Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 5/7/2024
2) Contract Type: Expense
3) Renewal Contract: No
4) Department Name: Human Resources
5) Department Contact: Rebecca Gilliam
6) Description: STD, LTD, Life Insurance
7) PEID No:
8) Req No:
9) Orgkey: 7601-0000000-2312010, 7601-0000000-2302367, 7601-0000000-2312011, 7601-000000-2312012, 7601-000000-2312012
10) Object Code: 2312010,2302367,2312011, 2312012, 2312012
11) Vendor: MetLife
12) Vendor Contract No:
Expenditure Budget/Revenue Projections
13) Fund Name: 1101
14) Fund #: 7601-0000000-2312010, 7601-0000000-2302367, 7601-0000000-2312011, 7601-000000-2312012, 7601-000000-2312012
15) Current Year Budgeted:
16) Current Year Projected:
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals:
To Be Completed by Purchasing Department
22) Contract Start Date: 6/1/2024
23) Auto Renewal Contract: No
24) Bid No: NA
25) Contract End Date: 5/31/2025
26) Contract # Issued by Purchasing Department: CM24200
NOTES: PEID Pending - HB1295 to be requested - Application Only