Amend 0001 Attachment G - Certificate Insurance Form.pdf
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- Solicitation number
- N6247025R9003
About this file
This document is a Certificate of Insurance form for civil liability coverage under an agreement between the Kingdom of Spain and the United States of America on Defense Cooperation. The certificate outlines an insurance policy for a contractor working with U.S. Forces in Spain, providing coverage for potential damages or liabilities arising from the contractor's employees' actions during official functions or professional activities.
The insurance policy specifies indemnity limits of 601,012.10 Euros per casualty, with sub-limits of 90,151.82 Euros for personal liability, 60,101.21 Euros for property damage, and 6,010.12 Euros for judiciary bond. The policy includes two key clauses: the insurance company waives subrogation rights against the United States, and both parties agree to submit to Spanish court jurisdiction and laws for any disputes related to the policy. The document is a bilingual form with an English original and a Spanish courtesy translation.
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Text version
Certificate of Insurance
CERTIFICATE OF INSURANCE COVERAGE OF THE CIVIL LIABILITY REFERRED TO UNDER
ARTICLE 5 OF ANNEX 6 TO THE AGREEMENT BETWEEN THE KINGDOM OF SPAIN AND THE
UNITED STATES OF AMERICA ON COOPERATION FOR THE DEFENSE.
The insurance Company_______________________________________________with legal domicile in
_______________________________________________________________ Tel:__________________________ of Spanish/US nationality, registered in the Mercantile Registry of_______________________________________
Date:____________________, Number________, Book:_______, Section _____, Volume________, Page_______.
CERTIFIES
That (insert contractor or company name) of ___________ nationality has contracted with this company Policy
Number_______________ of civil liability against damages to persons or property which could arise from actions or omissions committed by any of their employees in the performance of their official functions/professional activities in Spain because of the contracts signed with U.S.Forces, and during the visit which, in respect of such contract, they may make to Spain, according to the general conditions in force for this type of insurance and also to the special conditions created for this purpose in the Spanish-U.S. Permanent Committee; that said company has paid the premium according to the agreed conditions; and that such Policy is in force.
The Policy establishes as coverage of the mentioned risks the following amounts:
INDEMNITY LIMITS:
- For casualty: --------------------------601,012.10 Euros
With the following sub-limits for each injured person:
- For personal liability: ----------------90,151.82 Euros
- For property damage: ---------------- 60,101.21 Euros
- For Judiciary Bond: -------------------- 6,010.12 Euros
The granted coverage is effective from ________________ through________________, and does not include any type of franchise, or similar limitation, to be deducted from the mentioned guarantees or any clause which requires the submission to any type of arbitration. The underwriting insurance company considers that the established amounts adequately cover the insured risks.
The policy sets forth the following clauses:
1. “The insurance company waives any right of subrogation against the United States of America which may arise by reason of any payment under this Policy.”
2. “The parties hereto explicitly agree to submit to the jurisdiction of the Spanish Courts of Law and to the
Spanish Laws to settle any matter related to the construction or enforcement of the clauses and conditions of this
Policy.”
IN WITNESS HEREOF, the present document is signed in______________________________, on the____________of_____________20____
For the Insured Company (signature) For the Insurance (signature)
(Courtesy Translation)
Certificado de Cobertura de Seguro
CERTIFICADO DE COBERTURA DE SEGURO DE LA RESPONSABILIDAD CIVIL A QUE SE
REFIERE EL ARTICULO 5 DEL ANEXO 6 AL CONVENIO ENTRE EL REINO DE ESPAÑA Y LOS
ESTADOS UNIDOS DE AMERICA SOBRE COOPERACION PARA LA DEFENSA.
La Compañia de Seguros ______________________________________ con domicilio social en la Calle/Avda./Pla.
____________________________________________________________________, Tlfo.: _________________ , de nacionalidad española/norteamericana, inscrita en el Registro Mercantil de______________________________, fecha _________________, Número ________, Libro _________, Sección ______, Tomo _______, Folio_______.
CERTIFICA:
Que ___(nombre del individuo o la empresa)______________, de nacionalidad _________________________, tiene suscrita con esta Compañia la Póliza número ____________________________, de responsabilidad civil contra daños a personas y cosas que pudieran derivarse de acciones u omisiones realizadas por sus empleados en el desempeño de sus funciones oficiales/actividades profesionales en España con ocasión de su contracto con las
Fuerzas de los EE.UU. y con la visita que en relación con dicho contrato realicen sus empleados a España, según las condiciones generales vigentes para este tipo de seguros y además las condiciones especiales elaboradas a este fin en el Comité Permanente Hispano-Norteamericano; habiéndose satisfecho la prima según las condiciones pactadas, y encontrándose dicha Póliza en vigor.
La Póliza establece como cobertura de los riesgos mencionados las siguientes cuantías:
LIMITES DE INDEMNIZACION:
- Por siniestro: -------------------------- 601.012,10 Euros
Con los siguientes sublímites por perjudicado:
- Por daños personales: ---------------- 90.151,82 Euros
- Por daños materiales: ---------------- 60.101,21 Euros
- Por fianzas judiciales: ----------------- 6.010,12 Euros
Las coberturas otorgadas son efectivas desde el ___________________________, hasta el
_________________________, no incluyéndose en las mismas ningún tipo de franquicia o limitación similar a deducir de las garantías indicadas ni ninguna disposición que requiera la sumisión a cualquier tipo de arbitraje. La
Compañia aseguradora que suscribe considera que las cuantías establecidas cubren adecuadamente los riesgos asegurados.
La Póliza establece las siguientes cláusulas:
1. “La Compañia Aseguradora renuncia a cualquier derecho de subrogación contra los Estados Unidos de
América que pueda provenir por razones diferentes a pago, bajo la Póliza epígrafiada.”
2. “Las partes se someten expresamente a la jurisdicción de los tribunales españoles y al derecho español para resolver cualquier cuestión relativa a la interpretación o aplicación de las cláusulas y condiciones de la Póliza.”
Y para que conste a los efectos oportunos, se firma el presente en __________________ a _______________ de
_____________ 20___.
Tomador: Asegurador:
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