LAYTON RISK MANAGEMENT CONTRACTOR CONTROLLED INSURANCE PROGRAM MANUAL FOR THE PROJECT NAME. Layton Construction and Gallagher Construction Services

Transcription

1 LAYTON RISK MANAGEMENT CONTRACTOR CONTROLLED INSURANCE PROGRAM MANUAL FOR THE PROJECT NAME Presented By: Layton Construction and Gallagher Construction Services 1

2 Table of Contents Insurance Coverages... 3 Program Eligibility... 6 Enrollment Responsibilities Flow Chart... 8 Insurance Required from Subcontractors... 9 Enrollment Application Worksheet Instructions Enrollment Application Worksheet Payroll Report (due monthly) Notice of Work Completion Notice of Subcontractor Award Accident Reporting for Workers' Compensation Claims Accident Reporting for General Liability Claims Incident Reporting Forms Definitions Personnel Directory

3 Insurance Coverages Attachment B Layton Construction provides the following insurance to all enrolled subcontractors under the CCIP program. Policy copies are available upon request: (a) Workers Compensation Insurance: Statutory limits, with Coverage B - Employer's Liability limits of: Bodily Injury by Accident $1,000,000 Each Accident Bodily Injury by Disease $1,000,000 Each Employee Bodily Injury by Disease $1,000,000 Policy Limit (b) Commercial General Liability Insurance: (Excluding Automobile, Professional, and Pollution Liability) applying to all Insureds jointly with the following Bodily Injury and Property Damage combined limits: $2,000,000 Each Occurrence $2,000,000 Personal and Advertising Liability $4,000,000 General Aggregate $4,000,000 Products and Completed Operations Hazard Aggregate Ten (10) years Completed Operations coverage, per project, from substantial completion. The General Aggregate reinstates annually There is a separate annual cap of $20 Million for the General Aggregate The PCOH Aggregate applies once per each project over $50 Million in CV The PCOH Aggregate applies once per each project $50 Million and less in CV subject to a $20 Million program cap (c) Lead Excess Liability Insurance: $25,000,000 Each Occurrence $25,000,000 General Aggregate $25,000,000 Products and Completed Operations Hazard Aggregate The General Aggregate reinstates annually There is a separate annual cap of $125 Million for the General Aggregate The PCOH Aggregate applies once per each project (d) 2 nd Layer Excess Liability Insurance: $25,000,000 Each Occurrence $25,000,000 General Aggregate $25,000,000 Products and Completed Operations Hazard Aggregate The General Aggregate reinstates annually There is a separate annual cap of $125 Million for the General Aggregate The PCOH Aggregate applies once per each project 3

4 (e) Loss Sharing: Each enrolled party will be responsible to share in the costs associated with the settlement of general liability claims insured by the CCIP, including defense costs incurred in litigated claims, for losses that are caused in whole or in part by subcontractor. This amount will be assessed on the value of the subcontract at the time of loss according to the following schedule. Layton will be the determinant of liability and participation. General Liability: For each contractor per occurrence $ 2,500 for subs with contracts up to $100,000 $ 5,000 for subs with contracts between $100,001 and $250,000 $10,000 for subs with contracts between $250,001 and $500,000 $25,000 for subs with contracts over $500,000 (f) Defense Costs: Defense costs are in addition to the limits of liability (g) Evidence of Insurance: Gallagher Construction Services will issue certificates of insurance evidencing coverages provided under the CCIP to each Insured. The certificate of insurance and insurance policy will include a 30-day notice of cancellation clause. The coverages under this program do not include all insurance needed by the Subcontractor and its Subcontractors of any tier. For example, Workers' Compensation and General Liability coverages apply only to the operations of and for each Insured at the Project Site. They do not apply to the operations of any Insured in their regularly established main or branch office, factory, warehouse, or similar place. Independent Truckers/Haulers will not be Insureds under the Program. (h) Known Exclusions, Terms & Conditions Nuclear Energy Liability Exclusion Silica Exclusion Lead Exclusion Asbestos Exclusion Endorsement Exclusion Contractors Professional Liability Exclusion Violation of Statues that Govern s, Fax, Phone Calls or Other Methods of Sending Material or Information Fungi or Bacteria Exclusion Employment Related Practices Exclusion Absolute Pollution Exclusion Limitation of Designation Premises PD to Insured's Work ("that particular part") Property Damage to Owner s Property Exclusion (Builder s Risk Exclusion) Extended On-Going Operations Repair Work Endorsements 12 Months Notice of error in claim reporting Notice of Occurrence Two or More Policies Endorsement Limited Contractual Liability Unintentional Failure to Disclose Fellow Employee Coverage Specified Employees Only Incidental Medical Malpractice Liability Coverage Waiver of Transfer of Rights of Recovery Against Others 4

5 (i) Program Term: August 20, 2012 to January 1, 2018 plus 10-year completed operations tail Attachment B (j) Project Term: [Insert Project Term] plus 10-year completed operations tail (k) Insurance Carriers: Commercial General Liability Insurance: Indemnity Insurance Company of North America Workers Compensation Insurance: ACE American Insurance Company Excess Liability Insurance: ACE Property & Casualty Insurance Company Excess Liability Insurance: Allied World National Assurance Company (l) Credit Calculation: 1. Subcontractors bids will include their costs of all insurances required hereunder (general liability, excess liability, and workers compensation) and provided by the CCIP. The enrollment worksheet in the CCIP Manual must be completed and returned with all required supporting documents. Lower-tier subcontractors must also complete the enrollment worksheet and provide the supporting documents. 2. A credit calculation worksheet will be sent to your office from Gallagher at the beginning of the job based on the data supplied with your enrollment forms. Each enrolled contractor will be assessed a credit for its estimated cost of its insurances. This estimated credit will be converted to a percentage of your contract amount. On a monthly basis, the estimated credit percentage will be applied to your pay application and withheld from your payment. This will be automatically performed in Textura using Textura s payment discount functionality. You will be able to verify and accept the payment discount in Textura. All change orders will be handled in the same manner. 3. Credits for lower tier subcontractors will be made through the prime subcontractorês contract with Layton. It will be the prime subcontractorês responsibility to pass these credits to their lower tier subcontractors. 4. Gallagher will perform a true-up calculation at the end of your work to determine the final amount of the credit based on actual payroll and final contract amount. The final credit amount will be made on the final payment application. Unconditional lien releases will reflect the entire amount of the pay application submitted, not the net amount of the payment. Payroll must be reported on a monthly basis to Gallagher. Failure to report payroll on a monthly basis may result in the holding of your progress payment. Adjustments may be made through the contract if it appears that the estimates are materially incorrect. Contractor rates that are deemed materially incorrect at project closeout will cause an adjustment to be made to the final credit. The coverages under this program do not include all insurance needed by the Subcontractor and its Subcontractors of any tier. For example, Workers' Compensation and General Liability coverages apply only to the operations of and for each Insured at the Project Site. They do not apply to the operations of any Insured in their regularly established main or branch office, factory, warehouse, or similar place. Independent Truckers/Haulers will not be Insureds under the Program. This Summary is not intended to amend or alter any provisions of the actual insurance policies. If a conflict should occur, the insurance policies shall govern. Actual policy copies will be provided upon written request. Gallagher automatically distributes policy copies upon enrollment. 5

6 Program Eligibility Attachment B Prior to providing any Subcontractor Work at the Project site, Subcontractor shall satisfy all requirements for enrollment in the CCIP, including completing and submitting to Gallagher Construction Services (the CCIP Administrator ) the CCIP Enrollment Worksheets contemplated by the CCIP Manual (the Enrollment Worksheet(s) ). Subcontractor shall be responsible to ensure that it and its Sub-subcontractors comply in all respects with the enrollment requirements for the CCIP before any onsite activities occur at the Project Site. Subcontractor represents and warrants that the information provided in Enrollment Worksheets submitted to the CCIP Administrator is true, correct and complete in all respects. Upon the request of Contractor or CCIP Administrator, Subcontractor shall provide copies of insurance records, policies, declaration pages of policies, insurance rating information, certificates of self-insurance, and such other documents as may be requested by the CCIP Administrator in order to assure the truth, accuracy and completeness of Subcontractor s insurance information and data. If these items are not timely furnished to the reasonable satisfaction of Contractor and the CCIP Administrator, the Subcontract Price shall be reduced by 3.25% to offset costs incurred by Contractor for Subcontractor s participation in the CCIP. Coverage Trigger Coverage will begin the date you begin work at the site and is contingent on a properly completed Enrollment Worksheet. Once your enrollment has been completed you will receive a Certificate of Insurance confirming the coverage from Gallagher Construction Services. It is your responsibility to complete and return all enrollment materials before you begin work on the project. Failure to supply all requested insurance documents on page 9, will result in a flat 3.25% charge against your entire contract amount. You are also responsible for ensuring that any lower tier subcontractors you hire are also enrolled before they begin their work at the project site. If you or your lower tier subcontractors have not completed the enrollment worksheet and received confirmation of enrollment from Gallagher Construction Services, no coverage will be afforded. The Payroll Form must be submitted monthly to Gallagher Construction Services by the 5 th of every month. 6

7 Ineligible Parties Attachment B Subcontractors who present an exceptionally hazardous exposure or risk to the job site may not be eligible to participate, at Layton Construction s discretion. It is your responsibility to contact Gallagher and confirm your eligibility before you begin work on the project. Not everyone will be a participant. For example, the following are ineligible for the program: Subcontractors of any tier that are: Vendors Suppliers who do not provide labor or hire any on-site installation Material dealers, Off-site fabricators with no on-site installation or do not hire on-site installation Others who merely transport, pick up, deliver or carry materials, personnel, parts or equipment or any other items or persons to or from the project site Temporary labor services that would traditionally supply you with temporary labor (where workers' compensation coverage is provided for those employees by the temporary agency). This situation needs to be reviewed on an individual basis. Abatement or Environmental contractors Exterminators Temporary Fence Rental Companies Contractors working under Professional Services Agreement(PSA) Demolition Contractors If you are uncertain whether your firm will be a participant in this program, or wish confirmation of your eligibility, please contact John Drew, Gallagher Construction Services at or John_Drew@ajg.com. Layton Construction will coordinate the program at the project site. Gallagher Construction Services will be administering the program from their offices. A complete contact list is in the back of this Manual. 7

8 CCIP Enrollment Responsibilities Flow Chart Attachment B Action Item Responsibility Distribute CCIP Manual to prospective bidders or subcontractors. Send CCIP Manual to your Insurance Agent/Broker for assistance, if necessary, in completing the CCIP Enrollment Forms. Distribute CCIP Manual to prospective lower tier bidders/subcontractors. Forward to Gallagher CCIP Enrollment Worksheet and insurance documents for you and your lower tier subcontractors. Send Insurance Certificate to Layton Construction in accordance with the Insurance Addendum Requirements of the Subcontract Agreement. Layton Construction Subcontractor Subcontractor Subcontractor Subcontractor 6 Ensure that Monthly Payroll reports are submitted for you and your lower tier subcontractors. Subcontractor 7 Confirm all site subcontractors and/or lower-tier subcontractor(s) enrollment in CCIP program. Gallagher will issue written confirmation. Gallagher 8 Certificate of Insurance and policy copies issued to CCIP participant. Gallagher 9 Advise your Insurance Agent/Broker of insurance coverages provided by CCIP so that proper notice can be made to your current insurers. Subcontractor Lower-tier subcontractor 8

9 Insurance Required From Subcontractors of Any Tier Please note that the coverages provided by the CCIP are designated to cover you only while you are actively engaged in construction activities at the PROJECT NAME Project site. Therefore it is imperative that you maintain your own insurance coverage for off-site operations. The required insurance of every CCIP participant is outlined in detail in the Subcontract Attachment Addendum to Work Authorization Notice (Insurance Requirements). Please refer to that subcontract document for the requirements that pertain to you. The Subcontractor of any tier shall require their respective vendors, suppliers, off-site fabricators, material dealers, truckers, drivers and others, who merely transport, pick-up, deliver or carry materials, personnel, parts or equipment to or from the project site to maintain insurance in the form and with the limits as specified in the Subcontract Attachment Addendum to Work Authorization Notice Insurance Requirements. The Attachment Addendum to Work Authorization Notice of the Subcontract Agreement outlines in detail the required coverages for all CCIP participants. It is important to review that document and supply the required Certificate of Insurance prior to the start of work. Please note that progress payments may be withheld if required insurance is not on file. If you have questions regarding any of the required insurance, feel free to contact John Drew at

10 CCIP Enrollment Application Worksheet Instructions Every CCIP participant must complete the CCIP Enrollment Application Worksheet on the following page, identifying your insurance premiums. Please contact John Drew at if you have any questions regarding the completion of this worksheet, as he can walk you through it. Please keep in mind that the CCIP coverage includes: Worker s Compensation coverage including Employers Liability Limits of $1,000,000/$1,000,000/$1,000,000. General Liability limits of $2,000,000/$4,000,000/$4,000,000 for all insureds combined, with the limits specific to the PROJECT NAME Project. The General Aggregate reinstates annually, a separate annual cap of $20 Million for the General Aggregate, the PCOH Aggregate applies once per each project over $50 Million in CV and the PCOH Aggregate applies once per each project $50 Million and less in CV subject to a $20 Million program cap Excess limits of $50,000,000 for all insureds combined, with such limits specific to the PROJECT NAME Project, for premises operations and $50,000,000 for completed operations. The General Aggregate reinstates annually, a separate annual cap of $250 Million for the General Aggregate and the PCOH Aggregate applies once per each project. Ten years completed operations tail with project specific limits. Please keep in mind the following: You will need to collect the CCIP Enrollment Application Worksheet from each of your lower-tier subcontractors The CCIP does NOT INCLUDE automobile coverage (including trucks and licensed equipment) or tools and equipment; The CCIP provides Workers' Compensation only for employees working at the PROJECT NAME Project. Your yard or plant workers, off-site clerical staff, drivers who only deliver or pick up at the project, and management or supervisory personnel who are not dedicated to the project are NOT COVERED by the CCIP. Labor provided through labor service companies should be discussed with Gallagher to determine eligibility. The CCIP provides General Liability only for operations at the PROJECT NAME Project. Operations of each subcontractor of any tier at other locations (not approved by the underwriter) are NOT COVERED by the CCIP. Your workers compensation insurance credit will be based on estimated payroll provided at the time of enrollment and used for the calculation of your CCIP premiums. It will be verified against final payroll, which may result in additional premiums charged to you. Your general liability insurance credit will be based on the limits outlined in Attachment D of the Addendum to Work Authorization Notice and will be based on your estimated payroll or contract value provided at the time of enrollment and used for the calculation of your CCIP premiums. It will be verified against final payroll or contract value, which may result in additional premiums charged to you. You may need to include a portion of your excess liability coverage to meet this requirement. If you do not have Excess liability policy, please contact Gallagher. 10

11 If your current insurance program contains a deductible or SIR, you will need to include a deductible premium as it applies to the payroll or revenue on this project. If you do not supply this information, a 3.25% rate against contract value will apply. At the time of your contract closeout a final audit will be performed based on your final payroll or contract value (if applicable) reported to Gallagher on a monthly basis. Any additional insurance credits or adjustments due will be made from your pay application or final retention. If you have any questions, please contact Gallagher All Workers Compensation Claims and Audited Payroll records for this project will be reported to the Workers Compensation Rating Bureau for the state in which the Project is located. Therefore, your loss claims history on this project will affect your Experience Modification Rate (EMR) just as it would on any other project. 11

12 SBU #: Project #: State: Attachment B CCIP Enrollment Application Worksheet FAX TO or to John_Drew@ajg.com SECTION 1 : SUBCONTRACTOR TO FILL IN THIS SECTION WORKSHEET PAGE 1 OF 3 SUBCONTRACTOR NAME CONTACT NAME PHONE: FAX: MAIN ADDRESS CONTACT FEIN NUMBER ACCOUNTING RECORDS LOCATION ADDRESS ESTIMATED WORK START DATE ESTIMATED WORK COMPLETION DATE FORM OF ENTITY CORP PARTNERSHIP JOINT VENTURE OTHER IF JV OR PARTNERSHIP, LIST NAMES: DESIGNATED SAFETY PERSON SITE SUPERINTENDENT SAFETY/CRISIS MGMT CONTACT DAY PHONE AFTER HOURS PHONE SCOPE OF WORK WHO WILL YOU BE UNDER SUBCONTRACT TO? ESTIMATED CONTRACT AMOUNT $ ESTIMATED % TO BE SUBCONTRACTED % ESTIMATED OVERHEAD/PROFIT ON INSURANCE % SELF-PERFORMED ON-SITE LABOR DESCRIPTION WORK COMP CLASS CODE ON-SITE MAN- HOURS UNBURDENED PAYROLL ESTIMATE NAME OF PERSON COMPLETING THIS SECTION 12

13 SECTION 2: TO BE COMPLETED BY SUBCONTRACTOR'S BROKER WORKSHEET PAGE 2 OF 3 WC INSURER EXPIRATION DATE EMPLOYERS LIABILITY LIMITS POLICY NUMBER NORMAL ANNIVERSARY DATE $ EXPERIENCE MODIFIER % PER OCCURRENCE DEDUCTIBLE/SIR $ AGGREGATE DEDUCTIBLE/SIR $ GENERAL LIABILITY INSURER PER OCCURRENCE LIMIT $ AGGREGATE LIMITS $ PER OCCURRENCE DEDUCTIBLE/SIR $ AGGREGATE DEDUCTIBLE/SIR $ UMBRELLA OR EXCESS LIABILITY INSURER PER OCCURRENCE LIMIT $ AGGREGATE LIMITS $ 1. ATTACH DECLARATIONS AND RATE PAGES FROM WORKERS' COMP, GENERAL LIABILITY AND UMBRELLA OR EXCESS POLICIES. 2. Attach any other documentation necessary to evidence minimum premium, aggregate deductible and per occurrence deductible. 3. Please note the Insurance Requirements of Layton Construction s Subcontract Agreement. 4. Please have a Certificate and Additional Insured Endorsement submitted with this Application. NAME OF PERSON COMPLETING THIS SECTION NAME OF BROKERAGE ADDRESS OF BROKERAGE PHONE NUMBER OF PERSON COMPLETING THIS SECTION 13

14 SECTION 3: LOWER TIER SUBCONTRACTORS SUMMARY WORKSHEET PAGE 3 OF 3 This section is to assist you in summarizing your lower-tier subcontractors job information. It is important for you to collect their fully completed CCIP Enrollment Application Worksheets, as they are required to enroll in the program. LOWER TIER SUBCONTRACTOR PAYROLL SUMMARY ATTACH ALL OF THE FULLY COMPLETED WORKSHEETS FOR ALL OF YOUR LOWER TIER SUBCONTRACTORS ASSOCIATED WITH THIS WORK. SHOW THEIR PAYROLL INFORMATION ON LINES BELOW. NAME OF LOWER TIER SUB AND ON- SITE LABOR DESCRIPTION (FROM SECTION 1 OF THEIR APP) CLASS CODE ESTIMATED CONTRACT AMOUNT ESTIMATED PAYROLL AMOUNT ESTIMATED START DATE SECTION 4: REVIEW Be sure to attach your Subcontractor s Policy information (declarations pages, rating pages) The insurance deduction process will be calculated using the above information. Layton Construction will process a deductive credit memo for the amount of the credit (including that of your lower tier subcontractors). REMEMBER TO: Attach all lower-tier subcontractors completed application sheets. 1. Attach your Declarations and Rate pages from WC, GL, and Excess Policies. Your estimated payroll and/or contract amount provided at the time of enrollment and used for the calculation of your premiums, will be verified against final payroll/contract amount, which may result in additional premiums charges to you. If your firm or your insurance broker does not supply the required documentation of insurance rates, deductibles, aggregate(s), etc., to verify the monthly insurance costs, a minimum 3.25% rate against contract value will. automatically apply until such time as the documentation is provided. As noted in this Manual, Layton Construction will purchase WorkersÊ Compensation, EmployersÊ Liability, General Liability and Excess Coverages for the benefit of participating subcontractors. In exchange for this benefit, the undersigned agrees as follows: This worksheet accurately reflects the total projected insurance costs (for bidder and all subcontractors noted on this sheet) that would apply if my regular insurance program were to provide coverage for this work. I agree that Layton Construction will apply the above insurance deducts, based on subcontractorês normal cost of insurance. This deduct will be taken from a submitted pay application. If necessary, Layton Construction will require payroll/contract amount and labor-hour reports for the undersigned and their subcontractors to calculate and process an accurate insurance deduct. Any and all returns of premium, dividends, discounts, or other adjustments to this CCIP policy is assigned, transferred and set over absolutely to Layton Construction. This assignment pertains to the policies as now written and as subsequently modified, rewritten or replaced including any additional amounts or coverages as a result thereof. Rights of cancellation of all insurance policies provided to Subcontractors of any tier by Layton Construction are also assigned to them. This assignment is only valid for Insurance policies whose premiums have been paid by Layton Construction on behalf of such Subcontractors of any tier. Subcontractor enrolled in the CCIP policy will be responsible for its proportionate share of insurance losses that are caused in whole or in part by subcontractor, including defense costs, of between $2,500-$25,000 per occurrence for General Liability, if determined by Layton that the subcontractor is liable for the associated claim. Insurance coverage under the CCIP is contingent on a properly completed Application with information that is accurately represented by the subcontractor(s). Gallagher Construction Services will provide each enrolled subcontractor with written confirmation of coverage. Signature Name 14 Date Title

15 Payroll Report PROJECT NAME This form must be completed and returned to Gallagher by the 5 th of each month. The Subcontractor will be responsible to enforce the submission of this form by their Subcontractors of any tier. Computer-generated payroll reports are acceptable if similar information is provided. REPORT FOR THE MONTH OF: NAME OF SUBCONTRACTOR OF ANY TIER: WORKING UNDER CONTRACT WITH: CONTRACT #: CONTRACT AMOUNT PAID TO: (PLEASE INCLUDE YOUR CONTRACT AMOUNT PAID TO DATE IF YOUR LIABILITY/EXCESS IS RATED ON CONTRACT AMOUNT) WORKERS' COMPENSATION CLASSIFICATION CODES MONTHLY HOURS MONTHLY UNBURDENED PAYROLL IN $$ (Straight Time) You do not need to list out individual employee payroll information. Summarize employees payrolls by class code and only report one payroll amount per code. I CERTIFY THAT THE DATA SHOWN ABOVE IS CORRECT. Signed Title Date Return completed form by 5 th of month to: Gallagher Construction Services Phone (877) Wrap-up Fax (415) gcssfwrap@ajg.com *HARD COPIES ARE NOT REQUIRED BY MAIL 15

16 Notice of Work Completion PROJECT NAME When the Subcontractor of any tier requests final payment, Subcontractor of any tier will complete this form and forward it to Gallagher for verification that all CCIP requirements have been met. 1. Subcontractor: 2. Job site: 3. Work Performed: 4. Date work completed: 5. Final Contract Value: (Include contract values for Lower tiers if applicable: Lower tier s CV: Lower tier s CV: 6. Subcontractors of any tier, if any, which are included in this Work: (Add attachment if more space is needed) Name Name Name Name 7. (Signed By) Return completed form to: Subcontractor of any tier Representative s Signature John Drew Gallagher Construction Services Phone Fax John_Drew@ajg.com 16

17 FORM COMPLETION INSTRUCTIONS Attachment B NOTICE OF SUBCONTRACT AWARD 1. Contractor/Subcontractor Information: Fill in Job Name 2. Subcontractor Award Information: Input the date. Fill in your company s complete name. Sign the form and input your title, phone, fax and address Input the subcontractor s name. Input the subcontractor s telephone, fax and address. 3. Bid Information: Input the contract amount. Input the estimated start date. Input the estimated completion date. Briefly describe the type of work the subcontractor will be doing at the job site. 4. Type of Contract: Circle the type of contract. If other please explain. 17

18 Complete this form only if you hire sub contractors (Tiers) Attachment B 1. Job Name: General Contractor/or Subcontractor Making Award: By: Phone: Title: Fax: Address: Date: We have awarded a subcontract as follows: 2. Subcontractor Name: Address: Contact Name: Phone: Fax: Address: 3. Contract Amount: $ Est. Start Date: Anticipated Completion Date Scope of Work: 4. Type of Contract: (PLEASE CHECK) Subcontractor who performs or contracts with another tier to perform on-site work. Vendor Suppliers (with no contract to provide labor on-site directly or indirectly) Off-site Fabricator (with no contract to provide labor on-site directly or indirectly) Material Dealers Transportation of materials, personnel, parts, equipment to and from Project Site Architect Engineer Testing Agency Other (Explain) Note: All qualified contracting subcontractors and their tiers who perform actual on-site labor are required to participate in the CIP. However, enrollment is not automatic. Completion of enrollment forms before subcontractors start date is required. Participation in the PLP program is mandatory. SUBMIT FORM TO: John Drew - CCIP Insurance Administrator Fax: Address: John_Drew@ajg.com Telephone:

19 WORKERS' COMPENSATION CLAIMS Accident Reporting and Claims Procedures 1. The injured employee's foreman/superintendent shall see that first aid is administered promptly and accompany the injured employee to the medical facility designated for the project. Be sure to give treating clinic the name of subcontractor as employer, and reference the PROJECT NAME as job site. Designated facility must be used because of prior established relationship and their knowledge of occupational injuries and transitional work. Authorization treatment forms (green) will be sent to the Layton Construction office at the job site, to be hand delivered to your designated safety person at the site. 2. Layton s Drug Free Workplace Policy requires that anyone involved in an incident on a Layton jobsite that results in injury or damage to equipment or vehicles MUST submit to immediate testing. Refusal to submit to testing will result in being banned from working on any Layton projects. Testing will be performed by medical facility staff at the designated medical facility. 3. All injuries will be reported immediately to Layton s Project Superintendant, On-site Safety Coordinator, or other designated Layton on-site staff. Layton s Incident Report needs to be submitted to the project team within 24 hours of any injury. 4. The subcontractor must immediately supply the injured employee with the Form 101- Employers Report of Injury as required by State law, and follow usual internal reporting procedures, with the exception of reporting the claim to their usual Workers' Compensation insurance carrier. 5. Foreman or superintendent must perform Accident Investigation, including Root Cause Analysis. A copy of the completed Accident Investigation must be sent to On-site Safety Coordinator. If injury is serious, please also fax to CCIP Safety Director (fax number is listed in Personnel Directory at back of this manual). 6. Any claim issues or problems may be directed to the treating clinic or ACE directly. If concerns or issues are not dealt with satisfactorily you may contact Joseph Domingo at Gallagher Construction Services in San Francisco for assistance in resolving problems (see directory for phone numbers). 7. Maintenance of records required by the Federal Occupational Safety and Health Act and all other applicable regulations are the responsibility of each subcontractor. 19

20 GENERAL LIABILITY CLAIMS Attachment B 1. If an injury is involved, the Subcontractor's superintendent must immediately arrange for first aid or other required medical treatment for the injured party. 2. Layton s Drug Free Workplace Policy requires that anyone involved in an incident on a Layton jobsite that results in injury or damage to equipment or vehicles MUST submit to immediate testing. Refusal to submit to testing will result in being banned from working on any Layton projects. Testing will be performed by medical facility staff at the designated medical facility. 3. All Incidents, regardless of severity, shall be reported immediately to the Job Site Contact and Onsite Safety Coordinator and reported to the Insurer by telephone 4. The Subcontractor's superintendent must complete a General Liability Loss Notice (located in the Gallagher Construction Services enrollment binder) for each accident with the following distribution: Indemnity Insurance Company of North America [ACE], Job Site Office, Gallagher Construction Services. 5. Any Court Summons, legal documents or other correspondence must be immediately referred to Gallagher Construction Services by registered mail. Additional questions concerning suit papers should be referred to Gallagher Construction Services. 20

21 Layton Construction Co. Supervisor's Incident Report Attachment B ALL FIELDS REQUIRED FOR INSURANCE CLAIM Claim Is: LAYTON SUBCONTRACTOR If Subcontractor, Name of Company: Employee's Name: First, Middle, Last: Craft: Years of Experience: # Of Hours Worked Last Week: Date/Time of Report: Date/Time of Incident: Foreman's Name: General Foreman's Name: # Of Hours Worked Previous Week: # Of Hours Worked Previous Week: # Of Hours Worked Previous Week: # Of Hours Worked Previous Week: Superintendent's Name: Project Name & Number: Nature of Incident: Location of Incident on Project: Date and Time Employee Sought Medical Attention: Treated in: Clinic Emergency Room Medical Status: FA Recordable W/ Restrictions LTA Date Restrictions / Lost Time Began: Was Safety Equipment Provided? Yes No Was It Being Used? Yes No Task Being Performed: Is the Injury Questionable? State Reasons: Description of Incident: Cause of Incident: Proposed Corrective Action: Case Status: Signature of Supervisor: 21

22 Layton Construction Co. Employee's Incident Report Attachment B ALL FIELDS REQUIRED FOR INSURANCE CLAIM Claim Is: LAYTON SUBCONTRACTOR If Subcontractor, Name of Company: Employee's Name: First, Middle, Last: Street Address: Age: Birth Date: City, State, Zip: Soc. Sec. #: Phone Numbers: Home: Cell: Date Hired: Marital Status: Single Married Divorced Number of dependents: Occupation/Job Title: Years at Position/of Experience: # Of Hours Worked Last Week: # Of Hours Worked Previous Week: Position is: Full Time Part Time # Of Hours Worked Previous Week: State You Were Hired In: Hourly Wage: $ # Of Hours Worked Previous Week: Foreman's Name: General Foreman's Name: Superintendent's Name: PTP Completed: Yes No JHA Completed: Yes No Date and Time of Incident: Time Shift Started: Stretch & Flex Performed: Yes No Date Incident Reported: Body Part Injured: Date / Time You Sought Medical Attention: Names of Witnesses: Where on Project Injury Occurred: Task Being Performed: Describe How Incident Occurred. What Happened? What Could Have Been Done To Prevent Incidents of This Type? Signature of Supervisor: 22

23 Layton Construction Co. Witness Incident Report Attachment B ALL FIELDS REQUIRED FOR INSURANCE CLAIM Claim Is: LAYTON SUBCONTRACTOR If Subcontractor, Name of Company: Name of Employee Involved in Accident: First, Middle, Last: Date/Time of Incident: Your Name: Your Address: Project Name: Date/Time of Your Report: Your Phone Number: City, State, Zip: Project City, State: DESCRIPTION OF INCIDENT (WHO, WHAT, WHERE,WHEN, WHY) Who Was Involved? What Happened? Where on Project Did It Happen? When (Date and Time)? Why? What or Who Caused It? Signature of Witness: Witness of Statment: 23

24 Definitions for Purposes of This Manual General Contractor: Project: LAYTON CONSTRUCTION PROJECT NAME STREET ADDRESS CITY, STATE Project: Site: Off-Site Exposures: Contract: Subcontractor of Any Tier: Work: Insured: The areas designated in writing by Layton Construction in a contract document for performance of the Work and such additional areas as may be designated in writing by Layton Construction for Contractor s use in performance of the Work. The Project Site shall also include (1) field offices, (2) property used for bonded storage of material for the Project approved by Layton Construction, (3) staging areas dedicated to the Project. Items 1 through 3 must be approved by the CCIP Insurer and listed in the CCIP Policy Offices, shops, warehouses, factories, or similar locations away from the designated project site that have not been approved by the CCIP Insurer and listed on the CCIP Policy ARE NOT COVERED. The agreement between Layton Construction and the Subcontractor. The terms "Contract" and "Agreement" are used interchangeably. The person, firm or corporation with whom Layton Construction has entered into Agreement to perform the Work. Or the Person or entity who has a contract with a Layton Construction Subcontractor to perform any of the Work at the Site. Operations, as fully described in the Contract, performed at or emanating directly from the PROJECT NAME. Subcontractors of any tier which have an executed subcontract agreement and which have received written confirmation of coverage by Gallagher Construction Services. The following are not Insureds under this CCIP - Vendors, suppliers, material dealers, off-site fabricators and others who merely transport, pick up, deliver or carry materials, personnel, parts or equipment or any other items or persons to or from the Project Site, et al. Insurers: - Workers' Compensation and Employer's Liability: ACE American Insurance Company - Commercial General Liability Insurance: Indemnity Insurance Company of North America - Excess Liability Insurance: ACE Property & Casualty Insurance Company - Excess Liability Insurance: Allied World National Assurance Company 24

25 Personnel Directory PROJECT CONTACT: PROJECT MANAGER: INSERT CONTACT INSERT CONTACT INSERT CONTACT INSERT CONTACT CCIP SAFETY DIRECTOR: RISK MANAGEMENT: INSERT CONTACT Layton Construction INSERT CONTACT PHONE NUMBER INSERT CONTACT FAX Ken Ames Layton Construction 9090 So. Sandy Parkway Sandy, UT (801) (801) /fax ENROLLMENT/ADMINISTRATION: BACKUP ADMINISTRATOR: John Drew Gallagher Construction Services 505 North Brand Blvd, Suite 600 Glendale, CA direct line fax Marisa Herrera Gallagher Construction Services (818) direct line (818) fax WORKERS COMPENSATION CLAIMS: Joseph Domingo Gallagher Construction Services (415) (415) /fax GENERAL LIABILITY CLAIMS: Francine Mueller Gallagher Construction Services (415) (415) /fax 25