Supplemental Application
Account Name / Producer Name
Account Contact Name
/ Account Telephone No:
Account web site address
/ Account e-mail address
/ Date Completed
Contractors License Number:
Are you a member of a trade association? / Yes No
ELIGIBILITY:
Enter the percentage of your PAYROLL that emanates from the following operations. Exclude work that you subcontract when determining eligibility percentages. Do not add % of payroll if the activity is part of a primary job. For example, if you do grading as part of putting in a driveway, 100 % of payroll should be allocated to Driveway.
Percentage based on payroll:
- Grading of Land - Residential
- Grading of Land - Commercial
- Grading of Land - Curb to Curb
- Excavation
- Irrigation or Drainage System Construction
- Driveway, Parking Lot or Sidewalk - Paving or Repaving
- Street/road construction or reconstruction, including clearing of right-of-way, excavation, filing
- Street/road paving or repaving or surfacing, including street/road striping
- Conduit construction for cables and wires
- Telephone, telegraph or cable television line construction (underground only)
- Tunneling operations for the installation, service or repair of underground utility lines
- using trenchless excavation construction
- Gas mains or connections construction
- Water Mains or connections construction including Residential Hook-Up’s
- Water Mains or connections construction excluding Residential Hook-Up’s
- Sewer mains or connections construction including Residential Hook-Up’s
- Sewer Mains or connections construction excluding Residential Hook-Up’s
- Concrete Work – sound walls, concrete cutting, etc. Do not include pad work
- Water Well Drilling
- Septic Tank
- Asphalt Works, Sand/Gravel Digging, Stone Crushing
- Contractor Permanent Yards
If the total is less than 100%, you may be ineligible for the LCA Program. TOTAL / %
Describe any other operations: / %
Do you communicate with the USA Dig Alert and the area utility owners that are not members of the USA Dig Alert prior to all excavation work? If no, you are ineligible for the LICA Program / Yes No
Related operations:
- Hook-ups for water, sewer or gas?
- Airport runways or warming aprons
- Any residential finish grading which is not curb to curb?
Are you involved in any of the following operations:
- Bridge construction – including bridge culvert and tunneling unless clearance is less than 10 ft. and not more than 20 ft. wide
- Concrete Construction of a structural nature and/or foundation work
- Dam Construction (reservoirs) except ponding basins
- Demolition works except in conjunction with site development work not over 2 stories and clearing land for agricultural purposes
- Flood Control or Prevention except in conjunction with site work
- Foundation Pouring Work - load bearing
- Hauling for others except if incidental (less than 20% of gross receipts)
How many per year? / Commercial / % / Residential / %
- Irrigation companies or water-works operations
- Levee or Breakwater Construction Except for agricultural irrigation
- Oil or gas well drilling, repair or service
- On-site Waste Treatment except septic tanks
- Pile Driving or Caisson work
- Quarry, mining, or asphalt plant operations including gravel digging, stone crushing and asphalt batch plant operations if more than 30% sold to others
- Removal of underground petroleum storage tanks
- Renting or leasing of owned equipment (power or otherwise) without operator to others
- Sewage/Water Treatment Plant Construction other than site grading and excavation
- Street or Road Work on Freeway, Bi-ways, connectors or Express Highway construction
- Subcontracting other than incidental amounts (less than 25%) as described in the eligibility guidelines
- Surveyors third party
- Tree Pruning or Removal except for clearing land for agricultural purposes or incidental to other site development work
- Tunneling except at street crossings unless trenchless
- Underpinning buildings
- Work done within city-center (downtown) or major metro areas (City of Los Angeles, San Francisco, and San Diego) unless incidental to operations
- Work on hillsides with slopes greater than 20 percent
If Yes to any of the above you may be ineligible for the LICA Program.
- You operate as:
Construction Manager% / General Contractor % / Subcontractor %
- Any current or past involvement with wrap-up/OCIP? Yes No
Any residential wrap-ups? / Yes No
Note: Be sure to exclude receipts and payroll from above operations.
- Enter the percentage of your payroll and/or sales that emanate from residential or commercial work from the following operations:
Residential site preparation: / Rough grading / % / Finish grading / % / Soil compaction / %
Commercial site preparation: / Rough grading / % / Finish grading / % / Soil compaction / %
Building site pad preparation / % / Soil stabilization / %
Foundation form construction / % / Foundation design / %
Concrete pouring for foundations / Foundation pier hole drilling
- Indicate the average percentage of your TOTAL payroll or sales during the past 3 years for the following:
Percentages based on: (Check one) / Payroll or Sales
COMMERCIAL WORK / %
INDUSTRIAL WORK / %
HABITATIONAL WORK / %
TOTAL (THE TOTAL SHOULD EQUAL 100 %.) / %
Please complete if you do any habitational work.
HABITATIONAL WORK BREAKDOWN / % NEW or MAJOR REHAB/ RENOVATION / + / % SERVICE OR MAINTENANCE / =
CONDOMINIUMS (High And Low Rise) / % / + / % / = / %
MULTI-FAMILY DEVELOPMENTS (including townhouses) / % / + / % / = / %
APARTMENTS / % / + / % / = / %
TRACT HOUSING / % / + / % / = / %
CUSTOM HOMES / % / + / % / = / %
Other / % / + / % / = / %
TOTAL (THE TOTAL SHOULD EQUAL 100 %.) / % / + / % / = / %
Do you have any future plans related to work involving apartments, condos, townhouses, tract homes, custom homes or homes of unusual design? / Yes No
If Yes, please describe.
PAYROLL/GROSS RECEIPTS HISTORY
Year / Payroll / Subcontractor Costs / Non – OCIP Receipts / OPIC Receipts / Premium / Deductible
Anticipated / $ / $ / $ / $ / N/A / N/A
Current / $ / $ / $ / $ / $ / $
1st Prior / $ / $ / $ / $ / $ / $
2nd Prior / $ / $ / $ / $ / $ / $
3rd Prior / $ / $ / $ / $ / $ / $
4th Prior / $ / $ / $ / $ / $ / $
List the states you have worked in during the last 5 years.
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Have you ever been cited for any OSHA or state labor board violations in the past three years / Yes NoIf yes, please explain:
Describe your three largest jobs currently underway or planned for the next year:
Start Date / End Date / Description / Value
Describe the four largest projects completed in the past five years:
Year Completed / Description / Value
Have you ever been named in claims and/or litigation regarding faulty or defective construction or workmanship, including claims due to subsidence or construction defect issues? / Yes No
If Yes, were you acting as a general or sub-contractor? / Yes No
Was it a habitational project? / Yes No
Was it a commercial project? / Yes No
Provide detail on claims/litigation and what loss control measures you implemented for the future.
Do you have knowledge of any pre-existing act, omission, event; condition or damages to any person or property that may potentially give rise to any future claim or legal action? If Yes, please describe. / Yes No
Do you have an architect on staff? / Yes No
If Yes, do you carry professional liability insurance? / Yes No
If No, do you require that the architect carry his/her own professional liability insurance? / Yes No
Do you sub-contract work? / Yes No
Indicate percent of receipts: / %
List the types of work subcontracted.
Do you obtain Certificates of insurance from all subcontractors? / Yes No
Are you named as an additional insured on all subcontractors’ policies? / Yes No
Do require all subcontractors to carry primary limits equal to or greater than their own? / Yes No
Do you use written subcontractor agreements containing hold harmless/indemnity agreements in your favor? / Yes No
- .
Indicate the types of subcontractor agreements you typically sign when you are working for a general.
Standard (AGC, AIA contracts) / Custom / Other
RISK CONTROL
1. / Do you have a quality control program? / Yes No
If Yes, is it? Informal Formal Documented
Is it a written a written quality control program? / Yes No
Do you retain job files? / Yes No
If Yes, how long are they retained? / years
Do you employ a full-time safety director and have a written safety program? / Yes No
The safety program includes driver selection and training requirements. / Yes No
Do you have a drug testing program? / Yes No
SEWER AND WATER – UNDERGROUND UTILITY WORK
Do you communicate with the One-Call Service Center and non-members of the center a minimum of 48 hours before the job begins (or per state regulations)? / Yes No
Is the route of excavation white lined before the utility locator arrives on site? / Yes No
Do you do hand digging within 18 inches to 24 inches (depending on state regulations) from the center of the utility line? / Yes No
Do you request new locates for excavations incurring extended time requirements (10 days or more) and following inclement weather? / Yes No
Are photographs or videos taken before and after the excavation? / Yes No
HIGH PRIORITY/CRITICAL JOBS
The utility owner needs to be asked if this job is considered a high priority or critical job. Some job examples would be high pressure water or gas pipe, power transmission lines, 15-pair communication cable, Sonet Ring Architecture Fiber Optics, etc.
In addition to the five requirements noted above, do you:
Schedule a pre-excavation meeting on the job-site with the facility owner and prime contractor? / Yes No
Utilize pot holing, air knives, or vacuum excavation techniques to verify utility locates? (A substitute for pot holing would be the excavator’s use of state of the art locating equipment). / Yes No
Map the coordinates of the locations in relation to a stationary object(s), such as a tree, building, fence, etc? / Yes No
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Producer’s Signature / DateApplicant’s Signature / Date
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