Shared Lab Usage Agreement Request

To request a Shared Laboratory Usage Agreement with the Boston University Photonics Center, please complete and submit the form below.

Shared Lab Usage Agreement Set up Information

Insurance Requirement Aknowledgement*
Please note there is a requirement for your company to provide a Certificate of Liability Insurance as part of the agreement. The Required Minimum Insurance includes:

A. Workers Compensation/Employer’s Liability – as required by law

B. General Liability
• $1,000,000 Bodily Injury and Property Damage Per Occurrence
• Includes contractual liability, products liability and completed operations

C. Umbrella/Excess
• $4,000,000 Each Occurrence Excess of Underlying
• $4,000,000 Products/Completed Operations Aggregate Excess of Underlying

D. Property insurance
• Limits equal to the full replacement value of all assets the Company
has an insurable interest in; including but not limited, to equipment,
inventory, etc.

E. Environmental / Pollution Liability
• $1,000,000 per occurrence / $2,000,000 aggregate
• Coverage should include direct, indirect, business interruption and
property devaluation losses

Aknowledged
Official name of company:*
Official Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Person who will sign the shared laboratory usage agreement document.*
First Last Title
Email address for the person who will sign the shared laboratory usage agreement document.*
(If different from Signee)Point of contact for the agreement to be sent to:
First Last Title
(If different from Signee)Email address for the person to whom the agreement will be sent:
Year of incorporation:*
State of incorporation:*
List of Users

Please enter the names, email addresses, and BU ID Numbers (U#) of users of the shared labs. If a new member is being added who does not have a BU number, please indicate that they are a new user you would like to be set up.
If there is a different person to whom insurance certificate requests should be made, please list their contact here(optional):
First Last
Email address:
Point of contact for billing (i.e. invoices will be sent to the attention of this person):*
First Last
Phone Number for billing contact*
Email address for billing contact*