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Insurance Waiver Forms for Subcontractors - Download as Excel

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					                                              ATTACHMENT C

                           FRINGE BENEFIT STATEMENT
CONTRACT NUMBER                     CONTRACT TITLE                           TODAY'S DATE
V664C-405-8(A)                          CYSTO REMODEL OR 8 03002

SUBCONTRACTOR:                               ADDRESS:


IN ORDER THAT THE PROPER FRINGE BENEFIT RATES CAN BE VERIFIED WHEN CHECKING PAYROLLS IN THE
ABOVE CONTRACT, THE HOURLY RATES FOR FRINGE BENEFITS, SUBSISTENCE AND/OR TRAVEL ON THE
ALLOWANCE PAYMENT MADE FOR EMPLOYEES ON THE VARIOUS CLASSES OF WORK ARE TABULATED BELOW.
CLASSIFICATION:                     EFFECTIVE DATE:     SUBSISTANCE OR TRAVEL PAY:

         HEALTH AND                        PAID TO: NAME:
         WELFARE                $          ADDRESS:
 FRINGE PENSION                            PAID TO: NAME:
BENEFITS                        $          ADDRESS:
         VACATION/                         PAID TO: NAME:
         HOLIDAY                $          ADDRESS:
         TRAINING AND/OR                   PAID TO: NAME:
         OTHER                  $          ADDRESS:
CLASSIFICATION:                   EFFECTIVE DATE:   SUBSISTANCE OR TRAVEL PAY:

         HEALTH AND                        PAID TO: NAME:
         WELFARE                $          ADDRESS:
 FRINGE PENSION                            PAID TO: NAME:
BENEFITS                        $          ADDRESS:
         VACATION/                         PAID TO: NAME:
         HOLIDAY                $          ADDRESS:
         TRAINING AND/OR                   PAID TO: NAME:
         OTHER                  $          ADDRESS:
CLASSIFICATION:                   EFFECTIVE DATE:   SUBSISTANCE OR TRAVEL PAY:

         HEALTH AND                          PAID TO: NAME:
         WELFARE                $            ADDRESS:
 FRINGE PENSION                              PAID TO: NAME:
BENEFITS                        $            ADDRESS:
         VACATION/                           PAID TO: NAME:
         HOLIDAY                $            ADDRESS:
         TRAINING AND/OR                     PAID TO: NAME:
         OTHER                  $            ADDRESS:
SUPPLEMENTAL STATEMENTS MUST BE SUBMITTED DURING THE PROGRESS OF WORK SHOULD A
CHANGE IN RATE OF ANY OF THE CLASSIFICATIONS
SUBMITTED: SUBCONTRACTOR                                BY:
          ATTACHMENT C

GE BENEFIT STATEMENT



T RATES CAN BE VERIFIED WHEN CHECKING PAYROLLS IN THE
R FRINGE BENEFITS, SUBSISTENCE AND/OR TRAVEL ON THE
EES ON THE VARIOUS CLASSES OF WORK ARE TABULATED BELOW.




MITTED DURING THE PROGRESS OF WORK SHOULD A
ATIONS
                                                   ATTACHMENT E-1
                                                                                                       FORM APPROVED OMB
                  STATEMENT AND ACKNOWLEDGEMENT                                                        NO. 3090-0119

                                       PART 1 - STATEMENT OF PRIME CONTRACTOR
1. PRIME CONTRACT NUMBER               2. DATE SUBCONTRACT             SUBCONTRACTORS NUMBER
                                       AWARDED:

4. PRIME CONTRACTOR:                                          5. SUBCONTRACTOR (NAME, ADDRESS AND ZIP CODE)
                                                              (2nd Tier)
             STRONGHOLD ENGINEERING, INC.
             3421 GATO COURT
             RIVERSIDE, CA 92507

6. THE PRIME CONTRACTOR STATES THAT UNDER THE CONTRACT SHOWN IN ITEM 1, A SUBCONTRACT WAS AWARDED ON DATE
SHOWN IN ITEM 2 BY (NAME OF AWARDING FIRM):      STRONGHOLD ENGINEERING, INC.                                          (1st Tier)
(SCOPE OF WORK) - 2ND TIER SUB




7. PROJECT                                                    8. LOCATION


9. NAME AND TITLE OF PERSON SIGNING                  10. BY (SIGNATURE)             11. DATE SIGNED
MACKIE MCNICHOLAS
SUBCONTRACT MAN., STRONGHOLD ENGINEERING, INC.
                          PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR
12. THE SUBCONTRACTOR ACKNOWLEDGES THAT THE FOLLOWING CLAUSES OF THE CONTRACT
SHOWN IN ITEM 1 ARE INCLUDED IN THIS SUBCONTRACT.
           CONTRACT WORK HOURS AND SAFETY            DAVIS-BACON ACT
           STANDARDS ACT - OVERTIME                  APPRENTICES AND TRAINEES
           COMPENSATION - CONSTRUCTION               COMPLIANCE WITH COPELAND REGULATIONS
           PAYROLLS AND BASIC STANDARDS              SUBCONTRACTORS
           WITHHOLDING OF FUNDS                      CONTRACTOR TERMINATION - DEBARMENT

13. NAMES OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY:                      (1ST TIER SUB) - ADDRESS




14. NAME AND TITLE OF PERSON SIGNING             15. BY       (SIGNATURE)                              16. DATE SIGNED




(2ND TIER SUB)

FORM SF 1413
                                                             ATTACHMENT E-1
                                                                                                                            FORM APPROVED OMB
                       STATEMENT AND ACKNOWLEDGEMENT                                                                       NO. 9000-0014
PUBLIC REPORTING BURDEN FOR THIS COLLECTION OF INFORMATION IS ESTIMATED TO AVERAGE .15 HOURS PER RESPONSE, INCLUDING THE TIME FOR
REVIEWING INSTRUCTIONS, SEARCHING EXISTING DATA SOURCES, GATHERING AND MAINTAINING THE DATA NEEDED, AND COMPLETING AND REVIEWING
THE COLLECTION OF INFORMATION. SEND COMMENTS REGARDING THIS BURDEN ESTIMATE OR ANY OTHER ASPECT OF THIS COLLECTION OF INFORMATION
INCLUDING SUGGESTIONS FOR REDUCING THIS BURDEN TO THE FAR SECRETAIAT (VRS), OFFICE OF FEDERAL ACQUISITION AND REGULATORY POLICY,
 GSA, WASHINGTON, D.C. 20405; AND TO THE OFFICE OF MANAGEMENT AND BUDGET, PAPERWORK REDUCTION PROJECT (9000-0014_, WASHINGTON,
D.C. 20503.
                       PART 1 - STATEMENT OF PRIME CONTRACTOR
1. PRIME CONTRACT NUMBER 2. DATE SUBCONTRACT         SUBCONTRACTORS NUMBER
V664C-405-8(A)           AWARDED:                                03002

4. PRIME CONTRACTOR:                                                         5. SUBCONTRACTOR (NAME, ADDRESS AND ZIP CODE)

          STRONGHOLD ENGINEERING, INC.
          3421 GATO COURT
          RIVERSIDE, CA 92507
6. THE PRIME CONTRACTOR STATES THAT UNDER THE CONTRACT SHOWN IN ITEM 1, A SUBCONTRACT
WAS AWARDED IN DATE SHOWN IN ITEM 2 BY (NAME OF AWARDING FIRM):




7. PROJECT                                                                   8. LOCATION
                      CYSTO REMODEL OR 8                                                           VA SAN DIEGO, CA

9. NAME AND TITLE OF PERSON SIGNING                                        11. DATE SIGNED
          MACKIE MCNICHOLAS
          SUBCONTRACT MANAGER
                       PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR
12. THE SUBCONTRACTOR ACKNOWLEDGES THAT THE FOLLOWING CLAUSES OF THE CONTRACT
SHOWN IN ITEM 1 ARE INCLUDED IN THIS SUBCONTRACT.
          CONTRACT WORK HOURS AND SAFETY     DAVIS-BACON ACT
          STANDARDS ACT - OVERTIME           APPRENTICES AND TRAINEES
          COMPENSATION - CONSTRUCTION        COMPLIANCE WITH COPELAND REGULATIONS
          PAYROLLS AND BASIC STANDARDS       SUBCONTRACTORS
          WITHHOLDING OF FUNDS               CONTRACTOR TERMINATION - DEBARMENT
          DISPUTES CONCERNING LABOR STANDARDS          CERTIFICATION OF ELIGIBILITY
13. NAMES OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY:




14. NAME AND TITLE OF PERSON SIGNING 15. BY                                                                                 16. DATE SIGNED
      Job Specific
      rev 4-10-03

                                CERTIFICATE OF LIABILITY INSURANCE
PRODUCER                                               THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO
                                                       RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,
                                                       EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
                                                                                                 COMPANIES AFFORDING COVERAGE
                                                       COMPANY        ALL TO BE CALIFORNIA ADMITTED INSURANCE COMPANY WITH BEST
                                                       LETTER A       RATING OF A-OR BETTER.
                                                       COMPANY
INSURED                                                LETTER B
                                                       COMPANY
                                                       LETTER C
                                                       COMPANY
                                                       LETTER D

COVERAGES
CO                                          POLICY       EFFECTIVE                EXPIRATION
LTR              TYPE OF INSURANCE          NUMBER         DATE                      DATE                                                  LIMITS
 A    GENERAL LIABILITY                                                                                   GENERAL AGGREGATE                     $    2,000,000.00
                CLAIMS MADE                  XXXXXX       XX/XX/XX                   XX/XX/XX             PRODUCTS COMP/CP AGG                  $    1,000,000.00
        X       OCCUR                                                  GL Must include the additionally   PERSONNEL & ADV INJURY                $    1,000,000.00
                OWNERS & CONTRACTORS PROT                              insured endorsement attached to    EACH OCCURRENCE                       $    1,000,000.00
                                                                       policy or letter of endorsement    FIRE DAMAGE (ANY ONE FIRE)            $      50,000.00
                                                                       application to underwriter.        MEDICAL EXP (ANY ONE PERSON)          $        5,000.00
 A    AUTOMOTIVE LIABILITY
        X       ANY AUTO                     XXXXXX       XX/XX/XX                   XX/XX/XX             COMBINED SINGLE LIMIT                 $    1,000,000.00
                ALL OWNED AUTOS                                                                           BODILY INJURY (PER PERSON)

                SCHEDULED AUTOS                                                                           BODILY INJURY (PER ACCIDENT))

                HIRED AUTOS                                                                               PROPERTY DAMAGE

                NON-OWNED AUTOS


      GARAGE LIABILITY                                                                                    AUTO ONLY EACH ACCIDENT

                ANY AUTO                                                                                  OTHER THAN AUTO ONLY

                                                                                                                                EACH ACCIDENT

                                                                                                                                    AGGREGATE

      EXCESS LIABILITY                                                                                    EACH OCCURRENCE

                UMBRELLA FORM                                                                             AGGREGATE

                OTHER THAN UMBRELLA FORM
 B    WORKERS COMP. & EMPLOYERS                                                                           WC STATUTORY LIMITS______

      LIABILITY.                             XXXXXX XX/XX/XX                         XX/XX/XX             OTHER _______

      THE PROPRIETOR/PARTNERS/                                                                            EL EACH ACCIDENT                          $2,000,000.00
      EXECUTIVE OFFICES ARE:                                                                              EL DISEASE-POLICY LIMIT                   $2,000,000.00
                INCLUSIVE                                                                                 EL DISEASE-EA EMPLOYEE                    $2,000,000.00
                EXCLUSIVE
            *   WAIVER OF SUBROGATION
                IS REQUIRED
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS.
CERTIFICATE MUST NAME STRONGHOLD ENGINEERING, INC. &   OWNER
THEIR DIRECTORS, OFFICERS, AGENTS & EMPLOYEES AS ADDITIONAL INSURED PER ATTACHED ENDORSEMENT.
PROJECT:                        All Operations
CERTIFICATE HOLDER           CANCELLATION                                                 All SEI PROJECTS
STRONGHOLD ENGINEERING, INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
2000 MARKET STREET           THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER

RIVERSIDE, CA 92501          NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OF ANY KIND

                                            UPON THE COMPANY, IT'S AGENTS AND REPRESENTATIVES.

                                            AUTHORIZED REPRESENTATIVE

				
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Description: Insurance Waiver Forms for Subcontractors document sample