INSURANCE CERTIFICATE Attachment 4.doc

Attachment 4

FA3030-09-R-0006

INSURANCE UNDER FIXED-PRICE CONTRACTS.

Whenever the clause 52.228-5, Insurance—Work on a Government Installation, is included in a contract, prime contractors shall be required to either provide copies of insurance certificates or state in writing that the required insurance has been obtained before commencing work on the installation. If the contractor's statement is used in lieu of submission of insurance certificates to the contracting officer, the following Notification of Compliance with Insurance Requirements shall be used for the prime contractor. After completion by the contractor, the Notification of Compliance shall become part of the official contract file.

NOTIFICATION OF COMPLIANCE WITH INSURANCE REQUIREMENTS

CONTRACT NO. _______________________________

The undersigned Contractor hereby acknowledges that he/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 Texas 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' proofs of required 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)