Recipient Proof of Insurance. Recipient shall provide the following information upon submission of the signed Agreement. All insurance listed herein and required by Exhibit C, must be in effect prior to Agreement execution. Commercial General Liability Insurance Company: Policy #: Expiration Date: Automobile Liability Insurance Company: Policy #: Expiration Date: Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: Policy #: Expiration Date: Certification. Without limiting the generality of the foregoing, by signature on this Agreement, the undersigned hereby certifies under penalty of perjury that: Recipient is in compliance with all insurance requirements in Exhibit C of this Agreement and notwithstanding any provision to the contrary, Recipient shall deliver to the OHA Agreement Administrator (see page 1 of this Agreement) the required Certificate(s) of Insurance within 30 days of execution of this Agreement. By certifying compliance with all insurance as required by this Agreement, Recipient acknowledges it may be found in breach of the Agreement for failure to obtain required insurance. Recipient may also be in breach of the Agreement for failure to provide Certificate(s) of Insurance as required and to maintain required coverage for the duration of the Agreement; Recipient acknowledges that the Oregon False Claims Act, ORS 180.750 to 180.785, applies to any “claim” (as defined by ORS 180.750) that is made by (or caused by) the Recipient and that pertains to this Agreement or to the project for which the grant activities are being performed. Recipient certifies that no claim described in the previous sentence is or will be a “false claim” (as defined by ORS 180.750) or an act prohibited by ORS 180.755. Recipient further acknowledges that in addition to the remedies under this Agreement, if it makes (or causes to be made) a false claim or performs (or causes to be performed) an act prohibited under the Oregon False Claims Act, the Oregon Attorney General may enforce the liabilities and penalties provided by the Oregon False Claims Act against the Recipient; The information shown in this Section 5a. “Recipient Information”, is Recipient’s true, accurate and correct information; To the best of the undersigned’s knowledge, Recipient has not discriminated against and will not discriminate against minority, women or emerging small business ent...
Recipient Proof of Insurance. Recipient shall provide the following information upon submission of the signed Agreement. All insurance listed herein and required by Exhibit C, must be in effect prior to Agreement execution. If Recipient is self-insured for any of the Insurance Requirements specified in Exhibit C of this Agreement, Recipient may so indicate by: (i) writing “Self-Insured” on the lines below; and (ii) submitting a certificate of insurance as required in Exhibit C. Commercial General Liability Insurance Company: Policy #: Expiration Date: Automobile Liability Insurance Company: Policy #: Expiration Date: Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: Policy #: Expiration Date:
Recipient Proof of Insurance. Recipient shall provide the following information upon submission of the signed Agreement. All insurance listed herein and required by Exhibit C, must be in effect prior to Agreement execution. Commercial General Liability Insurance Company: Policy #: Expiration Date: Automobile Liability Insurance Company: Policy #: Expiration Date: Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: Policy #: Expiration Date:
Recipient Proof of Insurance. Recipient shall provide the following information upon submission of the signed Agreement. All insurance listed herein and required by Exhibit C, must be in effect prior to Agreement execution. Commented [MTR15]: OPTIONAL language. Most private organizations are NOT self-insured. Some are, however, particularly large corporations. If you do NOT want to use this optional language delete paragraph. If Recipient is self-insured for any of the Insurance Requirements specified in Exhibit C of this Agreement, Recipient may so indicate by: (i) writing “Self-Insured” on the lines below; and (ii) submitting a certificate of insurance as required by Exhibit C. Professional Liability Insurance Company: Policy #: Expiration Date: Commercial General Liability Insurance Company: Policy #: Expiration Date: Automobile Liability Insurance Company: Policy #: Expiration Date: Fidelity Bond Insurance Company: Policy #: Expiration Date: Directors, Officers and Organization Liability Insurance Company: Policy #: Expiration Date: Other #1 (list type of coverage and Company): Policy #: Expiration Date: Other #2 (list type of coverage and Company): Commented [MTR16]: DELETE lines for insurance not required by Exhibit C. Policy #: Expiration Date: Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: Policy #: Expiration Date:
Recipient Proof of Insurance. Recipient shall provide the following information upon submission of the signed Agreement. All insurance listed herein and required by Exhibit C, must be in effect prior to Agreement execution. Professional Liability Insurance Company: Durham & Xxxxx Insurance Policy #: 2023-75706 Expiration Date: 9/21/24 Commercial General Liability Insurance Company: Durham & Xxxxx Policy #: 2023-75706 Expiration Date: 09/21/24 Automobile Liability Insurance Company: Geico Policy #: 4554387680 Expiration Date: 02/6/24 X Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Employers Workers’ Compensation Insurance Company: Policy #: EIG512252700 Expiration Date: 11/18/2024
Recipient Proof of Insurance. Recipient shall provide the following information upon submission of the signed Agreement. All insurance listed herein and required by Exhibit C, must be in effect prior to Agreement execution. Professional Liability Insurance Company: Policy #: Expiration Date: Commercial General Liability Insurance Company: Policy #: Expiration Date: Automobile Liability Insurance Company: Policy #: Expiration Date: Fidelity Bond Insurance Company: Policy #: Expiration Date: Directors, Officers and Organization Liability Insurance Company: Policy #: Expiration Date: Other #1 (list type of coverage and Company): Policy #: Expiration Date: Other #2 (list type of coverage and Company): Policy #: Expiration Date: Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: Policy #: Expiration Date:
Recipient Proof of Insurance. Recipient shall provide the following information upon submission of the signed Agreement. All insurance listed herein and required by Exhibit C, must be in effect prior to Agreement execution. If Recipient is self-insured for any of the Insurance Requirements specified in Exhibit C of this Agreement, Recipient may so indicate by: (i) writing “Self-Insured” on the lines below; and (ii) submitting a certificate of insurance as required in Exhibit C. Commercial General Liability Insurance Company: Policy #: Expiration Date: Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: Policy #: Expiration Date:
Recipient Proof of Insurance. All insurance listed must be in effect at the time of provision of services under this Agreement. Professional Liability Insurance Company: __________________________________________ Policy #: _____________________________________ Expiration Date: _______________ Commercial General Liability Insurance Company: ___________________________________ Policy #: _____________________________________ Expiration Date: _______________ Automobile Liability Insurance Company: __________________________________________ Policy #: _____________________________________ Expiration Date: _______________ Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: _______________________________________ Policy #: _____________________________________ Expiration Date: _______________ Business Designation: (Check one box): Professional Corporation Nonprofit Corporation Limited Partnership Limited Liability Company Limited Liability Partnership Sole Proprietorship Corporation Partnership Other Recipient shall provide proof of Insurance upon request by DHS or DHS designee.
Recipient Proof of Insurance. Recipient shall provide the following information upon submission of the signed Agreement. All insurance lTisytpede hteerxetinhearned required by Exhibit C, must be in effect prior to Agreement execution.
Recipient Proof of Insurance. Recipient shall provide the following information upon submission of the signed Agreement. All insurance listed herein and required by Exhibit C, must be in effect prior to Agreement execution. If Recipient is self-insured for any of the Insurance Requirements specified in Exhibit C of this Agreement, Recipient may so indicate by: (i) writing “Self-Insured” on the lines below; and (ii) submitting a certificate of insurance as required in Exhibit C. Professional Liability Insurance Company: Policy #: Expiration Date: Commercial General Liability Insurance Company: Policy #: Expiration Date: Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027? (Check one box): YES NO If YES, provide the following information: Workers’ Compensation Insurance Company: Policy #: Expiration Date: Certification. Without limiting the generality of the foregoing, by signature on this Agreement, the undersigned hereby certifies under penalty of perjury that:
