Attachment 15 NOTIFICATION OF COMPLIANCE WITH INSURANCE REQUIREMENTS.docx
DOCX document 21 KB Posted
- Attached to
- V225--Ground Ambulance
- Solicitation number
- 36C25626Q0347
About this file
This is a Notification of Compliance with Insurance Requirements template form for federal contract 36C25626Q0347. The document serves as an acknowledgment by the contractor that they have reviewed and understand all insurance requirements specified in the contract and agree to maintain the required insurance coverage throughout the entire performance period, including any contract modifications or time extensions. Contractors must ensure that insurance policies include endorsements protecting the Government's interest in the event of cancellation or material changes, with notice requirements complying with applicable state law or 30 days' written notice to the Contracting Officer, whichever is longer. Additionally, contractors must maintain state workers' compensation insurance or a reciprocal agreement with another state for the full contract performance period.
The form requires contractors to identify their insurance company or companies, provide contact telephone numbers, and supply company information including name, address, authorized signature, date, and typed name and title. Contractors are also obligated to obtain and maintain proof of insurance from all subcontractors and make these documents available to the Contracting Officer upon request. This template becomes part of the official contract file once completed and signed by the contractor.
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ATTACHMENT 15 – NOTIFICATION OF COMPLIANCE WITH INSURANCE REQUIREMENTS
36C25626Q0347
NOTIFICATION OF COMPLIANCE WITH INSURANCE REQUIREMENTS
The undersigned Contractor hereby acknowledges that he or she has read and understands the insurance requirements specified in this contract and hereby agrees (1) that such insurance will be maintained in at least the amounts and types specified in this contract and during any modifications and or time extensions granted thereto; (2) that the policies evidencing required insurance shall contain an endorsement to the effect that any cancellation or any material change adversely affecting the Government's interest shall not be effective for such period as the laws of the State in which this contract is to be performed prescribe, or until 30 days after the insurer or contractor gives written notice to the Contracting Officer, whichever period is longer; (3) that ________________ (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 any modifications and time extensions granted thereto; and (4) that a copy of all subcontractors’ proof of insurance shall be maintained and shall be made available to the Contracting Officer upon request. This agreement shall become a part of the above referenced contract file.
INSURANCE COMPANY(S): ____________________________________
(NAME[S]) (TELEPHONE NUMBER[S]):______________________________________________
CONTRACTOR: ____________________________________________
(NAME): __________________________________________________
(ADDRESS):._______________________________________________
(AUTHORIZED SIGNATURE) (DATE):._______________________________________________
(TYPED NAME AND TITLE):.________________________________________________________
File details come from the government source that posted it. Updated .