Attachment 3 - Insurance Form.pdf

Notification of Compliance with Contract Insurance Requirements

Contract Number:

The undersigned Contractor hereby acknowledges that he/she has read and understands the insurance requirements specified in this contract and hereby provides notification (1) that such insurance shall be maintained in at least the amounts and types as stated in FAR

28.307-2 and during any modifications and/or time extensions granted thereto; (2) that the required insurance policies shall contain an endorsement to the effect that any cancellation of material changes 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 thirty (30) calendar days after the insurer or contractor gives written notice to the Contracting Officer, whichever period is longer; (3) that

Workers' 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/or time extensions granted thereto; and (4) that a copy of all subcontractors' proofs of required insurance shall be maintained and shall be made available to the Contracting Officer upon request.

This agreement shall be a part of subject contract and shall be legally binding and enforceable at law.

Insurance Company Information

Name:

Address:

Policy Number:

Telephone Number:

E-mail Address:

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Contractor Information

Name:

Address:

Telephone Number:

E-mail Address:

Authorized Signature

Date Typed Name, Rank, Title Authorized Signature

FA460822B0007

Attachment 3

1101737590C Typewritten Text

1101737590C Typewritten Text