Enter Basic Contract Information
Administrative Information
Basic Contract Details
| Vendor Name |
Friends Research Institute--Outpatient
|
| Vendor Number (3____ for AP and 00___ for AR) |
318234
|
| Vendor Contact Name |
Jennifer Reyes
|
| Vendor Contact Email |
[email protected]
|
| Contract / Amendment Title |
2020-21 Contract Renewal
|
| Contract / Amendment Amount |
$147,200.00
|
| 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? |
9608
|
| Supplemental Insurance (for Risk team only) |
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|
Upload Contract Documents
Upload Documents
| Upload Contract or Amendment Authorization Form |
Friends_Outpatient.pdf
|
| Upload Agreement or Amendment |
Friends Outpatient.pdf
|
| Upload Docusign "Certificate(s) of Completion" |
Summary.pdf
|
| Upload Insurance Documents (COI, Endorsements, WOS, etc.) |
COI WeHo w.Endts.pdf
|
| Describe changes to Insurance Requirements, if any (if no insurance is required, type "None required") |
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|
| Upload approval for insurance changes, if any (e.g., email from Risk) |
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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 |
07/01/20
|
| Policy Expiration Date |
07/01/21
|
| Policy Amount |
$1,000,000.00
|
| Endorsements |
PNC, AI, WOS
|
Automobile Policy Details
| Effective Date |
07/01/20
|
| Expiration Date |
07/01/21
|
| Policy Amount |
$1,000,000.00
|
Workers Comp Policy Details
| Effective Date |
07/01/20
|
| Expiration Date |
07/01/21
|
| Policy Amount |
$1,000,000.00
|
| Endorsements |
WOS
|
Professional Liability Policy Details
| Effective Date |
07/01/20
|
| Expiration Date |
07/01/21
|
| Policy Amount |
$1,000,000.00
|
Other Policy Details
| Other Policy Name 1 |
Crime Coverage
|
| Effective Date 1 |
07/01/20
|
| Expiration Date 1 |
07/01/21
|
| Policy Amount 1 |
$1,000,000.00
|
| Other Policy Name 2 |
Excess Liability
|
| Effective Date 2 |
07/01/20
|
| Expiration Date 2 |
07/01/21
|
| Policy Amount 2 |
$5,000,000.00
|
