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 |
Amendment No. 2 to Agreement for Services
|
| Contract / Amendment Amount |
$59,000.00
|
| Is this a new agreement or an amendment to an existing agreement? |
Amendment
|
| If this is if a Contract Amendment, what is the Contract Number? |
9736
|
| Supplemental Insurance (for Risk team only) |
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|
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Supplemental Risk Information
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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 |
04/01/2022
|
| Expiration Date |
04/01/2023
|
| 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
|
