ATTACHMENT H Notification of Compliance with Insurance Requirements.docx
DOCX document 17 KB Posted
- Attached to
- Waste and Refuse Services
- Solicitation number
- 36C25627Q0003
About this file
This is a template form for contractor notification of compliance with insurance requirements for federal contracts. The form is specific to solicitation 36C25627Q0003, a waste and refuse services contract issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The contractor must acknowledge understanding and agreement to maintain insurance at the minimum amounts and types specified in the contract throughout the performance period and any modifications or time extensions. Required insurance policies must include endorsements ensuring that cancellations or material changes adversely affecting the Government's interest cannot take effect until 30 days after written notice to the Contracting Officer, or per state law requirements, whichever period is longer. The contractor must also maintain state Workers' Compensation Insurance or provide a reciprocal agreement letter with another state for the entire contract performance period. Additionally, the contractor is responsible for obtaining and maintaining copies of all subcontractors' proof of insurance, which must be made available to the Contracting Officer upon request. The form includes blank fields for the contractor to complete with insurance company names and telephone numbers, contractor identification information, authorized signature, date, and typed name and title.
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ATTACHMENT H – NOTIFICATION OF COMPLIANCE WITH INSURANCE REQUIREMENTS
36C25627Q0003
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 .