Attachment 0003.pdf
PDF 143 KB Posted
- Attached to
- Psychological Services
- Solicitation number
- N4523A24R1600
About this file
This document is a malpractice insurance certification form required to be submitted with offers for psychological services solicited under solicitation number N4523A24R1600 by the Department of the Navy Naval Supply Systems Command. Key details include that the contractor must maintain malpractice insurance in compliance with FAR clause 52.237-7 and provide information such as the insurer, whether coverage is on an occurrence or claims-made basis, coverage limits of at least $500,000 per incident and $1,000,000 aggregate for each individual provider, and proof of coverage. The contractor must also specify whether its plan is group or individual and if claims-made whether tail coverage is provided for how long.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment 0001.pdf | ||
| Attachment 0009.pdf | ||
| Attachment 0005.pdf | ||
| Attachment 0008.pdf | ||
| Attachment 0010.pdf | ||
| Attachment 0004.pdf | ||
| Attachment 0002.pdf | ||
| A10.0 Psychological Services Q & A.pdf | ||
| Attachment 0006.pdf | ||
| Attachment 0007.pdf | ||
| A04.01 PWS_Rvd_11-3-23_Redacted.pdf |
Show all 11
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
ATTACHMENT 0003
MALPRACTICE INSURANCE CERTIFICATION FORM
Contractor shall complete the following and submit with their offer.
1. Contractor has or will maintain malpractice insurance in compliance with the terms and conditions of this solicitation (including FAR Clause 52.237-7, Indemnification and Medical Liability Insurance. Yes No
Reasons:
2. Insurer: _______________________ Insuree: ______________________
Address: ______________________________________________________
Phone: ________________________________________________________
3. Is or will yours be a group plan or are proposed physicians individually insured?
____Group By individual
4. Is malpractice coverage _____ occurrence or _____ claims made?
5. If claims made, is extended reporting endorsement (tail) provided? (Yes/No/NA) For how long a period?
years
Can the tail be invoked within 90 days of notification by the Government? (Yes/No)
6. What is the extent of coverage?
$ per incident
$ aggregate
Do these limits apply to each individual provider (Yes/No)
If no, explain
7. Will your malpractice insurance coverage be in effect immediately upon award? (Yes/No) If "no", when will coverage begin?
If yes, attach proof of malpractice coverage to this form and include with your offer.
Signature of Authorized Insurance Company Agent: _____________________
Title: _________________________
Date: _________________________
File details come from the government source that posted it. Updated .