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					      New York City School
     Construction Authority




Owner Controlled INSURANCE PROGRAM
     CONSTRUCTION INSURANCE MANUAL
           JANUARY 1, 2011 - JANUARY 1, 2014



Willis of New York Inc.
One World Financial Center
200 Liberty Street, 6th Floor
New York, New York 10281
Phone: (212) 915-7702
Toll Free: (866) 400-8395
                           SCA’S OCIP
   NEW YORK CITY SCHOOL CONSTRUCTION AUTHORITY



       OWNER CONTROLLED INSURANCE PROGRAM
                                                OCIP
______________________________________________




          OCIP INSURANCE MANUAL

                                 30-30 Thomson Avenue
                             Long Island City, New York 11101



____________________________________________
Willis of New York, Inc., 1 World Financial Center, 200 Liberty Street, New York, New York 10281
OCIP Insurance Manual –This manual is a contract document. Issued as of January 1, 2011



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The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011



                                   TABLE OF CONTENTS
1.     INTRODUCTION                                                                                3

2.     DEFINITIONS                                                                            4–5

3.     INSURANCE                                                                              6 – 24

       3.1       CONTRACTORS’ RESPONSIBILITIES UNDER THE OWNER
                 CONTROLLED INSURANCE PROGRAM
       3.2       OWNER CONTROLLED INSURANCE PROGRAM PROVIDED
                 COVERAGES:
                 3.2.1 OWNER CONTROLLED INSURANCE PROGRAM PROVIDED
                       COVERAGES FOR NON-ENVIRONMENTAL CONTRACTORS
                 3.2.2 OWNER CONTROLLED INSURANCE PROGRAM PROVIDED
                       COVERAGES FOR ENVIRONMENTAL CONTRACTORS
       3.3       CONTRACTORS’ PROVIDED COVERAGES:
                 3.3.1 NON-ENVIRONMENTAL CONTRACTORS’ PROVIDED
                       COVERAGES
                 3.3.2 ENVIRONMENTAL CONTRACTORS’ PROVIDED COVERAGES
4.     ADMINISTRATION AND ENROLLMENT PROCEDURES                                              24 – 25
5.     SAFETY PROGRAM                                                                        25 – 26
6.     CLAIM PROCEDURES                                                                      26 – 30
       REQUEST FOR LOSS HISTORY
7.    ADMINISTRATION DIRECTORY                                                               31– 36
      INTERNET BASED PAYROLL REPORTING
EXHIBITS
E-1                Contractors’ Request for Insurance Form (RFI) and
                   Subcontractor Approval Form (SAF) (4 pages)
E-2                       Jobsite Incident Report and SCA Emergency/Incident Notification Report
                           (2 pages)
E-3                       Employer’s Report of Work-Related Accident / Occupational Disease C-2
                          (6 pages) and
                          Patient Information Packet (8 pages)
E-4                       General Liability Notice of Occurrence / Claim (4 pages)
E-5                       Property Loss Notice (3 pages)




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The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011



                                    1.       INTRODUCTION

The New York City School Construction Authority (SCA) has elected to purchase and administer the SCA’s
Owner Controlled Insurance Program (SCA’s OCIP) for the renovation and construction of New York City
educational facilities throughout the five (5) boroughs.

This manual identifies, defines, and assigns responsibilities related to the administration and structure of
the SCA’s OCIP for the New York City School Construction Authority and is intended to provide general
information as to the insurance afforded or required, and the procedures to be followed in administering the
program.

It describes the SCA’s OCIP and details the insurance-related responsibilities of the various parties
involved. It provides a basic understanding of the SCA’s OCIP structure and operations with an overview
of coverages provided by the SCA’s OCIP and guidelines for carrying out specific administrative and audit
procedures.

Insurance coverages and limits provided under the SCA’s OCIP are limited in scope and are specific to
work performed after the inception date of your enrollment into this program.

All SCA’s OCIP Eligible Contractors and Subcontractors of all tiers working at the Project Sites will be
subject to the provisions of the SCA’s OCIP. The provisions for insurance shall in no way be interpreted as
relieving any of the parties of any responsibility whatsoever. Your insurance representative should review
this information. Any additional coverage you wish to purchase will be at your own option. SCA’s OCIP
Eligible Contractors and Subcontractors of all tiers may carry, at their own expense, such additional
insurance, as they may deem necessary.

This manual provides answers to questions concerning the program that are likely to arise during the
course of the Project. Since it is impossible to anticipate every question or situation that may arise, the
directory lists those involved in the administration of the SCA’s OCIP and their areas of expertise. Please
feel free to contact these individuals with any questions.

This manual does not provide coverage interpretations, complete information about coverages, and
exclusions or answers to specific claims questions.


DISCLAIMER: The materials in this Manual are not intended to provide coverage interpretations or
serve as a substitute for the actual policies. The information in this manual is intended to outline
the SCA’s OCIP. The terms and conditions of the OCIP policies alone govern how coverages are
applied. Policies will be issued and will be made available upon request. Therefore, if any conflict
exists between this manual and the OCIP insurance policies, the OCIP policies will govern.




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The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011



                                       2.      DEFINITIONS

Owner Controlled Insurance
Program (OCIP)                A centralized insurance, claims, and loss control program implemented to
                              cover the Owner and all eligible Contractors and Subcontractors of all tiers.
                              The Program under which Workers’ Compensation and Employers’ Liability,
                              Commercial General Liability, Umbrella and Excess Liability, Contractors’
                              Pollution Liability, and Builder’s Risk coverages are procured or provided on a
                              project “wrap-up” basis for Contractors or Subcontractors of any tier, who
                              have been properly enrolled, while performing operations at Project Sites.

Insureds                      New York City School Construction Authority (NYCSCA), collectively
                              hereinafter called “the Owner”, Contractors and Subcontractors of any tier
                              who are enrolled in the SCA’s OCIP and who have been named in a policy,
                              certificates of insurance, or evidence of insurance signed by a duly authorized
                              representative of the Insurers.

Insurers                      Workers' Compensation and Employers’ Liability – Liberty Mutual Insurance
                              Company
                              Commercial General Liability – Liberty Mutual Insurance Company
                              Umbrella & Excess Liability – Lloyds of London
                              Contractors’ Pollution Liability – American International Specialty Lines
                              Insurance Company (Chartis, formerly known as AIG)
                              Builder’s Risk – Travelers Property Casualty Company of America

OCIP Administrator            Willis of New York, Inc., Construction Practice is the firm responsible for the
                              brokering and administration of the SCA’s OCIP.

Project Sites or Project
Locations                     Educational Facilities throughout the five (5) boroughs of New York City and
                              any sites designated by “the Owner”. The Project Sites include operations
                              necessary or incidental thereto, providing such necessary or incidental
                              operations shall not include operations at the insured’s regularly established
                              workplace, plant, factory, office, shop, warehouse, yard, or other property
                              even if such operations are for fabrications of materials to be used at the
                              Project.

On-site Activities            Those activities at the Project Sites or emanating therefrom such as adjacent
                              sidewalks, streets, and areas as directed by New York City School
                              Construction Authority.

Program Participants          The Construction Managers, SCA’s OCIP Eligible Contractors and
                              Subcontractors of all tiers. Persons who only transport, pickup, deliver, or


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Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


                              carry materials; personnel or parts of equipment to or from the project sites,
                              material men and consultants providing professional services shall not be
                              program participants.

OCIP Eligible Contractors
and Subcontractors        Includes Contractors or Subcontractors of all tiers who perform direct
                          operations at Project Sites in connection with the work, and who have been
                          approved SCA’s OCIP Eligible by the Owner for participation in the SCA’s
                          OCIP. Temporary labor services and leasing companies are to be treated as
                          Subcontractors.

OCIP Ineligible Contractors
and Subcontractors          Includes (but are not limited to) consultants, suppliers (who do not perform or
                            subcontract installation), truck men, delivery personnel, material handlers
                            and / or vendors, and other temporary project services. Excluded Parties are
                            not granted any insurance coverage under the OCIP.

Certificate of Insurance       Written evidence of the existence of coverages outlining the limits of liability,
                               terms, and conditions of insurance policies.

Evidence of Coverage           Each Enrolled Party will be issued an individual Worker’s Compensation
                               policy provided by the OCIP primary insurer. The OCIP Administrator will
                               provide, if applicable, a Certificate of Insurance evidencing Workers’
                               Compensation, Employers’ Liability, General Liability, Umbrella Liability,
                               Excess Liability, Contractors’ Pollution Liability, and Builder’s Risk Coverage
                               to each Enrolled Party. Each will be added as an Additional Named Insured
                               to the OCIP General Liability insurance policy. Copies of the OCIP policies
                               will be issued by the carriers and will be made available for review upon
                               request.

Contract Document              A written agreement between the SCA and their General
                               Contractors/Construction Managers or a written agreement between the
                               General Contractors/Construction Managers and their Subcontractors of any
                               tier.

Work                           Operations, as fully described in the Contract Document performed at the
                               Project Sites.




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The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011



                                        3.      INSURANCE
New York City School Construction Authority hereinafter collectively called the Owner has elected to
implement an Owner Controlled Insurance Program (SCA’s OCIP) that will provide Workers’ Compensation
and Employers’ Liability, Commercial General Liability, Umbrella and Excess Liability, Contractor’s
Pollution Liability, and Builder’s Risk coverages to all SCA’s OCIP Eligible Contractors and Subcontractors
of every tier providing direct labor at Project Sites. The Owner agrees to pay all premiums associated with
the SCA’s OCIP.

While the SCA’s OCIP is intended to provide broad coverages and high limits, the SCA’s OCIP is not
intended to meet all the insurance needs of the Contractors and Subcontractors. The SCA’s OCIP does
not provide coverages for Automobile Liability, Contractors’ Equipment, Payment and Performance
Bonds, or Disability Insurance. We recommend that the Contractors and Subcontractors discuss the
coverages provided under the SCA’s OCIP with their insurance brokers, agents or consultants to assure
that they procure such additional insurance as they may deem necessary.

3.1 CONTRACTORS’ RESPONSIBILITIES UNDER THE SCA’S OCIP
3.1.1   Applicability of the SCA’s OCIP

Participation in the SCA’s OCIP is mandatory, but not automatic. All Contractors and Subcontractors must
complete a Subcontractor Approval Form (SAF) and a Contractor’s Request for Insurance Form, refer to
Exhibit E-1, and submit these forms to the Owner.

3.1.2   Contractors’ Responsibilities for their Subcontractors

It is the responsibility of each Contractor to require that all of its Subcontractors complete and submit a
Subcontractor Approval Form (SAF) and a Contractor’s Request for Insurance, refer to Exhibit E-1.

3.1.3   Audit and Recovery of Contractors Insurance Cost

The Contractors agree, and shall require all tiers of Subcontractors to agree, to keep and maintain accurate
and classified records of their operations at Project Sites. The Contractors and Subcontractors shall permit
the Owner and its representatives to examine and / or audit their books and records. Contractors shall also
provide any additional information to the Owner or its appointed representatives as may be required.

3.1.4   Certificates of Insurance and Policies

Certificates of Insurance will be furnished by Willis of New York, Inc. evidencing enrollment under the
SCA’s OCIP for the Workers’ Compensation, Employers’ Liability, Commercial General Liability, Umbrella
and Excess Liability, Contractors’ Pollution Liability, and Builder’s Risk coverages. These policies are
available for review by the Contractors upon request to the Owner. The terms of such policies or
programs, as such policies or programs may be from time to time amended, are incorporated herein by



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Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


reference. Contractors hereby agree to be bound by the terms of coverages as contained in such
insurance policies.

3.1.5   Termination / Modification of the SCA’S OCIP

Workers’ Compensation Insurance will be terminated, except as noted under Commercial General Liability,
Umbrella and Excess Liability Insurance for Completed Operations, when SCA’s OCIP Eligible Contractors
or Subcontractors have completed their work at Project Sites. The Contractors will promptly notify the
SCA’s Project Officers and submit a Notice of Completion of Work to the Owner’s Construction
Management. An audit will be performed and issued shortly thereafter.

If a Notice of Completion of Work is not received, all policies will be automatically audited after
expiration of the policies!

The Owner reserves the right to terminate or to modify the SCA’s OCIP or any portion thereof. To exercise
this right, the Owner shall provide thirty (30) days advance written notice of termination or material
modification to the Contractors and Subcontractors covered by the SCA’s OCIP. In such event, the
Contractors and Subcontractors shall promptly obtain appropriate replacement insurance coverage
acceptable to the Owner. Written evidence of such insurance shall be provided to the Owner prior to the
effective date of the termination or modification of the SCA’s OCIP coverages.

3.1.6   Contractors’ Responsibilities

The SCA’s OCIP Eligible Contractors and Subcontractors are required to cooperate with OCIP Insurance
Administrators with regard to the administration and operation of the SCA’s OCIP. The Contractors’ /
Subcontractors’ responsibilities shall include, but not be limited to:

-       Compliance with applicable Construction Safety Program, SCA’s OCIP Program Construction
        Insurance Manual and claims procedures as outlined in the respective manuals setting forth the
        procedures required of the Contractors or Subcontractors;
-       Provision of necessary contract, operations and insurance information;
-       Cooperation with any insurance companies or SCA’s OCIP Insurance Administrators with respect to
        requests for claims, payroll or other information required under the program;
-       Completion and submission of administrative forms as described in Section 4, Administration and
        Enrollment Procedures.

3.1.7   Payroll and Audit Procedures

The Insurance Company may audit SCA’s OCIP Eligible Contractors' and Subcontractors' records at any
time during the normal business hours. Payroll and Workers’ Compensation losses will be filed with the
appropriate Rating Bureau.




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The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


All SCA’s OCIP Eligible Contractors and Subcontractors will be required to:
-       Maintain all records including payroll information pertaining to this project for a period of not less
        than three (3) years after acceptance of the Work;
-       Maintain payroll records separate from the SCA’s OCIP Eligible Contractors' and Subcontractors'
        normal operations payroll for the work performed on all Projects, and to have such records
        available upon request of the insurance company;
-       Assign payrolls to the proper Workers' Compensation classification and maintain records in a
        manner that will readily permit the payroll auditor to distinguish premium for overtime pay and limit
        the payroll in accordance with the New York State Payroll Limitation Law; and
-       Verify that payrolls reported shall be for Project Site Work only.

3.1.8   Assignment of Return Premiums

The Owner will be responsible for the payment of all premiums associated with the SCA’s OCIP and will be
the sole recipient of any dividend(s) and / or return premium(s) generated by the OCIP. In consideration of
the Owner’s provision of said coverages under the SCA’s OCIP Program, the Contractors and
Subcontractors agree to:
-       Remove all applicable insurance costs from their contract bid price and cooperate with the SCA’s
        OCIP Insurance Administrator in the identification of the Contractors’ insurance costs, if requested
        to do so; and
-       Irrevocably assign to, and for the benefit of the Owner, all return premiums, premium refunds,
        premium discounts, dividends, retentions, credits, and any other monies in connection with the
        SCA’s OCIP insurance.


3.2 SCA’S OCIP PROVIDED COVERAGES

3.2.1 SCA’S OCIP Provided Coverages for Non Environmental Contractors
The SCA’s OCIP will be for the benefit of the Owner, SCA’s OCIP Eligible Contractors and Subcontractors
of any tier. Such coverage applies only to work performed under the Agreement with the Owner at the
Project Site. SCA’s OCIP Eligible Contractors and Subcontractors must provide their own insurance
for off-site activities.

The Owner, at its sole expense, will provide and maintain in force as part of the SCA’s OCIP, the types of
insurance listed in sub-sections (A) through (E) below. The Contractors and Subcontractors enrolled in the
SCA’s OCIP agree that the insurance companies’ policy limits of liability, coverages, terms, and conditions
shall determine the scope of coverage provided by the SCA’s OCIP.

The insurance below will apply only to claims arising out of operations conducted at the Project
Sites.



                                                                                               Page 8 of 36
The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


(A)     Workers’ Compensation and Employers’ Liability

Will be provided in accordance with the laws of the State of New York, or any other applicable jurisdiction.
Employees covered by this insurance are those employees whose full-time duties will be performed at
Project Sites, and other employees actually doing work in connection with the Project while physically on
the Project Sites. Each enrolled Contractor and Subcontractor will receive its own SCA’s OCIP Workers’
Compensation policy for all work performed for the Owner for a period of one year as follows:

(a)     Limits

        Workers’ Compensation – New York State Statutory Benefits

        Employers’ Liability

        $2,000,000       Bodily Injury by Accident – Each Accident
        $2,000,000       Bodily Injury by Disease – Policy Limit
        $2,000,000       Bodily Injury by Disease – Each Employee

(B)     Commercial General Liability

Will be provided on ISO CG 00 01 (12 04) Occurrence Form as follows:

(a)     Limits

        $ 5,000,000      Each Occurrence
        $ 2,000,000      Personal and Advertising Injury
        $10,000,000      General Aggregate Limit - Per Location *
        $ 5,000,000      Products / Completed Operations Aggregate Limit - Per Borough**
        $ 1,000,000      Damages to Premises Rented to You Limit - Any one Premises
                         (Subject to an Occurrence Limit)
        $    10,000      Medical Expense - Any one Person (Subject to Occurrence Limit)

        *        General Aggregate will reinstate annually
        **       Seven (7) years Products / Completed Operations Aggregate - Per Borough will have
                 one (1) aggregate Per Borough for seven (7) years. The Products Completed
                 operations Aggregate Limits will apply separately to each Borough as defined:

                  1.     Bronx
                  2.     Brooklyn
                  3.     Manhattan
                  4.     Queens
                  5      Staten Island




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The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


(b)     Terms and Conditions

        _        Blanket Contractual Liability amended to delete provision which excludes work within 50 feet of
                 railroad
        −        Limitation of Coverage to Designated Premises
        −        Blanket Additional Insureds as required by written contract
        −        Waiver of Subrogation as required by written contract
        −        Cross Liability and Severability of Interest
        −        Explosion, Collapse, and Underground “XCU” Coverage
        −        Notice of Occurrence
        −        Knowledge of Occurrence / Loss
        −        Unintentional Failure to Disclose
        −        Broadened Damage to Premises Rented To You Coverage
        −        Damage to Your Work Amendment

(c)     Exclusions include, but are not limited to:

        −        Any loss or damage to the Project itself
        −        Engineers, Architects or Surveyors Professional Liability
        −        Contractors’ Professional Liability
        −        Total Pollution Exclusion with a Building Heating Equipment Exception and Hostile Fire
                 Exclusion
        −        Discrimination Exclusion
        −        New York Asbestos Exclusion
        −        New York Lead Exclusion
        −        Exterior Insulation and Finish Systems
        −        Mold and Mold Related Construction Defect Exclusion / Fungus
        −        War
        −        Nuclear Energy Liability Exclusion
        −        Employment - Related Practices
        −        Abuse or Molestation Exclusion
        −        Radioactive Matter
        −        Aircraft Products Exclusion

This policy does not cover off-site operations. This insurance is primary for all occurrences at the Project
Sites for enrolled parties. A single General Liability policy will be issued for all Enrolled Parties with all
Enrolled Parties Named as Insureds.

(C)    Umbrella and Excess Liability

Will be provided as follows:

(a)     Limits



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The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


        $200,000,000 Each Occurrence
        $200,000,000 General Aggregate
        $200,000,000 Products and Completed Operations

(b)      Coverage, Terms, and Conditions & Exclusions

        -        Follow Form Underlying

(c)     Excess Insurance Carriers with Corresponding Policy Numbers

  Excess    Aspen $10 M
                                           13349U11
  1st       Aegis $5 M                                  $25,000,000 excess of primary
  Layer     Lexington $10 M                13548U11
            XL $22.5 M                     13559U11
  Excess
            ACE USA $22.5 M                13555U11     $75,000,000 excess of
  2nd
            Aspen $15 M                    13569U11     $25,000,000
  Layer
            Ironshore $7.5 M               13572U11
  Excess    Chartis $50 M                  13568U11
  3rd       AWAC $25 M                     13567U11     $100,000,000 xs $100,000,000
  Layer     Argo $25 M                     13571U11

These policies do not cover off-site operations. Excess Coverage is over the OCIP General Liability and
Employer’s Liability.

(D)     Contractors’ Pollution Liability

Will be provided as follows:

(a)    Limits

        $25,000,000      Each Claim
        $25,000,000      General Aggregate

(b)    Retro Date

       January 1, 2005 for all Contractors

(c)    Terms and Conditions

        Refer to the policy (available upon written request to the Owner). Owner is responsible for the
        applicable deductible under this policy.

(d)    Exclusions

       - Refer to the policy (available upon written request to the Owner


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The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


(E)     Builder’s Risk Coverage
“All Risk” Builder’s Risk coverage is written on a Replacement Cost Basis and includes coverage for direct
physical damage to the Project Work and all real and personal property that will be incorporated into the
project while being stored at the Project Sites, at a temporary locations, and while in transit.
The Builder’s Risk will not provide coverage against loss of any tools, equipment, and machinery of
the Contractors and Subcontractors. Also the Contractors and Subcontractors must agree to indemnify,
defend, and hold the Owner and its officers, agents, and employees harmless from any such loss or
damage.

(a)     Limits

        $100,000,000          Structures – All Risks (For any one occurrence)

(b)     Sub-Limits

        $50,000,000           Earth Movement per occurrence and annual aggregate

        $50,000,000           Flood per occurrence and annual aggregate, except for $12,500,000 Flood
                              Zones A & V (all suffixes)

        $ 5,000,000           Delay in Completion Coverage (s) for Soft Costs

        $10,000,000           Property in Inland Transit

        $10,000,000           Off Site Temporary Storage

        $ 1,000,000           Pollution Clean Up and Removal
                                  • Debris Removal
                                       25% of the covered loss

        $10,000,000           Ordinance & Law

                              Demolition and Increased Cost of Construction is included in Ordinance or
                              Law Coverage

        $ 5,000,000           Expediting Expenses

        $ 2,500,000           Valuable Papers and Records

        $    100,000          Fire Protective Systems

        $    500,000          Fire Department Service Charges

        $    250,000          Trees, Shrubs, Lawns, and Signs

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        $     25,000          Construction Contract Penalty

        $    100,000          Appraisal and Loss Adjustment Expenses / Claims Preparation Expense

        $ 1,000,000           Mold

        $ 1,000,000           Damage to Existing Real Property of Department of Education

(c)     Deductibles

        $    25,000           All Perils Each Occurrence except, as follows:

                              $ 25,000     Earth Movement – Per Occurrence

                              $ 25,000     Flood – Per Occurrence, except $250,000 for Flood Zones A and
                                           V (all suffixes) only

                              $ 25,000     Wind and Hail (Windstorm) per location with a $100,000
                                           maximum per occurrence within 1 mile from the shore line in
                                           Brooklyn, Queens, and all of Staten Island

All General Contractors are responsible for Builder’s Risk losses within the
deductibles. General Contractors are responsible for the applicable deductible under
this policy.

(d)     Valuation

        Cost to repair or replace the property lost or damaged at the time and place of loss with material of
        like kind and quality including contractors’ reasonable profit and overhead. If not replaced, the
        Actual Cash Value with proper deduction for depreciation.
(e)     Exclusions
        -      Damage resulting from any hostile or warlike action.
        -      Normal and natural wear and tear, corrosion, erosion, latent defects, and inherent vice.
               However, ensuing damage from a resulting covered peril is included.
        -      Normal settling, shrinkage or expansion in foundation / walls, floors, and ceilings.
        -      Loss or damage resulting from pollution and contamination.
        -      Cost of making good defective design or specifications, faulty material, or faulty
               workmanship. However, this exclusion shall not apply to loss or damage resulting from such
               defective design or specifications, faulty material, or faulty workmanship. In the event of loss
               or damage to which this exclusion applies, this exclusion shall only apply to the costs that
               would have been incurred if the condition had been rectified prior to the loss or damage.

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Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


        -      Loss or damage caused by infidelity or dishonesty of the Insured; embezzlement of the
               Insured’s property by any of the Insured’s employees; nor loss or damage resulting from the
               Insured voluntarily parting with title or possession of any property if induced to do so by any
               fraudulent scheme, trick, device, or false pretense; nor any unexplained loss, mysterious
               disappearance, or loss or shortage disclosed on taking inventory, except this exclusion does
               not prohibit providing the amount of any loss otherwise provable by inventory.
        -      Indirect or Remote Loss or Damage.
        -      Existing Realty - Building and Structures.
        -      Contractors’ Tools, Equipment and Machinery

        CONTRACTORS’ TOOLS AND EQUIPMENT:

        SCA’s OCIP does not cover Contractors’ and Subcontractors’ tools and equipment.
        Contractors and Subcontractors are advised that they must provide their own insurance for
        owned, leased, rented, and borrowed equipment or tools whether such equipment, leased or
        borrowed tools are located at a Project Site or “in transit”. Contractors and Subcontractors
        are solely responsible for any loss or damage to their personal property.

3.2.2 SCA’S OCIP Provided Coverages for Environmental Contractors

The SCA’s OCIP will be for the benefit of the Owner, SCA’s OCIP Eligible Contractors, and Subcontractors
of any tier. Such coverages apply only to work performed under the Contract Document / Agreement with
the Owner at the Project Site. SCA’s OCIP Eligible Contractors and Subcontractors must provide their own
insurance for off-site activities.

The Owner, at its sole expense, will provide and maintain in force as part of the SCA’s OCIP, the types of
insurance listed in sub-sections (B) through (E) below. The Contractors and Subcontractors enrolled in the
SCA’s OCIP agree that the insurance companies’ policy limits of liability, coverages, terms, and conditions
shall determine the scope of coverages provided by the SCA’s OCIP.

The insurance below will apply only to claims arising out of operations conducted at the Project Sites.

(A)     Workers’ Compensation and Employers’ Liability

Will not be provided under the SCA’s OCIP. All Contractors and Subcontractors are responsible for
providing their own Workers’ Compensation and Employers’ Liability per Section 3.3.2 –
Environmental Contractors Provided Coverages.

(B)     Commercial General Liability

Will be provided on ISO CG 00 01 (12 04) Occurrence Form as follows:




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Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


(a)     Limits

        $ 5,000,000      Each Occurrence
        $ 2,000,000      Personal and Advertising Injury
        $10,000,000      General Aggregate Limit - Per Location *
        $ 5,000,000      Products / Completed Operations Aggregate Limit - Per Borough**
        $ 1,000,000      Damages to Premises Rented to You Limit - Any one Premises
                         (Subject to an Occurrence Limit)
        $    10,000      Medical Expense - Any one Person (Subject to Occurrence Limit)

        *        General Aggregate will reinstate annually
        **       Seven (7) years Products / Completed Operations Aggregate - Per Borough will have
                 one (1) aggregate Per Borough for seven (7) years. The Products Completed
                 operations Aggregate Limits will apply separately to each Borough as defined:
                      1.      Bronx
                      2.      Brooklyn
                      3.      Manhattan
                      4.      Queens
                      5.      Staten Island

(b)     Terms and Conditions

        _        Blanket Contractual Liability amended to delete provision which excludes work within 50 feet of
                 railroad
        −        Limitation of Coverage to Designated Premises
        −        Blanket Additional Insureds as required by written contract
        −        Waiver of Subrogation as required by written contract
        −        Cross Liability and Severability of Interest
        −        Explosion, Collapse, and Underground “XCU” Coverage
        −        Notice of Occurrence
        −        Knowledge of Occurrence / Loss
        −        Unintentional Failure to Disclose
        −        Broadened Damage to Premises Rented To You Coverage
        −        Damage to Your Work Amendment

(d)     Exclusions include, but are not limited to:

        −        Any loss or damage to the Project itself
        −        Engineers, Architects or Surveyors Professional Liability
        −        Contractors’ Professional Liability
        −        Total Pollution Exclusion with a Building Heating Equipment Exception and Hostile Fire
                 Exclusion
        −        Discrimination Exclusion
        −        New York Asbestos Exclusion


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Effective January 1, 2011


        −        New York Lead Exclusion
        −        Exterior Insulation and Finish Systems
        −        Mold and Mold Related Construction Defect Exclusion / Fungus
        −        War
        −        Nuclear Energy Liability Exclusion
        −        Employment - Related Practices
        −        Abuse or Molestation Exclusion
        −        Radioactive Matter
        −        Aircraft Products Exclusion

(C)    Umbrella and Excess Liability

Will be provided as follows:

(a)     Limits

        $200,000,000 Each Occurrence
        $200,000,000 General Aggregate
        $200,000,000 Products and Completed Operations

(b) Coverage, Terms, and Conditions and Exclusions

        -        Follow Form Underlying

(c)     Excess Insurance Carriers with Corresponding Policy Numbers

  Excess    Aspen $10 M
                                           13349U11
  1st       Aegis $5 M                                  $25,000,000 excess of primary
  Layer     Lexington $10 M                13548U11
            XL $22.5 M                     13559U11
  Excess    ACE USA $22.5 M                13555U11     $75,000,000 excess of
  2nd
            Aspen $15 M                    13569U11     $25,000,000
  Layer
            Ironshore $7.5 M               13572U11
  Excess    Chartis $50 M                  13568U11
  3rd       AWAC $25 M                     13567U11     $100,000,000 xs $100,000,000
  Layer     Argo $25 M                     13571U11

(D)     Contractors’ Pollution Liability

Will be provided as follows:

(a)    Limits

        $25,000,000      Each Claim
        $25,000,000      General Aggregate

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(c) Retro Date

        January 1, 2005 for all Contractors

(c)     Terms and Conditions

       - Refer to the policy (available upon written request to the Owner)

(d)     Exclusions

        Refer to the policy (available upon written request to the Owner). Owner is responsible for the
        applicable deductible under this policy.

(E)     Builder’s Risk Coverage
“All Risk” Builder’s Risk coverage is written on a Replacement Cost Basis and includes coverage for direct
physical damage to the contracted Work and all real and personal property that will be incorporated into the
project while being stored at the Project Sites at a temporary location, and while in transit.
The Builder’s Risk will not provide coverage against loss of any tools, equipment, and machinery of
the Contractors and Subcontractors. Also the Contractors and Subcontractors must agree to indemnify,
defend, and hold the Owner and its officers, agents, and employees harmless from any such loss or
damage.

(a)     Limits

        $100,000,000          Structures – All Risks (For any one occurrence)


(b)     Sub-Limits

        $50,000,000           Earth Movement per occurrence and annual aggregate

        $50,000,000           Flood per occurrence and annual aggregate, except for $12,500,000 Flood
                              Zones A & V (all suffixes)

        $ 5,000,000           Delay in Completion Coverage (s) for Soft Costs
        $10,000,000           Property in Inland Transit

        $10,000,000           Off Site Temporary Storage

        $ 1,000,000           Pollution Clean Up and Removal

                              Debris Removal
                              25% of the covered loss



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Effective January 1, 2011


        $10,000,000           Ordinance & Law
                                  • Demolition and Increased Cost of Construction is included in
                                     Ordinance or Law Coverage

        $ 5,000,000           Expediting Expenses

        $ 2,500,000           Valuable Papers and Records

        $    100,000          Fire Protective Systems

        $    500,000          Fire Department Service Charges

        $    250,000          Trees, Shrubs, Lawns, and Signs

        $     25,000          Construction Contract Penalty

        $    100,000          Appraisal and Loss Adjustment Expenses / Claims Preparation Expense

        $ 1,000,000           Mold

        $ 1,000,000           Damage to Existing Real Property of Department of Education

(c)     Deductibles

        $    25,000           All Perils Each Occurrence except, as follows:

        $    25,000           Earth Movement – Per Occurrence

        $    25,000           Flood – Per Occurrence, except $250,000 for Flood Zones A and V (all
                              suffixes) only

        $    25,000           Wind and Hail (Windstorm) per location with a $100,000 maximum per
                              occurrence within 1 mile from the shore line in Brooklyn, Queens, and all of
                              Staten Island
All General Contractors are responsible for Builder’s Risk losses within the
deductibles. General Contractors are responsible for the applicable deductible under
this policy.

(d)     Valuation

        Cost to repair or replace the property lost or damaged at the time and place of loss with material of
        like kind and quality including Contractors’ reasonable profit and overhead. If not replaced, the
        Actual Cash Value with proper deduction for depreciation will be used.



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Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


(e)       Exclusions
          −       Damage resulting from any hostile or warlike action.
          −       Normal and natural wear and tear, corrosion, erosion, latent defects, and inherent vice.
                  However, ensuing damage from a resulting covered peril is included.
          −       Normal settling, shrinkage or expansion in foundation / walls, floors, and ceilings.
          −       Loss or damage resulting from pollution and contamination.
          −       Cost of making good defective design or specifications, faulty material, or faulty
                  workmanship. However, this exclusion shall not apply to loss or damage resulting from
                  such defective design or specifications, faulty material, or faulty workmanship. In the
                  event of loss or damage to which this exclusion applies, this exclusion shall only apply to
                  the costs that would have been incurred if the condition had been rectified prior to the loss
                  or damage.
          −       Loss or damage caused by infidelity or dishonesty of the Insured; embezzlement of the
                  Insured’s property by any of the Insured’s employees; nor loss or damage resulting from
                  the Insured voluntarily parting with title or possession of any property if induced to do so by
                  any fraudulent scheme, trick, device or false pretense; nor any unexplained loss,
                  mysterious disappearance, or loss or shortage disclosed on taking inventory, except this
                  exclusion does not prohibit providing the amount of any loss otherwise provable by
                  inventory.
          −       Indirect or Remote Loss or Damage.
          −       Existing Realty - Building and Structures.
          −       Contractors’ Equipment and Tools.

      CONTRACTORS’ TOOLS AND EQUIPMENT:

      SCA’s OCIP does not cover Contractors’ and Subcontractors’ tools and equipment. Contractors
      and Subcontractors are advised that they must provide their own insurance for owned, leased,
      rented, and borrowed equipment or tools whether such equipment, leased or borrowed tools are
      located at a Project Site or “in transit”. Contractors and Subcontractors are solely responsible
      for any loss or damage to their personal property.

3.3. CONTRACTORS’ PROVIDED COVERAGES
3.3.1 Non Environmental Contractors’ Provided Coverages

For any Work under Contract, and until completion, and final acceptance of the Work, the SCA’s OCIP
Eligible Contractors and all Subcontractors, at their own expense, must promptly furnish upon request
to the Owner’s Insurance Administrators, certificates of insurance providing evidence that the following
existing coverages are in force.



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Effective January 1, 2011


(a)     Automobile Liability Insurance

        To cover all owned, hired and non-owned automobiles, trucks, and trailer used in connection with
        the work with the following minimum limits:

        -     $1,000,000 Bodily Injury / Property Damage Combined Single Limit;

        -     Commercial Automobile Liability Insurance to cover all vehicles owned, hired, or used by or
              on behalf of the Contractors or Subcontractors in the performance of the work.

NOTE:       Automobiles are defined in accordance with the 1986 ISO insuring agreement. This definition
            includes, but is not limited to, a land motor vehicle, trailer or semi-trailer designed for travel on
            public road, whether licensed or not (including any machinery or apparatus attached thereto).

(b)     Workers’ Compensation and Employers’ Liability Insurance for Off-Site Activities only

        -     Workers’ Compensation - New York State Statutory Benefits

        -     Employers’ Liability Limits to be provided as follows:

              $1,000,000      Bodily Injury by Accident - Each Accident
              $1,000,000      Bodily Injury by Disease - Policy Limit
              $1,000,000      Bodily Injury by Disease - Each Employee

        -     The policy should be endorsed to exclude all Projects for the Owner for which coverages are
              afforded to the Contractors and Subcontractors under the SCA’s OCIP.

(c)     Commercial General Liability Insurance for Off-Site Activities only

        -   Limits to be as follows:

              $1,000,000      Bodily Injury / Property Damage Each Occurrence
              $1,000,000      General Aggregate
              $1,000,000      Products / Completed Operations Aggregate

        -     The policy should be endorsed to exclude all Projects for the Owner for which coverages are
              afforded to the Contractors and Subcontractors under the SCA’s OCIP. Permission granted
              for the policy to be Excess and/or Difference In Conditions over SCA’s OCIP at Contractors’
              and Subcontractors’ own cost.

        -        Coverage’s, at minimum, will include:
                 Occurrence Basis
                 Premises Operations
                 Contractual Liability


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Effective January 1, 2011


                 Products / Completed Operations
                 Independent Contractors
                 XCU Coverage

        Contractors’ and Subcontractors’ Certificates of Insurance must include the
        following as “Additional Insureds” under your Commercial General Liability policy:

        (1) New York City School Construction Authority
            30-30 Thomson Avenue, Long Island City, New York 11101;

        (2) New York City Department of Education
            52 Chambers Street, New York, New York 10007;

        (3) The City of New York
            100 Church Street, New York, New York 10007;

        (4) The Construction Manager (s) or General Contractor (s) ; and

        (Project (s) or name of school (s) and SCA’s Contract Numbers must be shown on the certificate of
        insurance.

NOTE: Please name the New York City School Construction Authority as the Certificate Holder. All
certificates of insurance shall be addressed to:

        New York City School Construction Authority
        Finance/Risk Management Department, 3rd Floor
        30-30 Thomson Avenue, Long Island City, New York 11101

3.3.2 Environmental Contractors’ Provided Coverages

For any work under this contract, and until completion, and final acceptance of the work, the SCA’s OCIP
Eligible Contractors and all Subcontractors, at their own expense, must promptly furnish upon request
evidence that existing coverages are in force.

(A)     Automobile Liability Insurance

        -     $1,000,000 Bodily Injury / Property Damage Combined Single Limit

        -     Commercial Automobile Liability Insurance to cover all vehicles owned, hired, or used by or
              on behalf of the Contractors or Subcontractors in the performance of the work.

        (For haulers: The Automobile Liability policy must be endorsed to include MCS-90)




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Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


NOTE:       Automobiles are defined in accordance with the 1986 ISO insuring agreement. This
            definition includes, but is not limited to, a land motor vehicle, trailer or semi-trailer
            designed for travel on public road, whether licensed or not (including any machinery or
            apparatus attached thereto).

(B)     Hazardous Material Transportation Liability (a.k.a MCS-90)

        -   $5,000,000 Hazardous Material Transportation Liability *

        *The limit may be provided through a combination of Automobile Liability and Umbrella /
        Excess Liability that equal $5,000,000.

(C)     Workers’ Compensation and Employers’ Liability Insurance

        -     Workers’ Compensation - New York State Statutory Benefits
        -     Employers’ Liability Limits to be provided as follows:

              $1,000,000      Bodily Injury by Accident - Each Accident
              $1,000,000      Bodily Injury by Disease - Policy Limit
              $1,000,000      Bodily Injury by Disease - Each Employee

        -     The policy will provide coverage for the Contractors’ employees for all Projects

(D)     Commercial General Liability Insurance for Off-Site Activities only

        -   Limits to be provided as follows:

              $1,000,000      Bodily Injury / Property Damage Each Occurrence
              $1,000,000      General Aggregate
              $1,000,000      Products / Completed Operations Aggregate

        -     The policy should be endorsed to exclude all Projects for the Owner for which coverages are
              afforded to the Contractors and Subcontractors under the SCA’s OCIP. Permission granted
              for the policy to be Excess and/or Difference In Conditions over OCIP at Contractors’ and
              Subcontractors’ own cost.

        -   Coverage, at minimum, will include:

                 Occurrence Basis
                 Premises Operations
                 Contractual Liability
                 Products/Completed Operations
                 Independent Contractor




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Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


        Contractors’ and Subcontractors’ Certificates of Insurance must include the
        following as “Additional Insureds” under your Commercial General Liability policy:

        (1) New York City School Construction Authority
            30-30 Thomson Avenue, Long Island City, New York 11101;

        (2) New York City Department of Education
            52 Chambers Street, New York, New York 10007;

        (3) The City of New York
            100 Church Street, New York, New York 10007;

        (4) The Construction Manager (s) or General Contractor (s).

        (Project (s) or name of school (s) and SCA’s Contract Numbers must be shown on the certificate of
        insurance.

NOTE: Please name the New York City School Construction Authority as the Certificate Holder. All
certificates of insurance shall be addressed to:

        New York City School Construction Authority
        Finance/Risk Management Department, 3rd Floor
        30-30 Thomson Avenue, Long Island City, New York 11101

3.3.3   Offsite Certificates of Insurance

Certificates of insurance acceptable to the Owner shall be filed with the Owner within ten (10) days after
award of a contract to the Contractors and Subcontractors and prior to commencement of the work. All
required insurance shall be maintained without interruption from the date of commencement of the
work until the date of the final payment. These certificates of insurance and the insurance policies shall
contain a provision that coverages afforded under the policies will not be materially modified or allowed to
expire until at least thirty (30) days prior written notice has been given to the Owner. The provisions of this
Section shall apply to all policies of insurance required to be maintained by the Contractors and
Subcontractors pursuant to the Contract Documents.

3.3.4   Other Insurance

Any type of insurance or any increase of limits of liability not described in this section which the Contractors
and Subcontractors require for their own protection or on account of any statute shall be their own
responsibility and provided at their own expense. Each item must be shown as a line item and approved
by the Owner.




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Effective January 1, 2011


3.3.5     No Release

The provision of the SCA’s OCIP by the Owner shall in no way be interpreted as relieving the Contractors
or any Subcontractors of any other responsibility or liability under this Contract Document / Agreement or
any applicable law, statute, regulation, or order.

3.3.6     Approval of Forms and Companies

All insurance described in this section shall be written by an insurance company or companies satisfactory
to the Owner and maintained by the Contractors and Subcontractors pursuant to the Contract Documents.


4.        ADMINISTRATION AND ENROLLMENT PROCEDURES
The SCA’s OCIP Eligible Contractors and Subcontractors shall adhere to and follow all reporting
requirements as detailed. Failure to follow the procedures outlined in this manual may result in fines being
assessed by the appropriate state agencies or commissions. The party at fault shall at its own expense, be
responsible for any fines or judgments arising out of failure to follow the procedures. The Owner shall
deduct from monies due or to become due under the provisions of the Contract Document for any
applicable fines or judgments that are assessed.

4.1 Enrollment under the OCIP

The SCA’s OCIP Eligible General Contractors and Subcontractors shall provide the Owner’s Contract
Administration - Prequalification Unit with the following completed forms:

        (a)   Contractors’ Request for Insurance Form (RFI) and Subcontractor’s Approval Form
              (SAF), refer to Exhibit E-1; and

        (b)   Certificates of Insurance evidencing existing coverages for on-site or off-site activities
              as specified in Section 3.3 Contractors’ Provided Coverages.

The SCA’s OCIP Eligible Contractors and Subcontractors of any tier shall submit to the Owner’s
Prequalification Unit with their Subcontractor Approval Form (SAF) on the Internet based software called
Vendor Access System (VAS) located on the SCA’s website.

The SCA’s General Contractors may be excluded from Internet based software submission at this time:
Manual submission to the Owner’s Prequalification Unit is still permissible for the Wicks
Subcontractors.
All questions regarding these procedures should be addressed to the Owner’s Contract Administration –
Contractors’ Pre-Qualification Unit. The SCA has implemented an online Vendor Access System “VAS”




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Effective January 1, 2011


portal that offers Contractors and Subcontractors seeking to do business with the SCA a streamlined way
to do so online. Please refer to Section 7, Administration Directory.
The site includes a step-by-step process designed to simplify meeting the SCA’s requirements.


                                  5. SAFETY PROGRAM
5.1     Introduction

The Owner has a well established Safety and Health program that guides and directs the management,
staff, and Contractors working on all New York City educational facilities. All Contractors and
Subcontractors are required to adhere to the policies and procedures set forth within this program.
However, every Contractor and Subcontractor is responsible to provide a safe working environment for its
employees that meet all City, State, and Federal safety laws and regulations. The Owner is committed to
safety and considers effective safety management a shared responsibility. Each employee of the SCA’s
OCIP Eligible Contractors or Subcontractors, regardless of position, shall be required to accept safety
responsibilities and shall be held accountable for such performance.

5.2     Objectives of the Program

The intent of this program is to assist the Owner in providing a quality program in a safe and cost-effective
manner. Its objectives are to develop and maintain a safe and healthy work-place that promotes safe
behaviors, compliments production, and avoids injuries to persons and damage to Owner’s existing
properties and adjacent structures. The Construction Management Team and Environmental and
Regulatory Compliance Department are committed to the program and their strict enforcement.

The Mission of the Owner’s Environmental and Regulatory Compliance Department is:

        to educate:

        Owner’s personnel, General Contractors, and all Subcontractors of the City, State, and Federal
        safety rules and regulations.

        to enforce:

        Applicable Safety Rules and Regulations in a firm, fair, and consistent manner.

        to provide optimum protection:

        To the students, teachers, school personnel, and general public during all the new construction
        and the renovation of New York City educational facilities.




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Effective January 1, 2011


5.3     Contractors’ and Subcontractors’ Responsibilities

        -        Totally manage of the safety and health environment of its employees and all other
                 persons and property affected by its construction operations.
        -        Obtain all required permits and submit the required safety plans to the Owner.
        -        Designate safety coordinators and / or site safety representatives as well as competent
                 persons and emergency contacts.
        -        Comply with all City, State, and Federal safety laws and regulations, as well as SCA‘s
                 policies and procedures within the Safety Program.
        -        Cooperate with SCA’s Construction Management and the Environmental and Regulatory
                 Compliance Department during all pre-planning, audits, and accident investigations.
        -        Provide safety orientation for all newly hired employees.
        -        Provide proper training and education to employees.
        -        Document and submit daily safety inspections and all toolbox meetings.
        -        Maintain proper control of hazardous products (HazCom Program, Storage and Use).
        -        Recognize and control excessive noise levels.
        -        Locate all underground utilities before work begins.
        -        Provide approved and appropriate equipment for the project.
        -        Provide each employee with all required personal protective equipment for the task.
        -        Immediately report all injuries and incidents as delineated in the SCA’s procedures,
                 including the SCA’s OCIP Administrator.

                              6.      CLAIMS PROCEDURES
This section explains the procedures to be followed in the event of an occupational injury, occupational
illness, bodily injury or property damage loss (claim). The SCA’s OCIP is designed to provide certain
coverages to the Owner and the Eligible Contractors and Subcontractors; however, the program does not
change any of the Contractors’ or Subcontractors’ contractual and / or statutory responsibilities for
reporting claims. In the event of a claim, the following procedures must be strictly adhered to:

(a)     Injury to employees - Workers’ Compensation Claims

        First report all injuries or occupational-related illnesses on a C-2, refer to Exhibit E-3 for blank
        form, MUST be completed by employer within 24 hours.

        The employer is to include its OCIP’s Worker’s Compensation policy number, school name,
        borough, and Owner’s Contract Number. Immediately send all subsequent medical return to work
        notes, Injuries or correspondence about an Injured Party. The form must be sent to the following:




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Effective January 1, 2011


        Willis of New York, Inc.
        30-30 Thomson Avenue, 3rd Floor
        Long Island City, New York 11101

        Attention:                         Ms. Khem Henry
        Telephone number:                  (718) 472-8753
        Cell number:                       (646) 258-3813
        Fax number:                        (718) 472-8770
        E-Mail:                            Khem.Henry@willis.com

        Workers’ Compensation claims can also be reported directly to Liberty Mutual Insurance
        Company (Customer Service Center) at:

        Telephonically:                    (800) 362-0000 available 24 hours
        Fax number:                        (800) 329-3297

After a report is submitted to the insurance company, one copy of the C-2 must be sent to Khem Henry as
noted above, one copy should be retained in the employer's file and one copy should be given to the
Owner’s Project Officer and / or Construction Manager.

The main responsibility for any Party is first to see that the injured worker receives immediate
medical care, if any employee is involved in an accident or occurrence resulting in bodily injury.
The following are the responsibilities of the Contractors or Subcontractors of all tiers.

-       Prompt and thorough accident investigations of all injuries;
-       Response to Liberty Mutual Insurance Company regarding questions about employment history
        of injured workers;
-       Prompt and accurate reporting of additional information required;
-       Prompt notification of serious injuries to Liberty Mutual Insurance Company and Owner’s Project
        Officers and / or Construction Managers.

(b)     Third Party Bodily Injury or Property Damage (Letters of Representation / Notice of Claims /
        Summons) - General Liability Claims

        Contractors and Subcontractors must immediately report all accidents at the Project Sites involving
        death, injury, or damage to property or non-employee personnel (the public, tenants, and visitors).
        As soon as the Contractors’ on-site personnel become aware of the accident or occurrence, they
        must:

        Take appropriate emergency measures to prevent additional injury or damage, including
        contacting the police and fire authorities as required by law.




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Effective January 1, 2011


        Reports of bodily injuries or damage to property of others should be provided on a Jobsite Incident
        Report or SCA Emergency/Incident Notification Report, Refer to Exhibit E-2 for blank form, or
        General Liability Notice of Occurrence/Claim, Refer to Exhibit E-4 for blank form.

        The Jobsite Incident Report or SCA Emergency/Incident Notification Report, including lawsuits:
        Letters of Representation, Notice of Claims, Summons, Summons and Verified Complaint, Third-
        Party Summons, etc. must be immediately reported following the occurrence or knowledge of an
        accident or incident to:

        Willis of New York, Inc.
        30-30 Thomson Avenue, 3rd Floor
        Long Island City, New York 11101

        Attention:                         Ms. Khem Henry
        Telephone number:                  (718) 472-8753
        Cell number:                       (646) 258-3813
        Fax number:                        (718) 472-8770
        E-Mail:                            Khem.Henry@willis.com

        General Liability claims can also be reported directly to Liberty Mutual Insurance Company
        (Customer Service Center) at:

        Telephonically                     (800) 362-0000 available 24 hours
        Fax number:                        (800) 329-3297

After a report is submitted to the insurance company, one copy of the form must be sent to Khem Henry as
noted above, one copy should be retained in the Contractor’s file, and one copy should be given to the
Owner’s Project Officer and / or Construction Managers.

It is essential that all such claims be thoroughly investigated by the Contractor, Safety Inspector assigned
and the insurance company. All available facts, evidences, photos, and information, including the names of
witnesses, must be secured while such information is still available. Unless prompt action is taken in this
respect, witnesses may disappear, facts may become obscure, and the further handling of the claim will be
compromised.

The Owner will assist in the investigation. However, it is the responsibility of the Contractor to see that all
third party injury or property damage claims are thoroughly investigated and promptly reported the SCA’s
OCIP Administrator, the Owner, and the insurance company.

DO NOT VOLUNTARILY ADMIT LIABILITY AND COOPERATE WITH THE ADJUSTERS
REPRESENTING THE INSURER.

If a Contractor makes repairs or hires other Contractors to make repairs when damage is caused to
a third party, this does not in itself mean that the insurance company will reimburse the Contractor



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Effective January 1, 2011


for the cost of repairs. The policy provisions clearly state that the Contractor is not allowed to make
voluntary repairs or payments until the insurance company has had sufficient time to evaluate the
loss. By making repairs or making voluntary payments, the insurance company may find it difficult
to evaluate the loss and may deny the claim.

(c)     Automobile Claims

        No coverage is provided for automobile accidents under the OCIP. It is the sole responsibility of
        each Party to report accidents/claims involving their automobiles to their own insurers. Report all
        Auto claims to your insurance carrier. However, all accidents occurring in or around the Project
        Sites must be reported to the SCA’s Insurance OCIP Administrator.

        Failure to promptly report an incident or a claim may be construed as LATE NOTICE and
        coverage for such claim may be denied.

(d)     Property Claims - Damage to Contractors’ work - Builder's Risk
        There is coverage for direct physical damage to the contracted Work and all real and personal
        property that will be incorporated into the project while being stored at the Project Sites at a
        temporary location and while in transit.

        The Contractor, upon learning of any damage to its work that may give rise to a claim under
        Builder's Risk Insurance, shall give immediate notice to:

        Willis of New York, Inc.
        30-30 Thomson Avenue, 3rd Floor
        Long Island City, New York 11101

        Attention:                         Ms. Khem Henry
        Telephone number:                  (718) 472-8753
        Cell number:                       (646) 258-3813
        Fax number:                        (718) 472-8770
        E-Mail:                            Khem.Henry@willis.com

Submit one copy of the Comprehensive Written Report, SCA Emergency/Incident Notification Report or
Jobsite Incident Report; refer to Exhibit E-2 for blank form. These completed reports must be sent to
Khem Henry as noted above, one copy of each report should be retained in the Contractor's file, and one
copy should be given to the Owner’s Project Officer and / or Construction Manager.

DO NOT VOLUNTARILY ADMIT LIABILITY AND COOPERATE WITH THE ADJUSTERS
REPRESENTING THE INSURER.

If a Contractor makes repairs or hires other Contractors to make repairs when damage is caused,
this does not in itself mean that the insurance company will reimburse the Contractor for the cost of
repairs. The policy provisions clearly state that the Contractor is not allowed to make voluntary


                                                                                           Page 29 of 36
The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


repairs or payments until the insurance company has had sufficient time to evaluate the loss. By
making repairs or making voluntary payments, the insurance company may find it difficult to
evaluate the loss and may deny the claim.

Failure to promptly report an incident or a claim may be construed as LATE NOTICE and coverage
for such claim may be denied.

(e)     Environmental incident or damage – Contractors’ Pollution Liability

        The Contractor, upon learning of any incident, accident, occurrence or circumstance that
        give rise to a claim under Contractors’ Pollution Liability, shall give immediate notice to:

        Willis of New York, Inc.
        30-30 Thomson Avenue, 3rd Floor
        Long Island City, New York 11101

        Attention:                         Ms. Khem Henry
        Telephone number:                  (718) 472-8753
        Cell number:                       (646) 258-3813
        Fax number:                        (718) 472-8770
        E-Mail:                            Khem.Henry@willis.com

Submit one copy of the Comprehensive Written Report, SCA Emergency/Incident Notification Report or
Jobsite Incident Report; refer to Exhibit E-2 for blank form. These completed reports must be sent to
Khem Henry as noted above, one copy of each report should be retained in the Contractor's file, and one
copy should be given to the Owner’s Project Officer and / or Construction Manager.

Failure to promptly report an incident or a claim may be construed as LATE NOTICE and coverage
for such claim may be denied.

NOTE: The failure of the Construction Manager, Contractor or Subcontractor to give
prompt notice to the Owner, SCA’s OCIP Administrator or the insurance company of
any incident, accident, occurrence or circumstance which may give rise to a claim
under any of the SCA’s OCIP provided coverages may result in a denial of coverage.

(f)     REQUEST FOR LOSS HISTORY

        ALL GENERAL CONTRACTORS, CONSTRUCTION MANAGERS, AND SUBCONTRACTORS
        MAY REQUEST IN WRITING FOR THEIR LOSS HISTORY UNDER THE OCIP. REFER TO OCIP
        WILLIS’ ADMINISTRATORS SHOWN IN THE DIRECTORY




                                                                                        Page 30 of 36
The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


                        7. ADMINISTRATION DIRECTORY
OWNER – New York City School Construction Authority
                                                                      Legal Department
   New York City School Construction
                Authority                                               Mr. Ross J. Holden
                                                           Executive Vice President and General Counsel
        30-30 Thomson Avenue                                             P: (718) 472-8220
    Long Island City, New York 11101                            Email: RHolden@nycsca.org

                 Finance Department                                   Safety Department

                   Ms. Marianne Egri                                    Mr. Michael Slevin
 Vice President of Finance and Information Technology              Director of Operations, Safety
                   P: (718) 472-8012                                     P: (718) 472-8153
                   F: (718) 752-8012                                    F: (718) 472-8640
             E-Mail: MEgri@nycsca.org                              Email: MSlevin@nycsca.org

                                                                       Mrs. Madhu Luther
                 Mr. John F. Hepburn                           Deputy Director of Operations, Safety
                      Comptroller                                      P: (718) 472-8468
                   P: (718) 472-8314                                   F: (718) 472-8640
                   F: (718) 752-8611                             E-Mail: MLuther@nycsca.org
            E-Mail: JHepburn@nycsca.org


                                                                 Labor Law Compliance Unit
             Ms. Lori Weisenberg-Catalano
                 Manager of Operations
                                                                 Internet Based Payroll Reporting
                    P: (718) 472-8824
                                                                    Login: Laborlaw.nycsca.org
                    F: (718) 752-8611                              Email: LaborLaw@nycsca.org
           E-Mail: LWeisenberg@nycsca.org                             Hotline: (718) 472-8100

 Contractor Administration – Contractors’                     Doing Business with the SCA
 Pre-qualification Unit
                                                        INTERNET BASED PORTAL – Vendor Access
 Ms. Barbara Gavosto                                    System (VAS)
 Director of Prequalification Unit                      Contractor Prequalification Department
 P: (718) 472-9594                                      T: (718) 472-8777
 Email: PChirumbolo@nycsca.org                          Business Development Division
                                                        T: (718) 472-8899
                                                        Link: http://dobusiness.nycsca.org/internal



                                                                                     Page 31 of 36
The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


   OWNER CONTROLLED INSURANCE PROGRAM’S ADMINISTRATORS
ON-SITE - SCA’S RISK MANAGEMENT
                                          Willis of New York, Inc.
                                        SCA’s OCIP Administration

                                       30-30 Thomson Avenue, 3rd Floor
                                          Long Island City, NY 11101
                                       P: 718 472-8000 or 212 344 8888



         *Ms. Khemrajie (Khem) N. Henry                                  *Mr. Bryan P. Paul
         Team Manager / OCIP Administrator                        Assistant OCIP Administrator
                  P: (718) 472-8753                                 Contractors’ Enrollment
                 F: (718) 472-8770                                     P: (718) 472-8755
                C: (646) 258-3813                                      F: (718) 472-8770
          E-Mail: Khem.Henry@Willis.com                                C: (917) 605-7002
                                                                E-Mail: Bryan.Paul@Willis.com


            Mrs. Jasmati (Cindy) Shah                                    *Mr. Deyan Tranev
            Assistant OCIP Administrator                         Assistant OCIP Administrator
                   Administration                                       Claims Reporting
                 P: (718) 752-5315                                     P: (718) 752-5326
                 F: (718) 472-8770                                     F: (718) 472-8770
         E-Mail: Jasmati.Shah@Willis.com                       Email: Deyan.Tranev@Willis.com



                 Mr. Grant Murray
           Loss Control OCIP Administrator
                 P: (718) 472-8468
                 F: (718) 472-8640
           E-Mail: GMurray@nycsca.org



NOTE: *REQUEST FOR ALL CONTRACTORS’ LOSS HISTORY
WORKERS COMPENSATION AND GENERAL LIABILITY




                                                                                        Page 32 of 36
The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


                         OFF-SITE – SCA’S INSURANCE BROKER

                          Willis of New York, Inc. / Construction Practice

                                          1 World Financial Center
                                             200 Liberty Street
                                            New York, NY 10281
                                          Toll Free: (866) 400-8395
                                                P: (212) 915-7702


                 Ms. Sonia Drexler                                       Mr. Gerry McCarthy, Esq.
                   Client Advocate                                   Property & Casualty Claims Manager
                  P: (212) 915-7998                                           P: (212) 915-8229
                 C: (646) 431-7855                                            C: (917) 214-3880
         E-Mail: Sonia.Drexler@Willis.com                           E-Mail: Gerry.McCarthy@Willis.com


                Mr. Daniel Heefner                                          Mr. Frank McIntyre
          Builder’s Risk Claims Specialist                                 Loss Control Manager
                 P: (212) 915-7871                                           C: (631) 742-0351
                M: (516) 606-9937                                   E-Mail: Frank.McIntyre@Willis.com
        E-Mail: Daniel.Heefner@Willis.com


                  Mr. Robert Albin                                     Mr. Brian Goldenberg
        Property & Casualty Claims Specialist                          Loss Control Specialist
                 P: (212) 915-8119                                       C: (917) 723-2973
                 C: (347) 401-4008                            Email: BRIAN.GOLDENBERG@Willis.com
         E-Mail: Robert.Albin@Willis.com


              Mr. David Moskowitz                                          Mr. Sohan Balcharan
      Mentor Surety Program / Client Advocate                            INFORM - RMIS Manager
                T: (212) 915-8784                                       P: (631) 851 0222, Ext. 14
                C: (212) 292-7503                                   E-Mail: Sohan_Balcharan@ibi.com
      E-mail: David.Moskowitz@Willis.com




                                                                                             Page 33 of 36
The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011


                         OCIP INSURANCE CARRIERS – CLAIMS

                Liberty Mutual Insurance Company – Worker’s Compensation

                                        Elmsford – Office 205
                                 Liberty Mutual Insurance Company
                           Commercial Market Claims/National Markets Accounts

                                                P.O. Box 1203
                                             Elmsford, NY 10523
                                        P: (800) 422-0820 Ext. 25146
                                              F: (603) 334-8111


                                              Medical Billing
                                     Liberty Mutual Insurance Company
                                               P.O. Box 7203
                                             London, KY 40742


                                            Claims Service Team

                                             Ms. Melinda Owens
                                              Claims Manager

                                       P: (800) 422-0820 Ext. 25198
                                Email: Melinda.Ownes@LibertyMutual.com


                                              Mr. Brett Giarruso
                                               Team Manager

                                       P: (800) 422-0820, Ext. 25227
                               E-Mail: Brett.Giarrusso@LibertyMutual.com


                                        Ms. Ayde (Maritza) Montalvo
                                         Senior Claims Consultant

                                       P: (800) 422-0820 Ext. 25191
                               Email: Ayde.Montalvo@Liberty.Mutual.com




                                                                                Page 34 of 36
The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011




     Liberty Mutual Insurance Company –                 Liberty Mutual Insurance Company –
               General Liability                            Safety/Loss Control Services

         Liberty Mutual Insurance Company                        Mr. Jeffery J. LaBarge
              Commercial Market Claims                         Senior Technical Consultant

                 70 Sunrise Highway                              Direct Line: (518) 782-2541
                    P.O. Box 9001                                     C: (518) 491-6191
               Valley Stream, NY 11582                                F: (518) 782-2555
                                                        Email: Jeffery.LaBarge@LibertyMutual.com
         P: (800) 441-0122 or (516) 593-8200
                   F: (800) 329-3297
                                                                  Mr. Rick Kropp, CSP
                                                              Loss Control Advisory Services
                  Mr. Egon Brown
               Regional Claims Manager                          P: (973) 533-6509 Ext. 2081
                                                                     C: (908) 868-8847
   P: (800) 441-0122 or (516) 593-8200 Ext. 20700       Email: Richard.Kropp@LibertyMutual.com
      Email: Egon.Brown@LibertyMutual.com

                                                           Liberty Mutual Insurance Company –
               Mr. Richard Fitzmaurice                              Auditing Services
              Director of Technical Claims

   P: (800) 441-0122 or (516) 593-8200 Ext. 20681
                                                                     Alan Burdick
  Email: Richard.Fitzmaurice@LibertyMutual.com
                                                                    Auditing Manager

                                                                     P: (603) 606 1040
               Ms. Lynette Jen-Acot                                  F: (603) 422-0112
          Senior Technical Claims Specialist             Email: Alan.Burdick@LibertyMutual.com
   P: (800) 441-0122 or (516) 593-8200 Ext. 20694
   Email: Lynette.Jen-Acot@LibertyMutual.com




                                                                                       Page 35 of 36
The New York City School Construction Authority (SCA)
Owner Controlled Insurance Program (OCIP) Manual
Effective January 1, 2011



                  Builder’s Risk                           Contractor’s Pollution Liability
     Travelers Property Casualty Company of                Chartis Insurance Company (formerly AIG)
                    America                                              Environmental

                  One Town Square                                     Mr. Patrick J. Sweeney
                  Hartford, CT 06183                                     Account Manager
                                                         Construction Claims Service and Marketing Group
                   T: (800) 328-2189                                175 Water Street, 6th Floor
                                                                       New York, NY 10038

               Mr. Louis Thomas Vella                                    P: (212) 458-6334
               Travelers Inland Marine                                   F: (212) 458-6331
             343 Thornall Street, Suite 530             E-Mail: Patrick.Sweeney@Chartisinsurance.com
                  Edison, NJ 08837
                  T: (732) 205-9248                                   Dedicated Adjusters
                  F: (866) 381-0834
            Email: LVella@Travelers.com                               Ms. Tanya Crawford
                                                               Analyst-Pollution Insurance Products

                   Mr. John Rocca                                 101 Hudson Street, 29th Floor
            Unit Manager/Property Claims                         Jersey City, New Jersey 07302
                   100 Baylis Road
                  Melville, NY 11747                                    P: (201) 631-7158
                  T: (631) 577-7606                                     F: (866) 467-3498
                  F: (866) 899-8376                      E-Mail: Tanya.Crawford@Chartisinsurance.com
           Email: JRocca@Travelers.com

                                                                       Mr. Craig A. Rosen
                                                                       Complex Director

                                                                       P: (201) 631-7794
                                                                       F: (201) 631-5051
                                                          E-Mail: Craig.Rosen@Chartisinsurance.com




                                                                                            Page 36 of 36
_____________________
      EX HIBIT
        E–1
_____________________
                 NEW YORK CITY SCHOOL CONSTRUCTION AUTHORITY
                   CONTRACTOR’S REQUEST FOR INSURANCE FORM

  THIS FORM MUST BE COMPLETED BY ALL CONTRACTORS AND SUBCONTRACTORS WHO
              WILL PERFORM WORK AT THE CONSTRUCTION JOBSITE.

SCA’S CONTRACT NO:_____________PRIME CONTRACTOR_______________________

PROJECT / SCHOOL NAME ________________________________ BOROUGH______________

PROJECT / SCHOOL ADDRESS _____________________________________________________

____________________________________________________________________________________

CONTRACTOR/SUBCONTRACTOR’S FIRM NAME ____________________________________

CONTRACTOR/SUBCONTRACTOR’S FIRM ADDRESS



CITY, STATE AND ZIP _______________________________________________________________

FIRM’S TELEPHONE                  NO.     (                        )_________________                CELL   NO.   (
)____________________

FIRM’S FAX NUMBER (                 )    _______________________________________________________

FIRM’S E-MAIL ADDRESS

FIRM’S FEDERAL TAX I.D. NUMBER

                    Project Representative                                     Insurance Risk Manager

Name

Address ________________________________



Telephone Number

BRIEF DESCRIPTION OF JOB SITE ACTIVITIES TO BE DONE WITH FIRM’S WORKFORCE ONLY:


(Be trade specific)



FIRM’S ESTIMATED JOB SITE START DATE

FIRM’S ESTIMATED JOB SITE FINISH DATE
C:\Documents and Settings\chou_vi\Local Settings\Temporary Internet Files\OLK3D\EXHIBIT-E-1-REQUEST FOR           1
INSURANCE.docm
Contractor’s Firm Name _________________________________________

Firm’s Tax ID No. _______________________________________________

                                   WORKERS’ COMPENSATION DATA

              CLASSIFICATION                                    CLASS                      TOTAL ESTIMATED
              OF OPERATIONS                                     CODE                          PAYROLL
                                                                                             (rounded to the nearest dollar)




*Include only the estimated jobsite payroll to be directly performed by your company (and not by your subcontractors) for the
period coverage is provided.

W.C. EXP. MOD.                                           ____      RATING DATE

Location of Payroll Records                              _____________________________________________

Contact for Payroll Records                                        ____________________________________

Estimated Contract Amount $

                                   PRESENT INSURANCE COVERAGE

                            WORKERS’ COMPENSATION                            GENERAL LIABILITY

INSURER

POLICY NUMBER

POLICY TERM               From___________ To______________                From___________ __To_________________

AGENT/BROKER

ADDRESS

CITY/STATE/ZIP

ACCOUNT EXEC.                                             _____________________________________ _______

TELEPHONE NO.                                                        _____________________________________

•        Not Applicable – Our firm performs work for the SCA only.

Please attach, mail or fax a copy of the Acord Certificate of Insurance evidencing these coverages.
C:\Documents and Settings\chou_vi\Local Settings\Temporary Internet Files\OLK3D\EXHIBIT-E-1-REQUEST FOR                        2
INSURANCE.docm
Contractor’s Firm Name ___________________________________________

Firm’s Tax ID No. ________________________________________________


ADDITIONAL MISCELLANEOUS INFORMATION


1.       Will your Firm need a Building Permit for this job?                                 ( Yes / No )




                                             CERTIFICATION


The statements in my Request for Insurance are true to the best of my
knowledge. I understand that my firm’s Workers’ Compensation loss
experience incurred on this project is reported annually to the Workers’
Compensation Bureau and will be used to promulgate my firm’s experience
modification factor.


Please also attach completed SCA’s SUBCONTRACTOR APPROVAL FORM (SAF)


__________________________________                               __________________________________
      Officer of Firm’s Signature                                Print Officer’s Name




__________________________________                               __________________________________
      Date Signed                                                Officer’s Title




C:\Documents and Settings\chou_vi\Local Settings\Temporary Internet Files\OLK3D\EXHIBIT-E-1-REQUEST FOR     3
INSURANCE.docm
                            SCA SUBCONTRACTOR APPROVAL FORM (SAF)


SECTION "A" (PRIME INFORMATION)
 1 PRIME CONTRACTOR'S NAME:

 2 FEDERAL TAX I.D. NUMBER:

 3 PRIME'S PROJECT OFFICER:                                                 TEL:

 4 CONTRACT NO.:                                         SOLICITATION NO:

 5 SCA PROJECT OFFICER:

 6 SCA PROJECT SCHOOL:                     SCHOOL:                                           BORO:

 7 SCA PROJECT DESCRIPTION:

SECTION "B" (SUBCONTRACTOR INFORMATION)
 1 SUBCONTRACTOR'S NAME:

     FEDERAL TAX I.D. NO:

 2 SECONDARY SUBCONTRACTOR'S NAME:

     SECONDARY SUBCONTRACTOR'S FEDERAL TAX I.D. NO:

 3 ADDRESS:

                      CITY                               STATE:                              ZIP CODE:


 4 TELEPHONE NO:                                         FAX NUMBER:


 5 OWNER:                                                                   SOCIAL SECURITY NUMBER:

 6 FED. TAX I.D. NO:                                                        LICENSE TYPE:

     LICENSE TYPE

     LICENSE NO:                                  EXPIRATION DATE


 7   ESTIMATED VALUE OF FIRM'S SUBCONTRACT WORK:


 8 DESCRIPTION OF WORK TO BE DONE BY SUBCONTRACTOR'S WORKFORCE ONLY (MUST BE TRADE SPECIFIC) :


                      SPEC. SECTION:                                 CSI TRADE CODE:


 9 START DATE:                             AWARD DATE:                      FINISH DATE:


                      NO      YES                 NO     YES                                 NO       YES
10 MBE                                      WBE                             LBE


     SCA                      N.Y. STATE                 PT. AUTH.                           N.Y.C.


     OTHER:


11 IDENTIFY APPRENTICESHIP PROGRAM SUBCONTRACTOR PARTICIPATES IN THAT COVERS THE DESCRIPTION OF WORK
   BEING Done ON THIS JOB BY YOUR FIRM:
           PRIORITY        WORK PERMIT REQUIRED




                                                                     NO      YES
                                                  APPROVED
     MANAGER, PREQUALIFICATION
                                                                                                            DATE

SAF Form
_____________________
       EX HIBIT
         E–2
_____________________
                                             JOBSITE INCIDENT REPORT

  LOST PROPERTY    DAMAGED PROPERTY    BODILY INJURY   FIRE   FLOOD/WATER
DAMAGE
  SUSPECTED CRIME OR OFFENSE ANY    OTHER UNUSUAL OCCURRENCE OR CONDITION (Explain)



DATE OF REPORT

DATE AND TIME OF OCCURRENCE

PROJECT NAME AND NUMBER

 ADDRESS

WHERE (DESCRIBE PROPERTY INVOLVED)

HOW - A Detail Description of Incident or Occurrence




Name of Injured or Name of Property Owner:

Estimated Cost of Repairs (Property Damage):


NYC POLICE DEPT. RESPONDING NAME

PRECINCT                                                               SHIELD NUMBER

WITNESS’                    NAME
                            ADDRESS
                            CITY, STATE
                            PHONE

CONTRACTORS’                NAME
General Contractor          ADDRESS
and Subcontractor           CITY, STATE
                            PHONE

SUPERVISORS ON SITE


PREPARED BY                 NAME
                            TITLE

C:\Documents and Settings\chou_vi\Local Settings\Temporary Internet Files\OLK3D\EXHIBIT-E-2 JOBSITE-INCIDENT-REPORT REVISED AS OF MAY 6
2011.DOC
SCA’S EMERGENCY / INCIDENT NOTIFICATION REPORT

Date and Time of Incident _________________________________________________
Project Name and School Name____________________________________________
Project Address _________________________________________________________
            Loss Property                                                            Fire
            Damaged Property                                                         Injury
            Suspected Crime or Offence                                               Labor Dispute
            Broken Window                                                            Falling Material
            Inappropriate Behavior                                                   Other (Explain)________________
CHECK AS MANY BOXES AS APPLY

DESCRIPTION OF INCIDENT WITH CAUSE AND RESULTS________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
FOLLOW-UP ACTION REQUIRED: YES      NO     BY WHOM_____________
NAME OF SUPERVISOR NOTIFIED _______________________________________
OTHER AGENCIES NOTIFIED                            BOE           NYPD            FDNY           DEP           OTHER______________


PRECINCT _______________________SHIELD NUMBER_____________________

WITNESS, IF ANY
NAME _________________________________________________________________
ADDRESS ______________________________________________________________
PHONE/CELL __________________________________________________________

CONSTRUCTION MANAGER____________________________________________
GENERAL CONTRACTOR ______________________________________________
SUBCONTRACTOR INVOLVED _________________________________________

INJURED PARTY, IF ANY
NAME _________________________________________________________________
ADDRESS ______________________________________________________________
PHONE/CELL __________________________________________________________

SUPERVISOR (S) ON SITE _______________________________________________
REPORT PREPARED BY:
Name __________________________________________________________________
Title ___________________________________________________________________
SIGNATURE ______________________________________DATE _______________
PLEASE SUBMIT COPIES OF THIS COMPLETED FORM IMMEDIATELY TO YOUR SENIOR
PROJECT OFFICER, CHIEF PROJECT OFFICER OR THE VICE PRESIDENT OF CONSTRUCTION
MANAGEMENT AND COMMUNITY RELATIONS.

C:\Documents and Settings\chou_vi\Local Settings\Temporary Internet Files\OLK3D\EXHIBIT-E2 EMERGENCY-INCIDENT NOTIFICATION REPORT REVISED AS OF
MAY 6 2011.doc
_____________________
       EX HIBIT
         E–3
_____________________
                                        STATE OF NEW YORK
                                   WORKERS’ COMPENSATION BOARD
                                      100 BROADWAY-MENANDS
                                          ALBANY, NY 12241
                                            (877) 632-4996




                  You were injured at work. What now?
The New York State Workers’ Compensation Board has received notice you suffered a
workplace injury or illness, so we’re preparing a workers’ compensation case in your
name. You may have already received medical treatment. If you haven’t, you should
seek medical care as soon as possible.

A Worker’s Responsibilities
 You must tell your employer, in writing, when, where and how you were injured.
   Do this within 30 days of injury.
 Medical reports are necessary for your case. Advise your doctors that you have a work-
   related injury, and give the name of your employer. Do not pay for your care
   yourself or use other health insurance. Tell your doctor to file reports with the Board
   and with your employer or its insurance carrier. If your case is disputed, the Board
   needs a medical report on your injury to begin resolving your claim.

Starting a Case
Once your employer knows of your injury, it must notify this Board by filing a C-2
form. You should file an employee claim (C-3 form) reporting your injury as soon as possible.
(You must notify the Board of your injury or illness within two years.) If you injured the
same body part before, or had a similar illness, you must also file a Form C-3.3.

If you haven’t already filed a C-3 or C-3.3 (if necessary), there are three ways to do it.

   Visit www.wcb.state.ny.us/content/main/onthejob/howto.jsp to complete the form.
   Complete the enclosed paper forms, and mail them to the Board.
   Call 1-866-396-8314. A Board employee will complete the form with you.

Health Care Bills
Do not pay your doctor or hospital. Those bills are paid by the insurer unless the Board
disallows your case. If your case is disputed, the providers are paid when the Board
decides your case. If the Board decides against you, or if you don’t pursue a case, you will
have to pay the doctor or hospital.

Your employer’s insurance covers medically necessary drugs and equipment your
doctor prescribes. You’re also entitled to carfare or necessary expenses incurred when
traveling for treatment. (Get receipts for those expenses.)




                   THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
Claimant Information Packet


Generally, you can choose any doctor authorized by the Board. You can also use
occupational health clinics. However, if your employer’s insurer has a preferred
provider organization to provide care for workers' compensation injuries, you must get
your initial treatment from those providers. If that insurer also has a pharmacy or
diagnostic network, you must get service within these networks. If the carrier uses these
networks, it must also tell you its service providers and how to use them.

Benefits for Lost Wages
You are entitled to a portion of your lost wages if your injury affects you in one or more
ways:
  1. It keeps you from work for more than seven days;
  2. Part of your body is permanently disabled;
  3. Your pay is reduced because you now work fewer hours or do other work.

An employer or insurer can accept your claim and begin paying your lost wage benefit
promptly. Sometimes, employers and carriers dispute a claim. When that occurs, the
Board strives to resolve most cases within 90 days.

You may hire an attorney or licensed representative, who can be helpful with complex
or disputed claims, but it isn’t required. The Board sets their fees and they will be
deducted from your lost wages award. You or your family should not pay anything
directly to your attorney or licensed representative.

If your case is disputed, you may receive disability benefits while the case is heard.
You’d pay them back out of your lost wages award. To get a DB-450 form, visit
www.wcb.state.ny.us/content/main/forms/db450.pdf or a Board office, or call (800) 353-3092.

Help is Available
People sometimes need help getting back to work. Your employer may have a return to
work program that can get you back to work in light duty or an alternative position
while you heal. An injury can also cause family or financial problems. The Workers'
Compensation Board has rehabilitation counselors and social workers to help. Call (877)
632-4996 for more assistance.

What’s Next?
Your employer or its insurance carrier will contact you if your claim is accepted. When
that happens, your treatment will be paid and lost wage benefits begin. If your case is
challenged, the Board will notify you about resolving the case. If more information is
necessary, the Board will contact you and tell you how to file it.

Important Contact Information
 Workers’ Compensation Board            (877)632-4996           General_Information@wcb.state.ny.us
 Disability Benefits                    (800)353-3092           www.WCB.State.NY.US
 NYS Bar Association Lawyer             (800)342-3661           lr@nysba.org.
 Referral and Information Service



                              NEW YORK STATE WORKERS' COMPENSATION BOARD
                                                                      Employee Claim
                                               State of New York - Workers' Compensation Board                                                                       C-3
                Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness. Type or
                print neatly. This form may also be filled out on-line at www.wcb.state.ny.us.
 WCB Case Number (if you know it):
 A. YOUR INFORMATION (Employee)
     1. Name:                                                                                                                    2. Date of Birth: ______/______/______
                                 First                          MI                            Last

     3. Mailing address:
                                         Number and Street/PO Box                          City                                        State         Zip Code

     4. Social Security Number:               -          -                   5. Phone Number: (_____)_______________ 6. Gender:                                     Female
                                                                                                                                                         Male
     7. Will you need a translator if you have to attend a Board hearing?                    Yes                No If yes, for what language?
 B. YOUR EMPLOYER(S)
     1. Employer when injured:                                                                                              2. Phone Number: (_____)_______________

     3. Your work address:
                                                              Number and Street                          City                                    State          Zip Code

     4. Date you were hired: _____/_____/_____                  5. Your supervisor's name:

     6. List names/addresses of any other employer(s) at the time of your injury/illness:



     7. Did you lose time from work at the other employment(s) as a result of your injury/illness?                           Yes       No
 C. YOUR JOB on the date of the injury or illness
     1. What was your job title or description?
     2. What types of activities did you normally perform at work?_________________________________________________________________



     3. Was your job? (check one)                  Full Time                 Part Time            Seasonal               Volunteer        Other:____________________
     4. What was your gross pay (before taxes) per pay period?                                                     5. How often were you paid?
     6. Did you receive lodging or tips in addition to your pay?                   Yes            No     If yes, describe:


 D. YOUR INJURY OR ILLNESS
     1. Date of injury or date of onset of illness: ______/______/______                             2. Time of injury:                            AM           PM

     3. Where did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)



     4. Was this your usual work location?              Yes           No          If no, why were you at this location?



     5. What were you doing when you were injured or became ill? (e.g., unloading a truck, typing a report) _______________________________



      6. How did the injury/illness happen? (e.g., I tripped over a pipe and fell on the floor)




     7. Explain fully the nature of your injury/illness; list body parts affected (e.g., twisted left ankle and cut to forehead):______________________




                                                             THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE
C-3.0 (1-11) Page 1 of 2                                               WITH DISABILITIES WITHOUT DISCRIMINATION                                   www.wcb.state.ny.us
        YOUR NAME:________________________________________________                                             DATE OF INJURY/ILLNESS: ______/______/______
                            First                       MI                           Last
 D. YOUR INJURY OR ILLNESS continued
      8. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?                 Yes         No     If yes, what?
      9. Was the injury the result of the use or operation of a licensed motor vehicle?                    Yes       No
         If yes,      your vehicle           employer's vehicle          other vehicle                 License plate number (if known):
          If your vehicle was involved, give name and address of your motor vehicle insurance carrier:


     10. Have you given your employer (or supervisor) notice of injury/illness?                       Yes         No
         If yes, notice was given to: ____________________________________                            orally       in writing Date notice given: _____/_____/_____
     11. Did anyone see your injury happen?                  Yes      No       Unknown If yes, list names:________________________________________


 E. RETURN TO WORK
      1. Did you stop work because of your injury/illness?                 Yes, on what date? _____/_____/_____                       No , skip to Section F.
      2. Have you returned to work?               Yes          No    If yes, on what date? _____/_____/_____                       regular duty          limited duty
      3. If you have returned to work, who are you working for now?                     Same employer                  New employer            Self employed
      4. What is your gross pay (before taxes) per pay period?                                                   How often are you paid?
 F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS
      1. What was the date of your first treatment? ______/______/______                               None received (skip to question F-5)
      2. Were you treated on site?             Yes            No
      3. Where did you receive your first off site medical treatment for your injury/illness?                       none received            Emergency Room
                        Doctor's office                      Clinic/Hospital/Urgent Care                         Hospital Stay over 24 hours
          Name and address where you were first treated:
                                                                                                                           Phone Number: (_____)_______________
      4. Are you still being treated for this injury/illness?  Yes          No
        Give the name and address of the doctor(s) treating you for this injury/illness:
                                                                                                                           Phone Number: (_____)_______________
      5. Do you remember having another injury to the same body part or a similar illness?    Yes        No
         If yes, were you treated by a doctor?     Yes      No      If yes, provide the names and addresses of the doctor(s) who treated
         you and COMPLETE AND FILE FORM C-3.3 TOGETHER WITH THIS FORM:




      6. Was the previous injury/illness work related?      Yes      No
         If yes, were you working for the same employer that you work for now?                        Yes         No
   I am hereby making a claim for benefits under the Workers' Compensation Law. My signature affirms that the information I am providing is true
   and accurate to the best of my knowledge and belief.
        Any person who knowingly and with INTENT TO DEFRAUD presents, causes to be presented, or prepares with knowledge or belief that it
        will be presented to, or by an insurer, or self-insurer, any information containing any FALSE MATERIAL STATEMENT or conceals any
        material fact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT.

 Employee's Signature:                                                        Print Name:                                                      Date: _____/_____/_____
 On behalf of Employee:                                                       Print Name:                                                      Date: _____/_____/_____
   An individual may sign on behalf of the employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated.
 I certify to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the allegations and other factual
 matters asserted above have evidentiary support, or are likely to have evidentiary support after a reasonable opportunity for further investigations or discovery.
 Signature of Attorney/Representative (if any):                                                                                          Date: _______/_______/_______
 Print Name:                                                                                 Title:

 ID No., if any: R                                   If Licensed Representative, License No.:                                 Expiration Date: _______/_______/_______
C-3.0 (1-11) Page 2 of 2
                                               Limited Release of Health Information
                                                                                 (HIPAA)
                                                  State of New York - Workers' Compensation Board
                                                                                                                                                      C-3.3
                WCB Case No. (if you know it):___________________________
To Claimant: If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current
Claim, fill out this form. This form allows the health care providers you list below to release health care information about your previous injury/
illness to your employer's workers' compensation insurer. The federal HIPAA law (Health Insurance Portability and Accountability Act of 1996)
says you have a right to get a copy of this form. If you do not understand this form, talk to your legal representative. If you do not have a legal
representative, the Advocate for Injured Workers at the Workers' Compensation Board can help you. Call: 800-580-6665.
To Health Care Provider: A copy of this HIPAA-compliant release allows you to disclose health information. If you send records to the
employer's workers' compensation insurer in response to this release, also mail copies to the Claimant's legal representative. (If no legal
representative is listed below, send copies to the Claimant.) Health care providers who release records must follow New York state law and
HIPAA.
 This release is:
                                                                                                      This form does NOT allow your health care provider(s)
   Voluntary. Your health care provider(s) must give you the same care,                               to release the following types of information:
   payment terms, and benefits, whether you sign this form or not.
   Limited. It gives your health care provider(s) permission to release only
   those health records that are related to the previous illness/condition you                           HIV-related information
   describe below.
   Temporary. It ends when your current claim for compensation is established                            Psychotherapy notes
   or disallowed and all appeals are exhausted.
   Revocable. You can cancel this release at any time. To cancel, send a letter                          Alcohol/Drug treatment
   to the health care provider(s) listed on this form. Also, send a copy of your
   letter to your employer's workers' compensation insurer and the Workers'
                                                                                                         Mental Health treatment (unless you check below)
   Compensation Board. Note: You may not cancel this release with respect to
   medical records already provided.
   For records only. It gives your health care provider(s) listed on this form                           Verbal information (your health care providers may
                                                                                                         not discuss your health care information with anyone)
   permission to send copies of your health care records to your employer's
   workers' compensation insurer.
  Any medical records released will become part of your workers' compensation file and are confidential under the Workers' Compensation Law.
A. YOUR INFORMATION (Claimant)
   1. Name:__________________________________________________________________ 2. Social Security Number:______-_____-______
   3. Mailing Address: _________________________________________________________________________________________________
   4. Date of Birth: ______/______/______ 5. Date of the current injury/illness: ______/_______/_______
   6. Current injury/illness, including all body parts injured:_____________________________________________________________________
      ______________________________________________________________________________________________________________
   7. Your legal representative's name and address (if any):___________________________________________________________________
       ______________________________________________________________________________________________________________
       Check here if you allow your health care provider(s) to release mental health care information.
B. YOUR HEALTH CARE PROVIDER(S) (List all health care providers who treated you for a previous injury to the same body part or similar
     illness. If more than 2 providers attach their contact information to this form.)
   1. Provider:__________________________________________________________________ 2. Phone Number: (______)_______________
   3. Mailing Address: _________________________________________________________________________________________________
   4. Other provider (if any):_______________________________________________________ 5. Phone Number: (______)_______________
   6. Mailing Address:_________________________________________________________________________________________________
C. READ AND SIGN BELOW. I hereby request that the health care provider(s) listed above give my employer's workers' compensation
    insurer copies of all health records related to any previous injury/illness, to all body parts, described above.

      ____________________________________________________________________________________________________________
       Claimant's signature (ink only -- use blue ballpoint pen, if possible.)                                                       Date

        If the claimant is unable to sign, the person signing on his/her behalf must fill out and sign below:

      ______________________________________________________________________________________________________________
       Your name                          Relationship to Claimant                Signature (ink only -- use blue ballpoint pen, if possible.)        Date


C-3.3 (12-09)                                   Versión en español al reverso de la forma.                                                       www.wcb.state.ny.us
                                Divulgación limitada de información sobre la salud
                                                                        (HIPAA)
                                        Estado de NuevaYork - Junta de Compensación Obrera (WCB)
                                                                                                                                 C-3.3
 WCB Case No. (if you know it) (Número de caso WCB [si lo sabe])
Al reclamante: Si usted recibió tratamiento por una lesión anterior en la misma parte del cuerpo o por una enfermedad similar a la que motiva
ahora su reclamación, complete este formulario. Este formulario les permite a los proveedores de salud que usted señala a continuación divulgar
a la compañía de seguros de compensación obrera de su empleador la información sobre su salud relacionada con su lesión/enfermedad
anterior. La Ley federal HIPAA (Ley de portabilidad y responsabilidad del seguro de salud de 1996) establece que usted tiene derecho a recibir
una copia de este formulario. Si no comprende este formulario, hable con su representante legal. Si no tiene un representante legal, el
Representante de los obreros lesionados de la Junta de Compensación Obrera puede ayudarlo. Llame al 800-580-6665.
Al proveedor de salud: Una copia de esta divulgación, redactada según lo que establece la ley HIPAA, le permite divulgar información sobre la
salud. Si envía los registros al asegurador de compensación obrera del empleador en respuesta a la presente divulgación, también debe enviar
por correo copias al representante legal del reclamante. (Si a continuación no se especifica un representante legal, envíe las copias al
reclamante). Los proveedores de salud que divulgan los registros deben cumplir con las leyes del estado de Nueva York y la HIPAA.
  Esta divulgación es:
                                                                                        Este formulario NO autoriza a su(s) proveedor(es) de
     Voluntaria. Su(s) proveedor(es) de salud deben otorgarle la misma
     atención, condiciones de pago y beneficios, independientemente de que              salud a divulgar los siguientes tipos de información:
     usted firme este formulario o no.
     Limitada. Le otorga a su(s) proveedor(es) de salud permiso para divulgar               Información relacionada con el VIH
     únicamente los registros médicos que se relacionen con la enfermedad/
     afección anterior que usted describe a continuación.
     Temporal. Termina cuando se otorgue o desestime su actual reclamación                  Notas de terapia psicológica
     de compensación y se hayan agotado todas las apelaciones.
     Revocable. Usted puede cancelar esta divulgación en cualquier momento.                 Tratamientos por abuso de alcohol o drogas
     Para hacerlo, envíe una carta al (a los) proveedor(es) de salud que se
     indican en este formulario. Además, envíe una copia de su carta a la
     compañía de seguros de compensación obrera de su empleador y a la Junta                Tratamiento de salud mental (a menos que usted lo
     de Compensación Obrera. Nota: No podrá cancelar esta divulgación en lo                 indique a continuación)
     que se refiere a registros médicos que ya se hayan provisto.
     Solamente para registros. Le otorga a su(s) proveedor(es) de salud que se
     indica(n) en este formulario permiso para enviar copias de sus registros de            Información verbal (sus doctores no pueden hablar
     salud a la compañía de seguros de compensación obrera de su empleador.                 con nadie sobre su información de salud)

  Los registros médicos divulgados se incorporarán a su expediente de compensación obrera y son confidenciales conforme a la
  Ley de compensación obrera.
     CONTESTA LAS SIGUIENTES PREGUNTAS, EN INGLÉS SI ES POSIBLE, EN LOS ESPACIOS PROVISTOS Y FIRMA
     AL FRENTE DE LA FORMA.
A. YOUR INFORMATION (Claimant) INFORMACIÓN PERSONAL (Reclamante)
    1. Name (Nombre)                                             2. Social Security Number (Número de seguro social)
    3. Mailing Address (Dirección postal)
    4. Date of Birth (Fecha de nacimiento)                       5. Date of the current injury/illness (Fecha de la lesión/enfermedad actual)
    6. Current injury/illness, including all body parts injured (Descripción de la lesión/enfermedad actual, incluyendo todas las partes del
       cuerpo lesionadas)
    7. Your legal representative's name and address (if any) (Nombre y dirección de su representante legal [si corresponde])
       Check here if you allow your health provider(s) to release mental health care information. (Marque aquí si autoriza a su(s) proveedor(es) de
       salud a divulgar información sobre tratamientos de salud mental.)
B. YOUR HEALTH CARE PROVIDERS (List all health care providers who treated you for a previous injury to the same body part or similar
     illness. If more than 2 providers, attach their contact information to this form.
     SU(S) PROVEEDOR(ES) DE SALUD (Enumere todos los proveedores de salud que le han tratado por lesiones previas a las mismas
     areas del cuerpo ó por enfermedades semejantes.Si son más de 2 proveedores, adjunte su información de contacto a este formulario.)
    1. Provider (Proveedor de salud)                 2. Phone Number (No de teléfono)
    3. Mailing Address (Dirección postal)
    4. Other provider (if any) (Otro proveedor [si corresponde])     5. Phone Number (No de teléfono)
    6. Mailing Adress (Dirección postal)
C. READ AND SIGN BELOW I hereby request that the health care provider(s) listed above give my employer's workers' compensation
     insurer copies of all health records related to any previous injury/illness, to all body parts, described above. LEA Y FIRME A
     CONTINUACIÓN. Por la presente solicito que los proveedores de salud aquí enumerados le provean al asegurador de compensación
     obrera de mi patrono copias de todos los records médicos relacionados a cualquier lesión/enfermedad aquí enumeradas.
   If the claimant is unable to sign, the person signing on his/her behalf must fill out and sign below: (Si el reclamante no puede firmar, la
     persona que firme el formulario en su nombre y representación debe llenar y firmar a continuación)
         xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
         Claimant's signature (Firma del reclamante ) use solo tinta - preferiblemente azul Date (Fecha)
         xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
         Your name (Su nombre) Relationship to Claimant (Relación con el reclamante) Signature(Firma) Date(Fecha)
C-3.3 (12-09)                                                                                                             www.wcb.state.ny.us
                       Instructions for Completing Form C-3, “Employee Claim”
Please complete this form and send it to your local Workers' Compensation Board district office (DO) to apply for workers'
compensation benefits. The addresses are listed at the bottom of these instructions. If you need additional help in completing
this form, contact the Workers' Compensation Board at 1-877-632-4996. You may also fill this form out online at: http://
www.wcb.state.ny.us/

If you do not have or know your Workers' Compensation Board Case Number, please leave this field blank. It is not
required to process your claim. Remember to enter your name and the date of your injury/illness on the top of page
two.
                                        Section A - Your Information (Employee):
Item 1: Enter your full name, including first name, middle initial, and last name.
Item 2: Enter your date of birth in month/day/year format. Include the four digit year.
Item 3: Enter your mailing address, including P.O. Box, if applicable, city or town, state, and Zip code.
Item 4: Enter your Social Security Number. This is very important to help service your claim faster.
Item 5: Indicate the primary contact phone number, including area code. This may include a cell phone number.
Item 6: Indicate your gender (Male or Female).
Item 7: Board hearings are conducted in English. If you will need a translator to understand the proceeding, the Board will
        provide one. Check Yes and indicate the language needed.

                                               Section B - Your Employer(s):
Item 1: Indicate the employer you were working for at the time you were injured or became ill.
Item 2: Enter the phone number for this employer, either a primary contact number or the number for your supervisor.
Item 3: Enter the employer's address, including P.O. Box, if applicable, city or town, state, and Zip code.
Item 4: Indicate the date you were hired by this employer.
Item 5: Enter your direct supervisor's name, whom you report to on a regular basis.
Item 6: If you have more than one job, please indicate the names and addresses of all other employers you work for besides
        the one you were injured at. Please attach a separate sheet if you need more room.
Item 7: Check Yes if you lost time from any of your other jobs as a result of your injury or illness; otherwise, check No.

                                Section C - Your Job on the Date of the Injury or Illness:
Item 1: Indicate your current job title or job description (e.g., warehouse worker).
Item 2: Indicate your typical work activities for this job (e.g., keeping inventory, unloading trucks, etc.).
Item 3: Check the type of job you had.
Item 4: Enter your gross pay (before taxes) per pay period.
Item 5: Indicate how often you received a paycheck (weekly, bi-weekly, etc.).
Item 6: Indicate if you received any tips or lodging in addition to your regular pay. If you did, describe them.

                                               Section D - Your Injury or Illness:
Item 1: Enter the date when you were injured or the first date you noticed you became ill. Enter the date in month/day/year
        format. Include the four digit year. If this is an illness or occupational disease, then skip item 2.
Item 2: Enter the time when the injury occurred. Check whether it was AM or PM.
Item 3: Indicate the location where the injury/illness occurred, including the address of the building and the physical
        location in the building where the injury/illness happened.
Item 4: Check whether this was your normal work location. If it was not, explain why you were at this location.
Item 5: Describe in detail what you were doing at the time of the injury/illness (e.g., unloading boxes from a truck by hand).
        This explains the events leading up to the injury.
Item 6: Describe in detail how the injury/illness occurred (e.g., I was lifting a heavy box off a truck). This should include all
        people and events involved in the injury/illness.
Item 7: Indicate fully the nature and extent of your injury/illness, including all body parts injured. Be as specific as possible.
        (e.g., I strained my back trying to lift a heavy box. It hurts to bend over or hold even lighter objects now.)
Item 8: Indicate if some object was involved in the accident OTHER THAN a licensed motor vehicle. Other objects may
        include a tool (e.g., hammer), a chemical (e.g., acid), machinery (e.g., forklift or drill press), etc.
Item 9: Indicate if a licensed motor vehicle was involved in the accident. If so, check if the motor vehicle involved was
        yours, your employer's, or a third party's. Include the license plate number (if known). If your vehicle was involved,
        fill out the name and address of your automobile liability insurance carrier.
Item 10: Check if you gave your employer or supervisor notice of your injury or illness. If so, indicate who you gave notice
          to as well as if it was orally or in writing. Include the date you gave notice.
Item 11: Check if anyone else saw the injury happen. If anyone did see it, include their name(s).

                                               Section E - Return to Work:
Item 1: If you stopped working as a result of your work-related injury/illness, check Yes and indicate on what date you
        stopped working. If you have not stopped working, check No and skip to the next section.

 C-3.0 (1-11)
                                              Section E - Return to Work (cont):
Item 2: If you have since returned to work, check Yes. Also indicate on what date you started working again, as well as if you
        have returned to your Normal Duties or if you are on Limited or Restricted Duty. (If you have not returned to your full
        pre-injury or illness work duties, then you are on Limited Duty.)
Item 3: If you have returned to work, indicate who you are working for now.
Item 4: Enter your gross pay (before tax pay) per pay period for the job you are working at now. Indicate how often you are
        receiving a paycheck (weekly, bi-weekly, etc.).
                                   Section F - Medical Treatment for This Injury or Illness:
Item 1: If you did not receive medical treatment for this injury/illness, check None Received and skip to item 5. Otherwise,
        enter the date you first received treatment for this injury/illness and complete the rest of this section.
Item 2: Check if you were first treated on the job for this injury or illness.
Item 3: Check the location where you first received off site medical treatment for your injury or illness. Include the name and
        address of the facility as well as the phone number (including area code).
Item 4: If you are still receiving ongoing treatment for the same injury or illness, check Yes and indicate the name and
        address of the doctor(s) providing treatment as well as the phone number (including area code); otherwise check No.
Item 5: If you believe you already had an injury to the same body part or a similar illness, check Yes and indicate if you were
        treated by a doctor for this injury or illness. If you were treated by a doctor, indicate the name(s) and address(es) of the
        doctor(s) whom provided care and complete and file Form C-3.3 together with this form.
Item 6: If you had a previous injury or illness, check if your previous injury or illness was work-related. If Yes, check if
        the injury or illness happened while working for your current employer.
 Sign Form C-3 in the place provided for "Employee's Signature on page 2, print your name, and enter the date you signed the
form. If a third-party is signing on behalf of the employee, that person should sign on the second signature line. If you have
legal representation, your representative must complete and sign the attorney/representative's certification section on the
bottom of page 2.
                     What Every Worker Should Do in Case of On-The-Job Injury or Occupational Disease:
1.   Immediately tell your employer or supervisor when, where and how you were injured.
2.   Secure medical care immediately.
3.   Tell your doctor to file medical reports with the Board and with your employer or its insurance carrier.
4.   Make out this claim for compensation and send it to the nearest Workers' Compensation Board Office. (See below.) Failure to file
     within two years after the date of injury may result in your claim being denied. If you need help in completing this form, telephone or
     visit the nearest Workers' Compensation Board Office listed below.
5.   Go to all hearings when notified to appear.
6.   Go back to work as soon as you are able; compensation is never as high as your wage.

                                                                Your Rights:
1.   Generally, you are entitled to be treated by a doctor of your choice, provided he/she is authorized by the Board. If your employer is
     involved in a preferred provider organization (PPO) arrangement, you must obtain initial treatment from the preferred provider
     organization which has been designated to provide health care services for workers' compensation injuries.
2.   DO NOT pay your doctor or hospital. Their bills will be paid by the insurance carrier if your case is not disputed. If your case is
     disputed,
     the doctor or hospital must wait for payment until the Board decides your case. In the event you fail to prosecute your case or the
     Board decides against you, you will have to pay the doctor or hospital.
3.   You are also entitled to be reimbursed for drugs, crutches, or any apparatus properly prescribed by your doctor and for carfares or other
     necessary expenses going to and from your doctor's office or the hospital. (Get receipts for such expenses.)
4.   You are entitled to compensation if your injury keeps you from work for more than seven days, compels you to work at lower wages,
     or results in permanent disability to any part of your body.
5.   Compensation is payable directly and without waiting for an award, except when the claim is disputed.
6.   Injured workers or dependents of deceased workers may represent themselves in matters before the Board or may retain an attorney or
     licensed representative to represent them. If an attorney or licensed representative is retained, his/her fee for legal services will be
     reviewed by the Board and if approved will be paid by the employer or insurance company out of any compensation benefits due.
     Injured workers or dependents of deceased workers should not directly pay anything to the attorney or licensed representative
     representing them in a compensation case.
7.   If you need help returning to work, or with family or financial problems because of your injury, contact the Workers' Compensation
     Board office nearest you and ask for a rehabilitation counselor or social worker.

        This form should be filed by sending directly to the appropriate WCB district office (DO) at the address listed below:
Albany DO - 100 Broadway-Menands, Albany NY 12241 (866) 750-5157 (for accidents in the following counties: Albany, Clinton, Columbia,
Dutchess, Essex, Franklin, Fulton,Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington)
Binghamton DO - State Office Building, 44 Hawley Street, Binghamton NY13901 (866) 802-3604 (for accidents in the following counties: Broome,
Chemung, Chenango, Cortland,Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins)
Buffalo DO - 295 Main Street, Suite 400, Buffalo NY 14203 (866) 211-0645 (for accidents in the following counties: Cattaraugus,
Chautauqua, Erie, Niagara)
Rochester DO - 130 Main Street West, Rochester NY 14614 (866) 211-0644 (for accidents in the following counties: Allegany, Genesee, Livingston,
Monroe, Ontario, Orleans,Seneca, Steuben, Wayne, Wyoming, Yates)
Syracuse DO - 935 James Street, Syracuse NY 13203 (866) 802-3730 (for accidents in the following counties: Cayuga, Herkimer, Jefferson, Lewis,
Madison, Oneida, Onondaga,Oswego,St. Lawrence)
Downstate Centralized Mailing - PO Box 5205, Binghamton NY, 13902-5205 for all DO's in NYC (800) 877-1373; in Hempstead (866) 805-3630; in
Hauppauge (866) 681-5354; in Peekskill (866) 746-0552 (for accidents in the following counties: Bronx, Kings, Nassau, New York, Orange, Putnam,
Queens, Richmond, Rockland, Suffolk, Westchester)
C-3.0 (1-11)
_____________________
       EX HIBIT
         E–4
_____________________
_____________________
       EX HIBIT
         E–5
_____________________

				
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