Atch 5 Insurance Certification.doc

ACKNOWLEDGEMENT AND CERTIFICATION OF COMPLIANCE WITH CONTRACT INSURANCE REQUIREMENTS

CONTRACT NUMBER

The undersigned Contractor hereby acknowledges that he/she has read and understands the insurance requirements specified in this contract and hereby certifies; 1) that such insurance has been obtained and agrees that said insurance will be maintained in at least the amount and types specified in this contract and during any modifications and/or time extensions granted thereto; 2) that these required insurance policies will each contain an endorsement to the effect that any cancellation or any material change to the insurance policies 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 in surer or the Contractor gives written notice to the Contracting Officer, whichever period is longer; 3) that Washington 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 and during any modifications and/or time extensions granted hereto; 4) where applicable, at least five (5) days before entry of each subcontractor’s personnel on the Government installation, the Contractor shall furnish (or ensure that there has been furnished) to the Contracting Officer, a current certificate of insurance, satisfying the contract insurance requirements, for each such subcontractor.

CONTRACTOR/SUBCONTRACTOR

STREET ADDRESS

CITY, STATE, ZIP

AUTHORIZED SIGNATURE/DATE

TYPED NAME AND TITLE

GENERAL LIABILITY

A.

AUTO LIABILITY

B.

WORK COMP/EMPLOYEE LIABILITY

C.

B.

C.

B.

C.

B.

C.

B.

C.

(POLICY NUMBER)

FA4479-09-R-0010

Attachment 5