Common use of Recipient Information Clause in Contracts

Recipient Information. Recipient shall provide the information set forth below. Street address: City, state, zip code: Email address: Telephone: ( ) Facsimile: ( ) Is Recipient a nonresident alien, as defined in 26 USC § 7701(b)(1)? (Check one box): YES NO Recipient Proof of Insurance, as required by Exhibit C, Section 7: All insurance listed must be in effect at the time of provision of services under this Agreement. Professional Liability Insurance Company: Policy #: Expiration Date: Commercial General Liability Insurance Company: Policy #: Expiration Date: Automobile Liability Insurance Company: Policy #: Expiration Date: Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: Policy #: Expiration Date: Business Designation: (Check one box): Professional Corporation Nonprofit Corporation Limited Partnership Limited Liability Company Limited Liability Partnership Sole Proprietorship Corporation Partnership Other The above information must be provided prior to Agreement execution. Recipient shall provide proof of Insurance upon request by DHS or DHS designee.