ATTACHMENT G Notification of Compliance with Insurance Requirements.docx
DOCX document 18 KB Posted
- Attached to
- S205--Waste and Refuse Collection services
- Solicitation number
- 36C25626Q0325
About this file
This file is a notification form template for contractor compliance with insurance requirements under solicitation 36C25626Q0325. The form serves as an acknowledgment that the contractor has read and understands all insurance requirements specified in the contract and agrees to maintain required insurance coverage at specified amounts and types throughout the contract period, including any modifications or time extensions. The contractor must ensure that insurance policies contain endorsement language stating that cancellations or material changes adversely affecting the Government's interest shall not be effective for the period prescribed by state law or until 30 days after written notice to the Contracting Officer, whichever is longer. Additionally, the contractor commits to maintaining workers' compensation insurance for the designated state or providing a letter of reciprocal agreement with another state for the entire performance period and any extensions, and to maintain copies of all subcontractors' proof of insurance for presentation to the Contracting Officer upon request.
The form includes designated fields for the contractor to populate with insurance company names and telephone numbers, contractor name and address, authorized signature, date, and typed name and title. This template is intended to be completed and filed as part of the contract documentation for the waste and refuse collection services requirement at Gulf Coast Veterans Health Care System, with performance scheduled for April 1, 2026 through September 30, 2026, plus four optional 12-month renewal periods.
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ATTACHMENT G – NOTIFICATION OF COMPLIANCE WITH INSURANCE REQUIREMENTS
36C25626Q0325
NOTIFICATION OF COMPLIANCE WITH INSURANCE REQUIREMENTS
The undersigned Contractor hereby acknowledges that he or she has read and understands the insurance requirements specified in this contract and hereby agrees (1) that such insurance will be maintained in at least the amounts and types specified in this contract and during any modifications and or time extensions granted thereto; (2) that the policies evidencing required insurance shall contain an endorsement to the effect that any cancellation or any material change 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 30 days after the insurer or contractor gives written notice to the Contracting Officer, whichever period is longer; (3) that ________________ (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 any modifications and time extensions granted thereto; and (4) that a copy of all subcontractors’ proof of insurance shall be maintained and shall be made available to the Contracting Officer upon request. This agreement shall become a part of the above referenced contract file.
INSURANCE COMPANY(S): ____________________________________
(NAME[S]) (TELEPHONE NUMBER[S]): ______________________________________________
CONTRACTOR: ____________________________________________
(NAME): __________________________________________________
(ADDRESS): _______________________________________________
(AUTHORIZED SIGNATURE) (DATE): _______________________________________________
(TYPED NAME AND TITLE):________________________________________________________
File details come from the government source that posted it. Updated .