Attachment 5 - Insurance Certification.pdf
PDF 220 KB Posted
- Solicitation number
- FA667026Q0014
About this file
This is a federal contract insurance acknowledgement and certification form for Air Force contract FA6670-26-X-00XX.
The contractor certifies compliance with specified insurance requirements, including obtaining and maintaining required insurance coverage at the minimum amounts and types stipulated in the contract throughout the entire performance period and any modifications or time extensions. The contractor agrees that all insurance policies must include endorsements requiring minimum 30-day written notice to the Contracting Officer before any cancellation or material adverse changes become effective, in compliance with applicable state law. The contractor must maintain New York State Workmen's Compensation Insurance or a reciprocal agreement with another state for the full contract performance period. Additionally, the contractor is responsible for ensuring all subcontractors possess current insurance certifications satisfying contract requirements. The agreement becomes a legally binding and enforceable part of the contract upon execution by both the contractor and the Air Force Contracting Officer. The form requires signature and contact information from the contractor and their insurance company agent, along with acceptance and incorporation into the contract by the Contracting Officer in compliance with FAR 52.228-5 or 52.228-8, as applicable.
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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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