AGREEMENT between BROWARD COUNTY and Cummings ...

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Exhibit 2 Page 188 of 379 FIRST REPORT OF INJURY OR ILLNESS RECEIVED BY CARRIER SENT TO DIVISION DIVISION REC'D DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION For assistance call 1-800-342-1741or contact your local EAO Office. Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953 PLEASE PRINT OR TYPE EMPLOYEE INFORMATION Name (First, Middle, Last) Social Security Date of Accident Time of Home Address Employee's Description of Accident (Include Cause of injury) Street/Apt #: City: State: Zip: Telephone: OCCUPATION Cause of Injury: DATE OF BIRTH SEX INJURY/ILLNESS THAT OCCURED PART OF BODY AFFECTED Company D.B.A.: Contact: Street: City: State : FL Zip: EMPLOYER INFORMATION FEDERAL ID NUMBER (FEIN) NATURE OF BUSINESS DATE FIRST REPORTED POLICY/MEMBER NUMBER Telephone Number: DATE EMPLOYED PAID FOR DATE OF INJURY Employer's Location Address (if different) Street: City: State: FL Zip: Location # : LAST DATE EMPLOYEE WORKED RETURNED TO WORK WILL YOU CONTINUE TO PAY WAGES INSTEAD OF WORKERS’ COMP LAST DAY WAGES WILL BE PAID INSTEAD OF WORKERS’ COMP IF YES, GIVE DATE RATE OF PAY PER Hour Day Place of Accident (street, city, Zip) DATE OF DEATH (If applicable) Number of hours per day Street: AGREE WITH DESCRIPTION OF ACCIDENT Number of hours per week City: State: Zip: County of Accident: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. I have reviewed, understand and acknowledge the above statement. ____________________________________ _______ Employee Signature Date _______ Employee Signature Date Number of days per week NAME, ADDRESS AND TELEPHONE OF OF PHYSICIAN OR HOSPITAL Physician: Hospital: AUTHORIZED BY EMPLOYER CLAIMS-HANDLING ENTITY INFORMATION 1(a) Denied Case - DWC-12, Notice of Denial Attached 2. Medical Only which became Lost Time Case (Complete all required information in #3) 1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached Employee’s 8TH Day of Disability _______ / ______ / _______ Entity’s Knowledge of 8TH Day of Disability ______ / _______ / _______ 3. Lost Time Case - 1st day of disability ____ / ____ / ____ Full Salary in lieu of comp YES Full Salary End Date ______/ ______ / ______ Date First Payment Mailed _________ / _________ / _________ AWW ____________________________ Comp Rate ____________________________ T.T. T.T. - 80% T.P. I.B. P.T DEATH SETTLEMENT ONLY Penalty Amount Paid in 1st Payment $___________ Interest Amount Paid in 1st Payment $__________ REMARKS: INSURER NAME INSURER Code EMPLOYEE'S RISK CLASS CODE EMPLOYER'S NAICS CODE Service Co/TPA Code # CLAIMS-HANDLING ENTITY FILE # Week Month Yes Broward County Risk Management 115 S. Andrews Avenue, Suite 210 Ft. Lauderdale FL 33301 (954) 357-7200 Form DFS-F2-DWC-1 (08/2004) B
Exhibit 2 Page 189 of 379 CONTRACTOR’S DRUG TESTING CERTIFICATION I, _________________________(Principal Officer of Employing Company), as an authorized representative of _________________________________(Company Name), hereby certify that all employees reporting for work on the work sites have been tested for the presence of drugs or alcohol. _____________________________ Company Name By _________________________ STATE OF __________________ Title _________________________ COUNTY OF __________________ Sworn to and subscribed before me this ___________ day of ______________, 20____ by __________________________ who is personally known / or who produced identification ___________________________ (type of identification produced). ______________________________________________________ Notary Public My commission expires: _____________ No. ___________________________ C
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Exhibit 2 Page 3 of 379 Terminal 4
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Terminal 4 Gate Replacement - Weste
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Exhibit 2 Page 99 of 379 Owner Cont
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Exhibit 2 Page 101 of 379 TABLE OF
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Exhibit 2 Page 103 of 379 OVERVIEW
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Exhibit 2 Page 105 of 379 OVERVIEW
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Exhibit 2 Page 107 of 379 OCIP PROG
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Exhibit 2 Page 109 of 379 OCIP INSU
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Exhibit 2 Page 111 of 379 OCIP INSU
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Exhibit 2 Page 113 of 379 CONTRACTO
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Exhibit 2 Page 123 of 379 CLAIM REP
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Exhibit 2 Page 125 of 379 CLAIM REP
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AONWRAP WEB INSTRUCTION Exhibit 2 P
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AONWRAP WEB INSTRUCTION 10. Type yo
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AONWRAP WEB INSTRUCTION Exhibit 2 P
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Exhibit 2 Page 133 of 379 Form-3 En
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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
Page 183 and 184: D. Security - General Project Rules
Page 185 and 186: I. Delivery and Removal of Material
Page 187: Exhibit 2 Page 187 of 379 FIRST REP
Page 191 and 192: Exhibit 2 Page 191 of 379 d. Analyz
Page 193 and 194: Exhibit 2 Page 193 of 379 4. PPE cu
Page 195 and 196: Exhibit 2 Page 195 of 379 WITNESS S
Page 197 and 198: Exhibit 2 Page 197 of 379 Sequence
Page 199 and 200: Exhibit 2 Page 199 of 379 LOCK-OUT
Page 201 and 202: Exhibit 2 Page 201 of 379 ORIENTATI
Page 203 and 204: Exhibit 2 Page 203 of 379 SAFETY OB
Page 205 and 206: Exhibit 2 Page 205 of 379 CONTRACTO
Page 207 and 208: Exhibit 2 Page 207 of 379 DIVISION
Page 209 and 210: DIVISION 1 SPECIFICATIONS - SECTION
Page 215 and 216: DIVISION 1 SPECIFICATIONS SECTION 0
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DIVISION 1 SPECIFICATIONS SECTION 0
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DIVISION 1 SPECIFICATIONS - SECTION
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Exhibit 2 Page 303 of 379 DIVISION
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Exhibit 2 Page 311 of 379 DIVISION
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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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AGREEMENT between BROWARD COUNTY and Cummings ...

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