SUBCONTRACTOR START UP SHEET

Transcription

1 SUBCONTRACTOR START UP SHEET Date: Job Name: Company Name: Contact: Phone #: Please review the following and complete all forms. All documents must be completed, accurate and submitted to Encompass Building Group Inc. by, before work can begin! FORM: COMPLETED: Contract (attached) [ ] Review, initial all pages, sign and date. Exhibit A Subcontract Specific Requirements (attached) [ ] Sign and date. Exhibit B Insurance Requirements (attached) [ ] Review the required limits, and make any adjustments to your policy. Certificate of Insurance - COI [ ] Have insurance company submit with Owner and Encompass Building Group Inc. listed as Additional Insured. If auto policy is a separate personal policy, please provide proof. W-9 (attached blank) [ ] Submit completed form. Lien Waiver (attached) Interim lien waiver to be submitted with each pay app. Final lien waiver to be submitted with final pay app. [ ] Pay App (attached) [ ] To be completed and submitted for payment. Vendor Contact Sheet (attached) [ ] Submit completed form. If you have any questions or concerns, please contact us immediately. Thank you! Mail: PO Box 1306, Indian Trail, NC Street: 2910 Old Monroe Road, Suite C, Stallings, NC O: F:

2 EXHIBIT B SUBCONTRACT DOCUMENTS INSURANCE REQUIREMENTS Subcontractor: Project Name: A.1 SUBCONTRACTOR S INSURANCE AND MINIMUM LIMITS OF LIABILITY: Prior to the start of Work, Subcontractor shall provide and maintain in force at all times during the performance of this Agreement the following insurance: 1. Commercial General Liability with limits equivalent to not less than: 1,000,000 per occurrence combined for bodily injury or property damage, 2,000,000 general policy aggregate, 1,000,000 products, completed operations aggregate. Comprehensive Automobile Liability with the following limits and insuring: (a) Per accident limit of 1,000,000 (b) All owned or leased vehicles; (c) All hired vehicles; and, (d) All other non-owned vehicles. (e) Contractor, Owner, Architect and all other parties required of the General Contractor, shall be included as Additional Insureds on the auto policy. Comprehensive General Liability under the following form: ISO Commercial General Liability Policy, occurrence form CG (10/01), or providing equivalent coverage and shall cover liability arising from Premises, Operations and Personal and Advertising Injury Products- Completed Operations including Blanket Contractual, Independent Contractor Coverage without any endorsements excluding explosion, collapse and underground hazards, modified by ISO form #CG2503, Amendment Aggregate Limits of Insurance (per project) or its equivalent. Contractor, Owner, Architect and all other parties required of the Contractor shall be included as Insureds on the CGL, using ISO Additional Insured Endorsement CG (11/85) or current combination of CG (10/01) and CG (10/01) or an endorsement providing equivalent coverage to the Additional Insureds. It shall apply as Primary and Non- Contributing Insurance before any other insurance or self-insurance, including any deductible, maintained by, or provided to, the Additional Insured. Subcontractor shall maintain Completed Operations coverage for itself and each additional insured for at least eight (8) years after completion of the Work or through the Statute of Repose. 2. Worker s Compensation and Employers Liability: (a) Worker s Compensation Coverage as required by law, including statutory coverage for the state in which the Work is performed and the state of domicile of Subcontractor. (b) Coverage will cover all of Subcontractor s Employees, officers, directors, shareholders, agents, owners, volunteers and consultants. Please Initial Mail: PO Box 1306, Indian Trail, NC Street: 2910 Old Monroe Road, Suite C, Stallings, NC O: F:

3 (c) Employer s Liability Insurance limits of at least 500,000 each accident for Bodily Injury by accident and 500,000 each Employee for injury by disease and 500,000 disease policy limit. (d) Where applicable, U.S. Longshore and Harborworker s Compensation Act Endorsement shall be attached to the policy. (e) When applicable, the Maritime Coverage Endorsement shall be attached to the policy. 3. Commercial Umbrella/Excess: (a) Umbrella/Excess limits must be at least 1,000,000 each occurrence and aggregate limit. (b) Umbrella/Excess coverage must include as Insureds all entities that are Additional Insureds on the Commercial General liability Policies. (c) Umbrella/Excess policy must be a Following-Form policy. 4. Professional Liability Required: ( ) Yes ( X ) No (only required if and to the extent Subcontractor is required under Attachment C of this Agreement to perform engineering or architectural design services) in the amount of 2,000,000 limit for Each Act and 2,000,000 aggregate limit. Covering claims made against Contractor and/or Subcontractor arising out of the performance of professional engineering or architectural services under this Agreement and caused by errors, omissions, or negligent acts for which Subcontractor is legally liable. This insurance, if applicable, shall be maintained in force by Subcontractor for a minimum of five (5) years after the date of completion of the Project or as established pursuant to the Contract Documents. 5. Commercial Pollution Liability Required: ( ) Yes ( X ) No (only required if and to the extent Subcontractor is required under Attachment F Specific Summary of Work of this Agreement) in the amount of 5,000,000 per occurrence, 5,000,000 aggregate limit covering claims made against Contractor and/or Subcontractor for bodily injury, property damage, environmental exposures, damage caused by pollution conditions resulting from covered operations and coverage for transportation to non-owned disposal sites. Said policy shall be on an occurrence form. The peril of mold may be on a claims-made policy if the retroactive date is before the commencement of the abatement and tail coverage is provided for a term of at least ten (10) years following project completion or such longer period required by the Contract Documents. Separate mold sub-limits are not permitted. The policy shall provide for severability of interests. Contractor, Owner, Architect and all other parties required of the Contractor shall be included as insureds. The Commercial Pollution Liability Policy shall apply as Primary and Non-Contributing Insurance before any other insurance or self-insurance, including any deductible, maintained by, or provided to, the Additional Insured. Subcontractor shall maintain coverage for itself and all Additional Insureds for the duration of the project and maintain coverage for itself and each Additional Insured for at least ten (10) years after completion of the Work. If the commercial general liability or the professional liability requirement is met by a claims made form policy, Subcontractor agrees to maintain continuous uninterrupted coverage for a minimum of eight (8) years, or for the greater length of time of the applicable statute of limitations and/or statute of repose where the work is being performed (the greater time limitation will apply), following completion and acceptance of Subcontractor s Work Page 2 of 4 Please Initial

4 either through purchase of an extended reporting provision or through purchase of successive renewals of insurance with a retroactive date not later than the beginning of performance under this Agreement. The limits of insurance may be increased, reduced or waived at the Contractor s sole option with an appropriate adjustment to the Subcontract Price. Contractor, Owner, Architect shall be named as Additional Insureds on each of these policies, except for Workers Compensation, or Subcontractor shall provide at its sole expense a separate Owners, Architects and Contractors Protective Liability Policy in the limits specified above or as modified at Contractors option, and naming Owner, Architect and Contractor as insureds. Subcontractor shall not subcontract any part of its Work without securing same insurance from its subcontractors. A.2 CERTIFICATE OF INSURANCE: The Subcontractor shall furnish the Contractor with Certificates of Insurance on ACORD form evidencing that such insurance is provided and is in full force and effective before starting work and at any other time requested by the Contractor. Attached to each Certificate of Insurance shall be a copy of the Additional Insured Endorsement that is part of the Subcontractor s Commercial General Liability Policy. All of said certificates shall set forth on the face thereof contractual coverage as required herein. No amendment or cancellation of any of said policy shall be effective until after thirty (30) days notice, in writing, to the Contractor. The failure of the Subcontractor to supply certificates evidencing full compliance with the requirements of the provision shall not abrogate its duty to provide and maintain the required insurance, including the naming of the Contractor as an Additional Insured. A.3 NUMBER OF POLICIES: General and other liability insurance may be arranged under a single policy for the full limits required or by a combination of underlying policies with the balance provided by an excess or umbrella liability policy, providing such excess or umbrella policies have a per project aggregate provision. A.4 CANCELLATION, RENEWAL OR MODIFICATION: Subcontractor shall maintain in effect all insurance coverage required under this Agreement at Subcontractor s sole expense with admitted insurance companies having a minimum A.M. Best rating of A or through other approved insurance mechanisms acceptable to Contractor. All insurance policies shall contain a provision that the coverage afforded thereunder shall not be cancelled, non renewed, materially changed, or have restrictive modifications added, until at least thirty (30) days prior written notice has been given to Contractor unless otherwise specifically required in the Contract Documents. Certificates of Insurance or certified copies of policies acceptable to Contractor shall be filed with the Contractor prior to commencement of Subcontractor s Work. In the event Subcontractor fails to obtain or maintain any insurance coverage required under this Agreement, Contractor may at its sole option purchase such coverage and charge the expense thereof to Subcontractor or terminate this Agreement. A.5 WAIVER OF SUBROGATION: Subcontractor waives all rights against Contractor, Owner, Architect and their agents, officers, directors and employees for recovery of damages to the extent these damages are covered by Commercial General Liability, Commercial Umbrella/Excess Liability, Commercial Pollution Liability, Commercial Professional Liability, Comprehensive Automobile Liability, Builder s Risk or any other property or equipment insurance, Workers Compensation and Employers Liability insurance maintained pursuant to the requirements referred to in this Article. Subcontractor s Workers Compensation policy has WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORESEMENT with Contractor, Owner, and Architect listed on SCHEDULE. A.6 REPORTS OF ACCIDENT AND INJURY: Subcontractor shall immediately advise Contractor, in writing, of the facts and details of every accident and personal injury occurring with relation to Subcontractor s Work and simultaneously furnish to Contractor a copy of every accident report furnished to Subcontractor s insurance carrier. Page 3 of 4 Please Initial

5 A.7 ON AND OFF-SITE STORAGE: Subcontractor shall procure and maintain, at Subcontractor s own expense, property and equipment insurance for portions of Subcontractor s Work stored on or off the Project site as well as in transit, when such portions of Subcontractor s Work are to be included in an application for payment under Article 3. A.8 BUILDER S RISK: Subcontractor and Contractor shall pay all or a portion of all deductibles on any Builder s Risk policy obtained by Owner or contractor as follows: (a) if Subcontractor and/or Contractor is responsible, in whole or in part, for the insured damages, each shall pay that part of the deductible proportionate to the insured damages for which it is responsible compared to the total insured damages; (b) Contractor will seek contributions from other subcontractors consistent with Part a ; and (c) for that part of the deductible not paid under Parts a or b, Subcontractor shall pay, in addition to any payment required under Part a, an amount proportionate to the insured damages to the Subcontract Work compared to the total insured damages to the total Contract Work. A.9 NO DEDUCTIBLES: Unless expressly agreed in writing by Contractor, all specified insurance coverage shall be without any deductible of any kind or amount. To the extent that at any time during the course of performance under this Agreement Contractor determines a deductible exists without the express written consent of the Contractor, then at Contractor s sole election, Contractor may withhold from payments otherwise due Subcontractor under this Agreement, the amount of such deductible until expiration of all contractual warranties required under this Agreement. Additionally, in the event of any occurrence(s) or claim(s) under any of these policies including any applicable Builders Risk policy which would otherwise have fully covered, but for the presence of such deductible, Contractor may withhold any additional amount from payments to Subcontractor for each such claim or occurrence in the amount of the damages claimed for such occurrence/claim or the amount of deductible whichever is the greater and may apply such withholdings to cover such damages should full recovery not be obtained under the insurance coverage because of the presence of such deductible. Page 4 of 4 Please Initial

6 COMMERCIAL GENERAL LIABILITY GEN'L AGGREGATE LIMIT APPLIES PER: PRO- X POLICY JECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS x Comp/Coll UMBRELLA LIAB CERTIFICATE OF LIABILITY INSURANCE OCCUR SCHEDULED AUTOS x NON-OWNED AUTOS x 250/500 ded OCCUR EXCESS LIAB CLAIMS-MADE DED X RETENTION 10, /1/2013 4/1/2014 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) n N / A /1/2013 4/1/2014 If yes, describe under DESCRIPTION OF OPERATIONS below EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG EACH OCCURRENCE AGGREGATE WC STATU- TORY LIMITS E.L. EACH ACCIDENT OTH- ER E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT DATE (MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Ascension Insurance Agency, Inc Fairview Road Suite 500 Charlotte NC INSURED Encompass Building Group Inc PO Box 1306 Indian Trail NC CONTACT NAME: PHONE (A/C, No, Ext): ADDRESS: INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE 6/4/2013 Debbie Eldridge FAX (704) (A/C, No): deldridge@ascensionins.com COVERAGES CERTIFICATE NUMBER: REVISIONNUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS GENERAL LIABILITY A A x x B B X CLAIMS-MADE X x Blanket Addl Ins x Blkt WOS X X /1/2013 4/1/2014 NAIC # Owners Insurance Company Auto Owners Insurance Company COMBINED SINGLE LIMIT (Ea accident) /22/ /01/2014 BODILY INJURY (Per person) BODILY INJURY (Per accident) /01/ /01/2014 PROPERTY DAMAGE (Per accident) x 1,000, , ,000 1,000,000 3,000,000 3,000, ,000,000 1,000,000 1,000,000 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) PROJECT: Summit Midwifery Clinic Blanket additional insured applies for General Liability per written contract requirements. CERTIFICATE HOLDER CANCELLATION Gaston County Health Department Gaston County 128 W Main Avenue Gastonia, NC ACORD 25 (2010/05) INS025 (201005).01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE D Eldridge/ELDDE ACORD CORPORATION. All rights reserved. The ACORD name and logo are registeredmarks of ACORD

7 Form W-9 (Rev. December 2011) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification: Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Exempt payee Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) Requester s name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the Name line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners share of effectively connected income. Date Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section ). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No X Form W-9 (Rev )

8 INTERIM LIEN WAIVER To be submitted with your Progress Payment Requisition Date Project Name Subcontract # Subcontractor Address City, St, Zip Phone Fax Pay Request # Pay Period to INTERIM WAIVER AND RELEASE I hereby certify that the work performed and the materials supplied to date, as shown above, represent the actual value of accomplishment under the terms of the Contract (and all authorized changes thereto) between the undersigned and Encompass Building Group Inc. relating to the above referenced project. I also certify that the payments, less applicable retention, have been made throughout the period covered by previous payments received from the contractor, to (1) all my subcontractors (sub-sub-subcontractors) and (2) for all materials and labor used in or in connection with the performance of this Contract. I further certify that I am in compliance with Federal, State, and local tax laws, including Social Security laws, Unemployment Compensation laws and Workman's Compensation laws insofar as applicable to performance of this Contract. Furthermore, in consideration of the payments received, and upon receipt of the amount of this request, the undersigned does hereby waive, release and relinquish all claims (including bond claims) or rights to lien against the owner and Encompass Building Group Inc. and it's sureties for work performed through the period of this pay application, other than claims for applicable retention, and for specified claims in stated amounts, as follows: The undersigned subcontractor further agrees to indemnify, defend and hold harmless the owner, and Encompass Building Group Inc. and its sureties from any claims, liens, or causes of actions for nonpayment of labor, equipment, material, goods or services arising under or by virtue of said contract except as provided above, and certifies that no amounts payable under said contract have been assigned to anyone. SIGNATURE NAME / TITLE State of County of Subscribed and sworn (or affirmed) before me on by. (date) (name of person making statement) NOTARY PUBLIC (SEAL) My Commission Expires

9 WAIVER AND RELEASE UPON FINAL PAYMENT To be submitted with your Final Payment Requisition Project Name Subcontract # Subcontractor Address City, St, Zip Phone Fax Date Upon receipt of a check by the undersigned from Encompass Building Group, Inc in the amount of, payable to (Amount of Payment) (Name of Subcontractor/Supplier) and when the check has been properly endorsed and has been paid by the bank upon which it is drawn, this document shall become effective to release any claim, mechanic's lien, stop notice, or bond right the undersigned has on the project, contract number NA, whose owner is. In consideration of this final payment, the undersigned subcontractor does release and forever discharge the owner, and Encompass Building Group, Inc. its officers, agents, employees and its sureties, of and from any and all liabilities, obligations, and claims whatsoever, in law and equity, arising out of or by virtue of said contract, except specified claims in stated amounts as follows: The undersigned subcontractor further agrees to indemnify, defend and hold harmless the owner, and Encompass Building Group, Inc and its sureties from any claims, liens, or causes of actions for nonpayment of labor, equipment, materials, goods or services arising under or by the virtue of said contract except as provided above, and certifies that no amounts payable under said contract have been assigned to anyone. This Final Payment shall be accepted as full and final payment for all services, materials and labors rendered in connection with the above referenced contract. Final Release executed this day of 2013 Authorized Signer Primt Name / Title State of County of Subscribed and sworn (or affirmed) before me on NOTARY PUBLIC My Commission Expires (date) by (name of person making statement) (SEAL)

10 Project Name Address 1 Address 2 City, ST Zip 000

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12 VENDOR SET UP SHEET Job #: Job Name: Company Name: Shipping Address: City: State: Zip: Billing Address: City: State: Zip: Main Phone: Main Fax: Website: License #: State: Expiration Date: Main/Project Contact Name: Phone #: Alternate Phone #: Estimating Contact Name: Phone #: Alternate Phone #: Accounting Contact Name: Phone #: Alternate Phone #: Additional Information: Mail: PO Box 1306, Indian Trail, NC Street: 2910 Old Monroe Road, Suite C, Stallings, NC O: F: