SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYY)

Date Cert Issued

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NO AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER JOHN DOE INSURANCE AGENCY 123 Main Street Houston TX 77002

CONTACT NAME: John DoePHONE (A/C, No. Ext): 713 555 1212

FAX (A/C, No): 713 555 1213

E-MAIL ADDRESS: JohnDoe@johndoeagency.com

INSURER(S) AFFORDING COVERAGE NAIC#

INSURED Legal Name of the Contracting Party 123 Mailing Address Lane City, ST ZIP

INSURER A : Illinois National Insurance Company 23817

INSURER B : ACE American Insurance Company 22667

INSURER C : Indemnity Insurance Co of North America 86514

INSURER D : XL Insurance America, Inc. 24554

INSURER E : INSURER F:

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR

TYPE OF INSURANCE

ADDL INSR

SUBR WVD

POLICY NUMBER POLICY EFF (MM/DD/YYY)

POLICY EXP (MM/DD/YY)

LIMITS

A

GENERAL LIABILITY Y

Y

CGL123456

4/1/2013

4/1/2014

EACH OCCURRENCE $1,000,000

X COMMERCIAL GENERAL LIABILITY DAMAGES TO RENTED PREMISES(Ea occurrence)

$100,000

CLAIMIS-MADE X OCCUR MED EXP (Any one person) $10,000

PERSONAL & ADV INJURY $1,000,000

GENERAL AGGREGATE $2,000,000

GEN’L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000

POLICY PRO- JECT

LOC

B

AUTOMOBILE LIABILITY Y

Y

BAP123456

4/1/2013

4/1/2014

COMBINED SINGLE LIMIT (Ea accident)

$1,000,000

X ANY AUTO BODILY INJURY(Per person) $

ALL OWNED AUTOS

SCHEDULED AUTOS

BODILY INJURY(Per accident) $

HIRED AUTOS NON-OWNED

AUTOS PROPERTY DAMAGE (Per accident)

$

$

C

X UMBRELLA LIAB X OCCUR Y

Y

EXS123456

4/1/2013

4/1/2014

EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION $ $

D

WORKERS COMPENSATION AND EMPLOYERS ‘ LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

Y/N

N/A

Y

WC1234567

4/1/2013

4/1/2014

X WC STATU- TORY LIMITS OTH-

ER

E.L. EACH ACCIDENT $1,000,000

E.L. DISEASE – EA EMPLOYEE

$1,000,000

E.L. DISEASE – POLICY LIMIT

$1,000,000

OTHER

DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

CERTIFICATE HOLDER CANCELLATION

The University of Houston System and Component Campus Name C/O Department Contact Person’s Name Department Mailing Address

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE John Doe’s signature

SAMPLE

Version 10/3/16. Revised 3/28/17. Reference: MAPP 04.04.01A and SAM 03.A.05

Division:__________________________________________________________Vendor Name:________________________________________________________Department ID/Department Name:_____________________________________Total Amount of Contract:_______________________________________________Contact Person (Originator):__________________________________________Event Name/Services Type:______________________________________________Business Services Contact (DBA or Designee):___________________________ Event Date/Service Start Date:____________________________________________

1 MemoA. For Contracts $25K or above, attach a memo regarding the purpose of the service, from originator addressed to Delegated Signature Authority.

2 Contract CoversheetA. Description of services being provided or equipment being purchased.B. Start dates are in the future or services will not start until the agreement is executed. C. Total amount of contract should match supporting source documentation.D. Cost centers/account code included and funding has been verified.E. Originator has reviewed and initialed all applicable certifications.F. Rush - Inform if the contract is a rush by checking (Yes or No). If yes, add justification for rush and the date it is needed by.G. Originator has signed the coversheet acknowledging all contract requirements are met.

3 Binding AgreementA. UH Standard AgreementB. Non-Standard Agreement

4 Recommendation for Award (All Agreements require this form)Expense

A. Procurement Method: Explain how the quotes were obtained or if it was a Formal Bid; list RFP/ITB/RFQ and include the number.B. Price Tabulations: List the different prices obtained from the quotes or RFP/ITB/RFQ.C. Basis for Best Value to the University: Explain why the selected vendor was chosen. Ex: Due to pricing or previous work with vendor.D. Preferred Vendor: List the Vendor Name.E. College Department/Division: List the Department Name.F. Signed By: College Administrator, Department Administrator, or Division Administrator.

Revenue GeneratingA. Procurement Method: List N/A.B. Price Tabulations: List the price expected to be paid to UH.C. Basis for Best Value to the University: List N/A.D. Preferred Vendor: List the Vendor Name.E. College Department/Division: List the Department Name.F. Signed By: College Administrator, Department Administrator, or Division Administrator.

5 Documents for Procurement Method Used$0 - $5K Spot Purchase; No Competition Required.$5K & Up Sole Source Purchase, with signatures (if applicable).$5K - $25K Informal Quotes Obtain and Approved by Purchasing, (attach Purchasing approval).$25K & Up Formal Procurement Process (RFP/ITB/RFQ), (attach procurement method).$100K & Up Addendum C needs to be completed for purchases exceeding $100K, with signatures, and department needs to attach with contract packet for review.

6 InsuranceUH Standard Agreement

A. Vendor agrees to the Insurance language on the Standard Agreement.B. Vendor has provided the Certificate of Insurance (COI) with Insurance requirements, and department needs to attach with contract packet for review. C. Vendor requests Waiver/Deviation Form from Insurance requirements on the Standard Agreement.

(The "Request for Waiver/Deviation of Insurance Requirements for Standard Agreements" Form is reviewed/approved by Risk Management.)Non-Standard Agreement

A. Insurance language is included. Risk Management has reviewed and approved the language (include approve e-mails). B. Insurance language is not included. Forward the contract packet to Risk Management to ensure insurance requirements are added.

7 Non-Standard Expense ContractA. Attach form, "Alternative Dispute Resolution Clause." Form explains the process to attempt to resolve a claim from breach of contract by Contractor.

8 Payment Terms & PricingA. UH Standard Agreement: Compensation Section (i.e., Fixed Amount/Not Fixed) and Payment Term (i.e., Hourly/Monthly/Yearly fees).B. Non-Standard: Payment Section (i.e., Hourly/Monthly/Yearly fees).

9 Information Technology (Data Hosting of UH Data on Non-UH/UHS Servers)A. Attach the Form "Information Security Hosted Services Contract Checklist." Form is reviewed/approved by UIT, Mary Dickerson.

10 Vendor Status (All Agreements require this status)A. PeopleSoft Vendor Information: "Open for Ordering" box checked.B. Texas Comptroller website: Verify that Vendor has the right to transact business in Texas (Zero $0 or Revenue contract). https://fmcpa.cpa.state.tx.us/tpis/

UNIVERSITY of HOUSTON CENTRAL BUSINESS SERVICESContract Submission Checklist