Attachment 6 -Insurance Certification.pdf
PDF 220 KB Posted
- Attached to
- Replace CAC Carpeting B503, RVKQ 26-0007
- Solicitation number
- FA6670-26-Q-0010
About this file
This document is an Acknowledgement, Agreement and Certification of Compliance with Contract Insurance Requirements for federal contract FA6670-26-X-00XX. The contractor certifies that required insurance has been obtained and will be maintained at specified amounts and types throughout the contract performance period and any modifications or time extensions. The contractor acknowledges that all required insurance policies must contain endorsements ensuring that cancellation or material changes adversely affecting the government's interests cannot take effect for less than thirty days after written notice to the Contracting Officer, consistent with applicable state law.
The contractor further certifies that New York State Workmen's Compensation Insurance (or a reciprocal agreement with another state) will be maintained for the entire performance period and any extensions. The contractor is responsible for ensuring that each subcontractor obtains and maintains current certification of insurance satisfying contract requirements. The agreement becomes legally binding and enforceable as part of the referenced contract upon acceptance by the Contracting Officer, in compliance with FAR clauses 52.228-5 or 52.228-8, as applicable. The document provides signature blocks for the contractor and insurance company representative, as well as the Contracting Officer acceptance section.
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Text version
ACKNOWLEDGEMENT, AGREEMENT AND CERTIFICATION OF COMPLIANCE
WITH CONTRACT INSURANCE REQUIREMENTS
CONTRACT NUMBER FA6670-26-X-00XX
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 cancellation of any material change to the insurance policies adversely affecting the interest of the government 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; 3) that New York 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 thereto; 4) where shall ensure that each subcontractor possesses current certification of insurance satisfying the contract requirements; and
5) that this agreement shall become a part of the above referenced contract and shall be legally binding and enforceable by Law.
(CONTRACTOR) (INSURANCE COMPANY NAME)
(STREET ADDRESS) (STREET ADDRESS)
(CITY, STATE, ZIP) (CITY, STATE, ZIP)
(AUTHORIZED SIGNATURE, DATE) (AGENT, TELEPHONE NUMBER)
(TYPED NAME AND TITLE) (POLICY NUMBER)
ACCEPTANCE
The undersigned Contracting Officer, on behalf of the United Sates of America, hereby accepts the above Agreement and Certification and hereby incorporates the above Agreement into the above referenced contract in full text in compliance with FAR 52.228-5 or 52.228-8, as applicable.
UNITED STATES OF AMERICA
Date
, MSG PK
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