MIA Call-off Agreement

Note: An Authority should not enter into an MIA Call-Off Agreement unless either: 

(i) There is a current Overarching Master Indemnity Agreement with current insurance in place, as evidenced by the fact that the Supplier is on Master Indemnity Agreement Register with current insurance that can be viewed at: https://www.gov.uk/government/publications/master-indemnity-agreement-mia; or

(ii) In exceptional circumstances for reasons of urgency where it is not possible for the Supplier to enter into an Overarching Master Indemnity Agreement prior to the delivery of the Equipment or where the insurance is not current and where the Authority itself has carried out its own checks and confirmed that the Supplier has appropriate current public liability and product liability insurance in place in respect of public liability and product liability covering the Equipment with the minimum cover per claim of five million pounds (GBP) (£5,000,000) in accordance with the requirements of the Master Indemnity Agreement Terms and Conditions (August 2016) 

Company Name:
(“Supplier”)		
Address:		
		Postcode:		
Contact Name:		
Contact E-Mail:		
Telephone No.:		
Company Registration Number (i.e. the registration number of the Company at Companies House or other relevant national companies registry):		
Is there an Overarching Master Indemnity Agreement in place with current insurance? If yes, state “Yes” and insert the MIA number here. If not, state “No”:		
This box only requires completing where there is 
no Overarching Master Indemnity Agreement in place with current insurance. In these circumstances, the Authority should check that the insurance requirements have been met as per the note in red above and state “Insurances Checked by the Authority” here. 

Delivery Date:		(being the date of delivery of the Equipment to the Authority)	
Authority:		
Authority Address:		
		Postcode:		
Authority Contact Name:		
Authority Contact E-Mail:		
Authority Telephone No.:		
The Equipment to be supplied by the Supplier to the Authority	
Type of Equipment and its purpose:		
Model/Make:		
Serial Nos.:		
Value:		
Loan or transfer?: 

Note. Where disposable Equipment is provided, this should be on a transfer basis.  		
Purpose of loan or transfer:		
Loan Period (to be completed only where the Equipment is be loaned):

[                  days/months/years (delete as appropriate)] commencing on [     ] day of [                 ] 20[     ]	
Premises and Location(s) at which the Equipment will be kept:

	
In consideration of the Authority taking the Equipment on a loan or transfer basis for the purposes outlined above and the mutual exchange of obligations under the Master Indemnity Agreement Terms and Conditions (August 2016), the Authority and the Supplier confirm that the Master Indemnity Agreement Terms and Conditions (August 2016) shall apply to the provision of the above Equipment by the Supplier to the Authority (on either a loan or transfer basis as specified above) and that upon signature of this MIA Call-Off Agreement by both the Authority and the Supplier a legally binding agreement on such terms shall come into full force and effect between the parties incorporating such Master Indemnity Agreement Terms and Conditions (August 2016), which shall be effective from the delivery date of the Equipment as set out above. 

By signing this MIA Call-Off Agreement, the Supplier also confirms delivery of the Equipment detailed above to the Authority. By signing this MIA Call-Off Agreement, the Authority also acknowledges receipt of the Equipment detailed above on the delivery date referred to above. 	
SIGNED on behalf of the Supplier:		
Name and position:		
Date:		
SIGNED on behalf of the Authority:		
Name and position:		
Date:		

COLLECTION CONFIRMATION RECEIPT (for Equipment on loan only)
To be completed at the point the Equipment is collected by the Supplier.

Without prejudice to the Authority’s rights under this MIA Call-Off Agreement in relation to any outstanding obligations and/or liabilities of the Supplier, the Authority confirms collection by the Supplier, and the Supplier confirms receipt, of the Equipment detailed on the front page of this MIA Call-Off Agreement: 	
Date of Collection: 		
SIGNED on behalf of the Authority:

Name and position:		
Date:		
SIGNED on behalf of the Supplier:		
Name and position:		
Date: