Attachment 6 - Malpractice Insurance Certification Form.docx
DOCX document 15 KB Posted
- Attached to
- Mental Health services for Naval Surface Force Atlantic Force Resiliency/Toughness Program Federal contract opportunity
- Solicitation number
- N6264521R0007
About this file
This document contains a malpractice insurance certification form required for a federal solicitation seeking non-personal mental health services. The solicitation requests registered nurses, licensed clinical social workers, psychologists, medical administrators, data analysts and clinical support staff to support mental health programs at naval bases in Norfolk, Virginia and Mayport, Florida. Offerors must demonstrate proof of malpractice insurance coverage for individual practitioners beginning immediately upon award, listing the insurer name, address, phone, and policy limits of at least $500,000 per incident and $1,000,000 in the aggregate. Coverage must apply to each practitioner and remain in effect for the life of the contract.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Amendment 1 N6264521R0007.docx | DOCX document | |
| Attachment 1 - Past Performance Information Sheet.docx | DOCX document | |
| Attachment 2 - SAM Certification Sheet.docx | DOCX document | |
| Attachment 4 - Pricing Workbook for N62645-21-R-0007.xlsx | XLSX spreadsheet | |
| Attachment 5 - Establish U.S. Citizenship.docx | DOCX document | |
| Attachment 3 - Offerors Information Form.docx | DOCX document | |
| Attachment 6 - Malpractice Insurance Certification Form.docx | DOCX document | |
| Attachment 7 - DD Form 254.pdf | ||
| N6264521R0007.docx | DOCX document |
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Text version
ATTACHMENT 6 – 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.
8. If the Insuree is an entity other than the Offeror, this space shall be used to demonstrate that the insurance covers the Offeror.
Signature of Authorized Insurance Company Agent Title: _________________ Date: _________________
File details come from the government source that posted it. Updated .