Attachment_4_-_Malpractice_Insurance_Certification_Form.docx

ATTACHMENT 4 – MALPRACTICE INSURANCE FORM

MALPRACTICE INSURANCE CERTIFICATION FORM

Contractors shall complete the following and submit it with their offer. Awardee shall update and resubmit form annually.

1. Contractor has or will maintain(ed) malpractice insurance in compliance with the terms and conditions of this solicitation (including FAR Clause 52.2377, 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 practitioner? _____ (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: _________________