INSURANCE COST WORKSHEET (Fixed Price Type Contracts) Numbers reference attached instructions

Transcription

1 Form-a INSURNCE COST WORKSHEET (Fixed Price Type Contracts) Numbers reference attached instructions. Contractor Information: Federal ID # or Soc. Sec. #: State of Calif. CDCR Page of Company Name & dba: Contact Name & Title: ddress: City, State, Zip Code: Telephone: Fax: E.mail ddress: Business Information (headquarters) 3 Contact Information (address questions to..) B. Bid Information: Description of Work: Bid Package No.: Proposed Contract Price $: 3 re you Submitting a bid to CHCF - Stockton: Yes No mount of Self Performed Work $: 4 If No, identify to whom: 6 C. Workers Compensation Insurance Information for Work Described bove: (a) (attach a separate sheet if necessary) a State b Class Code c Description d Rate (per $00 payroll) e Man-hours f Payroll (Unburdened, Straight time payroll) g WC Premium (Payroll * Rate / 00) Totals 3 4 Identify the mount of Your Claim Retention Your Company s Workers Compensation Experience Modifier: 6 Modified Premium (line C4 x C6): 7 Employers Liability Rate: 8 Employers Liability Premium: 9 0 Modification & Discount Premium Factors Rate mount Mod : + or - Mod : + or - Mod 3: + or - Mod 4: + or - Mod : + or - Total Modification mount (Total of all amounts entered in column C): 3 D. General Liability: (a) Rate: Based On: Total Payroll (C3) Contract Price (B3) Other Excess/Umbr Liab: (a) Rate: 6 7 Based On: Total Payroll (C3) Contract Price (B3) Other Total Workers Compensation Premium (line C7 + C9 + C3): 4 3 Rate factor: Per 00 Per,000 8 Rate factor: Per 00 Per,000 4 Identify the mount of Your Claim Retention: GL Premium (D D D3): Excess/Umbr Premium (D7 D6 D8): 9 E. Builder s Risk/Installation Floater: () Rate: Rate factor Per 00 Per,000 Builder s Risk/Installation Floater Premium (B3 E E): 3 F. Other Insurance Premiums: () (Enter total premium costs identified on page ) G. Totals Total of all Insurance Premiums (Total of lines C4 +D + D9 + E3 + F): Overhead & Profit on Insurance Prem. %: % O/H & Profit mount (G x G): 3 Total Initial Insurance Cost (Total of lines G + G3): 4 Contractor s Initial Insurance Cost Rate (Line G4 divided by total payroll in line C3 00): H. Signature Block : I verify the information presented above and attachments are correct: Name: Date: Title: (please print) Signature: Completion of this form is a required part of your bid and must accompany your bid documents. Complete a separate form for each contractor, known subcontractor(s) and trades not currently awarded to a subcontractor. Duplicate this form as needed. (a) Please provide copies of the following documents to support your insurance cost calculations: Schedule of Values General Liability declaration and rate pages Workers Compensation declaration and rate pages Umbrella/Excess Liability declaration and rate pages Experience Modification worksheet years actual loss experience for each line of coverage in which Contractor retains more than $,000.

2 Form-a INSURNCE COST WORKSHEET (Instructions for Fixed Price Type Contracts) State of Calif. CDCR Page of Complete a separate form for each contractor, known subcontractor and trade not currently awarded to a subcontractor. Duplicate this form as needed. Completion of this form is a required part of your bid and must accompany your bid documents.. Contractor Information Enter your company s Federal ID number. This number can be found on filings made to the federal government such as your tax return. Enter your company s name, mailing address and phone/fax number for your company s main office location in the space provided below. 3 Enter the name of the person on should contact if questions arise. Include the mailing address, phone/fax and e.mail address if different than - B. Bid Information Enter the Bid Package Number, Contract Number or Purchase Order Number that was included in R J Donovan originating documentation. Provide a brief description of the work you will be performing at the project site. 3 Identify the total amount of your bid. Include both labor and material. 4 Identify the amount of work that you anticipate will be self-performed. Include both labor and material. Check the appropriate box that identifies if you contract directly with R J Donovan or are a subcontractor. 6 If you are a Subcontractor, identify the entity with whom you are under contract. C. Workers Compensation Insurance Information (Duplicate or attach additional sheets if necessary. You may create an electronic version of this document if all requested information is included): a Enter the two letter abbreviation for the state in which the work will be performed. b Enter each Workers Compensation class code that applies to your work identified in B. (Most states use a 4 digit Number) c Enter the Workers Compensation class code description that applies to each class code identified in Cb. d Enter the Workers Compensation rate that applies to the specified class code. e Enter the estimated Man-hours required to complete the described work for each Workers Compensation class code. f Enter the estimated Payroll required to complete your work. Use only unburdened payroll and exclude the premium portion of any overtime pay. g Calculate the WC Premium by multiplying the Payroll (Cf) by the Rate (Cd) and dividing the result by 00. Repeat this calculation for each WC class code. Total the estimated Man-hours for each class code. Be sure to include information from additional pages if used. 3 Total the estimated Payroll for each class code. Be sure to include information from additional pages if used. 4 Total the Workers Compensation Premium for each class code. Be sure to include information from additional pages if used. Enter the amount of the Claim Retention / Deductible your company has on their existing Workers Compensation. 6 Enter your WC Experience Modifier. This Information can be located on your Workers Compensation policy or on your NCCI Bureau Rating Sheet. 7 Calculate the Modified Premium by multiplying the WC Premium (C4) by the Experience Modifier (C6). 8 Enter your Employer s Liability Insurance Rate. This information can be found in your Workers Compensation policy. 9 Calculate your Employer s Liability Premium by multiplying the Modified Premium (C7) by the Employer s Liab. Rate (C8). 0 Identify the Modifiers that apply to your Workers Compensation Premium. This information can be located on your Workers Compensation Policy. Enter the Rate for each identified Modifier. The information can be located on your Workers Compensation Policy Calculate the Modified Premium Factor mount by multiplying the Modified Premium (C7) by the Modified Premium Rate (C) and dividing by 00. Be sure to identify if the Modification factor is an addition or reduction to your premium. 3 Total the Modified Premium mounts by adding the numbers in column C. 4 Calculate the Total Workers Compensation Premium by adding the Modified Premium (C7) to the Employer s Liab Premium (C9) and adding the Premium Modifications (C). D. General Liability & Umbrella/Excess Liability Insurance Enter the General Liability Rate. This number can be found on your General Liability Policy Identify the base the General Liability Rate applies to. If the base is other than Payroll or Revenue, enter the amount and the description in the space provided. 3 Identify the General Liability Rate factor by marking the box. 4 Identify the amount of your Claim Retention. Calculate the General Liability Premium by multiplying the Bases (D) by the Rate (D) and dividing by the factor (D3). 6 Enter the Excess/Umbr Liability Rate. This number can be found on your Excess/Umbr Liability Policy 7 Identify the base the Excess/Umbr Liab. Rate applies to. If the base is other than Payroll or Revenue, enter the amount and description in the space provided. 8 Identify the Excess/Umbr Liability Rate factor by marking the box. 9 Calculate the Excess/Umbr Liability Premium by multiplying the Bases (D7) by the Rate (D6) and dividing by the factor (00 or,000). E. Builder s Risk/Installation Floater Enter the Builder s Risk/Installation Floater Rate. Locate this information on your Property Policy or Builder s Risk Policy. Identify the base factor that it applies to (00 or,000). 3 Calculate the Premium by multiplying the Proposed Contract Price (B3) by the Rate (E) and dividing it by the Factor (E). F. Other Insurance Premiums For each of the Insurance Lines of Coverage identified below, Identify the Rate, Base and Factor. Calculate the Premium by multiplying the Base x Rate Factor. Total the Other Insurance Premiums in the space provided and carry that amount to the front page. Line of Coverage Rate Base Factor Premium Total Premium Coverage G. Totals Calculate the Total of all Insurance Premium by adding Workers Compensation (C4), General Liability (D), Excess/Umbr Liability (D9), Builder s Risk/Installation Floater (E3), and Other Insurance Premiums (F). Identify the Overhead & Profit Percentage that was applied to this project during the tabulation of the Proposed Contract Price. 3 Calculate the Overhead & Profit mount by Multiplying the Total of all Insurance Costs (G) by the Overhead & Profit Percentage (G). 4 Calculate the Total Initial Insurance Cost by adding the Overhead & Profit mount (G3) with the Total of all Insurance Premium (G) Calculate your rate by Dividing the Total Initial Insurance Cost (G4) by the Estimated Payroll (C3) and multiplying by 00. H. Signature Block: This form must be signed by a representative of your company with the authority to Verify the information is correct. Note: Please provide copies of the following documents as part of your submittal: Schedule of Values Workers Compensation declaration and rate pages Experience Modification worksheet General Liability declaration and rate pages Umbrella/Excess Liability declaration and rate pages years actual loss experience for each line of coverage in which Contractor retains more than $,000.

3 Form-. Bid Information Name of Prime Contractor: Proposed Contract Cost $: 3 B. on Form-a Summary Contracting Parties & Trades on Form-a Reference No. Prime Contractor : (ttach the on Form-a) Your Known Subcontractors (ttach a Separate on Form- a from each) INSURNCE COST SUMMRY Numbers reference attached instructions Bid Package or Purchase Order No.: Proposed Subcontract mount B3 (Form-a Ref.) Estimated Manhours C (Form-a Ref.) State of Calif. - CDCR Estimated Payroll C3 (Form-a Ref.) Page of Initial Insurance Cost G4 (Form-a Ref.) List dditional Trades NOT yet assigned to a subcontractor (attach an on Form a) 9 List by Trade or Function 0 3 C. Total for Contract: (Total all column entries) 3 4 D. Composite Insurance Cost Rate for Contract: (Line C4 C3 x00) E. Signature Block: I verify the information presented above and attachments are correct: Name: Title: (please print) Date: Signature: Completion of this form is a required part of your bid and must accompany your bid documents. Duplicate this form as needed. n on Form-a must be attached for each line entry made on this form. In addition, the following documentation must accompany each on Form-a. Schedule of Values General Liability declaration and rate pages Workers Compensation declaration and rate pages Umbrella/Excess Liability declaration and rate pages Experience Modification worksheet years actual loss experience for each line of coverage in which Contractor retains more than $,000.

4 Form- INSURNCE COST SUMMRY INSTRUCTION State of Calif. - CDCR Page of This form is to be used by a Prime Contractor to summarize subcontract activity. This form may also be used by Subcontracts that must summarize sub subcontract activity of any tier. Submit this form with your Bid Documents.. Bid Information Enter the Name of the Contractor whose activity is being summarized. For purposes of these instructions they will be called a Prime Contractor regardless of the fact that they may not hold a contract directly with R J Donovan. Enter the Bid Package Number, Contract Number or Purchase Order Number. This number accompanied R J Donovan s original documentation. 3 Enter the mount you have proposed as the Contract Price. B. on Form-a Summary (Information will either be found on the Contractor s on Form-a or in situations where the subcontract uses additional tiers of subcontractors, the information will be found on an on Form- that summarizes their activity with their subcontracted activity.) on Form-a Reference No. on Form- Reference No For the Prime Contractor enter the Estimated Man-hours C For the Prime Contractor enter the Estimated Payroll C3 3 For the Prime Contractor enter the Total Initial Insurance Cost G4 4 For each Subcontractor, enter the firm s Name For each Subcontractor, enter the Proposed Contract Cost B3 3 6 For each Subcontractor, enter the Estimated Man-hours C C 7 For each Subcontractor, enter the Estimated Payroll C3 C3 8 For each Subcontractor, enter the Total Initial Insurance Cost G4 C4 9 For the ctivity that has not been assigned to a Subcontractor, enter the Trade or Functional Description 0 For the ctivity that has not been assigned to a Subcontractor, enter the Estimated Contract mount B3 For the ctivity that has not been assigned to a Subcontractor, enter the Estimated Man-hours C For the ctivity that has not been assigned to a Subcontractor, enter the Estimated Payroll C3 3 For the ctivity that has not been assigned to a Subcontractor, enter the Estimated Initial Insurance Credit G4 C. Total Estimates for Contract Total the Proposed Subcontract mount for the identified activity. Total the Estimated Man-hours for the identified activity. 3 Total the Estimated Payroll for the identified activity. 4 Total the Initial Insurance Cost for the identified activity. D. Composite Insurance Cost Rate for Contract Calculate the Composite Rate for the Contract by dividing the Total Initial Insurance Cost (C4) by the Total Estimated Payroll (C3) and multiplying by 00. E. Signature Block : This form must be signed by a representative of your company knowledgeable of its accuracy. Completion of this form is a required part of your bid and must accompany your bid documents. Duplicate this form as needed. n on Form-a must be attached for each line entry made on this form. In addition, the following documentation must accompany each on Form-a. Schedule of Values General Liability declaration and rate pages Workers Compensation declaration and rate pages Umbrella/Excess Liability declaration and rate pages Experience Modification worksheet years actual loss experience for each line of coverage in which Contractor retains more the $,000.

5 Form-3 ENROLLMENT PPLICTION Numbers reference attached instructions State of Calif. - CDCR Page of 3 Examine your current Workers Compensation and General Liability Policies or contact your Insurance gent to assist you with completing this form. *** NOTICE *** Enrollment is not automatic and requires the satisfactory completion of the on Form-a or Form-b, Form- and Form-3. In addition, submit a Certificate of Insurance providing evidence of your off-site coverage. Please refer to the Insurance Manual for coverage requirements.. Contractor Information: Federal ID # or Soc. Sec. #: Company Name & dba: Contact Name & Title: ddress: City, State Zip Code: Telephone: Fax: E.mail ddress: Indicate your Organization s Structure: Business Information (headquarters) 3 4 Corporation Joint Venture Partnership Sole Proprietor S-Corporation Other Contact Information (address questions to..) B. Contract Information: Contract No.: Date Contract warded: Description of Work: 3 Proposed Contract Price $: 4 re you Submitting a bid to R J Donovan: 6 Yes No mount of Self Performed Work $: If No, identify to whom: 7 Start Date: C. Contacts: (Complete if pplicable) 8 ctual Estimated Completion Date: 9 ctual Estimated Position Name & Title Phone 3 Fax 4 e.mail address Project Mngr: Res. Engineer: Insurance: Contract dmin: Payroll: Claims: Safety Rep: Provide Location of payroll records if different than Corporate address: Phone: City, State, Zip Code: Fax: D. Workers Compensation Insurance Information for Work Described bove: (attach a separate sheet if necessary) a State b Class Code c Description d Man-hours e Payroll (Unburdened, Straight time payroll) Totals 3 E. Provide your current Off-Site Workers Compensation Information: (for each state you will perform work in) pplicable State Risk ID Number Rating Bureau nniversary Rating Date 3 4 Your WC Insurance Carrier: Policy #: 6 Effective Date: 7 Expiration Date: 8

6 Form-3 ENROLLMENT PPLICTION Numbers reference attached instructions State of Calif. - CDCR Page of 3 F. Subcontract Information: List all Subcontractors that will be working for you on this project (complete the information in the following table). Use additional paper if necessary: Subcontractor Subcontract $ 3 Contact Person 4 ddress Phone & Fax No 6 Estimated Start Date G. Enrollment Questions: nswer each question. Use additional paper if necessary. Will you have any off-site location(s) 00% dedicated to this project? Yes No If yes, please provide address: 3 4 Please check if: ny aircraft used on this project ny watercraft used on this project Please indicate if labor from the following sources will be used: Employee Leasing Firm Temporary Labor gency 6 7 H. WRRNTY PPLICBLE TO PROGRM INSURNCE COVERGE Premiums for this Program are the responsibility of R J Donovan and I agree any and all return of premium, dividends, discounts, or other adjustments to any Program policy(ies) is assigned, transferred and set over absolutely to R J Donovan. This assignment applies to the Program policy(ies) as now written or as subsequently modified, rewritten or replaced. Rights of Cancellation for all Program insurance policy(ies) arranged by R J Donovan are assigned to RJ Donovan. I will pay the cost of premium(s) for non-program insurance coverage, specified in the Contract Documents. I authorized the release of all claim information for all insurance policies under this Program. It is my responsibility to notify my insurance carrier(s) that I am enrolling in this Program. I have omitted from my bid the insurance costs for the coverage provided by R J Donovan. I further agree to the on Verified Insurance Cost Rate as described in the Insurance Manual. The statements in this insurance application are true to the best of my knowledge. I. Signature Block : I verify the information presented above and attachments are correct: Name: Date: (please print) Title: Signature: Fax or to: Brenda Michalak CS.construction@aon.com Phone: (866) ext. 6 Fax: (800)

7 Form-3 ENROLLMENT PPLICTION INSTRUCTION State of Calif. CDCR Page 3 of 3 This form must be completed and submitted by each successful Contractor and Subcontractor of any tier prior to Site mobilization for each contract awarded. The Contractor and Subcontractor will submit the completed form to on Risk Services. Upon receipt of this form, on will issue to the Contractor or Subcontractor a Certificate of Insurance evidencing coverage in the Controlled Insurance Program. The completed Certificate of Insurance and Workers Compensation insurance policy will be mailed to the Enrolled party.. Contractor Information Enter your company s Federal ID number. This number can be found on filings made to the federal government such as your tax return. Enter your company s name, mailing address and phone/fax number for your company s primary office location. 3 Enter the name of the person on should contact if questions arise. Include mailing address, phone/fax and e.mail address, if different than. 4 Identify your company s legal structure by checking the box that applies. If the correct legal structure is not specifically listed, please check the Other box and specify in the space provided. B. Contract Information Enter the Contract Number or Purchase Order Number that was included in R J Donovan originating documentation. Supply the Date this Contract was awarded to your organization. 3 Provide a brief description of the work you will be performing at the project site. 4 Identify the total amount of your contract. Include both labor and material. Identify the amount of work that you anticipate will be self-performed. Include both labor and material. 6 Check the appropriate box that identifies if you contract directly with R J Donovan or are a Subcontractor. 7 If you are a Subcontractor, identify the entity with whom you are under contract. 8 Enter the Date you anticipate starting work and then mark whether the date provided is actual or estimated. 9 Enter the Date you anticipate completing the described work and then mark whether the date provided is actual or estimated. C. Contacts (Requested Contact information is for specific functions. It is possible to have a single person fulfill multiple responsibilities.) Identify the name of the person and their title for each function. These individuals should be located, if at all possible, on-site. Provide the phone number for each person identified above. 3 Provide the fax number for each person identified above. 4 Provide the e.mail address for each person identified above, if applicable. Identify the physical location where your payroll records are retained. Provide the ddress, City, State, Zip Code, Telephone, Fax Number and E.mail ddress of the person responsible for maintaining the payroll information. D. Workers Compensation Information (Duplicate or attach additional sheets if necessary. You may create an electronic version of this document if all requested information is included.): a Enter the two letter abbreviation for the state in which the work will be performed. b Enter each Workers Compensation class code that applies to the work identified in B. (Most states use a 4 digit Number) c Enter the Workers Compensation class code description that applies to the work identified in Db. d e Enter the estimated Man-hours required to complete the described work by Workers Compensation class code. Enter the estimated Payroll required to complete the described work for each Workers Compensation class code. Use only unburdened payroll and exclude the premium portions of any overtime pay. Total all estimated Man-hours for each class code. Be sure to include information from additional pages if used. 3 Total all estimated Payroll for each class code. Be sure to include information from additional pages if used. E. Current Off-Site Workers Compensation Information (Information relates to your corporation s existing coverage; identify each modification factor that applies.) Enter the State that the Modification Information applies to. Enter your Bureau File Number also referred to as your Risk Identification Number. This number can also be found on your Modification worksheets. 3 Enter the Bureau Rating gency. In most states this is NCCI. 4 Provide your Company s nniversary Rating Date. Information can be located on your bureau s WC Experience Modification worksheets. Identify your insurance carrier for Workers Compensation Coverage. 6 Provide your Workers Compensation Policy Number. 7 Provide the effective date of your Workers Compensation policy. 8 Provide the expiration date of your Workers Compensation policy. F. Subcontractor Information (Provide the following information for each Subcontractor that will be performing work at the project site. Use additional sheets, if necessary.) Identify the name of the Subcontracting firm. Provide the estimated value of the subcontracted activity. 3 Provide a contact name, preferably the project manager, for the Subcontractor. 4 Provide the mailing address for the Subcontractor. Provide the phone number for the Subcontractor. 6 Provide the date the Subcontractor is scheduled to begin work. G. Enrollment Questions Determine if you will have any locations, off-site, that will be 00% dedicated to this project. Include material/supply storage as a possible location. Mark the appropriate box (yes/no). If you answer yes provide the address of each location you identified as 00% dedicated. Mark the box or boxes that apply. Contemplate only work performed under this contract. 3 Mark the box or boxes that apply. Employee Leasing Firm are those firms that supply the labor force for your company (You direct the activities of the Leasing Company s employees). Temporary Labor Firms supplement your labor force. H. Warranty Statements: -6 Read each Warranty statement thoroughly. If you have questions regarding any of these statements, contact the on administrator identified on page. I. Signature Block: This form must be signed by a representative of your company knowledgeable of its accuracy. Forward the completed Enrollment pplication to the on administrator identified at the bottom of page of this form. The administrator prior to the start of your work on-site must receive this form.

8 Form-4 ON-SITE PYROLL REPORT INSTRUCTION State of Calif. - CDCR Page The Contractor and every Subcontractor of any tier performing work at the Project Site for each Contract awarded must complete this form each month. The Contractor/Subcontractor must attach the completed report to their monthly pay request in order to receive interim payment. Contractors will be responsible for the submission of this form by their Subcontractors. on Risk Services can forward a supply of these forms to your company upon request.. Report Identification Fill in the month and day for the beginning of the period you are reporting on. Fill in the month and day for the ending of the period you are reporting on. 3 Fill in the year that applies to the reporting period. 4 Enter the name of your firm. If you are a Subcontractor, identify the name of the firm you are contracted to. If you are a Prime Contractor enter N/ 6 Provide your Contract Number B. ctivity Report For each Workers Compensation Class Code that applies to work performed during the reporting period, provide the following information: a Identify the state in which the work was performed. b Identify the Workers Compensation Class Code that applies to the work performed during the period. (Most states use a four digit No.) c Provide a brief description of the work by class code. d Identify the number of Man-hours worked by your employees for each applicable class code. e Provide the Gross Payroll paid to your employees. This should include overtime pay and vacation pay. f Determine the Reportable Payroll. Reportable Payroll does not include the premium portion of any overtime pay (i.e. 4 hours $0.00/hr = do not include the premium overtime pay of $.00 for the hours of overtime) Total the Man-hours provided on the payroll report. 3 Total the Gross Payroll provided. 4 Total the Reportable Payroll. C. dditional Data Requirements: If questions are listed in this section of the form, they are unique to this project. Please refer to the Insurance Manual. D. Signature Block: This form must be signed by a representative of your company with the authority to Verify the information is correct. Note: Information can be submitted on-line at Please contact your dministration Staff to obtain a user ID and Password.

9 Form- NOTICE OF WORK COMPLETION Instruction State of Calif. - CDCR Page This form will be completed and returned to the Program dministrator by the contractor or Subcontractor whenever work is completed for each Contract or Subcontract. This form will initiate the final payroll audit process for the Contractor/Subcontractor identified in item. Final Payments and Release of Retainage will not occur until all payroll work is complete and finalized.. General Information Provide the name of the Contractor completing their work. Enter the contract number for the work being completed. 3 Provide a brief description of the work being completed. 4 Provide the Date the Work was completed. Provide the Date the Contract was completed, if other than work completion date. B. Work Completion a Enter the name of each Subcontractor that performed work for you that has also completed their work. b Enter Subcontractors Contract Number. c Provide a brief description of their work. d Provide the Date they completed their work. Identify the physical location of where your payroll records are retained. Provide the ddress, City, State, Zip Code, Contact Name and Telephone Number of the person responsible for maintaining the payroll information for audit purposes. C. Signature Block This form must be signed by a representative of your company with the authority to Verify that the information is correct. Have this form approved by the Contractor that contracted with the Contractor identified in.. Note: Information will be submitted on-line at Please contact your dministration Staff to obtain a user ID and Password.

10 Sample INCLUDED Parties Certificate of Insurance CERTIFICTE OF LIBILITY INSURNCE DTE (MM/DD/YYYY) THIS CERTIFICTE IS ISSUED S MTTER OF INFORMTION ONLY ND CONFERS NO RIGHTS UPON THE CERTIFICTE HOLDER. THIS CERTIFICTE DOES NOT FFIRMTIVELY OR NEGTIVELY MEND, ETEND OR LTER THE COVERGE FFORDED BY THE POLICIES BELOW. THIS CERTIFICTE OF INSURNCE DOES NOT CONSTITUTE CONTRCT BETWEEN THE ISSUING INSURER(S), UTHORIZED REPRESENTTIVE OR PRODUCER, ND THE CERTIFICTE HOLDER. IMPORTNT: If the certificate holder is an DDITIONL INSURED, the policy(ies) must be endorsed. If SUBROGTION IS WIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTCT NME: PHONE (/C, No, Ext): E-MIL DDRESS: F (/C, No): INSURER(S) FFORDING COVERGE NIC # INSURED Sample Certificate for Included Parties INSURER : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERGES CERTIFICTE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THT THE POLICIES OF INSURNCE LISTED BELOW HVE BEEN ISSUED TO THE INSURED NMED BOVE FOR THE POLICY PERIOD INDICTED. NOTWITHSTNDING NY REQUIREMENT, TERM OR CONDITION OF NY CONTRCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICTE MY BE ISSUED OR MY PERTIN, THE INSURNCE FFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO LL THE TERMS, ECLUSIONS ND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MY HVE BEEN REDUCED BY PID CLIMS. INSR TYPE OF INSURNCE DDL LTR INSR SUBR POLICY EFF POLICY NUMBER WVD (MM/DD/YYYY) GENERL LIBILITY COMMERCIL GENERL LIBILITY CLIMS-MDE OCCUR GEN'L GGREGTE LIMIT PPLIES PER: POLICY PRO- JECT LOC UTOMOBILE LIBILITY NY UTO LL OWNED UTOS HIRED UTOS SCHEDULED UTOS NON-OWNED UTOS UMBRELL LIB OCCUR ECESS LIB CLIMS-MDE DED RETENTION $ WORKERS COMPENSTION ND EMPLOYERS' LIBILITY NY PROPRIETOR/PRTNER/EECUTIVE Y / N OFFICER/MEMBER ECLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERTIONS below N/ POLICY EP (MM/DD/YYYY) LIMITS Per Claim/Occ $,000,000 General gg $,000,000 Prod & Comp Opp gg $,000,000 Personal & dv. Injury $,000,000 Fire Damage Medical Expense Combined Single Limit $,000,000 Each Occurrence $,000,000 ggregate $,000,000 WC STTU- OTH- TORY LIMITS CT ER EL Each ccident $,000,000 EL Disease Limit $,000,000 EL Disease Each ccident $,000,000 Contractor s Equipment Floater $Value equal to contractor s equipment onsite DESCRIPTION OF OPERTIONS / LOCTIONS / VEHICLES (ttach CORD 0, dditional Remarks Schedule, if more space is required) Work performed at the Project are named as additional insureds. ll policies (including primary, excess and/or umbrella) must provide that coverage shall be primary and noncontributory to any insurance maintained by the Construction Manager or additional insured. dditional Insureds are covered on a Primary and Non-contributing basis on the General Liability (ISO endorsement CG 0 0-/8 or its equivalent), utomobile and Excess/Umbrella Liability Policies. Waiver of Subrogation in favor of Certificate Holders applies to all policies. LL COVERGES LISTED PPLY ONSITE FOR LL OPERTIONS OF THE INSURED. CERTIFICTE HOLDER State of California c/o on Risk Solutions CUSTOMER # Overlook Point Lincolnshire, IL acs.construction@aon.com Fax # CNCELLTION SHOULD NY OF THE BOVE DESCRIBED POLICIES BE CNCELLED BEFORE THE EPIRTION DTE THEREOF, NOTICE WILL BE DELIVERED IN CCORDNCE WITH THE POLICY PROVISIONS. UTHORIZED REPRESENTTIVE CORD CORPORTION. ll rights reserved. CORD (00/0) The CORD name and logo are registered marks of CORD

11 Sample ECLUDED Parties Certificate of Insurance CERTIFICTE OF LIBILITY INSURNCE DTE (MM/DD/YYYY) THIS CERTIFICTE IS ISSUED S MTTER OF INFORMTION ONLY ND CONFERS NO RIGHTS UPON THE CERTIFICTE HOLDER. THIS CERTIFICTE DOES NOT FFIRMTIVELY OR NEGTIVELY MEND, ETEND OR LTER THE COVERGE FFORDED BY THE POLICIES BELOW. THIS CERTIFICTE OF INSURNCE DOES NOT CONSTITUTE CONTRCT BETWEEN THE ISSUING INSURER(S), UTHORIZED REPRESENTTIVE OR PRODUCER, ND THE CERTIFICTE HOLDER. IMPORTNT: If the certificate holder is an DDITIONL INSURED, the policy(ies) must be endorsed. If SUBROGTION IS WIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTCT NME: PHONE (/C, No, Ext): E-MIL DDRESS: F (/C, No): INSURER(S) FFORDING COVERGE NIC # INSURED Sample Certificate for Excluded Parties INSURER : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERGES CERTIFICTE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THT THE POLICIES OF INSURNCE LISTED BELOW HVE BEEN ISSUED TO THE INSURED NMED BOVE FOR THE POLICY PERIOD INDICTED. NOTWITHSTNDING NY REQUIREMENT, TERM OR CONDITION OF NY CONTRCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICTE MY BE ISSUED OR MY PERTIN, THE INSURNCE FFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO LL THE TERMS, ECLUSIONS ND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MY HVE BEEN REDUCED BY PID CLIMS. INSR TYPE OF INSURNCE DDL LTR INSR SUBR POLICY EFF POLICY NUMBER WVD (MM/DD/YYYY) GENERL LIBILITY COMMERCIL GENERL LIBILITY CLIMS-MDE OCCUR GEN'L GGREGTE LIMIT PPLIES PER: POLICY PRO- JECT LOC UTOMOBILE LIBILITY NY UTO LL OWNED UTOS HIRED UTOS SCHEDULED UTOS NON-OWNED UTOS UMBRELL LIB OCCUR ECESS LIB CLIMS-MDE DED RETENTION $ WORKERS COMPENSTION ND EMPLOYERS' LIBILITY NY PROPRIETOR/PRTNER/EECUTIVE Y / N OFFICER/MEMBER ECLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERTIONS below N/ POLICY EP (MM/DD/YYYY) LIMITS Per Claim/Occ $,000,000 General gg $ 4,000,000 Prod & Comp Opp gg $ 4,000,000 Personal & dv. Injury $,000,000 Fire Damage Medical Expense Combined Single Limit $,000,000 Each Occurrence $,000,000 ggregate $,000,000 WC STTU- OTH- TORY LIMITS CT ER EL Each ccident $ 00,000 EL Disease Limit $ 00,000 EL Disease Each ccident $ 00,000 Contractor s Equipment Floater $Value equal to contractor s equipment onsite DESCRIPTION OF OPERTIONS / LOCTIONS / VEHICLES (ttach CORD 0, dditional Remarks Schedule, if more space is required) Work performed at the project are named as additional insureds. ll policies (including primary, excess and/or umbrella) must provide that coverage shall be primary and noncontributory to any insurance maintained by the Construction Manager or additional insured. dditional Insureds are covered on a Primary and Non-contributing basis on the General Liability (ISO endorsement CG 0 0-/8 or its equivalent), utomobile and Excess/Umbrella Liability Policies. Waiver of Subrogation in favor of Certificate Holders applies to all policies. LL COVERGES LISTED PPLY ONSITE FOR LL OPERTIONS OF THE INSURED. CERTIFICTE HOLDER State of California c/o on Risk Solutions CUSTOMER # Overlook Point Lincolnshire, IL acs.construction@aon.com Fax # CNCELLTION SHOULD NY OF THE BOVE DESCRIBED POLICIES BE CNCELLED BEFORE THE EPIRTION DTE THEREOF, NOTICE WILL BE DELIVERED IN CCORDNCE WITH THE POLICY PROVISIONS. UTHORIZED REPRESENTTIVE CORD CORPORTION. ll rights reserved. CORD (00/0) The CORD name and logo are registered marks of CORD

12 THE DDITIONL INSURED ENDORSEMENT MUST BE TTCHED TO THE CERTIFICTE OF INSURNCE ND INCLUDE THE FOLLOWING VERBIGE: The Department of Corrections and Rehabilitation, the State of California and its officers, agents, employees and servants, the Construction Manager, the OCIP dministrator, their respective officers, agents and employees, and any additional entities as the State may request as additional insureds, but only insofar as the operations under the Contract are concerned.