Attachment 4 - Notification of Compliance with Contract Insurance Rev 1.pdf
PDF 263 KB Posted
- Attached to
- Packing and Crating Services
- Solicitation number
- FA480327Q0003
About this file
This is a template form for contractor notification of compliance with federal contract insurance requirements for solicitation FA480327Q0003.
The form serves as a binding agreement in which the contractor acknowledges understanding and acceptance of insurance requirements specified in the contract. The contractor must maintain insurance at minimum amounts and types as specified in FAR 28.307-2, with continuous coverage throughout the contract performance period and any modifications or time extensions. Required insurance policies must include an endorsement stating that cancellations or material changes adversely affecting the Government's interest cannot take effect until the longer of: (1) the notice period prescribed by state law where contract performance occurs, or (2) thirty calendar days after written notice to the Contracting Officer. The contractor must also maintain Workers' Compensation Insurance for the applicable state or provide a letter of reciprocal agreement with another state for the entire performance period. Additionally, the contractor is responsible for obtaining and maintaining copies of all subcontractors' proofs of required insurance, which must be made available to the Contracting Officer upon request.
The form contains fill-in sections for contractor company information, authorized representative signature and date, and insurance company details including name, address, policy number, and telephone number. This template is intended to be completed and executed as part of the subject contract.
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Text version
FA480327Q0003
Attachment 04 Page
ATTACHMENT 04
Notification of Compliance with Contract Insurance Requirements
Solicitation No: FA480327Q0003
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 charges 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 ______________ (state) 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(S):
Name:
Address:
Policy #:
Telephone #:
CONTRACTOR:
Company Name:
Address:
(Typed Name and Title) (Date)
(Authorized Signature)
File details come from the government source that posted it. Updated .