Attachment 6 - Malpractice Insurance Certification Form.docx
DOCX document 12 KB Posted
- Attached to
- Mental Health services for Naval Surface Force Atlantic Force Resiliency/Toughness Program Federal contract opportunity
- Solicitation number
- N6264521R0007
About this file
This document contains a malpractice insurance certification form required for a federal solicitation seeking non-personal mental health services. The solicitation requests registered nurses, licensed clinical social workers, psychologists, and other clinical staff to support the Force Resiliency/Toughness Program at Naval Surface Force Atlantic bases in Norfolk, VA and Mayport, FL. Offerors must provide details of their malpractice insurance coverage including the insurer, insured, type of plan, coverage limits, and confirmation that insurance will be in effect upon award. The form requires a signature from an authorized insurance agent to verify the information.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Amendment 1 N6264521R0007.docx | DOCX document | |
| Attachment 6 - Malpractice Insurance Certification Form.docx | DOCX document | |
| Attachment 1 - Past Performance Information Sheet.docx | DOCX document | |
| Attachment 2 - SAM Certification Sheet.docx | DOCX document | |
| Attachment 4 - Pricing Workbook for N62645-21-R-0007.xlsx | XLSX spreadsheet | |
| Attachment 5 - Establish U.S. Citizenship.docx | DOCX document | |
| Attachment 7 - DD Form 254.pdf | ||
| Attachment 3 - Offerors Information Form.docx | DOCX document | |
| N6264521R0007.docx | DOCX document |
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Text version
ATTACHMENT 6 – MALPRACTICE INSURANCE FORM
MALPRACTICE INSURANCE CERTIFICATION FORM
Contractors shall complete the following and submit it with their offer. Awardee shall update and resubmit form annually.
1. Contractor has or will maintain(ed) malpractice insurance in compliance with the terms and conditions of this solicitation (including FAR Clause 52.2377, Indemnification and Medical Liability Insurance).
______ Yes _____ No Reasons:
2. Insurer:____________________ Insuree: ____________________ Address ____________________ ____________________ Phone ____________________ ____________________
3. Is or will yours be a group plan or are proposed physicians individually insured?
_______ Group ________ By individual
4. Is malpractice coverage ______ occurrence or ______ claims made?
5. If claims made, is extended reporting endorsement (tail) provided? ______(Yes/No/NA) For how long a period? ______ years Can the tail be invoked within 90 days of notification by the Government? _____(Yes/No)
6. What is the extent of coverage?
$_____________ per incident $_____________ aggregate
Do these limits apply to each individual practitioner? _____ (Yes/No) If no, explain. _________________________________________________
7. Will your malpractice insurance coverage be in effect immediately upon award? _______ (Yes/No) If "no," when will coverage begin?______________________________________________
If yes, attach proof of malpractice coverage to this form and include with your offer.
Signature of Authorized Insurance Company Agent Title: _________________ Date: _________________
File details come from the government source that posted it. Updated .