Enter Basic Contract Information
Administrative Information
Basic Contract Details
| Vendor Name |
Tarzana Treatment
|
| Vendor Number (3____ for AP and 00___ for AR) |
323128
|
| Vendor Contact Name |
Albert Senella
|
| Vendor Contact Email |
[email protected]
|
| Contract / Amendment Title |
Agreement for Services
|
| Contract / Amendment Amount |
$25,000.00
|
| 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? |
009598
|
| Supplemental Insurance (for Risk team only) |
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|
Upload Contract Documents
Upload Documents
| Upload Contract or Amendment Authorization Form |
autho.pdf
|
| Upload Agreement or Amendment |
amend2.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 |
03/10/2021
|
| Policy Expiration Date |
03/10/2022
|
| Policy Amount |
$1,000,000.00
|
| Endorsements |
PNC, AI, WOS
|
Automobile Policy Details
| Effective Date |
03/10/2021
|
| Expiration Date |
03/10/2022
|
| Policy Amount |
$1,000,000.00
|
Workers Comp Policy Details
| Effective Date |
11/26/2020
|
| Expiration Date |
11/26/2021
|
| Endorsements |
WOS
|
Professional Liability Policy Details
| Effective Date |
03/1/2021
|
| Expiration Date |
03/10/2022
|
| Policy Amount |
$1,000,000.00
|
Other Policy Details
| Other Policy Name 1 |
Sexual Misconduct
|
| Effective Date 1 |
03/10/2021
|
| Expiration Date 1 |
30/10/2022
|
| Policy Amount 1 |
$1,000,000.00
|
| Other Policy Name 2 |
Crime
|
| Effective Date 2 |
03/10/2021
|
| Expiration Date 2 |
03/10/2022
|
| Policy Amount 2 |
$1,000,000.00
|
