LONG BEACH UNIFIED SCHOOL DISTRICT MEASURE K BOND PROGRAM OWNER CONTROLLED INSURANCE PROGRAM. Insurance Manual. LBUSD Insurance Manual

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1 LONG BEACH UNIFIED SCHOOL DISTRICT MEASURE K BOND PROGRAM OWNER CONTROLLED INSURANCE PROGRAM Insurance Manual LBUSD Insurance Manual

2 OWNER CONTROLLED INSU R ANCE PROGRAM Insurance Manual The information presented in this manual is intended to serve as a guide to the Construction Manager, Subcontractors, and others with the Long Beach Unified School District for the administration of the Long Beach Unified School District s Owner Controlled Insurance Program. This manual serves as a ready reference tool and every effort has been made to assure accuracy. However, the governing documents defining responsibilities and roles of the various parties are the construction contract documents between the Construction Manager and the Long Beach Unified School District, and the insurance policies. In the event of conflict between this document and the contract documents or the insurance policies, the contracts or policies will govern. This manual is subject to change and reissue as needed to remain concurrent with changes in the program. Long Beach Unified School District 2425 Webster Avenue Long Beach, CA 90810

3 Table of Contents SECTION 1 OVERVIEW ABOUT THIS MANUAL...1 What This Manual Does... 2 What this Manual Does Not Do...2 KEY INFORMATION... 2 DEFINITIONS... 3 SECTION 2 OCIP ADMINISTRATION OCIP ADMINISTRATION... 5 SECTION 3 OCIP INSURANCE COVERAGE COVERED PARTIES... 6 EXCLUDED PARTIES... 6 EVIDENCE OF OCIP COVERAGE... 6 SUMMARY OF OCIP COVERAGES... 7 Workers' Compensation and Employer's Liability:... 7 Commercial General Liability... 7 Excess Liability... 8 Builder s Risk... 8 LIMITATIONS OF OCIP COVERAGES... 9 OCIP TERMINATION OR MODIFICATION... 9 SECTION 4 CONTRACTOR S REQUIRED COVERAGE CONTRACTOR-PROVIDED COVERAGE SPECIFICATIONS...10 Automobile Liability Workers Compensation And Employer s Liability Commercial General Liability/Umbrella Liability Watercraft and Aircraft Liability Professional Liability Pollution Liability Property Insurance... 12

4 SECTION 5 CONTRACTOR AND SUBCONTRACTOR RESPONSIBILITIES CONTRACTOR BIDS...14 ADJUSTMENTS FOR COSTS OF OCIP PROVIDED COVERAGES ENROLLMENT ASSIGNMENT OF RETURN PREMIUMS...15 PAYROLL REPORTS INSURANCE COMPANY PAYROLL AUDIT COMPLETION OF WORK CLAIMS REPORTING...17 SAFETY STANDARDS AND PREQUALIFICATION OFF-SITE LOCATIONS. 18 CHANGE ORDER PROCEDURES CLOSE OUT AND AUDIT PROCEDURES...18 SECTION 6 CLAIM PROCEDURES WORKERS COMPENSATION CLAIMS LIABILITY CLAIMS PROPERTY (BUILDER S RISK) CLAIMS AUTOMOBILE CLAIMS...21 POLLUTION INCIDENTS...21 SECTION 7 FORMS INSURANCE CREDIT WORKSHEET (SAMPLE) INSURANCE CREDIT WORKSHEET (BLANK) ENROLLMENT APPLICATION SAMPLE CERTIFICATE OF INSURANCE MPN INFORMATION (ENGLISH & SPANISH) MPN ACKNOLWEDGEMENT FORM...46 AUTHORIZATION FOR TREATMENT... 47

5 I N T R O D U C T I O N Section 1 Overview Welcome to the Long Beach Unified School District Owner Controlled Insurance Program. The Long Beach Unified School District has elected to insure this construction project under the Long Beach Unified School District s Owner Controlled Insurance Program (OCIP). An OCIP is a consolidated insurance program that insures the District, Enrolled Contractors, and their Enrolled Subcontractors and other designated parties for Work performed at the Project Site(s). Certain Subcontractors are ineligible for this program. These parties are identified in the definitions section of this manual. Coverage under the OCIP includes workers compensation, general liability, and excess liability. In addition, the District is providing course of construction insurance (builder s risk) for property that will become part of the finished work. There is no coverage provided under the OCIP for Contractor-owned property such as equipment. See Section 7 of this manual for samples of forms that will assist you in identifying your insurance cost. The OCIP Administrator (see p. 5) can assist in determining insurance costs. The District will pay the insurance premiums for the OCIP coverages described below. Contractors and Subcontractors should notify their insurance broker/insurer(s) of the coverages provided under this OCIP for on-site activities to avoid duplication of coverage. Each Eligible Contractor and Subcontractor is required to exclude from its bid price its normal cost for the insurance coverages that will be provided by the District. Bidders may be required to verify the insurance costs excluded from their bids through audit or on request. Contractors and Subcontractors should be aware that certain requirements for Contractor provided insurance apply in addition to coverage provided under the OCIP. Please refer to Section 4 of this manual and to the insurance conditions section of the construction contract documents. Note Insurance coverages and limits provided under the OCIP are limited in scope and are specific to this project only. Your insurance representative should review this information. Any additional coverage you may wish to purchase will be at your option and expense. 1

6 I N T R O D U C T I O N About This Manual The manual is designed to identify, define, and assign responsibilities for compliance with requirements, completion of documents and forms, and administration of the OCIP. What This Manual Does This Manual: Identifies responsibilities of the various parties involved in the project Provides a basic description of the OCIP operation Describes audit and administrative procedures Provides answers to basic questions about the OCIP Will be updated throughout the course of the Program as necessary What this Manual Does Not Do This Manual does not: Provide coverage interpretations Provide complete information about coverages Provide answers to specific claims questions Replace or supersede any of the contract documents or insurance policies applicable Specific questions about the OCIP, its administration, or the coverages provided should be referred to the appropriate party identified in the Project Directory (next section). Disclaimer The information in this manual is intended to outline the OCIP. If conflict exists between this manual and the OCIP insurance policies or Contracts between the District and Contractor, the policies or Contracts will govern. Key Information This manual includes several important sections that provide quick reference information for Contractors and Subcontractors. Among these are: Definitions: (beginning on p.3) a list of words used in the manual and their meanings Project Directory: (p.5) a listing of key contact people who can provide further information Forms: (beginning on p.22) copies of OCIP forms and instructions for their use 2

7 I N T R O D U C T I O N Definitions Approved Additional Sites: Certificate of Insurance: Confirmation Letter: Contract: Contractor: Contractor Obligation: Eligible parties: Employer: Enrolled: Excluded parties: Storage yards or staging areas used solely in connection with performance of work at the Project Site, approved by the District and the insurer and scheduled on the insurance policies. A document providing evidence of the existence of coverage for a particular insurance policy or policies. A letter issued by the OCIP administrator usually accompanied by a certificate of insurance confirming acceptance into the OCIP. A written agreement between the District and the Contractor for specific work, or an agreement between a Contractor and any tier of Subcontractor. The properly licensed person, firm, joint venture, corporation or other party that has entered into a Contract with the District to perform work at the Project Site. The amount the Contractor or Subcontractor is responsible for paying as its contribution for settlement of an insured loss; including defense to the extent losses are attributable to the work, acts or omissions, of Contractor or any of its Subcontractors. Parties performing labor or services at the Project site, unless an Excluded Party. Any individual, firm, or corporation that provides direct construction labor for work performed at the Project Site. Those eligible Contractors and Subcontractors who have submitted all necessary enrollment forms and have been accepted into the OCIP as evidenced by a Confirmation Letter and Certificate of Insurance. Excluded Parties are: (a) Hazardous materials remediation, removal and/or transport companies and their consultants; (b) Architects, surveyors, engineers, and soil testing engineers, and their consultants; (c) Vendors, suppliers, fabricators (unless they also install), material dealers, truckers, haulers, drivers and others who merely transport, pickup, deliver, or carry materials, personnel, parts or equipment or any other items or persons to or from the Project site; (d) Contractors and each of their respective 3

8 I N T R O D U C T I O N Subcontractors of all tiers that do not perform any actual labor on the Project site, during the term of the Contract; (e) Any other persons or entities not specifically identified or who, whether or not they qualify as Enrolled Parties, are expressly excluded by the District. Insured: Insurer: OCIP: OCIP Administrator: On-Site Activities: Program: Project Site: Subcontractor: Work: The Long Beach Unified School District, Enrolled Contractors and Enrolled Subcontractors, and any other party so identified in the insurance policies. The insurance companies named on a policy or certificate of insurance that provide coverage for the OCIP. The Long Beach Unified School District Controlled Insurance Program A consolidated insurance program providing specific insurance coverages as described in this manual for Work at the Project Site(s). Aon Risk Solutions of Southern California Those activities at or emanating from the project site The Long Beach Unified School District Measure K Bond Program projects eligible and enrolled in the OCIP. Project Site shall mean those areas designated in writing by the Long Beach Unified School District for performance of the Work and such additional areas as may be designated in writing by the Long Beach Unified School District for Contractor s use in performance of the Work. Subject to the notification and other requirements for off-site locations described on p. 17, the term Site shall also include (a) field office sites, (b) property used for bonded storage of material for the Project approved by the Long Beach Unified School District, (c) staging areas dedicated to the Project, and (d) areas where activities incidental to the Project are being performed by Contractor or Subcontractors covered by the worker s compensation policy included in the OCIP, but excluding any permanent locations of Contractor or such covered Subcontractors. Those persons, firms, joint ventures, corporations or other parties that enter into a Contract with a Contractor to perform Work relating to the Long Beach Unified School District Measure K Bond Program. Operations as fully described in the Contract, performed at or emanating directly from the Project Site. Also, the entire completed construction or the various separately identifiable parts required to be furnished under the Contract documents. 4

9 D I R E C T O R Y Section 2 OCIP Project Directory Key OCIP personnel OCIP Administrator Aon Risk Services, Inc. of Southern California 100 Bayview Circle, Suite 100 Tel Newport Beach, CA (License No ) Fax Senior Program Administrator Kathy Ritch kathleen.ritch@aon.com Program Manager Gayle Ramsdell gayle.ramsdell@aon.com Interim Program Manager Tom Harvey tom.harvey@aon.com Loss Control Consultant Chris Sarvis chris.sarvis@aon.com Program Risk Management The Long Beach Unified School District 2425 Webster Avenue Long Beach, CA Interim Administrative Coordinator Stella Escario-Doiron SEscarioDoiron@lbschools.net Risk Management Coordinator John Aube JAube@lbschools.net 5

10 O C I P I N S U R A N C E C O V E R A G E Section 3 OCIP Insurance Coverage This chapter provides a brief description of OCIP Coverages and should be read in conjunction with the Insurance Conditions of the Construction Documents. Refer to the actual policies for details concerning coverage, exclusions, and limitations. Covered Parties Parties covered as named insureds include the Long Beach Unified School District, Enrolled Contractor, and Enrolled Subcontractors. Parties included as additional insureds may include other parties that the Owner is required under contract to add as an additional insured. Excluded Parties Excluded Parties, as defined in Section 1 of this Manual, are precluded from OCIP coverage. The District reserves the right, at its sole discretion, to include or exclude any Contractor or Subcontractor from the OCIP, even if the Contractor or Subcontractor is eligible to enroll in the OCIP. Evidence of OCIP Coverage Each Enrolled Contractor and Enrolled Subcontractor will be issued an individual workers compensation policy. The OCIP Administrator will provide a Certificate of Insurance evidencing workers compensation, general liability, and excess liability insurance to each Enrolled Contractor and Enrolled Subcontractor, each of whom will be a named insured on the OCIP policies. Other documentation including workers compensation claim reporting forms, posting notices, etc., will be furnished to each Enrolled Contractor and Enrolled Subcontractor. Complete copies of policies may be requested from the OCIP Administrator. 6

11 O C I P I N S U R A N C E C O V E R A G E S Summary of OCIP Coverages The following sections describe the insurance policies that the District has included in the OCIP. These are summaries only. Refer to the policies for actual terms, conditions, exclusions and limitations. In the event of conflict between the policies and these summaries, the policies govern. Each Enrolled Contractor and Enrolled Subcontractor will be issued a separate workers compensation policy. Workers Compensation and Employers Liability: Part One - Workers Compensation: Annual Limits per Insured Statutory Part Two - Employer s Liability: Bodily Injury by Accident, each Accident: $1,000,000 Bodily Injury by Disease, each employee 1,000,000 Bodily Injury by Disease, policy limit: 1,000,000 A single policy will be issued for all insureds for all liability coverage. C O N T R A C T O R O B L I G A T I O N Contractor shall be responsible, at its own expense, for the first $25,000 of each occurrence including court costs, attorney fees and costs of defense for bodily injury or property damage to the extent losses are allegedly due to Contractor s Work, negligent acts or omissions, or the acts or omissions of any of its Subcontractors or any other entity or person for whom Contractor may be responsible. Sampling of Additional Coverages/Modifications: Other States Endorsement Designated Premises Endorsement Waiver of Subrogation Alternate Employer Endorsement Voluntary Compensation USL&H on if any basis Commercial General Liability Limits of Liability Shared by All Insureds Enrolled Contractor and General Aggregate Limit for all Enrolled Parties $4,000,000 Enrolled Subcontractors Products/Completed Operations Aggregate $4,000,000 will receive certificates. Personal/Advertising Injury Aggregate $2,000,000 Each Occurrence Limit $2,000,000 G E N E R A L L I A B I L I T Y Sampling of Additional Coverages/Modifications Insurance Services Office Occurrence Form CG Broad named insured Amend Bodily injury definition Fellow employee coverage supervisory personnel only Designated premises/project endorsement Incidental medical malpractice Annual Reinstatement of General Aggregate (except Products/Completed Operations) Ten (10) Year or Statute of Repose whichever is shorter, Products & Completed Operations Extension (single aggregate) for all Enrolled Parties Limited Coverage Repair/Warranty Work 12 months Total Pollution exclusion including lead, asbestos and fungi, bacteria or silica Exterior finish and insulation system (EFIS) exclusion Exclusion Construction Managers Errors and Omissions Exclusion Contractors Professional Liability 7

12 O C I P I N S U R A N C E C O V E R A G E S Excess Liability Limits of Liability Shared by All Insureds Each Occurrence Limit $100,000,000 Annual General Aggregate Limit for all Enrolled Parties $100,000,000 Sampling of coverage amendments Following form to underlying insurance Pay on behalf wording Annual reinstatement of limits Designated premises endorsement Scheduled Underlying Coverages: Employer s Liability; Primary Commercial General Liability Ten (10) Year or Statute of Repose whichever is shorter, Products & Completed Operations for all Enrolled Parties Excludes: Real & Personal Property in the care, custody or control of the insured; Terrorism; Asbestos; Lead; Discrimination & Wrongful Termination; ERISA; Owned & Non-owned Aircraft, Watercraft, and Automobile Liability; Nuclear Broad Form Liability B U I L D E R S R I S K C O N T R A C T O R O B L IG A TI O N Contractor will be responsible for: the first $25,000 of each loss under the District s builder s risk insurance policy for damage to work of Contractor or any Subcontractor of any tier including damage to work of other Subcontractors. Builder s Risk The District will purchase and maintain Builder's Risk insurance for all Work while in the course of construction, reconstruction, remodeling, or alteration, including materials incorporated in the Work, against physical loss or damage resulting from the perils normally insured under a "Specified Perils Course of Construction" policy with a Contractor Obligation of $25,000 for each loss including expenses or claim payments incurred by the Insurer for losses attributable to the Contractor s work, acts or omissions, or the work, acts or omissions of any tier subcontractor. In addition, if the Builder s Risk insurance includes deductibles, the Contractor shall pay costs not covered because of such deductibles if the loss is the result of the willful actions (including failure to protect the District s property or work), gross negligence, misconduct, or failure to follow the instructions of a representative of the District, by the Contractor or by any Subcontractors of any Tier. The term "materials incorporated in the Work" used in this paragraph shall mean materials stored at or in permanent place at the Project Site(s). Note Contractors are advised to arrange their own insurance for contractor-owned machinery, tools, equipment and materials not intended for inclusion in the project. The OCIP will not cover contractor property. The descriptions above provide a summary of coverages only. Contractors should refer to the policies for actual terms and conditions. 8

13 O C I P I N S U R A N C E C O V E R A G E S Limitations of OCIP Coverages The insurance provided under the OCIP does not extend coverage for ongoing operations liability to any insured Contractor or Subcontractor, or to any vendor, supplier, material dealer or others for any work that is performed, manufactured, fabricated, assembled, or otherwise worked upon away from the Project Site(s). There is no workers compensation coverage provided for work performed away from the Project Site(s) OCIP Termination or Modification The District reserves the right to terminate or modify the OCIP or any portion thereof. If the District exercises this right, Contractors will be provided notice as required by the terms of their individual contracts. At its option, the District may procure alternate coverage or may require the Contractors to procure and maintain alternate insurance coverage. 9

14 C O N T R A C T O R - R E Q U I R E D C O V E R A G E S Contractor s Required Coverage Contractor and ALL Subcontractors shall maintain coverage to protect against losses that occur away from the Site or that are otherwise not covered under the OCIP. Section 4 Contractor and all Subcontractors are required to maintain insurance that protects the District from liabilities arising from operations performed away from the Project site, for certain coverage not provided by the OCIP, and for operations performed by excluded parties. See Section 7 for sample certificate of insurance forms. I N S U R A N C E R E Q U I R E M E N T S N O T L I M I T I N G The limits of liability shown for the insurance required of the Contractor and Subcontractors are minimum limits only and are not intended to restrict the liability imposed on the Contractor and Subcontractors for Work performed under their Contract. Verification of insurance may be submitted in the form of a Certificate of Insurance on a standard ACORD Form 25. A sample of an acceptable Certificate of Insurance is provided in Section 7. Contractor and all Subcontractors must agree to provide or to require its insurance brokers or insurers to provide immediate written notice to District if any of the insurance required is suspended, voided, cancelled or not renewed during the term of their contract. Please note requirements include Waiver of Subrogation and Additional Insured endorsements for each policy naming the District, and other parties as referenced in Exhibit I of the General Conditions of the Construction Contract shall be provided. Insurers shall be rated A- VI or better by A. M. Best, unless otherwise approved in writing by the District. Contractor shall monitor Subcontractors (including Excluded Parties) evidence of insurance. The District reserves the right to disapprove use of Subcontractors unable to meet the insurance requirements. Certificates evidencing compliance shall be available to the District or the OCIP Administrator on request. Note: Evidence of Compliance Required Prior to mobilization and within three (3) days of any renewal, change or replacement of coverage, Contractor shall submit to the District a Certificate of Insurance evidencing the coverage as specified in this section. General, Excess, and Automobile Liability Policies shall include the District, the OCIP Administrator, their respective officers, agents, and employees and any additional entities as the District may request, as additional insureds and coverage shall be primary and non-contributory. Contractor shall require and maintain the same of all enrolled and excluded Subcontractors of all tiers, and provide copies to the District or OCIP Administrator upon request. 10

15 C O N T R A C T O R - R E Q U I R E D C O V E R A G E S Contractor-Provided Coverage Specifications All Contractors shall provide evidence of automobile liability insurance. The OCIP does not cover automobile liability for contractors. Enrolled Contractors shall provide evidence of workers compensation insurance for off-site activities, including design work. Excluded Contractors shall provide evidence of workers compensation insurance applicable to this project and off-site. Enrolled Contractors shall provide evidence of general liability insurance for offsite activities. Excluded Contractors shall provide evidence of general liability insurance applicable to this project and must add the District and other parties as additional insureds to the policy. Automobile Liability Covering all owned, hired and non-owned automobiles, trucks and trailers on a Business Automobile Policy, not less than the standard ISO form CA 00-01, with a limit not less than $1,000,000. Coverage shall apply both on and away from the Project Site. Workers Compensation and Employer s Liability Part One - Workers Compensation: Minimum Limits of Liability Statutory Limit Part Two - Employer s Liability: Annual limit Bodily Injury by Accident, each Accident: $1,000,000 Bodily Injury by Disease, each employee 1,000,000 Bodily Injury by Disease, policy limit: 1,000,000 Commercial General Liability/Umbrella Liability Minimum Limits of Liability from Enrolled Parties & Excluded Parties Enrolled Parties / Excluded Parties General Aggregate $2,000,000 / $3,000,000 Products/Completed Operations Aggregate 2,000,000 */ 3,000,000 * Personal/Advertising Injury Aggregate 1,000,000 / 3,000,000 Each Occurrence Limit 1,000,000 / 3,000,000 Limits may be provided by a combination of a primary Commercial General Liability policy and Excess/Umbrella Liability policy. Coverage shall be on an Occurrence form providing coverages not less than coverage provided under the Insurance Services Office form CG and must apply to bodily injury and property damage for operations (including explosion, collapse and underground coverage), independent Contractors, products and completed operations. Limits can be provided by a combination of a primary Commercial General Liability policy and Excess or Umbrella Liability policy. *Products/Completed Operations coverage shall be provided through the applicable statues of limitations and repose. Watercraft and Aircraft Liability Should watercraft or aircraft of any kind be used by Contractor, Subcontractor of any tier, or by anyone else on its behalf, Contractor or Subcontractor shall maintain or cause the operator of the watercraft or aircraft to maintain Liability insurance with a minimum Combined Single Limit for Bodily Injury and Property Damage including Passengers to be determined by the District. The policies shall add the District and others as required as an additional insured with primary and non-contributory wording. 11

16 C O N T R A C T O R - R E Q U I R E D C O V E R A G E S The District does not provide professional liability insurance for Contractors or Subcontractors. Professional Liability All professional service firms must provide appropriate professional liability insurance with a limit of not less than $1,000,000 per claim and in the aggregate. Contractor agrees to maintain continuous coverage for professional liability applicable to Work performed for a period of no less than three years after completion of the Work. If professional services are provided through a Subcontractor, Contractor shall insure that the Subcontractor complies with this requirement. Pollution Liability Hazardous substance remediation Contractors, demolition contractors, and Subcontractors whose work involves removal or treatment of hazardous materials shall provide and maintain Contractor s Pollution Liability insurance that specifically schedules the type of work to be done under the Contract with the District or with the District s General Contractor. The policy limit shall be no less than $1,000,000 per claim and in the aggregate. The District may require higher limits depending on the scope of work under the contract. All activities of the work shall be specifically scheduled on the policy as covered operations. The policy shall provide coverage for the hauling of waste from the Site to the final disposal location, including non-owned disposal sites. Property Insurance Contractor and Subcontractors shall arrange their own insurance for owned and leased equipment, whether such equipment is located at a Project Site or in transit. Contractor and Subcontractors are solely responsible for any loss or damage to their personal property including contractor machinery, tools and equipment, scaffolding and temporary structures, whether owned, used, leased or rented by the Contractor or Subcontractor. Contractor and Subcontractors are also responsible for any loss or damage to property or materials created or provided under the Contract until the property or materials arrives at the Project Site(s). *Note: All Limits Shown Above are Minimums For specific contracts where, in the sole opinion of the District, the hazards or nature of the work require special protection and which are Excluded from the OCIP, the District may require additional coverage or limits from the Contractor. Note: Waivers Required Workers Compensation, General Liability, Automobile, Umbrella or Excess Liability, and Property Insurers for Contractor, and all Subcontractors shall provide Waivers of Subrogation in favor of the District, the OCIP Administrator, its or their respective officers, agents, or employees, and any other contractor or Subcontractor performing Work or rendering services on behalf of the District in connection with the planning, development and construction of the Project and any additional entities as the District may request or as designated in the Contract. 12

17 C O N T R A C T O R - R E S P O N S I B I L I T I E S Section 5 Contractor and Subcontractor Responsibilities Throughout the course of the Project, Contractors will be responsible for reporting and maintenance of certain records as outlined in this section. Contractor and Subcontractors are required to cooperate with the District and its OCIP Administrator in all aspects of OCIP operation and administration. Responsibilities of the Contractor and Subcontractor are defined in the Contract and include: Providing each Subcontractor this OCIP Manual and Project Safety Standards Removing the cost of insurance from bids as appropriate Reviewing and understanding coverages, exclusions, and limitations of OCIP policies Enrolling in the OCIP (Aon Form-3), if eligible, and assuring all eligible subcontractors enroll within five (5) working days of execution of contract and prior to mobilization on the Site(s) Including OCIP provisions in all subcontracts as appropriate Providing timely evidence of Contractor s other insurance or Contractor-required insurance to the OCIP Administrator within five (5) working days of notice of award of contract and prior to mobilization on the Site(s). Subcontractors should provide this evidence of insurance to the Contractor. Notifying the OCIP Administrator of all subcontracts awarded Maintaining and reporting monthly OCIP payroll records via the AonWrap website Cooperating with the OCIP Administrator s requests for information Complying with all of the administrative, insurance, claim, and safety procedures Comply, and require all of its subcontractors to comply with OCIP Administrator s instructions for electronically reporting payroll using AonWrap." 13 13

18 C O N T R A C T O R - R E S P O N S I B I L I T I E S Construct a waterproof jobsite bulletin board to display all required posters at locations were project workers report every day. See OCIP Safety Standards for additional assistance. Promptly reporting ALL on-site incidents to the District and the OCIP Administrator Paying to the District general liability or builder s risk Contractor Obligations promptly. (The District will charge the Contractor by processing administrative deductions on the Contractor s progress payments.) Notifying the OCIP administrator immediately of any insurance cancellation or non- renewal (contractor-required insurance) Ensuring that Subcontractors comply with all appropriate provisions above Cooperating with Insurer claims personnel and auditors Contractor Bids See Section 7 for forms that can help identify your insurance costs. See Section 2 for information on contacting the OCIP Administrator. Since the District provides insurance for all Enrolled Parties under the OCIP for work performed at the Project Site, Contractor and Subcontractor bids and change orders should exclude insurance costs for these coverages as required in the Contract. Section 7 of this Insurance Manual contains several worksheets (Aon-1 & Aon-2) that are used to help identify insurance costs for this Project. Upon award of contract, t hese worksheets should be returned with your Enrollment Application to identify the credit applied. The OCIP Administrator can also help with your estimate. The section below, Adjustments for Costs of OCIP Provided Coverages describes the procedure for bidding, and how the Contractor and Subcontractors must remove the cost of OCIP provided insurance from the bid. Note Before estimating insurance costs or contacting your insurance representative about excluding this project from regular coverage, you should read this manual in its entirety. Adjustments for Costs of OCIP Provided Coverages The Contractor and each eligible Subcontractor is required to exclude the cost of OCIP provided insurance coverages from its bid price for the proposed scope of work (including subcontracted work whether or not the Subcontractor is identified at the time of the bid). To aid the Contractor and its Subcontractors in identifying its costs of OCIP provided insurance, the Insurance Credit Worksheet (Aon Form-1), included in Section 7, is available for use by Contractor and Subcontractor. Use a separate form for the Subcontractor s self-performed work, each identified tiered Subcontractor, and for unidentified Subcontractors at the time of the bid. The worksheets are provided to assist the Contractor and Subcontractor in identifying and removing the amount of the 14

19 C O N T R A C T O R - R E S P O N S I B I L I T I E S insurance costs from the bid so that bids remain competitive. The Aon Form-1 Insurance Credit Worksheet should be returned with your Enrollment Application following the award of contract to identify the amount of insurance credit applied. Change orders will be similarly priced by the Enrolled Parties to exclude the cost of OCIP provided insurance coverages. Under the District s OCIP, the final payroll is determined through an audit conducted by the OCIP Insurer. Contractor is responsible for ensuring that every Subcontractor (all tiers) also deducts the cost of OCIP provided insurance coverages from their bids. In addition, Subcontractors are required to identify the amount of insurance credit applied to the bid by completing the Aon Form-1 Insurance Credit Worksheet. Enrollment See Section 7 for OCIP enrollment forms. The Contractor shall provide details about its Subcontractors as necessary to enroll them in the OCIP. The Contractor and every Subcontractor must complete and submit the Enrollment Application form (Aon Form-3); included in Section 7. This form must be completed and submitted to the OCIP Administrator prior to mobilization on the Site(s) to obtain coverage under the OCIP. A new Enrollment Application is required from the Subcontractor for each new contract awarded. The Contractor and each Enrolled Subcontractor will receive a Confirmation Letter. A Confirmation Letter is a letter issued by the OCIP Administrator that confirms acceptance of the applicant into the District s OCIP. On-site work should not begin until you have received written confirmation of your coverage under the OCIP. Contractor and Subcontractors must comply with all the terms of this Manual, and the OCIP Safety Standards for contract compliance. Note: Enrollment Not Automatic Enrollment into the OCIP is required, but not automatic. The Contractor and all eligible Subcontractors MUST complete the enrollment forms and participate in the enrollment process for OCIP coverages to apply. Access to the project site will not be permitted until enrollment is complete and confirmed in writing. Assignment of Return Premiums The cost of the OCIP insurance coverages will be paid by the District. The District will be the sole recipient of any return OCIP premiums or dividends. The Contractor and all Enrolled Subcontractors shall assign to the District all adjustments, refunds, premium discounts, dividends, credits or any other monies due from the OCIP Insurers. Contractor shall assure that each Enrolled Subcontractor shall execute such an assignment. Aon Form-3 in Section 7 will be used for this purpose. The construction contract also stipulates Contractor and Subcontractor assignment of premiums to the District. 15

20 C O N T R A C T O R - R E S P O N S I B I L I T I E S Payroll Reports Contractor and each Enrolled Subcontractor of every tier must report their monthly OCIP payroll identifying worker-hours and payroll with Workers Compensation classification code for all Work performed at the Project Site. These reports must be submitted using the AonWrap website. This information will be used to provide the District s Insurers with information required for determining the District s insurance premiums. All Enrolled Parties must report their on-site payroll by the 10th of the following month using the website. Access information will be provided at the time of your enrollment into the Owner Controlled Insurance Program. The monthly worker-hour and payroll information should include any supervisory and clerical personnel that are on-site, and cover all Work performed at or emanating directly from each Project Site. If no on-site work was performed during the payroll-reporting period, the information must be submitted indicating zero. Note: Reporting Mandatory Failure to submit payroll reports as required may result in the withholding of payments until required documentation is received. Note: Separate Reports Required A separate Monthly Payroll Report is required for each Contract for Work you are performing. This report is not a certified payroll form. Insurance Company Payroll Audit Contractor and each Enrolled Subcontractor are required to maintain payroll records for each Contract. Such records will allocate the payroll by Contract and by Workers Compensation classification(s) code and exclude the excess or premium paid for overtime (i.e., only the straight time rate will apply to overtime hours worked). Furthermore, such records will limit the payroll for Executive Officers and Partners/Sole Proprietors to the limitations as stated in the state manual rules. All Enrolled Parties must properly classify payrolls, as these are reported to the rating bureau for promulgation of future Experience Modifiers for said firm. All Parties shall make available their payroll records, vouchers, contracts, documents, and records, of any and all kinds, to the auditors of the OCIP Insurer(s) and the District s representatives. Availability of records must be for the policy period, any extension, or during a final audit period as required by the insurance policies. The OCIP Insurer is the insurance company named on the policy or on the Certificate of Insurance that provides coverage for the OCIP. 16

21 C O N T R A C T O R - R E S P O N S I B I L I T I E S Completion of Work The Contractor and each Enrolled Subcontractor of every tier must submit a Notice of Work Completion (Aon Form-5) when their on-site work is complete and they no longer have workers on Site. The Notice of Work Completion must be submitted electronically via the AonWrap website. Final Payment will not be released by the District until all necessary forms have been submitted to the OCIP Administrator. Parties no longer Enrolled in or covered by the OCIP shall obtain and maintain, and shall require each of their Subcontractors of all tiers to obtain and maintain, the insurance coverage specified herein for all operations at and away from the project site. A claims kit will be provided to Contractor and all Enrolled Subcontractors. It will include details about claim reporting and is intended for use at the job site. Claims Reporting The Contractor and each Subcontractor shall follow claims procedures established by the OCIP Administrator. Contractor and Subcontractors agree to assist and cooperate in every manner possible with the adjustment of all claims and demands. Refer to Section 6 of this Manual for detailed claims procedures. A manual establishing minimum standards for Contractor safety programs will be provided to all Subcontractors. Safety Standards Each Contractor and Subcontractor is required to have a written safety program and to provide a designated safety representative who is on-site when any Work is in progress. Minimum standards for Contractor safety programs are outlined in the OCIP Safety Standards. Because the District must comply with Government Code Section , the Contractor may be asked to submit to LBUSD Subcontractors Cal/OSHA 300/300A Logs and/or details of Experience Modification Factors. 17

22 C L A I M P R O C E D U R E S Off-Site Locations The Contractor is responsible for applying for approval to have off-site locations covered. The Contractor shall notify the OCIP Program Administrator of the need and shall request approval of the site. The request should include the location, address, description of the site and the type of use it will be put to and the duration of the work to be preformed at the site. The off-site location must be 100% dedicated to the project. Change Order Procedures Change orders must also exclude the Contractor's and its Subcontractor s cost of OCIP provided insurance coverages. The OCIP Administrator can help contractors determine these costs. Close Out and Audit Procedures The Enrolled Contractor and Enrolled Subcontractors must submit a Notice of Work Completion (Aon Form-5) when the Contractor and each tier Subcontractor has completed its Work at the Project Site(s) and no longer has workers on Site. The Notice of Work Completion must be submitted electronically via the AonWrap website. The District will not authorize issuance of final payment until, among other things, all necessary forms have been submitted to the OCIP Administrator. Any general liability or builder s risk Contractor Obligation(s) for which the Contractor or Subcontractor of any tier is responsible will be considered at the time of closeout. General liability or builder s risk Contractor Obligation(s) previously paid will not be considered as a part of the close out. 18

23 C L A I M P R O C E D U R E S Section 6 Claim Procedures This section describes basic procedures for reporting various types of claims: workers compensation, liability, and damage to the project. A claims kit will be provided to all Enrolled Subcontractors. It will include details about claim reporting and is intended for use at the job site. Additional claim kits will be available from the OCIP Administrator. NOTE: Claim reporting telephone numbers may be revised. Workers Compensation Claims Where there is an injury, if needed, first see that the injured worker receives immediate medical care. Call 911 for emergency ambulance response to any life-threatening. In the event of a serious injury, immediately notify the LBUSD Project Manager and the OCIP Administrator. Please refer to your Claims Kit sent to you at the time of your OCIP enrollment for additional detailed instructions, including clinic information. To report a Worker s Compensation claim either: (1) complete the Form 5020 (also known as the Employer s First Report) and fax it to OR, (2) call the claim into the toll free number: The employer can call this Intake and Referral Line and they will complete the 5020 over the phone and fax a copy to the employer, the insurance company, and the OCIP Administrator. This number is available 24 hours a day, 7 days a week. Please refer to Client Number The District s OCIP Workers Compensation Insurer has arranged with an authorized medical provider for treatment of all minor or non-life threatening injuries. PLEASE REFER TO YOUR CLAIMS KIT SENT T O YOU WITH YOUR CONFIRMATION OF ENROLLMENT INTO THE LONG BEACH UNIFIED SCHOOL DISTRICT OWNER CONTROLLED INSURANCE PROGRAM FOR NAME AND LOCATION OF LOCAL APPROVED CLINICS. 19

24 C L A I M P R O C E D U R E S Employee Injuries Contractor and all Subcontractors must designate a representative at the site to take injured employees to the medical treatment center with the Authorization for Treatment, included in Section 7 of this manual and to report the claim. This individual is to remain with the injured employee at the medical treatment center while he/she is being treated. The treating physician should provide a written description of the injured employee s ability to return to work, a list of restrictions (if any), and the estimated length of time the injured worker must be on modified duty (if appropriate). The District strongly encourages transitional modified work to keep injured workers gainfully employed during recovery. Contractor shall institute a modified return to work program for any injured employee who is covered or entitled to coverage under the Workers Compensation insurance provided in the OCIP. Failure to provide reasonable accommodations will result in a penalty assessment of $1,500 per day until the injured worker is returned to work. Contractor and the OCIP administrator shall determine reasonable accommodations. Medical Provider Network (MPN) Requirements Contractor and Subcontractors must post and distribute Medical Provider Network (MPN) notices to every employee working on this project. The MPN notice is included in Section 7 of to this Manual. During the jobsite safety orientation meeting, Contractor and Subcontractors MUST obtain a signed document from each employee acknowledging receipt of the MPN notice and maintain this signed acknowledgement on file. In the event of a Workers Compensation claim, that employee s signed MPN acknowledgement should be submitted to the OCIP insurance carrier s claim administrator along with the Employer s First Report of Injury. Liability Claims Accidents at or around the Project Site(s) resulting in damage to property of others (other than your own work product) or bodily injury or death to a member of the public, must be reported immediately to the LBUSD Project Manager and the OCIP Administrator. Complete and deliver the Superintendent s Incident Report, including names, addresses, date, time, photos, etc. to the OCIP Administrator via fax to #: within 24 hours of the incident or otherwise notify the OCIP Administrator at Do not admit liability. Cooperate with the District and the OCIP Insurer representatives in the accident investigation. Property (Builder s Risk) Claims Report incidents or possible claims by immediately notifying the LBUSD Project Manager and the OCIP Administrator at of any physical damage to the Project. The Contractor will be assessed the first $25,000 of any such occurrence due under the District s builder s risk insurance program. See the discussion on builder s risk contractor obligation in Section 3 of this Manual. 20

25 C L A I M P R O C E D U R E S Automobile Claims No coverage is provided to contractors for automobile accidents under the OCIP. It is the sole responsibility of Contractor and each Subcontractor to report accidents involving their automobiles or other vehicles to their own insurers. Even though the OCIP does not cover auto liability, all accidents occurring in or around the job site must be reported to the OCIP Administrator at Fax the Superintendent s Incident Investigation Report to the OCIP Administrator at The accident will be investigated to determine any liability arising out of the Project construction activities that could result in future claims (i.e. due to the conditions of the roads, etc.). The Contractor and each Subcontractor shall cooperate in the investigation of all automobile accidents. Pollution Incidents IMPORTANT: Report all incidents or possible claims by immediately notifying the OCIP Administrator at of any known or suspected pollution incidents. Contractor shall institute a modified return to work program for any injured employee who is 21

26 Forms Section 7 This section contains the forms needed for reporting claims, reporting payroll and other administration of the OCIP. Aon Form-1 Aon Form -2 Aon Form -3 Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5 Exhibit 6 Exhibit 7 Exhibit 8 Insurance Credit Worksheet Insurance Summary Enrollment Application ACORD Certificate of Insurance (from Contractor/Subcontractor) ACORD Certificate of Insurance (from Excluded Parties) MPN Implementation Checklist MPN Implementation Notices English and Spanish State of CA Dept of Industrial Relations- Notice to Employees MPN Information English and Spanish MPN Acknowledgement Form English and Spanish Authorization for Treatment Note For assistance in completing these forms, please contact: Kathy Ritch Senior OCIP Administrator Gayle Ramsdell OCIP Program Manager

27 F O R M S Form-1 INSURANCE CREDIT WORKSHEET S A M P L E The Long Beach Unified School District Project # Page 1 of 1 1. Contractor Information: Federal ID No.: Company Name & dba / Business Information (headquarters) ABC Construction Company, Inc. Contact Name & Title: Address: 1 23 Main St. 1 Site Street Contact Information (address questions to.) ABC Construction Company, Inc. City, State Zip Code: Hometown, CA Projectown, CA Telephone: Fax: Bid Information: Bid Package No.: Long Beach Unified School District Scope of Work: Brief description of Work Package Proposed Contract Price: $ 75, 000, 000 Amount of Self Performed Work: $ 58, 685, 500 Are you a: Contractor If Subcontractor, Subcontractor identify under contract with: Workers Compensation Insurance Information: R State R Class Code Description Rate (per $100 payroll) Worker-hours Est. On-site Payroll WC Premium (Payroll * Rate / 100) CA Concrete Const , 788 2, 204, , 600 CA Excavation > $ , , , 994 CA 5040 Iron or Steel Const , , 206, , 875 CA 5432 Carpentry , 050 4, 1 00, , Totals 429, ,737,100 1, 597, Your Company s Workers Compensation Experience Modifier: 11. Modified Premium (Total WC Premium multiplied by line 10): 12. a) Employers Liability Rate: N/A b) Employers Liability Cost = line 11 x line 12a: 13. a) Modification Premium Factors: b) Rate c) Amount Modifier 1: 20% 325, 928 Modifier 2: d)total Modified Amount: 14. Total Workers Compensation Premium (line 11 plus 12 plus or minus 13): 15. a) General Liab. Rate: b) Based On: Payroll c) Rate factor: Per $100 Receipts Per $1,000 Other GL Premium Cost: 16. a) Builder s Risk/Installation Floater Rate: b) Property Premium Costs: 17. a) Excess/Umbrella Rate:. 262 b) Based On: c) Rate factor: Excess/Umbrella Payroll Per $100 Receipts Per $1,000 Premium Costs: Other 18. Total of all Insurance Premiums (total of lines 14, 15, 16 & 17): 19. Overhead & Profit on Insurance Prem. %: 1 0% O/H & Profit Amount: 20. Total of Lower Tier Subcontractors Insurance Credits (Line 7d from Aon-2) 21. Total Initial Insurance Credit (Total of lines 18, 19 & 20): , 629, 638 included (325, 928) 0 (325, 928) 1, 303, ,250 N/A 1 9,650 d) 1, 421, , , 71 1, 075 4, 274,

28 F O R M S Form-1 INSURANCE CREDIT WORKSHEET (Instructions located on the following page) The Long Beach Unified School District OCIP The Long Beach Unified School District Project # Page 1 of 1 1. Contractor Information: Federal ID No.: Company Name & dba / Contact Name & Title: Address: City, State Zip Code: Telephone: Fax: Business Information (headquarters) Contact Information (address questions to.) 2. Bid Information: Bid Package No.: Scope of Work: Proposed Contract Price: $ Amount of Self Performed Work: $ Are you a: Contractor Subcontractor Workers Compensation Insurance Information: R State R Class Code Description Rate (per $100 payroll) If Subcontractor, identify under contract with: Worker-hours Est. On-site Payroll WC Premium (Payroll * Rate / 100) 9. Totals 10. Your Company s Workers Compensation Experience Modifier: 11. Modified Premium (Total WC Premium multiplied by line 10): 12. a) Employers Liability Rate: b) Employers Liability Cost = line 11 x line 12a: 13. a) Modification Premium Factors: b) Rate c) Amount Modifier 1: Modifier 2: d)total Modified Amount: 14. Total Workers Compensation Premium (line 11 plus 12 minus 13): 15. a) General Liab. Rate: b) Based On: c) Rate factor: Payroll Per $100 Receipts Per $1,000 GL Premium Other Cost: 16. a) Builder s Risk/Installation Floater Rate: b) Property Premium Costs: ) E /U b ll Rt b) Based On: c) Rate factor: 18. Total of all Insurance Premiums (total of lines 14, 15, 16 & 17): 19. Overhead & Profit on Insurance Prem. %: O/H & Profit Amount: 20. Total of Lower Tier Subcontractors Insurance Credits (Line 7d from Aon-2) 21. Total Initial Insurance Credit (Total of lines 18, 19 & 20): N/A Name: Title: (please print) Signature: Date: 24

29 F O R M S INSTRUCTIONS FOR INSURANCE CREDIT WORKSHEET (AON FORM-1) Complete a separate form for: 1. each Contractor, 2. known Subcontractor, and 3. trade not currently awarded to a Subcontractor. Completion of this form may be a required part of your bid. Duplicate this form as needed: 1. Contractor Information: Provide your companies Federal ID Number. Provide your Business Information including the Company Name, Address, City, State, Zip Code, Telephone and Fax in the column. Provide the name of your employee that can answer insurance questions. If this person s Business Address, Telephone and Fax is different enter this information in the column provided. 2. Work Information: Provide a brief description of the work your firm will perform. Identify your estimated contract value. Identify the amount your firm will self-perform (100% if no Subcontractors are used; otherwise, your proposed contract price less the amount to be subcontracted out). Check the box that applies to your status on this bid. Identify with whom you are contracting with (The District or the name of the Contractor or Subcontractor). 3. through 8. Workers Compensation Insurance Information: Description of Worker s Compensation Column Information R State & Class Code provide the state in which the work will be performed and the workers compensation classification codes that are applicable to the scope of your work. Description Provide the workers compensation class code descriptions that apply to the codes. Rate enter rate your firm pays for coverage for each class code. This information can be obtained from your Workers Compensation policy. Man-hours Provide your estimated man-hours, by class code, for work that will be performed on-site. Estimated On-site Payroll Provide your estimated on-site payroll, by class code, for work that will be performed on-site. WC Premium For each classification you entered, multiply the Payroll by the Rate and divide by Totals Calculate totals for columns numbered, and. 10. Workers Compensation Experience Modifier - Enter your experience modification factor. This number is located on your Workers Compensation policy or on the Bureau s rating sheets. If you do not have an experience modifier, use Modified Premium Multiply the total on line 9 by your workers compensation experience modifier. 12. Employers Liability Rate a) Enter your Employers Liability Rate located on your Workers Compensation policy and b) calculate by multiplying the Modified Premium by the rate. 13. Modification Premium Factors Identify the premium modification factors that apply to your Workers compensation policy. These factors may include a Scheduled Credit or a Premium Discount. A) Identify the name of the Modifier, b) enter the Rate, c) compute the Amount by calculating the Modified Premium by the Rate. Total the amount computed in column 13.c). Enter the total in d). 14. Total Workers Compensation Premium Add the Modified Premium and the Employers Liability Premium (line 11 and 12). Subtract the Premium Modifications identified and totaled in line 13d). Other Insurance Items: 15. General Liability a) Enter the General Liability rate, b) identify the bases the rate applies to by checking the box (if the basis is other, identify in the space provided), c) Check whether the rate factor is ($100 or $1,000). Compute the General Liability Premium by using the formula (rate bases * rate / rate factor). 16. Builder s Risk/Installation Floater Enter the rate and multiply by the values to be insured. Enter the premium on line Excess/Umbrella Liability a) Enter your Excess or Umbrella Liability rate, b) identify the basis the rate applies to by checking the box (if the basis is other, identify in the space provided), c) Check whether the rate factor is ($100 or $1,000). Compute the Excess or Umbrella Liability Premium by using the formula (rate basis * rate / rate factor). Total Insurance Premiums: 18. Total of all Insurance Premiums Add lines 14, 15, 16 and Overhead & Profit - a) Identify your percentage mark-up for Overhead & Profit included in your pricing structure; b) apply the percentage to Overhead & Profit to the Total of all Insurance Premiums. 20. Total Of All Lower Tier Subcontractors - Total from line 7d. on AON-2 Insurance Summary Form. Each lower tier Subcontractor should complete an Insurance Credit Worksheet, which would be summarized on the AON Total Initial Insurance Credit Add lines 17, 18 and 19. Return the completed, signed and dated Aon Form-1 with your Enrollment Application to identify the amount of insurance credit applied to your bid. 25

30 F O R M S Form-2 INSURANCE SUMMARY The Long Beach Unified School District OCIP The Long Beach Unified School District Project # Page 1 of 1 1. Name of Contractor: 2. Bid Package No.: 3. Total Proposed Cost: $ Contracting Parties & Trades Aon Form-1 Reference No. a Amount of Contract 2. B Estimated Worker-hours 9. C Estimated Payroll 9. d Initial Insurance Credit Contractor : 6. List Additional Trades NOT yet assigned to a sub (attach separate Aon Form 1 5. Your Known Subcontractors (Attach a Separate Aon Form-1 from each) 7. Total Estimates for Contract: 7a 7b 7c 7d 26

31 F O R M S INSTRUCTIONS FOR INSURANCE SUMMARY (AON FORM-2) Make a separate entry on the Aon Form-2 for each Contractor, known Subcontractor and trade not currently awarded to a Subcontractor. Duplicate this form as needed: General Information 1. Name of Contractor Enter the name of the Contractor or Subcontractor that is being summarized on the form. Bid Package No. Enter the Bid Package No. The District assigned to the bid. 2. Proposed Contract Cost Enter the Proposed Contract Cost for the Contractor or Subcontractor being summarized. Contractor Specific Information 3. Contractor Enter the Contractor or Subcontract that is being summarized (include only self-performed work from the Aon Form-1) b) Estimated Worker Hours (line 9 and column ) c) Estimated On-site Payroll (line 9 and column ) d) Initial Insurance Credit line 21). 5. Known Subcontractors For each Subcontractor summarize their work and the work of lower level tiers. Information will be obtained from either an Insurance Summary Aon Form-2, if lower level tiers were used, or the Aon Form-1. The Aon Form-1 reference numbers are supplied below: a) Amount of Contract The Proposed Contract Cost from Bid Information Section (2). b) Estimated Worker Hours The work performed by the Subcontractor and all lower level Subcontractors. Information from line 9 and column 6. c) Estimated On-site Payroll The work performed by the Subcontractor and all lower level Subcontractors. Information from line 9 and column.7 d) Initial Insurance Credit The work performed by the Subcontractor and all lower level tiers. Information obtained from line Identified Trades NOT yet assigned to a Subcontractor For each trade, not yet assigned to a Subcontractor, estimate the amount of work and insurance costs on Aon Form-1s. a) Amount of Contract The Estimated cost to subcontract the work. Information is obtained from the Proposed Contract Cost from Bid Information Section (2). b) Estimated Worker Hours The estimated on-site trade worker-hours. Information from line 9 and column 6. c) Estimated On-site payroll The estimated on-site trade payroll. Information from line 9 and column 7. Initial Insurance Credit the computed insurance costs for the trade based on estimated subcontract cost, including Contract Amount, Worker-hours and Payroll. The OCIP Administrator is available to provide reasonable insurance rates for computing the insurance costs on the Aon Form-1. Information obtained from line Total Estimates for Contract The total amount entered in column a, b, c, and d. 27

32 F O R M S Form-3 ENROLLMENT APPLICATION LB Unified School District Project # Page 1 of 2 It is suggested that you examine your current Workers Compensation and General Liability Policies or contact your Insurance Agent to assist you with completing this form. *** NOTICE *** Enrollment is not automatic and requires the satisfactory completion of the of this Form. Please refer to the Insurance Manual for coverage requirements. 1. Contractor Information: Federal ID No. Company Name & dba / Contact Name & Title: Address: City, State Zip Code: Telephone: Fax: Entity: Business Information (headquarters) Sole Proprietor Partnership Contact Information (address questions to ) Corporation Other: 2. Provide your current Workers Compensation Information: Anniversary Rating Date: Experience Modification: Bureau File Number: Your WC Insurance Carrier: Policy #: Effective Date: Expiration Date: 3. Contract Information: Contract #: Location of Work: Contract Description: Prime Status on Project: Subcontractor If you are a Sub, Identify who your contract is with: Contract Award Date: Provide Payroll by Class Code in the following space provided (attach a separate sheet if necessary) State Class Code Sub Subcontractor Other Description Man-hours Payroll Contacts: Totals Position Name & Title Phone Fax Address Project Mgr: Safety Rep: Contract Admin: Payroll: Start Date: Actual Estimated Completion Date: Actual Estimated Contract Amount: 28

33 F O R M S Form-3 ENROLLMENT APPLICATION (Instructions located on the following page) The Long Beach Unified School District OCIP LB Unified School District Project # Page 2 of 2 4. Subcontract Information: List any Subcontractors that will be working for you on this Project (complete the information in the following table). Use additional paper if necessary: Subcontractor Address Subcontract $ Phone Contact Person 5. Will you have any off-site location(s) 100% dedicated to this Project? Yes No If yes, please provide address: 6. Does your project work involve Remediation or handling of any hazardous material? Yes No If yes, will you subcontract out that portion of the work? Yes No If yes, to whom: 7. If you are a subsidiary and/or division of another company, complete an ERM-14 Form. If you are a participant as a joint venture partner, also complete an ERM-14 form. 8. Please check if: Any aircraft will used on this Project Any watercraft will used on this Project 9. Are you a Union Contractor? Yes No If yes, does your firm participate in Alternative Dispute Resolution with the Union? Yes No 10 Please indicate if labor from the following sources will be used: Employee Leasing Firms Temporary Labor Agency WARRANT Y Workers Compensation, General and Excess Liability, and Builder s Risk Insurance coverages, as stated in the Contract Documents, are provided by the Long Beach Unified School District. The undersigned agrees and warrants: 11. It is the Contractor s responsibility to notify it s own insurance carrier to exclude, from its regular insurance all Work to be performed at the Project Site under this Contract 12. The statements in this insurance application are true to the best of my knowledge. 13. Contractor warrants that the cost of OCIP insurance and the cost of OCIP insurance for all subcontracted Work have been deducted from their bid. 14. Contractor agrees to be solely responsible for the cost of the non-ocip insurance specified in the Contract. 15. The costs of premiums for the coverage provided by the OCIP shall be paid by the Long Beach Unified School District. The District will receive or pay, as the case may be, all adjustments to such costs, whether by way of dividends, retrospective rating adjustments, return premiums, audits or otherwise. Each Contractor and each of its Subcontractors shall execute any instruments of assignment as may be necessary to permit the Long Beach Unified School District to receive such adjustments, unless otherwise provided in the Contract Documents. Date: Title: Name: Signature: (please print) to: Long Beach Unified School District Attn: OCIP Administrator Aon Risk Solutions of Southern California kathleen.ritch@aon.com 29

34 F O R M S INSTRUCTION FOR ENROLLMENT APPLICATION (AON FORM-3) This form must be completed and submitted by each Contractor and Subcontractor of any tier prior to Site mobilization for each contract awarded. The Contractor and Subcontractor will submit the completed forms to Aon Risk Solutions. Upon receipt of this form, Aon will issue, to the Contractor and Subcontractor, a Certificate of Insurance evidencing coverage in the District Controlled Insurance Program. The completed Certificate of Insurance and Workers Compensation insurance policy will be mailed to each Enrolled Contractor and Subcontractor. 1. Contractor Information Supply the Federal ID Number, Legal Company Name (include the doing business as, d.b.a. if applicable), mailing address and phone numbers. Identify the individual that will answer insurance questions and be responsible for your OCIP Worker s Compensation policy. Also identify the legal structure of your company by checking one of the boxes. If you choose Other, write the structure in the space provided. 2. Provide your current Workers Compensation Information a) Enter information concerning your Worker s Compensation Experience Modifier in the table. Refer to your copy of the Bureau s Rating Calculation or contract your insurance agent or broker. i) The Anniversary Rating Date is the effective date or your unique Experience Modifier Factor. ii) The Experience Modification Factor is calculated by the Rating Bureau based on your loss experience and payroll. iii) The Bureau File Number is your identification number with the Bureau. It may also be referred to as a Risk Identification Number. b) Enter information concerning your current Worker s Compensation Policy. This information is available on the Declarations or Information page. 3. Contract Information a) Provide the contract number that was assigned by the District or the party you contract with. b) Provide a brief description of your work under this contract number. c) Identify the location of your contract work. This could be an area, phase or sub-project. (Phase 1 Landscape is example) d) Identify your status by checking one of the boxes provided. If you select other, identify what type of a Contractor you are. e) Identify the effective date of your contract. f) If you are a Subcontractor, identify with whom you have a contract. g) Contacts Communication is key to a successful OCIP. Identify the key contacts for each function listed and provide the information requested. If a single individual handles multiple job duties, be sure to list the functions that apply. h) Provide the Start Date and the Completion Date. Identify if these are the actual dates or have been estimated. i) Provide the amount of your contract. If you have a time and materials contract, provide a reasonable estimate of your anticipated activity. 4. Subcontract Information - List Subcontractors that will perform work on-site during the term of your Contract. Enrollment is NOT automatic. If you add or change subcontracting firms during the course of your contract, be sure to notify the OCIP Administrator. 5. Indicate if you have off-site location(s), including warehouses that are dedicated solely to this Project by checking the appropriate box. If the answer is yes, provide the address. If additional room is need, attach a separate sheet. Be sure to include the Address, City, State and Zip Code. 6. Indicate if your contract work involves remediation or handling of any hazardous materials. The OCIP DOES NOT provide coverage for certain hazardous materials. Indicate if you will subcontract this portion of your work. 7. ERM-14 forms are available upon request. Please contact the OCIP Administrator. 8. Check the appropriate box if you will be using aircraft or watercraft. 9. Indicate if your company participates in Alternative Dispute Resolution with the Union. 10. Indicate if your firm is using any Employee Leasing Firms or Temporary Labor Agencies. Read the Warranty statements completely. Sign the Aon Form-3 and return it to the OCIP Administrator using the information supplied at the bottom of the form. This form has been designed to fit in a standard window envelope for your convenience. 30

35 Exhibit 1 Sample Certificate of Insurance from Enrolled Contractors/Subcontractors ACORD CERTIFICATE OF LIABILITY INSURANCE ISSUE DATE: CURRENT DATE 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 CONTACT NAME: Insurance Agent s Name Phone: and Address INSURER(S) AFFORDING COVERAGE INSURED Contractor or Subcontractor s Name and Address Sample Certificate from Enrolled Contractor or Subcontractor Required Insurance COMPANY A LETTER COMPANY B LETTER COMPANY C LETTER COMPANY D LETTER INSURANCE CARRIER INSURANCE CARRIER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. CO LTR A TYPE OF INSURANCE GENERAL LIABILITY COMMERCIAL GEN. LIABILITY CLAIMS MADE OCCUR. OWNER'S & CONTRACTOR'S PROT. POLICY NO. Policy Number POLICY EFF. DATE MM/DD/YY POLICY EXP. DATE MM/DD/YY ALL LIMITS EACH OCCURRENCE FIRE DAMAGE (Any one fire) MEDICAL EXPENSE (Any one person) PERSONAL & ADVERTISING INJURY GENERAL AGGREGATE PRODUCTS-COMP/OPS AGGREGATE $1,000,000 $1,000,000 $2,000,000 $2,000,000 A A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS EXCESS LIABILITY UMBRELLA OTHER THAN UMBRELLA FORM Policy Number Policy Number COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE EACH OCCURRENCE AGGREGATE $1,000,000 B WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY OTHER: Policy Number Policy Number STATUTORY LIMITS (Each accident) (Disease-policy limit) (Disease-each employee) DESCRIPTION OF OPERATIONS/LOCATIONS: The Long Beach Unified School District, the OCIP Administrator, their respective officers, agents, and employees are Additional Insureds on a Primary and Non-contributing basis for General Liability, Automobile and Umbrella coverage. Waiver of Subrogation is included for General Liability and Workers Compensation. Per the attached endorsement(s). General Liability and Workers Compensation apply only to off-site operations. CERTIFICATE HOLDER The Long Beach Unified School District c/o Aon Risk Solutions 100 Bayview Circle, Suite 100 Newport Beach, CA (NOTE: Subcontractors should send certificates to their prime contractor) CANCELLATION $1,000,000 $1,000,000 $1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE By: ACORD 25-S (2009/09) ACORD CORPORATION

36 Exhibit 2 Sample Certificate of Insurance from Excluded Parties ACORD CERTIFICATE OF LIABILITY INSURANCE ISSUE DATE: CURRENT DATE 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 CONTACT NAME: Insurance Agent s Name Phone: and Address INSURER(S) AFFORDING COVERAGE INSURED Name and Address Sample Certificate from Excluded Parties Required Insurance COMPANY A LETTER COMPANY B LETTER COMPANY C LETTER COMPANY D LETTER INSURANCE CARRIER INSURANCE CARRIER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. CO LTR A A A TYPE OF INSURANCE GENERAL LIABILITY COMMERCIAL GEN. LIABILITY CLAIMS MADE OCCUR. OWNER'S & CONTRACTOR'S PROT. AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS EXCESS LIABILITY UMBRELLA OTHER THAN UMBRELLA FORM POLICY NO. Policy Number Policy Number Policy Number POLICY EFF. DATE MM/DD/YY POLICY EXP. DATE MM/DD/YY ALL LIMITS EACH OCCURRENCE FIRE DAMAGE (Any one fire) MEDICAL EXPENSE (Any one person) PERSONAL & ADVERTISING INJURY GENERAL AGGREGATE PRODUCTS-COMP/OPS AGGREGATE COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE EACH OCCURRENCE AGGREGATE (IF NEEDED) $3,000,000 $ $ $3,000,000 $3,000,000 $3,000,000 $1,000,000 $0,000,000 B WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY Policy Number STATUTORY LIMITS (Each accident) (Disease-policy limit) (Disease-each employee) $1,000,000 $1,000,000 $1,000,000 OTHER: Policy Number DESCRIPTION OF OPERATIONS/LOCATIONS: The Long Beach Unified School District, the OCIP Administrator, their respective officers, agents, and employees are Additional Insureds on a Primary and Non-contributing basis for General Liability, Automobile and Umbrella coverage. Waiver of Subrogation is included for General Liability and Workers Compensation. Per the attached endorsement(s). ALL COVERAGES APPLY ON-SITE AND OFF-SITE. CERTIFICATE HOLDER CANCELLATION Prime Contractor Prime Contractor Name and Address SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE By: ACORD 25 (2009/09) ACORD CORPORATION

37 Exhibit OLD REPUBLI C CONSTR UCTION PROGRAMGROUP LONG BEACH UNIFI E D SCHOOL DISTRICT CALIFORNIA CUSTOM MEDICAL PROVIDER NETWORK (GBMCS MPN) EMPLOYER IMPLEMENTATION CHECKLIST Gallagher Bassett Services, Inc. Re: GBMCS MPN - DWC MPN Approval # Please follow this Checklist to implement your MPN. Please check off these steps as you complete them. Provide your current and new hire employees with the MPN Implementation Notice. There is both an English and Spanish version. Regardless of which language the employee speaks, please give the employee both the English and Spanish version. Ask each employee to sign to acknowledge receipt of the MPN information and keep a copy in the job file or their personnel file. Post the DWC-7 at the workplace. Place this information in the MPN section of the DWC-7. MPN effective date - This is the date you enrolled in the LBUSD OCIP. Post the Full Written MPN Notice next to the DWC-7, at the workplace. Both the English and Spanish versions must be posted. At time of injury, the injured worker must receive the Full Written MPN Notice. Create a MPN Panel Card and post it at the workplace. Using your Internet Browser, go to to create the Panel Cards. At the Client Login, select the First Health Portal Login. Your Employer/Client ID is GBMPN. On the next screen you will click on Channeling Tools. Then click on the Work Site Posters tab. Review the following GB California MPN Informational Internet Site. This MPN Informational Internet Site is designed for GB s clients. It provides the latest MPN information, rules and regulations, and allows you to download all the MPN documents contained in this package. Using your Internet Browser, go to click on the LOGIN The User Name is gb_training4; The Password is gbmcsmpn1 All California Employers Must Review the Poster & Employee Notification/Employer Obligations Web Page on the GB California MPN Informational Internet Site. This Web Page will alert you on your Employer Obligations for California Poster and Employee Notifications as of October 8, Send all MPN questions to your GB Account Manager or to gb-cm-gbmcs-mpnmail@gbtpa.com. Please include your GB client number (003138) in the subject line of your s. If you need additional information regarding programs and services offered by GB, please contact your OCIP administrator or insurer. 34