Attachment 5 - Insurance Form.pdf
PDF 2 MB Posted
- Solicitation number
- FA460822B0005
About this file
This document is an insurance notification form for a federal construction contract to install a security fence at an Air Force base. The contractor must maintain insurance in the amounts specified in FAR 28.307-2, including workers' compensation, and provide at least 30 days' notice of any cancellation or material changes to the insurance policies. The contractor must submit proof of insurance for any subcontractors. The contract is with the Department of the Air Force Global Strike Command to install a new 6-foot chain link security fence with 3 strands of barbed wire at the top for a total height of 7 feet, in accordance with the statement of work, from the industrial gate to the air park.
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Text version
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
FA460822B0005
Attachment 5
1101737590C Typewritten Text
1101737590C Typewritten Text
File details come from the government source that posted it. Updated .