Att_4_CoI.pdf

FA4600-16-R-0012

Attachment 4

CERTIFICATE OF COMPLIANCE WITH INSURANCE REQUIREMENTS

CONTRACT: FA4600-16-R-0012

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 has been obtained and will be maintained in at least the amounts and types specified in this contract and during any modifications and/or time extensions granted thereto; and (2) that these required insurance policies each contain an endorsement to the effect that cancellation or any material change in the policies adversely affecting the interests of the government in such insurance shall not be effective for such period as may be prescribed by the laws of the state in which this contract is to be performed and in no event less than thirty (30) days after written notice thereof has been given to the Contracting Officer; and (3) that Nebraska’s Workman’s Compensation Insurance, or letter of reciprocal agreement with another state has been obtained and, shall be maintained on this contract for and during the entire performance period and for and during any modifications and/or time extensions granted thereto; and (4) that this agreement is a part of the above referenced contract, and shall be legally binding and enforceable at law.

INSURANCE COMPANY (ies): _____________________ Phone No. _( )_______________

(Agent) ______________________ Phone No. _ ( )_______________

______________________ Phone No. _(___)_______________

Contractor: ___________________________________

(Date) (Authorized Signature)

(Name & Title)

ACCEPTANCE

The undersigned Contracting Officer, on behalf of the United States of America, hereby acknowledges receipt of the above certification.

UNITED STATES OF AMERICA

BY: _______________________________

(Contracting Officer)

CERTIFICATE OF COMPLIANCE WITH INSURANCE REQUIREMENTS