An Insurance Form

Insurance Information Certification Statement

The grantee organization will submit the following statement. The document may be modified as necessary to meet the specific conditions of the project.

I hereby certify that (name of grantee organization) has done the following:

Item 1:

• Purchased an insurance policy on the Government-funded facility which insures the facility at the full replacement value of the property. The insurance policy protects the property from total or partial physical destruction and will be maintained as long as the grant assisted property is owned by the facility; or
• Effectively self-insured against physical destruction and foreclosable liens, and that the grantee organization has sufficient funds available in the form of (describe source of the funds) to replace and/or repair the facility or satisfy a lien.

Item 2:

• Purchased a title insurance policy covering the full appraised value of the facility. The policy will be maintained as long as the grant assisted property is owned by the facility (Title insurance is not required if a legal or title opinion is provided.); or
• Holds fee simple title to the site, in the form of the attached legal or title opinion, free of all mortgages or other foreclosable liens to all land, rights-of-way, and easements necessary for the project.

A letter that addresses the following (it may be modified as necessary to meet the specific conditions of the project):

I hereby certify that on (date) (name of A/E firm) completed the final working drawings and final technical specifications for the (describe project) in accordance with the Owner/Architect Agreement signed and executed on (date). I further certify that the project was designed in accordance with all mandatory requirements imposed on federally-assisted construction projects by specific laws enacted by Congress, Presidential Executive Orders, or Departmental Policy, as well as all applicable program standards, state codes, and local codes and ordinances.