Attachment 3 - Insurance Certification.pdf
PDF 220 KB Posted
- Attached to
- Repair B300 Hot Water Heaters
- Solicitation number
- FA6670-26-B-0001
About this file
This is a federal contract insurance certification and acknowledgement form for contract number FA6670-26-X-00XX.
The document requires the contractor to certify that all insurance requirements specified in the contract have been obtained and will be maintained at the specified amounts and types throughout the contract performance period and any modifications or extensions. The contractor must ensure that all required insurance policies include an endorsement stating that cancellation or material changes adversely affecting the government's interests require a minimum of thirty (30) days' written notice to the Contracting Officer, consistent with applicable state laws. New York State Workmen's Compensation Insurance or a reciprocal agreement with another state must be maintained for the entire performance period. Additionally, the contractor must verify that each subcontractor possesses current insurance certification meeting contract requirements. The agreement becomes legally binding and enforceable upon execution. The form requires signature blocks for the contractor and insurance company representative, including company name, addresses, authorized signatures with dates, typed names and titles, agent contact information, and policy numbers. The Contracting Officer, on behalf of the United States of America, accepts and incorporates this agreement into the referenced contract in compliance with FAR 52.228-5 or 52.228-8, as applicable. The signature block for government acceptance includes the date and Contracting Officer identification at 914 MSG/PK.
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Text version
ACKNOWLEDGEMENT, AGREEMENT AND CERTIFICATION OF COMPLIANCE
WITH CONTRACT INSURANCE REQUIREMENTS
CONTRACT NUMBER FA6670-26-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 .