AGREEMENT between BROWARD COUNTY and Cummings ...

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FORMS Exhibit 2 Page 132 of 379 8 Forms This section contains the forms needed for reporting claims, reporting payroll and administration of the OCIP. Aon Forms 3-5 should be reported on-line at: https://www.aonwrap.aon.com This section contains the following forms: Aon Form-3 Aon Form-4 Aon Form-5 Aon Form-A Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Enrollment Application Monthly On-Site(s) Payroll Report Notice of Work Completion Notice of Award Sample Certificate of Insurance – Enrolled Contractors and Subcontractors Sample Certificate of Insurance – Excluded Contractors and Subcontractors Workers’ Compensation Claim Form Broward County Loss Notice Note: For assistance in completing these forms, please contact the Insurance Administrator listed below: Aon Risk Services – Diana Schrader , Program Administrator Phone: 407.804.2418 Fax: 407.804.1077 Email: Diana.Schrader@aon.com Broward County, Florida 31 Owner Controlled Insurance Program OCIP Manual – 07/01/2010 Rev. 0002
Exhibit 2 Page 133 of 379 Form-3 Enrollment Application Form 3 Numbers reference attached instructions BROWARD COUNTY, FL Page 1 of 3 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 Aon Form-1a or Form-1b, Form-2 and Form-3. In addition, submit a Certificate of Insurance providing evidence of your off- Site(s) coverage. Please refer to the Insurance Manual for coverage requirements. A. Contractor Information: Federal ID # or Soc. Sec. #: 1 Company Name & dba: Contact Name & Title: Address: u Business Information (headquarters) 2 3 u Contact Information (address questions to..) City, State Zip Code: Telephone: Fax: Email Address: Indicate your Organization’s Structure: 4 Corporation Joint Venture Partnership Sole Proprietor S-Corporation Other _____________________________ Contract No.: B. CONTRACT INFORMATION: BROWARD COUNTY Date Contract Awarded: 2 Description of Work: 3 Proposed Contract Price $: 4 Are you Submitting a bid to BROWARD COUNTY 6 Yes No Amount of Self Performed Work $: 5 If No, identify to whom: 7 7 Actual 8 Actual Start Date: Estimated Completion Date: Estimated C. Contacts: (Complete if Applicable) Position 1 Name & Title 2 Phone 3 Fax 4 email address Project Mgr: Res. Engineer: Insurance: Contract Admin: Payroll: Claims: Safety Rep: Provide Location of payroll records if 5 different than Corporate address: Phone: City, State, Zip Code: Fax: D. Workers’ Compensation Insurance Information for Work Described Above: (attach a separate sheet if necessary) a State b Class Code c Description d Man-hours 1 e Payroll Totals 2 3 E. Provide your current Off-Site(s) Workers’ Compensation Information: (for each state you will perform work in) Applicable State Risk ID Number Rating Bureau Anniversary Rating Date 1 2 3 4 Your WC Insurance Carrier: 5 Policy #: 6 Effective Date: 7 Expiration Date: 8
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Exhibit 2 Page 3 of 379 Terminal 4
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Page 81 and 82: Exhibit 2 Page 81 of 379 Terminal 4
Page 87 and 88: Terminal 4 Gate Replacement - Weste
Page 99 and 100: Exhibit 2 Page 99 of 379 Owner Cont
Page 101 and 102: Exhibit 2 Page 101 of 379 TABLE OF
Page 103 and 104: Exhibit 2 Page 103 of 379 OVERVIEW
Page 105 and 106: Exhibit 2 Page 105 of 379 OVERVIEW
Page 107 and 108: Exhibit 2 Page 107 of 379 OCIP PROG
Page 109 and 110: Exhibit 2 Page 109 of 379 OCIP INSU
Page 111 and 112: Exhibit 2 Page 111 of 379 OCIP INSU
Page 113 and 114: Exhibit 2 Page 113 of 379 CONTRACTO
Page 123 and 124: Exhibit 2 Page 123 of 379 CLAIM REP
Page 125 and 126: Exhibit 2 Page 125 of 379 CLAIM REP
Page 127 and 128: AONWRAP WEB INSTRUCTION Exhibit 2 P
Page 129 and 130: AONWRAP WEB INSTRUCTION 10. Type yo
Page 131: AONWRAP WEB INSTRUCTION Exhibit 2 P
Page 135 and 136: Exhibit 2 Page 135 of 379 Enrollmen
Page 137 and 138: Form-4 On-Site(s) Payroll Report In
Page 139 and 140: Form-5 Notice of Work Completion In
Page 141 and 142: Exhibit 1 - Sample Certificate of I
Page 143 and 144: Exhibit 3 - First Report of Injury
Page 145 and 146: Exhibit 2 Page 145 of 379
Page 147 and 148: TABLE OF CONTENT Exhibit 2 Page 147
Page 149 and 150: Exhibit 2 Page 149 of 379 SECURITY
Page 151 and 152: INTRODUCTION Exhibit 2 Page 151 of
Page 153 and 154: DEFINITIONS Exhibit 2 Page 153 of 3
Page 155 and 156: ACRONYMS Exhibit 2 Page 155 of 379
Page 157 and 158: Conduct hazard communication traini
Page 159 and 160: 12. Review and evaluate contractors
Page 161 and 162: or minimize exposures that will or
Page 163 and 164: 2) Positioning device system allows
Page 165 and 166: F. Welding and Cutting Exhibit 2 Pa
Page 167 and 168: 13) Complete and file on site a Loc
Page 169 and 170: M. Job Safety Analysis Exhibit 2 Pa
Page 171 and 172: SAFETY TRAINING Exhibit 2 Page 171
Page 173 and 174: 4. Contractor Safety Audit This Saf
Page 175 and 176: d) The OCIP insurance carrier perso
Page 177 and 178: Exhibit 2 Page 177 of 379 EMERGENCY
Page 179 and 180: Obtain a hurricane tracking and inf
Page 181 and 182: SECURITY Exhibit 2 Page 181 of 379
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D. Security - General Project Rules
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I. Delivery and Removal of Material
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Exhibit 2 Page 187 of 379 FIRST REP
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Exhibit 2 Page 189 of 379 CONTRACTO
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Exhibit 2 Page 191 of 379 d. Analyz
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Exhibit 2 Page 193 of 379 4. PPE cu
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Exhibit 2 Page 195 of 379 WITNESS S
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Exhibit 2 Page 197 of 379 Sequence
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Exhibit 2 Page 199 of 379 LOCK-OUT
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Exhibit 2 Page 201 of 379 ORIENTATI
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Exhibit 2 Page 203 of 379 SAFETY OB
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Exhibit 2 Page 205 of 379 CONTRACTO
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Exhibit 2 Page 207 of 379 DIVISION
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DIVISION 1 SPECIFICATIONS - SECTION
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DIVISION 1 SPECIFICATIONS SECTION 0
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Exhibit 2 Page 329 of 379 PART 1 -
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Exhibit 2 Page 331 of 379 Broward C
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Badging Requirements and Ramp Drivi
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Exhibit 2 Page 349 of 379 EXHIBIT 1
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Exhibit 2 Page 351 of 379 NUMBER VE
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TERMINAL 4 GATE REPLACEMENT - WESTE
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Exhibit 2 Page 359 of 379 TERMINAL
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Exhibit 2 Page 361 of 379 TERMINAL
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Exhibit 2 Page 363 of 379 FORM 1: C
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Exhibit 2 Page 365 of 379 FORM 3 FO
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Exhibit 2 Page 367 of 379 FORM 4: F
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Exhibit 2 Page 369 of 379 FORM OF P
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Exhibit 2 Page 371 of 379 FORM OF P
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MONTHLY (CBE) UTILIZATION REPORT Ex
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FINAL (CBE) UTILIZATION REPORT Exhi
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Exhibit 2 Page 377 of 379 CBE UNAVA
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Exhibit 2 Page 379 of 379 CERTIFICA
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