EXHIBIT A - Insurance Carriers or Agents Acknowledgment Form.docx
DOCX document 46 KB Posted
- Solicitation number
- Q0003
- Issued by
- Suffolk County, New York
About this file
The document is an Insurance Carriers or Agents Acknowledgment Form for the Suffolk County Water Authority (SCWA), specifically related to a Request for Quotes (RFQ) for furnishing and delivering chlorine tanks and accessories. The RFQ requires proposals to be submitted electronically via BidNetDirect.com no later than 11:00 AM EST on February 3, 2025, for delivery to 4060 Sunrise Highway, Oakdale, New York. The form is designed to ensure that potential bidders and their insurance carriers confirm their ability to meet the specified insurance requirements for the contract.
The form requires both the insurance agent and the bidder to acknowledge and verify compliance with multiple insurance coverage types, including automobile liability, general liability, excess liability, worker's compensation, and professional liability insurance, among others. Bidders must demonstrate they can procure the required insurance at no additional cost to SCWA. Questions about the RFQ should be submitted through BidNet or emailed to Steve Blevins, Procurement Agent, at least 72 hours before the response due date. The document emphasizes that failure to properly complete and sign the form may result in the bid being considered non-responsive.
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Other files
| File | Type | Posted |
|---|---|---|
| EXHIBIT B - Contact Info.docx | DOCX document | |
| Q&A Document 1.pdf | ||
| SCWA Purchase of Chlorine Tanks and Accessories.pdf |
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Text version
EXHIBIT A
Insurance Carrier or Agent's Acknowledgement
Project Description: RFQ No. _______ – __________________________________________________________________
Your Insurance Carrier or Agent must complete the Form below. You must complete the Bidder's Acknowledgment. This Form shall be returned with the Bid submission.
Insurance Agent:
NAME OF FIRM
Address:
Email:
Fax No.: Phone No.:
Please review the SCWA insurance requirements contained in this Contract which are listed in the Instructions to Bidders. Confirm that you have read these specific requirements (pay particular attention to required limits) and that you are complying with them by placing a check in the appropriate box.
1. Automobile Liability
1. Material is Delivered by common carrier
1. General Liability
1. Excess Liability
1. Vendor’s Endorsement
1. Worker’s Compensation
1. Owners and Contractors Protection Liability (OCP)
1. Professional Liability Insurance
1. Builders Risk or Installation Coverage Floater
1. Crime
We have reviewed the insurance requirements set forth in the above proposed contract and are capable of providing such insurance to our insured in accordance with such requirements in the event the contract is awarded to our insured and provided our insured pays the appropriate premium.
Dated: Sign:
Authorized Insurance Agent or Representative
Print Name:
BIDDER'S ACKNOWLEDGMENT
The Bidder herein acknowledges that he/she has reviewed the insurance requirements within this Contract and has considered the costs, if any, of procuring the required insurance and will be able to supply the insurance required as per the Contract, if awarded to the Bidder, at no additional cost to the SCWA.
Sign:
Officer of Company Print Name
(Failure To Have This Form Properly Filled Out and Signed by The Insurance Agent as Well as The Bidder May Result in Your Bid Being Considered Non-Responsive.)
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