Indemnity Approval Form

INDEMNITY APPROVAL FORM

Required under University of Victoria Indemnity Approval Procedures

This form must be used pursuant to the Indemnity Approval Procedures and must becompleted and signed by the person indemnified in "2" below.

Your Contact Information:
*	Name:
*	Email:
*	Phone:

Originating Department:

Person primarily responsible for carrying out the obligations under the agreement:

Name:

Phone:

Email:

Description of agreement containing indemnity:

[Provide a short, non-technical description of the purpose of the contract, grant, purchase agreement or other document containing the indemnity.]

Type here:

Description of Risk:

[Provide a description in non-technical language.]

a) Will carrying out the obligations of the University expose anyone to risk of physical injury, damage to health, death or property damage? If so, describe.

b) If the work required by this agreement was ot carried out properly, what might be the consequences?

c) Could these consequences cause any financial loss to the University?

Describe Risk here:

Legal Advice:

Have you consulted legal counsel about any part of this agreement? If so, briefly note name and advise of counsel, below:

Describe Legal Counsel here:

SECTION BELOW IS FOR ADMINISTRATIVE APPROVAL - PLEASE LEAVE BLANK. If you have finished fillout out the form, please review the information above and click the Submit button below. Thank you.

Document containing indemnity is attached. [Please flag indemnity clause.]

I request approval for the indemnity contained in the attached document. I recognize that once this approval is obtained, the contract must be signed in accordance with the Signing Authority Policy #1002.

_________________________________

[Signature of person indemnified in 2 above]

I certify that:

a) I am in Approving Officer* pursuant to the Indemnity Approval Procedures.

b) I have reviewed the document containing the indemnification attached and this Indemnity Approval Form.

c) I approve the inclusion of the indemnity caluse in this document.

________________________________

Signature

________________________________

Date

*Any one of the Associate Vice-President Legal Affiars; Associate Vice-President Research; Executive Director Budget and Capital Planning; Vice-President Finance and Operations; University Secretary; Risk Analyst.

Once you have clicked on the Subit Form button your request will be sent directly to Ben McAllister, Risk Analyst, for processing. Thank you.

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