date |
04/15/2022
|
| Policy Expiration Date |
04/15/2023
|
| Policy Amount |
$1,000,000.00
|
| Endorsements |
PNC, AI, WOS
|
Automobile Policy Details
| Effective Date |
04/15/2022
|
| Expiration Date |
04/15/2023
|
| Policy Amount |
$1,000,000.00
|
Workers Comp Policy Details
| Effective Date |
03/09/2022
|
| Expiration Date |
03/09/2023
|
| Policy Amount |
$1,000,000.00
|
| Endorsements |
WOS
|
Professional Liability Policy Details
| Effective Date |
01/01/2022
|
| Expiration Date |
01/01/2023
|
| Policy Amount |
$1,000,000.00
|
| Waived |
Prof Liability and Medical Malpractice coverage
|
