Attachment 10 - Malpractice Insurance Form.docx
DOCX document 12 KB Posted
- Attached to
- Roentgengraphic Interpreting Services
- Solicitation number
- N6264520QBREADER
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Combined Solicitation - N62645-20-Q-BREADER Amendment 0001.DOCX | DOCX document | |
| Attachment 5 - Certificate of Availability.docx | DOCX document | |
| Attachment 1 - NAVMED 62607 Form.pdf | ||
| Attachment 3 - Acceptable U.S. Citizenship Documents.docx | DOCX document | |
| Combined Solicitation - N62645-20-Q-BREADER.DOCX | DOCX document | |
| Attachment 6 - Past Performance Information Sheet.docx | DOCX document | |
| Attachment 8 - SAM Certification Sheet.docx | DOCX document | |
| Attachment 11 - Contract Administration Plan.docx | DOCX document | |
| Attachment 4 - DoDI 8582.01.pdf | ||
| Attachment 7 - Pricing Workbook.xlsx | XLSX spreadsheet | |
| Attachment 2 - QASP.doc | DOC document | |
| Attachment 9 - Offerors Information Form.docx | DOCX document |
Show all 12
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
ATTACHMENT 10
MALPRACTICE INSURANCE CERTIFICATION FORM
Contractors shall complete the following and submit it with their offer. Awardee shall update and resubmit form annually.
1. Contractor has or will maintain(ed) malpractice insurance in compliance with the terms and conditions of this solicitation (including FAR Clause 52.2377, 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 practitioner? _____ (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 .