Attachment 4 -2026 Niagara SABER - Insurance Certification.pdf
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- Solicitation number
- FA667026Q0015
About this file
This is a federal contract insurance acknowledgement and compliance certification form for Air Force contract FA6670-26-X-00XX. The document serves as a template for contractors to certify that they have obtained and will maintain required insurance coverage throughout the contract performance period and any modifications or time extensions. The contractor must acknowledge understanding of specified insurance requirements, confirm that insurance policies contain endorsements providing at least 30 days' written notice to the Contracting Officer before cancellation or material changes adversely affecting government interests, and maintain compliance with applicable state insurance laws. The contractor must also ensure that all subcontractors maintain current insurance certifications meeting contract requirements and maintain New York State Workmen's Compensation Insurance or a reciprocal agreement with another state for the entire performance period.
The form requires signature and authorization from the contractor with their street address, city, state, and zip code, along with their typed name and title. The insurance company must provide its name, street address, city, state, zip code, agent contact information, and policy number. A Contracting Officer representing the United States of America must accept the agreement and incorporate it into the contract in full compliance with FAR 52.228-5 or 52.228-8, as applicable. The document is completed when both parties execute the respective signature blocks with dates.
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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
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