Enter Basic Contract Information
Administrative Information
Basic Contract Details
| Vendor Name |
REGENTS UCLA
|
| Vendor Number (3____ for AP and 00___ for AR) |
301225
|
| Vendor Contact Name |
Christina Domer
|
| Vendor Contact Email |
[email protected]
|
| Contract / Amendment Title |
Individual License Agreement
|
| Contract / Amendment Amount |
$750.00
|
| 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 |
Authorization Form UCLA Longevity Center_FY21.pdf
|
| Upload Agreement or Amendment |
UCLA Longevity Center Renewal Agreement 2020-2021.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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|
| Add any notes you may have for Finance and Risk Review teams. |
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|
| Add name of RFP / RFQ / RFB, if issued |
none
|
| - or add weblink to RFP / RFQ / RFB, if issued |
None
|
Supplemental Risk Information
General Liability Details
| Policy Effective Date |
|
| Policy Expiration Date |
|
| Policy Amount |
|
| Endorsements |
|
| Waived |
Virtual Event - Vendor to sign waiver
|
Automobile Policy Details
| Waived |
Virtual Event - Vendor to sign waiver
|
Workers Comp Policy Details
| Waived |
Virtual Event - Vendor to sign waiver
|
