A04.4 Attachment 0003.pdf
PDF 143 KB Posted
- Attached to
- Psychological Evaluation Services
- Solicitation number
- N4523A24Q1304
About this file
This document is an attachment to a solicitation for psychological evaluation services. The Navy is seeking these services to support the Naval Supply Systems Command. The attachment requires offerors to submit proof of malpractice insurance coverage with their proposals. Offerors must carry either occurrence-based or claims-made insurance, and if the latter, they must provide an extended reporting endorsement. The attachment requests details on insurance limits, carriers, and whether coverage will be in effect at award. Offerors must also affirm their ability to comply with FAR Clause 52.237-7 regarding indemnification and medical liability insurance.
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Text version
ATTACHMENT 0003
MALPRACTICE INSURANCE CERTIFICATION FORM
Contractor shall complete the following and submit with their offer.
1. Contractor has or will maintain malpractice insurance in compliance with the terms and conditions of this solicitation (including FAR Clause 52.237-7, Indemnification and Medical Liability Insurance. Yes No
Reasons:
2. Insurer: _______________________ Insuree: ______________________
Address: ______________________________________________________
Phone: ________________________________________________________
3. Is or will yours be a group plan or are proposed physicians individually insured?
____Group By individual
4. Is malpractice coverage _____ occurrence or _____ claims made?
5. If claims made, is extended reporting endorsement (tail) provided? (Yes/No/NA) For how long a period?
years
Can the tail be invoked within 90 days of notification by the Government? (Yes/No)
6. What is the extent of coverage?
$ per incident
$ aggregate
Do these limits apply to each individual provider (Yes/No)
If no, explain
7. Will your malpractice insurance coverage be in effect immediately upon award? (Yes/No) If "no", when will coverage begin?
If yes, attach proof of malpractice coverage to this form and include with your offer.
Signature of Authorized Insurance Company Agent: _____________________
Title: _________________________
Date: _________________________
File details come from the government source that posted it. Updated .