Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 1/8/2025
2) Contract Type: Expense
3) Renewal Contract: Choose an item.
4) Department Name: Professional Services
5) Department Contact: Veronica Van Horn
6) Description: Hartford CrimeShield Advance-Employee Theft & Computer & Funds Transfer Fraud
7) PEID No: 719491
8) Req No:
9) Orgkey: 6130-151431
10) Object Code: 5491725
11) Vendor: GIA Insurance
12) Vendor Contract No:
Expenditure Budget/Revenue Projections
13) Fund Name: Self Insurance
14) Fund #: 6130
15) Current Year Budgeted:
16) Current Year Projected: $8,144.00
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals:
To Be Completed by Purchasing Department
22) Contract Start Date: 2/21/2025
23) Auto Renewal Contract: No
24) Bid No: NA
25) Contract End Date: 2/20/2026
26) Contract # Issued by Purchasing Department: CM24136
NOTES:
Renewal 61FA028331224 coverage 02/21/2025 to 02/21/2026