Policy Change Request

Policy Change Request

Requestor Information

Policy Reference

Policy Identifier:   Current Effective Date:

Recitals

WHEREAS, Requestor Name: represents the operational interests of the department identified above and has determined that the referenced policy requires modification to address operational, regulatory, or compliance concerns;

WHEREAS, Approving Entity: is authorized to approve or reject proposed changes to organizational policies in accordance with established governance procedures;

WHEREAS, the parties seek to document the proposed amendment, the process for evaluation, the allocation of any administrative costs, and the responsibilities for implementation and monitoring of the changed policy.

Scope of Work

The Requestor shall prepare and submit the detailed proposal and the Approving Entity shall conduct review, obtain any necessary stakeholder input, and render a decision in accordance with the timeline set forth below. The detailed activities and deliverables are described in the Scope of Work section.

Proposed Change

Impact Assessment

Implementation Plan & Schedule

Proposed Effective Date:   Expected Completion Date:

Payment Terms (Administrative Costs)

Administrative or implementation charges, if any, associated with processing and implementing this policy change shall be invoiced as set forth below.

Payment Schedule: One-time Installments Charged to cost center

Invoices shall be submitted to the payer listed on record. Failure to dispute an invoice in writing within the payment period constitutes acceptance of the invoice. Late payments shall accrue the late fee set forth above or, if no percentage is specified, interest at the maximum lawful rate.

Term and Termination

This Request shall be effective as of Start Date: and, unless earlier terminated in accordance with this section, shall expire on End Date: .

Either party may terminate this Request for convenience by providing written notice at least days prior to the intended termination date. Either party may terminate immediately for material breach if the breaching party fails to cure within 15 days of written notice of such breach.

Confidentiality

Each party acknowledges that in connection with the review and implementation of the proposed policy change it may receive Confidential Information. Confidential Information means nonpublic business, technical, employee, financial or other information clearly identified as confidential. Each party shall: (a) hold Confidential Information in strict confidence with at least the same degree of care it uses to protect its own confidential information but no less than reasonable care; (b) not use Confidential Information except to perform its obligations under this Request; and (c) not disclose Confidential Information to any third party except to its employees or permitted advisors who have a need to know and who are bound by confidentiality obligations no less restrictive than those contained herein. Confidentiality obligations shall survive termination of this Request for a period of three (3) years.

Governing Law

This Request shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that state for resolution of disputes.

Representations and Warranties

Each party represents and warrants that: (a) it has full power and authority to enter into and perform this Request; (b) the person signing this Request is authorized to bind the party on whose behalf the person signs; and (c) performance of the obligations under this Request will not violate any agreement or legal obligation applicable to the party.

Entire Agreement

This Request, including any attachments or exhibits expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals, negotiations and communications, whether written or oral. Any amendment or modification must be in writing and signed by authorized representatives of both parties.

Approvals and Additional Instructions

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