Attach 4 - Insurance Certification.pdf
PDF 202 KB Posted
- Attached to
- Repair Airfield Pavement Spalling Federal contract opportunity
- Solicitation number
- FA667025B0002
About this file
This document is an Acknowledgement, Agreement and Certification of Compliance with Contract Insurance Requirements for contract number FA6670-25-X-00XX. The form requires the contractor to certify that they have obtained and will maintain the specified insurance coverage, including provisions for 30-day notice before policy cancellation and maintaining New York State Workers' Compensation Insurance throughout the contract performance period. The contractor must also ensure that subcontractors have current insurance certification meeting the contract requirements. The document includes signature lines for the contractor, insurance company, and a government Contracting Officer's acceptance, with the form to be incorporated into the referenced contract in compliance with Federal Acquisition Regulation (FAR) clauses 52.228-5 or 52.228-8.
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Text version
ACKNOWLEDGEMENT, AGREEMENT AND CERTIFICATION OF COMPLIANCE
WITH CONTRACT INSURANCE REQUIREMENTS
CONTRACT NUMBER FA6670-25-X-00XX
The undersigned Contractor hereby acknowledges that he/she has read and understands the insurance requirements specified in this contract, and hereby certifies; 1) that such insurance has been obtained and agrees that said insurance will be maintained in at least the amount and types specified in this contract and during any modifications and/or time extensions granted thereto; 2) that these required insurance policies will each contain an endorsement to the effect that cancellation of any material change to the insurance policies adversely affecting the interest of the government shall not be effective for such period as may be prescribed by the laws of the State in which this contract is to be performed and in no event less than thirty (30) days after written notice thereof has been given to the Contracting Officer; 3) that New York State Workmen's Compensation Insurance, or letter of reciprocal agreement with another State, shall be maintained on this contract for and during the entire performance period and for and during any modifications and/or time extensions granted thereto; 4) where shall ensure that each subcontractor possesses current certification of insurance satisfying the contract requirements; and
5) that this agreement shall become a part of the above referenced contract and shall be legally binding and enforceable by Law.
(CONTRACTOR) (INSURANCE COMPANY NAME)
(STREET ADDRESS) (STREET ADDRESS)
(CITY, STATE, ZIP) (CITY, STATE, ZIP)
(AUTHORIZED SIGNATURE, DATE) (AGENT, TELEPHONE NUMBER)
(TYPED NAME AND TITLE) (POLICY NUMBER)
ACCEPTANCE
The undersigned Contracting Officer, on behalf of the United Sates of America, hereby accepts the above Agreement and Certification and hereby incorporates the above Agreement into the above referenced contract in full text in compliance with FAR 52.228-5 or 52.228-8, as applicable.
UNITED STATES OF AMERICA
Date
, MSG PK
File details come from the government source that posted it. Updated .