Jill and Frank Fertitta Hall Insurance Manual

Transcription

University of Southern California
USC
Owner Controlled Insurance Program
Jill and Frank Fertitta Hall
Insurance Manual
OWNER CONTROLLED INSURANCE PROGRAM
Insurance Manual
THE UNIVERSITY OF SOUTHERN CALIFORNIA
Capital Construction and Facilities Management Services
Jill and Frank Fertitta Hall (JFF)
Table of Contents
OVERVIEW ......................................................................................................................................................... 1 OCIP DEFINITIONS .............................................................................................................................................. 2 ABOUT THIS MANUAL ......................................................................................................................................... 5 What This Manual Does .................................................................................................................................. 5 What this Manual Does Not Do ....................................................................................................................... 5 OCIP PROJECT DIRECTORY ......................................................................................................................... 6 OCIP INSURANCE COVERAGE ..................................................................................................................... 8 ELIGIBLE PARTIES ................................................................................................................................................ 8 ENROLLED PARTIES ............................................................................................................................................. 8 EXCLUDED PARTIES ............................................................................................................................................. 8 EVIDENCE OF COVERAGE ..................................................................................................................................... 9 SUMMARY DESCRIPTION OF OCIP COVERAGES ................................................................................................. 10 Workers’ Compensation and Employers Liability ......................................................................................... 10 Commercial General Liability ....................................................................................................................... 10 Excess Umbrella Liability .............................................................................................................................. 11 Coverage of Off-site Locations ...................................................................................................................... 11 OCIP TERMINATION OR MODIFICATION ............................................................................................................ 12 INSURANCE REQUIRED FROM ALL CONTRACTORS AND SUBCONTRACTORS, INCLUDING
EXCLUDED PARTIES ..................................................................................................................................... 13 WORKERS’ COMPENSATION AND EMPLOYER’S LIABILITY ................................................................................. 14 COMMERCIAL GENERAL LIABILITY/UMBRELLA LIABILITY ............................................................................... 15 AUTOMOBILE LIABILITY .................................................................................................................................... 15 UMBRELLA/EXCESS LIABILITY INSURANCE ....................................................................................................... 15 PROPERTY INSURANCE ....................................................................................................................................... 16 ADDITIONAL INSUREDS ...................................................................................................................................... 16 WAIVER OF SUBROGATION ................................................................................................................................ 16 CONTRACTOR AND SUBCONTRACTOR RESPONSIBILITIES ........................................................... 17 CONTRACTOR AND SUBCONTRACTOR BIDS ....................................................................................................... 18 ADJUSTMENTS FOR OCIP INSURANCE COSTS .................................................................................................... 18 CHANGE ORDERS ............................................................................................................................................... 19 ENROLLMENT..................................................................................................................................................... 19 COVERAGE OF OFF-SITE LOCATIONS ................................................................................................................. 20 SAFETY STANDARDS .......................................................................................................................................... 20 PAYROLL REPORTS ............................................................................................................................................ 21 INSURANCE COMPANY PAYROLL AUDIT ............................................................................................................ 21 CLOSE OUT PROCEDURES .................................................................................................................................. 22 CLAIM REPORTING PROCEDURES .......................................................................................................... 23 GENERAL PROCEDURES ..................................................................................................................................... 23 Media Inquiries .............................................................................................................................................. 24 Investigation Assistance ................................................................................................................................. 24 WORKERS’ COMPENSATION CLAIMS.................................................................................................................. 24 Drug Test Program ........................................................................................................................................ 26 Modified Duty / Early Return to Work Policy................................................................................................ 26 Medical Provider Network (MPN) ................................................................................................................. 26 LIABILITY CLAIMS ............................................................................................................................................. 27 AUTOMOBILE CLAIMS ........................................................................................................................................ 27 FORMS ............................................................................................................................................................... 28 O V E R V I E W
SECTION 1
Overview
1
Section
Welcome to The University of Southern California’s USC Owner Controlled Insurance Program for the Jill and Frank Fertitta Hall. The University of Southern California (USC) has arranged for the USC project to be insured under the Owner Controlled Insurance Program, or “OCIP.” The OCIP is a single insurance program that insures the University of Southern California, Enrolled Contractors, Enrolled Subcontractors, and other designated parties for Work performed at the Project Site. Certain Contractors or Subcontractors are excluded from the OCIP. These parties are identified in Section 3 of this Manual. Coverage under the OCIP includes Workers’ Compensation/Employer’s Liability, General Liability, and Excess Liability. The University of Southern California will pay the insurance premiums for the OCIP coverages described in this Insurance Manual. You should notify your insurance broker/insurer(s) of the coverages provided under the OCIP for on‐site activities to avoid the duplication of coverage. Each bidder is required to bid net of all insurance costs for coverages provided by the University of Southern California. NOTE: Insurance coverages and limits provided under the OCIP are limited in scope and are specific to work performed after the inception date of your enrollment into this program. Your insurance representative should review this information. Any additional coverage you may wish to purchase will be at your option and expense. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 1
O V E R V I E W
OCIP Definitions
The following definitions shall apply throughout this manual: TERM BID NET OF COST OF OCIP COVERAGES: DEFINITION A bid submitted by Contractor or Subcontractors to perform Work or a portion of the Work, which is net of the Contractor’s or Subcontractors’ Cost of OCIP Coverages. CONTRACT: The term “Contract” means the written Agreement between the Contractor and Owner or Contractor and Subcontractor as set forth in the Contract Documents. CONTRACTOR: The term “Contractor” means the person or firm identified as the Contractor, CM/Contractor, Design Builder, or Prime Trade Contractor in the Agreement, and is referred to throughout the Contract Documents as if singular in number. COST OF OCIP COVERAGES: Cost of OCIP Coverages shall mean Contractor’s or Subcontractor’s projected or actual cost to provide the workers’ compensation and employer’s liability, commercial general liability insurance, and excess liability insurance being provided under the OCIP. The Cost of OCIP Coverages includes insurance premiums, related taxes and assessments, markup on the insurance premiums, and losses retained through the use of a self‐
funded program, self‐insured retention, or deductible program. The cost of insurance must include expected losses within any retained risk. ELIGIBLE PARTIES: See page 7. ENROLLED PARTIES: See page 7. EXCLUDED PARTIES: See page 7. OWNER: The University of Southern California, also referred to as USC USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 2
O V E R V I E W
PROJECT: The term “Project” means the Work of the Contract and all other work, labor, equipment, and materials necessary to accomplish the construction of the improvement of which the Work is a part. SUBCONTRACTOR: The term “Subcontractor” means a person or firm that has a contract with Contractor or with a Subcontractor to perform a portion of the Work. Unless otherwise specifically provided, the term Subcontractor includes Subcontractors of all tiers. OCIP ADMINISTRATOR: The entity hired by the University of Southern California to administer the OCIP. The OCIP Administrator is: Aon Risk Insurance Services West, Inc. 707 Wilshire Blvd., Suite 2600 Los Angeles, California 90017 OCIP COVERAGES: The insurance coverages provided under the OCIP, as set forth in the OCIP Policies, and as summarized in this Insurance Manual. OCIP INSURER: Any of the insurance companies providing insurance under the OCIP. OCIP POLICIES: The insurance policies issued by an OCIP Insurer for the OCIP. OCIP: The University of Southern California’s University Controlled Insurance Program. WORK: The term “Work” means all construction, services, and other requirements of the Contract Documents as modified by Change Order, whether completed or partially completed, and includes all labor, materials, equipment, tools, and services provided or to be provided by Contractor to fulfill Contractor's obligations. The Work will constitute a part of the Project. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 3
O V E R V I E W
Enrollment in the OCIP is mandatory for all Eligible Parties. In addition to the insurance provided under the OCIP, Enrolled Parties shall obtain and maintain, and shall require each of their Subcontractors of all tiers to obtain and maintain, the insurance coverage specified in Section 4. Excluded Parties and parties no longer enrolled in, or covered by, the OCIP shall obtain and maintain, and require each of their Subcontractors to obtain and maintain, the insurance coverage specified in Section 4. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 4
O V E R V I E W
About This Manual
This Insurance Manual has been prepared by Aon, the OCIP Administrator, and the University of Southern California. The Insurance Manual is designed to provide an overview of the OCIP and identify, define and assign responsibilities for the administration of the OCIP. This Insurance Manual may be updated as necessary during the course of construction to reflect any changes in State Rules and/or Regulation or Procedures that may become applicable. Said revisions shall replace all previous versions. Copies of any revised Insurance Manual shall be distributed by the OCIP Administrator. What This Manual Does
This Manual: 
Sets forth the responsibilities of the various parties involved in the Project, including the insurance‐related obligations of Contractors and Subcontractors, whether or not enrolled in the OCIP 
Describes the general structure of the OCIP 
Provides a basic description of OCIP coverages 
Describes audit and administrative procedures 
Provides answers to basic questions about the OCIP What this Manual Does Not Do
This Manual does not: 
Provide complete information about coverages 
Amend, modify or change the policy 
Provide coverage interpretations or answer specific claims questions Refer questions concerning the OCIP, its administration, insurance coverages, or claims to the appropriate party identified in the Project Directory. The Directory immediately follows this introduction. DISCLAIMER: The information in this Manual is intended to outline the OCIP Program. If any conflict exists between this Manual and the OCIP insurance policies or Contracts between the University of Southern California and the Contractor or their Subcontractors, the insurance policies or Contracts will govern. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 5
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P R O J E C T
2
D I R E C T O R Y
Section
OCIP Project Directory
The following list includes key personnel involved in the program
OCIP Administrator
Aon Risk Insurance Services West, Inc. 707 Wilshire Blvd., Suite 2600 Los Angeles, CA 90017 Subcontractor Service Coordinator Jane Rozental Sr. Program Administrator Kathy Ritch Program Manager Gayle Ramsdell Phone: (213) 630‐3200 Phone: (866) 243‐8266, option 4 Email: acs.construction@aon.com Phone: (949) 608‐6384 Email: kathleen.ritch@aon.com Phone: (949) 608‐6382 Email: gayle.ramsdell@aon.com Sr. Project Safety Consultant(s) Chris Sarvis Safety Director Rick Church Phone:
Email:
Phone:
Email:
(714) 422‐7742 chris.sarvis@aon.com (714) 325‐6378 rick.church@aon.com USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 6
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P R O J E C T
D I R E C T O R Y
General Contractor / Construction Manager Hathaway Dinwiddie Const. Co. Phone: (213) 236‐0500 Fax: (213) 236‐0501 Contracts Manager/Administrator Phone: (213) 236‐0500 Tina Coen Email: coent@HDCCO.com Project Manager Phone: (213) 814‐9738 Alex Maffei Email: maffeia@hdcco.com Project Superintendent Phone: (213) 435‐9479 Jason Fisher Email: Fisherj@HDCCO.COM Project Safety Manager Phone: (213) 595‐9427 Jim Hearn Email: HearnJi@HDCCO.COM USC The University of Southern California 3434 South Grand Ave. Los Angeles, CA 90089 Director‐Capital Construction Development William Marsh Senior Project Manager CCD Hunter Gaines Owner Safety Manager ‐ Barragan John Darlak OCIP Risk Manager – USC Executive Director of Risk Management Jim Andersen (213) 821‐4564 wmarsh@usc.edu (213) 821‐6569 hgaines@usc.edu (951) 248‐5512 john@bcsrm.com (213) 740‐7518 USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 Phone: Email: Phone: Email: Phone: Email: Phone: Email: jandersen@caps.usc.edu 7
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C O V E R A G E
OCIP Insurance Coverage
3
Section
This section provides a brief description of OCIP Coverages. You must refer to the actual policies for details concerning coverage, exclusions and limitations. Eligible Parties
Unless excluded (see below), each of the following who will perform any labor at the Project site are an “Eligible Party.” Contractor, Subcontractors of all tiers, and such other persons or entities as USC may designate, in its sole discretion. Enrolled Parties
Enrolled Parties are named insureds on the OCIP policies. Enrolled Parties include: 



The University of Southern California, and The University of Southern California’s Representative; A Contractor that is eligible for and enrolls in the OCIP; Subcontractors who are eligible for, and enroll in the OCIP; Any other Eligible Party that enrolls in the OCIP. Parties named as additional insureds include other parties that the University of Southern California is required under contract to add as additional insureds. These parties are also referred to as insureds. Excluded Parties
“Excluded Parties” are: 1. Heavy and/or structural demolition, hazardous materials remediation, removal and/or transport companies and their consultants; USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 8
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2. Architects, surveyors, engineers, and soil testing engineers, and their consultants (except for architects, surveyors, engineers and soil testing engineers that are employees of Contractor or Subcontractor); 3. Vendors, suppliers, fabricators, material dealers, truckers, haulers, drivers, common carriers and others who do not perform work at the Project site or who merely transport, pick up, deliver, or carry materials, personnel, parts or equipment, or any other items or persons to or from the Project site; 4. Subcontractors of all tiers that do not perform any actual labor on the Project site with their own forces; 5. Temporary labor services; 6. Persons or Entities who are not an Eligible Party who are enrolled in the OCIP; and 7. Any other person or entity that the University of California, acting in its sole discretion, elects to exclude, even if otherwise eligible. Excluded Parties are not eligible to enroll in the OCIP. The OCIP does not provide any coverage to an Excluded Party. All Excluded Parties, and any party no longer enrolled in, or covered by, the OCIP shall obtain and maintain, and shall require each of their subcontractors of any tier to obtain and maintain, the insurance coverage specified in Section 4. Evidence of Coverage
The OCIP Administrator will provide upon enrollment a Certificate of Insurance evidencing workers’ compensation, general liability, and excess liability coverage to each Enrolled Party, each of whom will then be a named insured on the OCIP policies. A Certificate of Insurance is a document providing evidence of coverage for a particular insurance policy or policies. Other documentation including claim reporting forms, posting notices, etc., will be furnished to each Enrolled Party. Each Contractor will receive a workers’ compensation policy, and copies of the remaining OCIP insurance policies will be available for your review upon a written request to the OCIP Administrator. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 9
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Summary Description of OCIP Coverages
This summary is not an insurance policy and is not intended to amend, alter, or extend the coverage afforded by the OCIP Policies. The coverage provided under the OCIP Policies is governed by the terms, conditions, exclusions, and limitations of the OCIP Policies. The following descriptions provide a summary of the insurance coverages provided under the OCIP: Workers’ Compensation and Employers Liability
State: California Part One ‐ Workers’ Compensation: Part Two ‐ Employer’s Liability: Bodily Injury by Accident, each accident Bodily Injury by Disease, each employee Bodily Injury by Disease, policy limit A single General Liability Policy will be issued covering all insureds. Contractor and Subcontractors of all Tiers Will Be Responsible for a $25,000 General Liability Obligation Per Occurrence, including claims costs, court costs, attorneys’ fees, and costs of defense for bodily injury or property damage to the extent losses are attributable to Contractor’s work, acts or omissions or the Work, acts or omissions of any Subcontractor or tiered subcontractor. LIMITS OF LIABILITY Statutory $1,000,000 $1,000,000 $1,000,000
Commercial General Liability
Per Project Limits Shared by All Insureds General Aggregate $4,000,000 Products/Completed Operations Aggregate $4,000,000 Bodily Injury & Property Damage–Each Occurrence $2,000,000 Personal/Advertising Injury–Each Occurrence $2,000,000  Products & Completed Operations Extension is 10 Years  This insurance will NOT provide coverage for products liability to any insured party, vendor, supplier, off‐site fabricator, material dealer or other party for any product manufactured, assembled or otherwise worked upon away from the Project Site.  The policy contains exclusions. Some of these exclusions are: Real & Personal Property in the care, custody or control of the insured; Asbestos; Lead; EFIS; Fungi and Bacteria; Discrimination & Wrongful Termination; ERISA; Architects & Engineers Errors & Omissions; Owned & Non‐Owned Aircraft, Watercraft, Pollution and Automobile Liability; Nuclear Broad Form Liability. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 10
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Excess Umbrella Liability
Shared by All Insureds $100,000,000 $100,000,000 Each Occurrence Limit General Aggregate Limit  The Policies follow form (provisions, coverage, exclusions, etc.) of underlying Commercial General Liability and Employer’s Liability policy wording.  University of Southern California reserves the right to supply additional limits upon final review. NOTE:
Insurance coverage and limits described in this Section are limited in scope and are specific to Work performed at the Project Site and after the inception date of your enrollment into this Program. Your insurance representative should review this information. Any additional coverage you may wish to purchase will be at your option and expense. Coverage of Off-site Locations
For purposes of the OCIP, Work (as in the General Conditions) that is performed at an off‐site location will be treated as on site Work, only if such off‐site coverage is offered by the Supplementary Conditions, and provided that (1) the off‐site location meets the requirements of the OCIP Coverage Questionnaire at a Dedicated Off‐Site Location (“Questionnaire”) and (2) the Contractor specifically requests from the Owner coverage for the off site location, and (3) the OCIP insurer approves enrollment of the location. The Enrolled Party must complete and submit the Questionnaire to the OCIP Administrator with their OCIP Enrollment Form. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 11
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NOTE:
Contractor and Subcontractors are advised to arrange their own insurance for Contractor or Subcontractors owned or leased equipment and materials not intended for inclusion in the Project. The OCIP will not cover Contractor or Subcontractor’s property. OCIP Termination or Modification
The Owner may, for any reason, modify the OCIP Coverages, discontinue the OCIP, or request that Contractor or any of its Subcontractors of any tier withdraw from the OCIP upon thirty (30) days written notice. Upon such notice Contractor and/or one or more of its Subcontractors, as specified by Owner in such notice, shall obtain and thereafter maintain during the performance of the Work, all (or a portion thereof as specified by Owner) of the OCIP Coverages. The form, content, limits of liability, cost, and the insurer issuing such replacement insurance shall be subject to Owner’s approval. The Owner shall pay Contractor for the reasonable cost of replacement coverage approved by the Owner. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 12
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R E Q U I R E D
Insurance Required From All
Contractors and
Subcontractors, Including
Excluded Parties
4
Section
Enrolled Contractor and Enrolled Subcontractors are required to maintain insurance coverages to protect against losses that occur away from the Project Site or that are otherwise not insured by the OCIP. Contractors and Subcontractors are required to maintain insurance coverage that protects the University of Southern California from liability for claims for damages. These liabilities may arise from the Contractor’s and Subcontractors’ operations performed off the Project Site at locations that have not been disclosed to the OCIP Administrator and scheduled on the OCIP policies, from activities not insured by the OCIP or from operations performed by Excluded Parties. There are two types of Contractors and Subcontractors: Enrolled Contractor and Subcontractors and Excluded Contractors and Subcontractors. See Section 7 for sample Certificate of Insurance. Enrolled Contractor and Subcontractors are to provide evidence of Workers’ Compensation and General Liability Insurance for off‐site activities and Automobile Liability Insurance for both on‐site and off‐site activities via a Certificate(s) of Insurance with additional insured endorsements as per the insurance specifications in the Contract. Excluded Subcontractors must provide evidence of Workers’ Compensation, General Liability, Auto Liability Insurance, and for other insurance as required by scope of work (i.e. Hazardous Remediation Pollution Liability), if any, for all activities including both on‐site and off‐site activities via a Certificate(s) of Insurance with additional insured endorsements as per the insurance specifications in the Contract. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 13
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Certificate of Insurance  5 days prior to mobilization and within ten (10) days of renewal, change or replacement of coverage, Contractor will submit to the University of Southern California c/o Aon and Subcontractor to the Contractor a Certificate of Insurance evidencing the coverage and limits as specified in this section.  A notice of cancellation provision, waiver of subrogation and additional insured status is required on all Certificates. Endorsements must be attached to all certificates of insurance.  Eligible Contractor/ Subcontractors shall provide evidence of workers’ compensation insurance for off‐site activities. Excluded Contractor/ Subcontractors shall provide evidence of workers’ compensation applicable to on and off‐
site project. R E Q U I R E D
Subcontractors must submit verification of insurance in the form of a Certificate of Insurance on a standard ACORD 25 form. They must provide a Certificate of Insurance to the Contractor prior to mobilization on site, and within ten (10) days of any renewal, change or replacement of coverage. A sample of an acceptable Certificate of Insurance is provided in Section 7. Subcontractor must provide a certificate of insurance providing a notice of cancellation clause in accordance with the policy provisions. The additional insured endorsements shall state that the coverage provided to the additional insureds is primary and non‐contributing with respect to any other insurance available to the additional insureds. Pursuant to the Instructions to Bidders, Contractor shall provide its certificates of insurance to the Owner within 10 days after receipt of notice of selection as the apparent lowest responsive and responsible Bidder. All other parties shall provide, prior to mobilization, their certificates of insurance directly to the Contractor. The limits of liability shown for the insurance required of the Contractor and Subcontractors are minimum limits only and do not restrict the liability imposed on the Contractor and Subcontractors for Work performed under their Contract. Limits required below can be provided by a combination of primary and umbrella/excess liability insurance. If umbrella/excess liability coverages are to be provided, such policies shall be follow form (provisions, coverage, exclusions, etc.) of underlying Commercial General Liability, Employer’s Liability and Automobile Liability policy wording. Workers’ Compensation and Employer’s
Liability
Part One ‐ Workers’ Compensation: Part Two ‐ Employer’s Liability: Bodily Injury by Accident, each accident Bodily Injury by Disease, each employee Bodily Injury by Disease, policy limit USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 Statutory Limit Annual Limits $1,000,000 $1,000,000 $1,000,000 14
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Eligible Contractor/ Subcontractors shall provide evidence of general liability insurance for off‐site activities. Excluded Contractor/ Subcontractors shall provide evidence of general liability insurance applicable to on and off‐site projects and must add the University of Southern California and other parties as additional insureds to their policy. Automobile Liability Contractor and Subcontractors shall provide evidence of automobile liability. The OCIP does not cover automobile liability. R E Q U I R E D
Commercial General Liability/Umbrella
Liability
General Aggregate Products/Completed Operations Aggregate Personal/Advertising Injury Aggregate Each Occurrence Limit Limits of Liability Enrolled / Excluded $2,000,000 / $2,000,000 $2,000,000 / $2,000,000 $1,000,000 / $1,000,000 $1,000,000 / $1,000,000 Coverage must be on an Occurrence Form and it must apply to bodily injury and property damage for operations (including explosion, collapse and underground coverage), independent Contractor or Subcontractor, products and completed operations. Automobile Liability
A Commercial Business Auto Policy which covers all owned, hired and non‐owned automobiles, trucks and trailers with coverage limits not less than $1,000,000. This can be a combination of the Automobile Liability and Excess Policy, each accident for bodily injury and property damage on‐site and off‐site. Where hazardous or regulated substances or hazardous or regulated waste are being transported by Contractor or Subcontractor, the limits of liability shall be not less than $5,000,000 each occurrence combined single limit and the policy shall contain endorsement MCS‐90. Umbrella/Excess Liability Insurance
Contractor shall provide Umbrella or Excess Liability insurance with limits of not less an
$10,000,000 per occurrence and $10,000,000 annual aggregate limit. While Contractor is
enrolled in the OCIP, this coverage shall apply only to activities or operations not
covered by the OCIP.
All other Enrolled Parties shall provide Umbrella or Excess Liability insurance with
limits of not less than $1,000,000 per occurrence and $1,000,000 annual aggregate limit.
While Enrolled Party is enrolled in the OCIP, this coverage shall apply only to activities
or operations not covered by the OCIP.
Excluded Parties shall provide Umbrella or Excess Liability insurance with limits of not
less than $2,000,000 per occurrence or $2,000,000 annual aggregate limit.
USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 15
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R E Q U I R E D
Umbrella or excess liability insurance shall provide following form bodily injury,
personal injury and property damage liability at least as broad as the primary coverage set
forth above, including Employers’ Liability, commercial general liability and commercial
automobile liability. Total required limits may be arranged through any combination of
primary and excess policies.
Property Insurance
Contractor and Subcontractors are advised to arrange their own insurance for owned and leased equipment (not to be permanently installed or incorporated into the Project), whether such equipment is located at a Project Site or “in transit”. Contractor and Subcontractors are solely responsible for any loss or damage to their personal property including Contractor and Subcontractor tools and equipment, temporary structures (including construction trailers), whether owned, used, leased or rented by the Contractor and Subcontractor. Contractor and Subcontractors are also responsible for any loss or damage to property or materials created or provided under the Contract until the property or materials arrives at the Project Site. Additional Insureds
With exception to Workers’ Compensation and Employer’s Liability insurance, the following shall be included as additional insureds as required by contract: The University of Southern California, the OCIP Administrator, and each of their Representatives, consultants, officers, agents, employees, each of their Representative's consultants, and all enrolled parties, regardless of whether or not identified in the Contract Documents or to the Contractor in writing. The general liability insurance policy must name the Owner as an additional insured pursuant to additional insured endorsement CG2010 (11/85) or a combination of both CG 2010 (10/01 or 07/04) and CG 2037 (10/01 or 07/04). Refer to the sample Certificate of Insurance provided with this Insurance Manual. The list of additional insureds may be updated at any time due to contractual requirements of the University of Southern California. Waiver of Subrogation
Contractor and Subcontractors of all tiers waive subrogation as set forth in the General Conditions. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 16
C O N T R A C T O R A N D S U B C O N T R A C T O R
R E S P O N S I B I L I T I E S
5
Section
Contractor and Subcontractor
Responsibilities
Throughout the course of the Project, Contractor and Subcontractors will be responsible for reporting and maintaining certain records as outlined in this section. The Contractor and Subcontractors are required to cooperate with the University of Southern California and its OCIP Administrator in all aspects of OCIP implementation and administration. Responsibilities include the following: 
Contractor and all Subcontractors must enroll in the OCIP, if eligible, and await written confirmation of coverage under the OCIP prior to mobilization. Prime Contractor has the responsibility to ensure that all eligible Subcontractors are enrolled prior to the Subcontractor’s commencement of Work. 
Contractor and Subcontractors must provide copies of their current Workers’ Compensation, General Liability and Excess Liability rate and declaration pages, deductible endorsements and any other required documentation. See Adjustments for OCIP Insurance Costs. 
Contractor and Subcontractors must provide timely evidence of required insurance. Contractor to provide to the OCIP Administrator and Subcontractors to the Contractor, prior to mobilization and upon renewal, modification or material change of insurance. 
Contractor and Subcontractors must include OCIP provisions in all contracts with Subcontractors. 
Contractor must provide each Subcontractor with a copy of the OCIP Insurance Manual. The OCIP Insurance Manual may be updated during the course of construction to reflect any changes in state rules and/or regulations or procedures that may be necessary, and said revisions shall replace all previous versions. Copies of any revised Insurance Manual shall be distributed by the OCIP Administrator. 
Contractor must notify the OCIP Administrator of all subcontracts, including lower tier subcontracts. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 17
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Contractor and Subcontractors must maintain and electronically report monthly payroll records. 
Contractor and Subcontractors must cooperate with the OCIP Administrator’s requests for information. 
Contractor shall be responsible for monitoring and ensuring that its Subcontractors of all tiers comply with the requirement for providing Certificates of Insurance. 
Contractor and Subcontractors must notify the OCIP Administrator immediately of any insurance cancellation, modification, material change or non‐renewal of required insurance. 
Subcontractors are required to provide work status reports to the Contractor following an injury sustained at the Project Site. 
Provide Medical Provider Network (MPN) packet to all employees working at the project site during individual employee site orientation and have the employee sign to acknowledge receipt. See Section 6 for more information. Contractor and Subcontractor Bids
See Section 7 for forms that can help identify your insurance costs. See Section 2 for information on contacting the OCIP Administrator.
The University of Southern California shall pay all premiums for the OCIP. Each Bidder is required to submit bids for the Project that are net of Contractor’s and Subcontractors’ Cost of OCIP Coverages. The section below, “Adjustments for OCIP Insurance Costs,” describes the procedure for identifying the Costs of OCIP Coverages when bidding so these costs can be removed from the bid price. Section 7 of this Insurance Manual contains worksheets that can be used to estimate your insurance costs, and those of your Subcontractors, for the coverages provided under the OCIP.
Adjustments for OCIP Insurance Costs
Each Eligible Contractor and Subcontractor is required to exclude from their bid the cost of the insurance that is provided under the OCIP. To aid the Contractor and its Subcontractors in determining the cost of insurance to remove from the bid, the Insurance Cost Worksheet form (Aon Form‐1) and Insurance Cost Summary form (Aon Form‐2) are provided in Section 7. A separate Aon Form‐1 is required from the Contractor and each Subcontractor for each contract awarded. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 18
Each Enrolled Contractor and Enrolled Subcontractor will be required to submit the insurance documentation listed below. Documentation will include the following pages from the Workers’ Compensation, General Liability and Excess Liability policies: 
Declarations or information page 
Rate page(s) – rates must reflect first dollar coverage; no composite rates or corporate allocations based on deductible/retention programs 
Deductible endorsements, if applicable 
Verification of experience modification (Workers’ Compensation only) 
Five (5) Years of loss history from the insurance carrier, and including self‐
paid losses, for entities that retain losses through deductible, self‐insured, or high retention programs in the amount of $5,000 or more. Change Orders
Change orders will be priced by the Enrolled Contractor and Subcontractors to exclude the cost of insurance provided under the OCIP. Contractor and Subcontractors are responsible for ensuring that their Subcontractors of all tiers also remove the Cost of OCIP Coverages from their Bid and Change Orders. OCIP Administrator will assist the Contractor and Subcontractors in verification of Subcontractors’ insurance reduction calculations. Enrollment
See Section 7 for
sample OCIP forms.
Enrolled Contractor shall provide details about its Subcontractors to the OCIP Administrator in order to enroll them in the OCIP. The Contractor and Subcontractors must complete and submit the Enrollment Application (Aon Form‐
3). This form can be found in Section 7. The Enrollment Application must be completed and submitted to the OCIP Administrator and accepted prior to commencing work On Site to obtain coverage under the OCIP. Enrolled Contractor and enrolled Subcontractors will receive a Confirmation Letter and OCIP Certificate of Insurance. A Confirmation Letter is a letter issued by the OCIP Administrator that confirms acceptance of the applicant into the OCIP. These documents will clearly identify the effective dates of the OCIP coverages for the Contract. A separate Workers’ Compensation policy will be issued and sent to each enrolled Contractor and Subcontractor. A Claims Kit will be provided to each Enrolled Contractor and Subcontractors with the Confirmation Letter. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 19
Should an enrolled Contractor or Subcontractor perform work under several Contracts, an Enrollment Application must be completed for each contract. A separate Confirmation Letter and Certificate of Insurance confirming acceptance of the applicant’s enrollment into the OCIP will be issued for each Contract. NOTE:
Enrollment into the OCIP is required, but not automatic. All Eligible Contractors and all Eligible Subcontractors MUST complete the enrollment forms and participate in the enrollment process to obtain OCIP coverage. Access to the Project Site will not be permitted until Enrollment into the OCIP is complete. Coverage of Off-site Locations
Safety Standards
establish minimum
standards for Contractor
safety programs. Safety
Standards are provided to all
participants during the
bidding process.
Subject to Article 11.1.1 and 11.1.2 of the General Conditions, for purposes of the OCIP, Work (as defined in Article 1.1.40 of the General Conditions) that is performed at an off‐site location will be treated as on site Work, only if such off‐site coverage is offered by the Supplementary Conditions, and provided that (1) the off‐site location meets the requirements of the OCIP Coverage Questionnaire For Fabrication at a Dedicated Off‐Site Location (“Questionnaire”) and (2) the Contractor specifically requests from the Owner coverage for the off site location, and (3) the OCIP insurer approves enrollment of the location. The Enrolled Party must complete and submit the Questionnaire to the OCIP Administrator with their OCIP Enrollment Form. Persons and entities eligible for such coverage (see Article 11.1.2), including Contractor and all Subcontractors, unless excluded under Article 11.1.5, will be required to enroll in the OCIP. Safety Standards
Each Contractor and Subcontractor is required to have a written safety program and to provide a designated safety representative who is on site when any Work is in progress. Minimum standards for Contractor and Subcontractor safety programs are outlined in the University of Southern California's Safety Standards Manual. A Drug Test Program has been implemented for this project. Testing is required “prior to commencing work at the project”, which will be paid for by the Contractor. In addition, testing will be required “post‐accident” and “for probable cause”, the financial burden associated with these tests will be the responsibility of the employer of the affected worker(s). The designated occupational clinic for the OCIP projects will administer the drug test at their facility for “post‐accident” and “for probable cause”. Please see the clinic address in the Claims Section. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 20
An employer representative will transport all injured workers (for non‐emergency cases ONLY) to the designated occupational clinic facility for treatment. Please see the contract documents or Contractor’s Drug Test Program for more details. Payroll Reports
Enrolled Parties must submit monthly payroll reports to the OCIP Administrator identifying work hours and payroll for all work performed at the Project Site by Contract and by Workers’ Compensation Classification Codes. Enrolled Parties shall submit payroll reports prior to the 10th of the following month through the online AonWrap Web Portal. Contact the OCIP Administrator for a User ID and Password to report payroll online if you do not receive this information during the Enrollment process. The monthly work hour and payroll reports should include supervisory and clerical personnel on‐site and cover all Work performed at or emanating directly from the Project Site. Payroll for overtime should be included only at the normal hourly rate (DO NOT INCLUDE EXTRA WAGES OR PREMIUM PORTION OF OVERTIME PAY WHEN CALCULATING ONSITE REPORTABLE PAYROLL). Overtime means those hours in excess of 8 hours worked each day, 40 hours in any week or on Saturdays, Sundays, or holidays, but only when there is an increase in the hourly rate to work such hours. Insurance Company Payroll Audit
Each Enrolled Party is required to maintain separate payroll records for each Contract. Such records will allocate the payroll by Workers’ Compensation classification(s) and exclude the excess or premium paid for overtime (i.e., only the straight time wage rate will apply to overtime hours worked). Furthermore, such records will limit the payroll for Executive Officers and Partners/Sole Proprietors to the limitations as stated in the state manual rules. It is important that you properly classify payrolls, as these are reported to the rating bureau for promulgation of future Experience Modification Ratings for your firm. All Enrolled Parties shall make available their books, vouchers, contracts, documents, and records, of any and all kinds, to the OCIP insurance carrier(s) auditors or the Owner’s representatives. Availability of records must be for a reasonable time during the policy period, any extension, or during a final audit period as required by the insurance policies.
Close Out Procedures
Enrolled Parties must submit the Notice of Work Completion form (Aon Form‐5), via the AonWrap Web Portal when all Work at the Project Site is complete and they no longer have workers on site. The completed Notice of Work Completion form will signal the final payroll report and initiate the audit of payroll by the OCIP Insurer. A sample of the Notice of Work Completion form with instructions on the proper method for completion is found in Section 7. Failure to submit the Notice of Work Completion and report all Payrolls in a timely manner may result in the University of Southern California withholding issuance of final payment and release of retention pursuant to Article 9 of the General Conditions. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 22
C L A I M
R E P O R T I N G
P R O C E D U R E S
6
Section
Claim Reporting
Procedures
This section describes basic procedures for reporting various types of claims including Workers’ Compensation, liability, and damage to the project. General Procedures
All Parties involved with the Project shall report all injuries, occupational‐related illnesses, or property damage to the Safety Manager immediately. Contractor, Subcontractors, and any other party involved with the Project will instruct employees and other personnel to report, in writing, within 24 hours all accidents and occurrences resulting in bodily injury or property damage to the Safety Manager. GC/CM Safety Manager: Cell Phone: E‐mail: Owners Safety Rep.: Cell Phone: Email: OCIP Safety Consultant: Cell Phone: Email: Jim Hearn (213) 595‐9427 HearnJi@HDCCO.COM John Darlak (951)255‐6445 john@bcsrm.com Chris Sarvis (714) 273‐8278 chris.sarvis@aon.com USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 23
C L A I M
R E P O R T I N G
P R O C E D U R E S
Media Inquiries
Make no statements to the media. Refer all questions from the media to the Communications Office at the University of Southern. Investigation Assistance
Contractor and all Subcontractors will report the claim promptly and assist in the investigation of any accident or occurrence involving injury to persons or damage to property. Contractor and all Subcontractors will cooperate with the companies involved in adjusting any claim by securing and giving evidence and obtaining the participation and attendance of witnesses required for the investigation and defense of any claim or suit. Workers’ Compensation Claims
Claims Reporting Instructions will be provided to all contractors and subcontractors upon enrollment. Claims Monitoring CM/Contractor will participate in monitoring Workers Compensation claims for Subcontractors. The main responsibility for all Parties is to first see that the injured worker receives immediate medical care. For emergency treatment, the paramedics will determine the best emergency facility available for treatment. All Parties involved with the Project shall report all injuries or occupational‐related illnesses to the Safety Manager as soon as possible. Enrolled Party personnel will follow these procedures if an employee sustains bodily injury or an occupational‐related illness while working at the Project Site: 1. Injured Workers should report to the Contractor job‐site offices for injury assessment. Where medical treatment is required beyond the scope of First‐Aid that can be administered on‐site, the injured Worker will be escorted to the designated Occupational Health Clinic or Hospital. The injured worker or accompanying supervisor should secure a Treatment Authorization Form from Contractor if they do not already have this form. 2. Contact the designated medical facility to advise them that an injured Worker will be arriving. Present the Treatment Authorization Form found in Section 7 of this manual to the clinic or hospital upon registration to identify the injured Worker as a OCIP participant working at a OCIP Project site. Contractor and Subcontractors must designate a representative at the site to escort an injured Worker to the medical facility. This individual is to remain with the injured employee at the medical facility while he/she is being treated. The treating physician will provide a Work Status Form stating whether or not the injured employee can return to work, a list of USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 24
C L A I M
R E P O R T I N G
P R O C E D U R E S
restrictions, if any, and the estimated length of time the injured worker must be on modified duty. Copies of the Work Status Form should be provided to the Employee, Employer, and the Contractor Safety Manager. If the Work Status Form is not submitted to the Contractor, the Contractor will request a copy from the injured Worker’s employer.
3. As soon as possible, and within 24 hours of notice of injury sustained at the Project Site, the employer of an injured worker shall do the following: 
Provide employee Workers' Compensation Claim Form (DWC‐1) 
Conduct a Supervisor's Accident Investigation 

Fill out Employee and Employer sections of the DWC‐1 and send it in to the insurance company when filing the claim Prepare the Employer’s Report of Occupational Injury or Illness (Form 5020) Report the Claim in one of the following ways: 1. Call Old Republic/Gallagher Bassett 1‐844‐539‐3802 Available 24 hours a day, 7 days a week Refer to: Client Code 006138; VPN Number 2224049 2. Fax your completed Workers’ Compensation Report of Accident, include the cover sheet from your Claims Kit and fax to 1‐800‐748‐6159 Refer to: Client Code 006138; VPN Number 2224049 When an employer reports the claim through one of the above methods, Gallagher Bassett, the OCIP claims administrators, will fill out the Employer’s Report of Occupational Injury or Illness (Form 5020) and send a completed copy to the State and back to the employer. This satisfies the employer’s requirement to provide the Report of Injury to the State Industrial Relations Division. The OCIP claims administrators also send a Claims Acknowledgement to the reporting employer with the assigned Claim Number and the Claim Adjuster contact information, as it becomes available. 4. Cooperate with the Claims Adjuster and keep Contractor informed of the current Work Status of the injured Worker. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 25
C L A I M
R E P O R T I N G
P R O C E D U R E S
Drug Test Program
A Drug Test Program has been implemented for this project. Testing is required “prior to commencing work at the project”, which will be paid for by the Contractor. In addition, testing will be required “post accident” and “for probable cause”, the financial burden associated with these tests will be the responsibility of the employer of the affected worker(s). The provisions of the Drug Test Program will meet or exceed the Contractor’s corporate program. Modified Duty / Early Return to Work Policy
Contractor shall institute a return to work program for any injured employee who is covered or entitled to coverage under the Workers’ Compensation insurance provided in the OCIP. Medical Provider Network (MPN)
Contractor and Subcontractors working on the OCIP Project will utilize the Medical Provider Network (MPN) program for industrial injuries. This program is a benefit to the employer as it allows for more effective medical control for the life of the claim and may reduce many of the Workers’ Compensation costs associated with each claim. The MPN contains an extensive number of occupational medicine facilities and other medical providers from which the injured worker is obligated by law to select if (1) the employer (Contractor/Subcontractor) has properly fulfilled its responsibilities and (2) the injured worker has not pre‐designated his own personal physician. MPN information is included in this OCIP Insurance Manual. These packets must be distributed to all employees who will work at the Project Site, and should be included the notification packets during each worker’s safety orientation. The information should be provided in English and Spanish and the employee must sign to acknowledge receipt of the information. USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 26
C L A I M
R E P O R T I N G
P R O C E D U R E S
Liability Claims
Report all Liability claims
to the General Contractor’s
Safety Representative, the
OCIP Administrator and to
the OCIP Insurer.
Claims
Monitoring
CM/Contractor will
participate in
monitoring General
Liability claims for
Subcontractors.
Incidents or accidents at or around the Project Site, or at a designated off‐site location that has been added to the OCIP policies (see definition of Project Site on page 2), resulting in damage to property of others (other than your own work product), or personal injury or death to a member of the public, must be reported immediately to the designated Project and Safety Managers. Follows these Procedures in the event of such an incident or accident: 1. Take appropriate emergency measures to prevent additional injury or damage, including contacting the police or fire authorities, as required by law. 2. Report the incident and all subsequent inquiries or correspondence about an insured loss or claim, including a summons or other legal documents, to the Safety Manager and the OCIP Administrator. 3. Report the Claim in one of the following ways: 1. Call Old Republic/Gallagher Bassett 1‐844‐539‐3802 Available 24 hours a day, 7 days a week Refer to: Client Code 006138; VPN Number 2224049 2. Fax your completed “General Liability Report Form”, include the cover sheet from your Claims Kit and fax to: 1‐800‐748‐6159 Refer to: Client Code 006138; VPN Number 2224049 Automobile Claims
Report all Auto claims to
your insurance carrier and
the OCIP Administrator.
No insurance coverage is provided for automobile accidents under the OCIP. It is the sole responsibility of Contractor and Subcontractors to report accidents/claims involving their automobiles to their own insurers. However, all accidents occurring in or around the Project Site must be reported to the designated Project and Safety Representatives and the Local OCIP Administrator. (See Section 2 for contact information). The accident will be investigated to determine any liability arising out of the project construction activities that could result in future claims (i.e., due to the conditions of the roads, etc.). Contractor and Subcontractors shall cooperate in the investigation of all automobile accidents.
F O R M S
7
Section
Forms
This section contains the forms needed for enrolling into the OCIP,
reporting payroll and overall administration of the OCIP.
This section contains the following forms:
Notice of Subcontract Award Aon Form‐1 Insurance Cost Worksheet Aon Form‐2 Insurance Cost Summary Aon Form‐3 Enrollment Application On‐Line Internet Payroll Reporting Aon Form‐5 Sample Notice of Work Completion Aon Form‐6 OCIP Coverage Questionnaire for a Dedicated Off‐Site Location Exhibit 1 Sample Certificate of Insurance for Enrolled Subcontractors Exhibit 2 Sample Additional Insured Endorsement – General Liability Exhibit 3 Sample Additional Insured Endorsement – Auto Exhibit 4 MPN Employment Notification Form 
English Version 
Spanish Version  MPN Employee Acknowledgement Form Exhibit 5 Designated Medical Clinic and Driving Directions Exhibit 6 Treatment Authorization Form For assistance completing these forms, please contact the OCIP
Administrator:
Jane Rozental
Aon Risk Solutions
USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 Phone – (866) 243-8266, Option 4
Email – acs.construction@aon.com
28
Notice of Subcontract Award
Today’s Date ______________
To:
Email:
Phone #:
Fax#:
Jane Rozental
acs.construction@aon.com
(866) 243‐8266, Option 4
(800) 363‐6695
From:
Email:
Phone #:
The subcontractor named below will be issued a contract to perform work on the following:
Project: USC - Jill and Frank Fertitta Hall
Contract Number:
Contract Value: $
Check here if the subcontractor is to be enrolled in the OCIP
Check here if the subcontractor is to be excluded from the OCIP
Check here if the subcontractor will be an excluded prime tier fabricator with eligible (enrolled)
sub-tier erector/installer
1. Name of subcontractor:
2. Subcontractor address:
3. Subcontractor FEIN:
4. Subcontractor contact person:
5. Subcontractor phone number:
6. Subcontractor fax number:
7. Subcontractor email address:
8. General description of work:
9. Date of award:
10 Anticipated on-site start date:
11. Anticipated completion date:
INSURANCE COST WORKSHEET
USC OCIP Jill and Frank
Fertitta Hall Page 1 of 2
(Fixed Price Type Contracts)
Form-1
Numbers reference attached instructions
A. Contractor Information:
Federal ID # or Soc. Sec. #:
1
 Business Information (headquarters)
Company Name & dba:
Contact Name & Title:
Address:
 Contact Information (address questions to..)
2
3
City, State, Zip Code:
Telephone:
Fax:
E.mail Address:
B. Bid Information:
Bid Package No.: 1
Description of Work: 2
Proposed Contract Price $: 3
Are you Submitting a bid to The University of Southern California: 5
Amount of Self Performed Work $: 4
 Yes
 No
If No, identify to whom: 6
C. Workers Compensation Insurance Information for Work Described Above: (a) (attach a separate sheet if necessary)
a
State
b
d
c
Class Code
e
Rate
(per $100 payroll)
Description
g
f
Work Hours
WC Premium
(Payroll * Rate / 100)
Payroll
1
Totals
Identify the Amount of Your Claim Retention
5
Employers Liability Rate:
8
2
3
4
Your Company’s Workers Compensation Experience Modifier: 6
Modified Premium (line C4 x C6): 7
Employers Liability Premium: 9
10 Modification & Discount Premium Factors
Mod 1:
Mod 2:
Mod 3:
Mod 4:
Mod 5:
+
+
+
+
+
or
or
or
or
or
11 Rate
-
12 Amount
Total Modification Amount (Total of all amounts entered in column C12): 13
Total Workers Compensation Premium (line C7 + C9 + C13): 14
D. General Liability:
Rate:
(a)
1
2 Based On:
Excess/Umbr Liab: (a)
Rate:
6
7 Based On:
Rate:
 Per 100
 Per 1,000
 Per 100
 Per 1,000
 Per 100
 Per 1,000
F. Other Insurance Premiums: (1) (Enter total premium costs identified on page 2)
Total of all Insurance Premiums (Total of
G. Totals
Overhead & Profit on Insurance Prem. %:
2
Identify the Amount of Your
Claim Retention: ___________
5
GL Premium (D2  D1  D3):
2 Rate factor
1
4
8 Rate factor:
Total Payroll (C3)
Contract Price (B3)
Other



E. Builder’s Risk/Installation Floater: (1)
3 Rate factor:
Total Payroll (C3)
Contract Price (B3)
Other



15%
Excess/Umbr Premium
(D7  D6  D8):
9
Builder’s Risk/Installation Floater 3
Premium (B3  E1  E2):
1
lines C14 +D5 + D9 + E3 + F1): 1
O/H & Profit Amount (G1 x G2): 3
Total Initial Insurance Cost (Total of lines G1 + G3): 4
Contractor’s Initial Insurance Cost Rate (Line G4 divided by total payroll in line C3  100): 5
H. Signature Block :
Name:
I verify the information presented above and attachments are correct:
Date:
(please print)
Title:
Signature:
Completion of this form is a required part of your bid and must accompany your bid documents. Complete a separate form for each contractor, known subcontractor(s)
and trades not currently awarded to a subcontractor. Duplicate this form as needed.
(a) Please provide copies of the following documents to support your insurance cost calculations:
 Rate Pages
 General Liability declaration and rate pages
 Workers Compensation declaration and rate pages  Umbrella/Excess Liability declaration and rate pages
 5 years actual loss experience for each line of coverage in which Contractor retains more than $5,000.
Form-1
INSURANCE COST WORKSHEET
(Instructions for Fixed Price Type Contracts)
Complete a separate form for each contractor, known subcontractor and trade not currently awarded to a subcontractor. Duplicate this form as needed. Completion of
this form is a required part of your bid and must accompany your bid documents.
A. Contractor Information
1 Enter your company’s Federal ID number. This number can be found on filings made to the federal government such as your tax return.
2 Enter your company’s name, mailing address and phone/fax number for your company’s main office location in the space provided below.
3 Enter the name of the person Aon should contact if questions arise. Include the mailing address, phone/fax and e-mail address if different than A-2
B. Bid Information
1 Enter the Bid Package Number, Contract Number or Purchase Order Number that was included in The University of Southern California’s originating documentation.
2 Provide a brief description of the work you will be performing at the project site.
3 Identify the total amount of your bid. Include both labor and material.
4 Identify the amount of work that you anticipate will be self-performed. Include both labor and material.
5 Check the appropriate box that identifies if you contract directly with The University of Southern California or are a subcontractor.
6 If you are a Subcontractor, identify the entity with whom you are under contract.
C. Workers Compensation Insurance Information (Duplicate or attach additional sheets if necessary. You may create an electronic version of this document if all requested information is included):
1 a Enter the two letter abbreviation for the state in which the work will be performed.
b Enter each Workers Compensation class code that applies to your work identified in B2. (Most states use a 4 digit Number)
c Enter the Workers Compensation class code description that applies to each class code identified in C1b.
d Enter the Workers Compensation rate that applies to the specified class code.
e Enter the estimated Work Hours required to complete the described work for each Workers Compensation class code.
f Enter the estimated Payroll required to complete your work. Use only unburdened payroll and exclude the premium portion of any overtime pay.
g Calculate the WC Premium by multiplying the Payroll (C1f) by the Rate (C1d) and dividing the result by 100. Repeat this calculation for each WC class code.
2
Total the estimated Work Hours for each class code. Be sure to include information from additional pages if used.
3
Total the estimated Payroll for each class code. Be sure to include information from additional pages if used.
4
Total the Workers Compensation Premium for each class code. Be sure to include information from additional pages if used.
5
Enter the amount of the Claim Retention / Deductible your company has on their existing Workers Compensation.
6
Enter your WC Experience Modifier. This Information can be located on your Workers Compensation policy or on your NCCI Bureau Rating Sheet.
7
Calculate the Modified Premium by multiplying the WC Premium (C4) by the Experience Modifier (C6).
8
Enter your Employer’s Liability Insurance Rate. This information can be found in your Workers Compensation policy.
9
Calculate your Employer’s Liability Premium by multiplying the Modified Premium (C7) by the Employer’s Liab. Rate (C8).
10 Identify the Modifiers that apply to your Workers Compensation Premium. This information can be located on your Workers Compensation Policy.
11 Enter the Rate for each identified Modifier. The information can be located on your Workers Compensation Policy
12 Calculate the Modified Premium Factor Amount by multiplying the Modified Premium (C7) by the Modified Premium Rate (C11) and dividing by 100. Be sure to
identify if the Modification factor is an addition or reduction to your premium.
13 Total the Modified Premium Amounts by adding the numbers in column C12.
14 Calculate the Total Workers Compensation Premium by adding the Modified Premium (C7) to the Employer’s Liab Premium (C9) and adding the Premium Modifications (C12).
D. General Liability & Umbrella/Excess Liability Insurance
1 Enter the General Liability Rate. This number can be found on your General Liability Policy
2 Identify the base the General Liability Rate applies to. If the base is other than Payroll or Revenue, enter the amount and the description in the space provided.
3 Identify the General Liability Rate factor by marking the box.
4 Identify the amount of your Claim Retention.
5 Calculate the General Liability Premium by multiplying the Bases (D2) by the Rate (D1) and dividing by the factor (D3).
6 Enter the Excess/Umbr Liability Rate. This number can be found on your Excess/Umbr Liability Policy
7 Identify the base the Excess/Umbr Liab. Rate applies to. If the base is other than Payroll or Revenue, enter the amount and description in the space provided.
8 Identify the Excess/Umbr Liability Rate factor by marking the box.
9 Calculate the Excess/Umbr Liability Premium by multiplying the Bases (D7) by the Rate (D6) and dividing by the factor (100 or 1,000).
E. Builder’s Risk/Installation Floater
1 Enter the Builder’s Risk/Installation Floater Rate. Locate this information on your Property Policy or Builder’s Risk Policy.
2 Identify the base factor that it applies to (100 or 1,000).
3 Calculate the Premium by multiplying the Proposed Contract Price (B3) by the Rate (E1) and dividing it by the Factor (E2).
F. Other Insurance Premiums
1 For each of the Insurance Lines of Coverage identified below, Identify the Rate, Base and Factor. Calculate the Premium by multiplying the Base x Rate  Factor.
Total the Other Insurance Premiums in the space provided and carry that amount to the front page.
Line of Coverage
Rate
Base
Factor
Premium
Total Premium
G. Totals
1 Calculate the Total of all Insurance Premium by adding Workers Compensation (C14), General Liability (D5), Excess/Umbr Liability (D9), Builder’s Risk/Installation
Floater (E3), and Other Insurance Premiums (F1).
2 Identify the Overhead & Profit Percentage that was applied to this project during the tabulation of the Proposed Contract Price.
3 Calculate the Overhead & Profit Amount by Multiplying the Total of all Insurance Costs (G1) by your Overhead & Profit Percentage (G2).
4 Calculate the Total Initial Insurance Cost by adding the Overhead & Profit Amount (G3) with the Total of all Insurance Premium (G1)
5 Calculate your rate by Dividing the Total Initial Insurance Cost (G4) by the Estimated Payroll (C3) and multiplying by 100.
H. Signature Block: This form must be signed by a representative of your company with the authority to Verify the information is correct.
Note: Please provide copies of the following documents as part of your submittal:


Rate Pages
Workers Compensation declaration and rate pages



USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 General Liability declaration and rate pages
Umbrella/Excess Liability declaration and rate pages
5 years actual loss experience for each line of coverage in which Contractor retains more than $5,000.
31
Form-2
INSURANCE COST SUMMARY
A. Bid Information
1
2
Name of Prime Contractor:
Proposed Contract Cost $:
Bid or Purchase Order No.:
3
B. Aon Form-1 Summary
Contracting Parties & Trades
Aon Form-1 Reference No.
Proposed
Subcontract
Amount
Estimated Work
Hours
Estimated
Payroll
Initial Insurance Cost
B3
(Form-1 Ref.)
C2
(Form-1 Ref.)
C3
(Form-1 Ref.)
G4
(Form-1 Ref.)
1
Prime Contractor : (Attach the Aon Form-1)
3
5
6
7
8
9 List by Trade or Function
10
11
12
13
1
2
3
4
List Additional Trades NOT yet assigned to
a subcontractor (attach an Aon Form –1)
Your Known Subcontractors
(Attach a Separate Aon Form-1 from each)
4
C. Total for Contract: (Total all Column Entries)
D. Composite Insurance Cost Rate for Contract: (Line C4  C3 x100)
E. Signature Block: I verify the information presented above and attachments are correct:
Name:
1
Date:
(please print)
Title:
Signature:
Completion of this form is a required part of your bid and must accompany your bid documents. Duplicate this form as needed. An Aon Form-1 must be attached for
each line entry made on this form. In addition, the following documentation must accompany each Aon Form-1.


Rate Pages



5 years actual loss experience for each line of coverage in which Contractor retains more than $5,000.
32
Form-2
INSURANCE COST SUMMARY
INSTRUCTIONS
USC OCIP - Jill and Frank
This form is to be used by a Prime Contractor to summarize subcontract activity. This form may also be used by Subcontracts that must summarize sub subcontract
activity of any tier. Submit this form with your Bid Documents.
A. Bid Information
Enter the Name of the Contractor whose activity is being summarized. For purposes of these instructions they will be called a
Prime Contractor regardless of the fact that they may not hold a contract directly with The University of Southern California.
Enter the Bid Package Number, Contract Number or Purchase Order Number. This number accompanied The University of
Southern California’s original documentation.
Enter the Amount you have proposed as the Contract Price.
1
2
3
B. Aon Form-1 Summary
(Information will either be found on the Contractor’s Aon Form-1 or in situations where the subcontract uses additional tiers of subcontractors, the
information will be found on an Aon Form-2 that summarizes their activity with their subcontracted activity.)
1
2
3
4
5
6
7
8
9
10
11
12
13
For the Prime Contractor enter the Estimated Worker Hours
For the Prime Contractor enter the Estimated Payroll
For the Prime Contractor enter the Total Initial Insurance Cost
For each Subcontractor, enter the firm’s Name
For each Subcontractor, enter the Proposed Contract Cost
For each Subcontractor, enter the Estimated Work Hours
For each Subcontractor, enter the Estimated Payroll
For each Subcontractor, enter the Total Initial Insurance Cost
For the Activity that has not been assigned to a Subcontractor, enter the Trade or
Functional Description
For the Activity that has not been assigned to a Subcontractor, enter the
Estimated Contract Amount
Estimated Worker Hours
Estimated Payroll
Estimated Initial Insurance Credit
Aon Form-1
Reference No.
C2
C3
G4
A2
B3
C2
C3
G4
Aon Form-2
Reference No
A1
A3
C2
C3
C4
A2
B3
C2
C3
G4
C. Total Estimates for Contract
Total the Proposed Subcontract Amount for the identified activity.
Total the Estimated Man Hours for the identified activity.
Total the Estimated Payroll for the identified activity.
Total the Initial Insurance Cost for the identified activity.
1
2
3
4
D. Composite Insurance Cost Rate for Contract
Calculate the Composite Rate for the Contract by dividing the Total Initial Insurance Cost (C4) by the Total Estimated Payroll
(C3) and multiplying by 100.
1
E. Signature Block: This form must be signed by a representative of your company knowledgeable of its accuracy.
Completion of this form is a required part of your bid and must accompany your bid documents. Duplicate this form as needed. An Aon Form-1 must
be attached for each line entry made on this form. In addition, the following documentation must accompany each Aon Form-1.


Rate Pages



5 years actual loss experience for each line of coverage in which Contractor retains more the $5,000.
33
ENROLLMENT APPLICATION
Form-3
Examine your current Workers Compensation and General Liability Policies or contact your Insurance Agent to assist you with
completing this form. *** NOTICE *** Enrollment is not automatic and requires the satisfactory completion of the Aon Form-1,
Form-2 and Form-3. In addition, submit a Certificate of Insurance providing evidence of your off-site coverage. Please refer
to the Insurance Manual for coverage requirements.
A. Contractor Information:
Federal ID # or Soc. Sec. #:
1
 Business Information (headquarters)
 Contact Information (address questions to..)
2
Company Name & dba:
Contact Name & Title:
3
Address:
City, State Zip Code:
Telephone:
Fax:
Email Address:
4
Indicate your Organization’s Structure:
 Corporation
 Joint Venture
 S-Corporation
 Other _____________________________
 Partnership
 Sole Proprietor
Contract No.: 1
B. Contract Information:
Date Contract Awarded: 2
Description of Work: 3
Proposed Contract Price $:
Are you Submitting a bid to The University of Southern 6
California:
4
Amount of Self Performed Work $: 5
 Yes
 No
If No, identify to whom: 7
8
 Actual
 Estimated
Start Date:
 Actual
 Estimated
9
Completion Date:
C. Contacts: (Complete if Applicable)
Position
1
Project Mngr:
Res. Engineer:
Insurance:
Contract Admin:
Payroll:
Claims:
Safety Rep:
Provide Location of payroll records if
different than Corporate address:
Name & Title
2
Phone
5
3
Fax
4
Email Address
Phone:
Fax:
D. Workers Compensation Insurance Information for Work Described Above: (attach a separate sheet if necessary)
a
State
b
Class Code
c
Description
d
Work Hours
e
Payroll
1
Totals
2
3
E. Provide your current Off-Site Workers Compensation Information: (for each state you will perform work in)
Applicable State
1
Risk ID Number
2
Your WC Insurance Carrier:
Policy #:
Rating Bureau
3
Anniversary Rating Date
4
5
6
USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 Effective Date:
7
Expiration Date:
8
34
Form-3
F. Subcontract Information:
List all Subcontractors that will be working for you on this project (complete the information in the following table). Use additional paper if
necessary:
1
2
3
4
5
6
Subcontractor
Subcontract $
Contact Person
Address
Phone & Fax No
Estimated Start Date
G. Enrollment Questions: Answer each question. Use additional paper if necessary.
1
Will you have any off-site location(s) 100% dedicated to this project?  Yes  No
2
Please check if:
3
 Any aircraft used on this project
If yes, please provide address:
 Any watercraft used on this project
Please indicate if labor from the following sources will be used:
 Employee Leasing Firm
 Temporary Labor Agency
4
5
6
7
H.
WARRANTY
APPLICABLE TO PROGRAM INSURANCE COVERAGE
1
Premiums for this Program are the responsibility of The University of Southern California and I agree any and all return of premium,
dividends, discounts, or other adjustments to any Program policy(ies) is assigned, transferred and set over absolutely to The University of
Southern California. This assignment applies to the Program policy(ies) as now written or as subsequently modified, rewritten or replaced.
Rights of Cancellation for all Program insurance policy(ies) arranged by The University of Southern California are assigned to The
University of Southern California.
2
I will pay the cost of premium(s) for non-Program insurance coverage, specified in the Contract Documents.
3
I authorized the release of all claim information for all insurance policies under this Program.
4
It is my responsibility to notify my insurance carrier(s) that I am enrolling in this Program.
5
I have omitted from my bid the insurance costs for the coverage provided by The University of Southern California.
6
The statements in this insurance application are true to the best of my knowledge.
I. Signature Block :
Name:
I verify the information presented above and attachments are correct:
Date:
(please print)
Title:
Email to:
Signature:
Jane Rozental
Aon Risk Insurance Services West, Inc.
USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 (800) 363‐6695 Fax
35
Form-3
INSTRUCTION
This form must be completed and submitted by each successful Contractor and Subcontractor of any tier prior to Site mobilization for each contract
awarded. The Contractor and Subcontractor will submit the completed form to Aon Risk Services. Upon receipt of this form, Aon will issue to the
Contractor or Subcontractor a Certificate of Insurance evidencing coverage in the Controlled Insurance Program. The completed Certificate of Insurance
and Workers Compensation insurance policy will be mailed to the Enrolled party.
A. Contractor Information
Enter your company’s Federal ID number. This number can be found on filings made to the federal government such as your tax return.
Enter your company’s name, mailing address and phone/fax number for your company’s primary office location.
Enter the name of the person Aon should contact if questions arise. Include mailing address, phone/fax and e.mail address, if different than A2.
Identify your company’s legal structure by checking the box that applies. If the correct legal structure is not specifically listed, please check the “Other” box
and specify in the space provided.
1
2
3
4
B. Contract Information
Enter the Contract Number or Purchase Order Number that was included in The University of Southern California’s originating documentation.
Supply the Date this Contract was awarded to your organization.
Provide a brief description of the work you will be performing at the project site.
Identify the total amount of your contract. Include both labor and material.
Identify the amount of work that you anticipate will be self-performed. Include both labor and material.
Check the appropriate box that identifies if you contract directly with The University of Southern California or are a Subcontractor.
If you are a Subcontractor, identify the entity with whom you are under contract.
Enter the Date you anticipate starting work and then mark whether the date provided is actual or estimated.
Enter the Date you anticipate completing the described work and then mark whether the date provided is actual or estimated.
C. Contacts (Requested Contact information is for specific functions. It is possible to have a single person fulfill multiple responsibilities.)
1
Identify the name of the person and their title for each function. These individuals should be located, if at all possible, on-site.
2
Provide the phone number for each person identified above.
3
Provide the fax number for each person identified above.
4
Provide the e.mail address for each person identified above, if applicable.
5
Identify the physical location where your payroll records are retained. Provide the Address, City, State, Zip Code, Telephone, Fax Number and E.mail
Address of the person responsible for maintaining the payroll information.
1
2
3
4
5
6
7
8
9
D. Workers Compensation Information (Duplicate or attach additional sheets if necessary. You may create an electronic version of this document if all requested information is included.):
1 a
b
c
d
e
2
3
Enter the two letter abbreviation for the state in which the work will be performed.
Enter each Workers Compensation class code that applies to the work identified in B2. (Most states use a 4 digit Number)
Enter the Workers Compensation class code description that applies to the work identified in D1b.
Enter the estimated Work Hours required to complete the described work by Workers Compensation class code.
Enter the estimated Payroll required to complete the described work for each Workers Compensation class code. Use only unburdened payroll and exclude the
premium portions of any overtime pay.
Total all estimated Work Hours for each class code. Be sure to include information from additional pages if used.
Total all estimated Payroll for each class code. Be sure to include information from additional pages if used.
E. Current Off-Site Workers Compensation Information
1
2
3
4
5
6
7
8
F. Subcontractor Information
1
2
3
4
5
6
(Information relates to your corporation’s existing coverage; identify each modification factor that applies.)
Enter the State that the Modification Information applies to.
Enter your Bureau File Number also referred to as your Risk Identification Number. This number can also be found on your Modification worksheets.
Enter the Bureau Rating Agency. In most states this is NCCI.
Provide your Company’s Anniversary Rating Date. Information can be located on your bureau’s WC Experience Modification worksheets.
Identify your insurance carrier for Workers Compensation Coverage.
Provide your Workers Compensation Policy Number.
Provide the effective date of your Workers Compensation policy.
Provide the expiration date of your Workers Compensation policy.
(Provide the following information for each Subcontractor that will be performing work at the project site. Use additional sheets, if necessary.)
Identify the name of the Subcontracting firm.
Provide the estimated value of the subcontracted activity.
Provide a contact name, preferably the project manager, for the Subcontractor.
Provide the mailing address for the Subcontractor.
Provide the phone number for the Subcontractor.
Provide the date the Subcontractor is scheduled to begin work.
G. Enrollment Questions
1
2
3
Determine if you will have any locations, off-site, that will be 100% dedicated to this project. Include material/supply storage as a possible location. Mark the
appropriate box (yes/no). If you answer yes – provide the address of each location you identified as 100% dedicated.
Mark the box or boxes that apply. Contemplate only work performed under this contract.
Mark the box or boxes that apply. Employee Leasing Firm are those firms that supply the labor force for your company (You direct the activities of the
Leasing Company’s employees). Temporary Labor Firms supplement your labor force.
H. Warranty Statements:
1-6
Read each Warranty statement thoroughly. If you have questions regarding any of these statements, contact the Aon administrator identified on page 2.
I. Signature Block: This form must be signed by a representative of your company knowledgeable of its accuracy.
Forward the completed Enrollment Application to the Aon administrator identified at the bottom of page 2 of this form. The administrator
prior to the start of your work on-site must receive this form.
Internet Payroll Reporting
Using the internet, go to www.AonWrap.Aon.com and utilize the password provided with your evidence of enrollment. The monthly man‐hour and payroll reports should include supervisory and clerical personnel on‐site and cover all Work performed at or emanating directly from each Project Site. If you need help understanding the system, please contact any Aon representative listed in the Directory. Please note: in the event of “interim demobilization”, that is when the Contractor/subcontractor is not performing work at the project site but is still enrolled in the CCIP, the Contractor/subcontractor will still be required to submit Monthly Payroll Reports. USC OCIP
Aon Assigned Identifier
Your Name here
NOTICE OF WORK COMPLETION
Form-5
A. General Information SAMPLE – TO BE COMPLTED ON LINE VIA THE AONWRAP WEB PORTAL
Contractor Name:
1
Under contract With:
2
Contract #:
3
Description of Work: Performed:
4
Date Work Completed:
5
Date this Contract Completed:
6
Final Contract Value:
7
B. Work Completion
The following Subcontractors have completed their Work at the Project Site:
(Add attachment if more space is needed)
a
Subcontractor’s Name
b
Contract Number
c
Description of Work
d
Date Completed
1
Location of your payroll records (Receipt of this form will initiate the payroll audit process):
Address:
2
Contact/Phone #:
C. Signature Block
The undersigned acknowledges request for termination of Coverage under the OCIP as of the date indicated above for the specified Contract.
Should we return to the work Site, we will be working under our own insurance program and must provide The University of Southern California with
a Certificate of Insurance showing our own Coverage as detailed in our contract.
Signed by:
1
Name & Title
Approved by:
Date
2
Construction Manager (Name & Title)
USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 Date
38
Form-5
NOTICE OF WORK COMPLETION
Instructions
This form will be completed and returned to the OCIP Administrator by the contractor or Subcontractor
whenever work is completed for each Contract or Subcontract. This form will initiate the final payroll
audit process for the Contractor/Subcontractor identified in item 1. Final Payments and Release of
Retainage will not occur until all payroll work is complete and finalized.
A. General Information
1
2
3
4
5
6
7
Provide the name of the Contractor completing their work.
Provide the name of the entity your contract is with (The University of Southern California or Parent
Contractor)
Enter the contract number for the work being completed.
Provide a brief description of the work being completed.
Provide the Date the Work was completed.
Provide the Date the Contract was completed, if other than work completion date.
Document final contract value (original contract amount plus change orders, purchase orders or work orders)
B. Work Completion
1a
b
c
d
2
Enter the name of each Subcontractor that performed work for you that has also completed their
work.
Enter Subcontractors Contract Number.
Provide a brief description of their work.
Provide the Date they completed their work.
Identify the physical location of where your payroll records are retained. Provide the Address,
City, State, Zip Code, Contact Name and Telephone Number of the person responsible for
maintaining the payroll information for audit purposes.
C. Signature Block
1
2
This form must be signed by a representative of your company with the authority to Verify that
the information is correct.
Have this form approved by the Construction Manager for the Project Site.
**ONLY USE THIS FORM IF SUPPLEMENTARY CONDITIONS OFFER OFF-SITE COVERAGE**
Form 6
OCIP COVERAGE QUESTIONNAIRE FOR
DEDICATED OFF-SITE LOCATION
USC OCIP - Jill
and Frank Fertitta
Hall Page 1 of 2
1. Name and address of the USC project site at which your company will perform work:
____________________________________________________________________________________
2. Your company name and address:
____________________________________________________________________________________
__________________________________________________________________________________
3. Will your company be performing work at the above project site location? (Transport, pick up, delivering or
carrying materials, personnel, parts or equipment, or any other items or persons to or from the project site do not qualify as
performing work.) (If No, the dedicated off-site location cannot be covered.) _____
4. Do the operations to be performed at the dedicated off-site location fall into the categories listed as
Excluded Parties in Section 3 of the OCIP Manual? (If Yes, the dedicated off-site location cannot be
covered.) _____
Excluded Parties include, but are not limited to, the following:
a. Heavy and/or structural demolition, hazardous materials remediation, removal and/or transport companies and their
consultants; b. Architects, surveyors, engineers, and soil testing engineers, and their consultants (except for architects,
surveyors, engineers and soil testing engineers that are employees of Contractor or Subcontractor); c. Vendors, suppliers,
fabricators, material dealers, truckers, haulers, drivers, common carriers and others who do not perform work at the Project site or
who merely transport, pick up, deliver, or carry materials, personnel, parts or equipment, or any other items or persons to or from
the Project site; d. Subcontractors of all tiers that do not perform any actual labor on the Project site with their own forces
or through a Subcontractor; e. Temporary labor services; f. Persons or Entities who are not an Eligible Party who are enrolled
in the OCIP; and g. Any other person or entity that the University of Southern California, acting in its sole discretion, elects to
exclude, even if otherwise eligible.
5. Will the dedicated off-site location be 100% dedicated to the USC project site identified in Item 1. above? If
No, will the work to be performed at the off-site location be segregated by a specific, clearly identifiable time
period wherein only USC project work will be performed? If work cannot be clearly segregated by a
specific, clearly identifiable time period wherein only USC project work is to be performed with
work logs evidencing the work run date, work run time, workers who performed the work, and
provide a USC dedicated storage area for the specified time, the location cannot be covered. _____
If the location meets the 100% dedicated requirements, please provide:
a. Dedicated off-site location address (must be within California, or it cannot be covered):
__________________________________________________________________________________
b. Describe scope of the work to be performed at the dedicated off-site location for the USC project
identified
in Item 1. above: ____________________________________________________________________
____________________________________________________________________________________
c. Describe the work process to be performed: ______________________________________________
_________________________________________________________________________________
d. What are the dates and times in which only USC work for the USC project identified in Item 1. above will
be performed and unfinished and finished materials stored at this off-site location? (If approved
by the insurance carrier, coverage will only be in effect during the time period during which the work is being performed.
The date of coverage cannot be earlier than enrollment into OCIP enrollment nor can it be in the past.)
_________________________________________________________________________________
6. Attach a Certificate of Insurance with the address of the dedicated off-site location to evidence coverage
for non-USC work being performed.
**ONLY
USE THIS FORM IF SUPPLEMENTARY CONDITIONS OFFER OFF-SITE COVERAGE**
Form 6
OCIP COVERAGE QUESTIONNAIRE FOR
FABRICATION AT A DEDICATED OFF-SITE LOCATION
Fertitta Hall
Page 2 of 2
7. Attach a copy of your site safety plan. Site plan must also include the name and qualifications of a
designated and secondary (back-up) credentialed CSP that will be on site at all hours of operations.
This information will be provided to and must be approved by the insurance carrier prior to the dedicated
off-site location being scheduled.
If the location is scheduled onto the OCIP program, by signing below, you agree to allow insurance carriers
and any other safety professionals to perform periodic safety reviews at your site during the time the USC
work is being performed, and you will comply with all loss control recommendations as outlined in a safety
report.
Signature Block
I verify that the information presented above and attachments are correct:
Signed by:
Name & Title
Email to:
Jane Rozental
Aon Risk Insurance Services West, Inc.
USC OCIP Insurance Manual Fertitta Hall 11‐14‐14 Date
(800) 363‐6695
41
Exhibit 1 – Sample Certificate of Insurance for OCIP Enrolled Subcontractors
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
01/11/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE
CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the
policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
Insurance Broker/Agent Name & Address
CONTACT
NAME:
Broker Name
PHONE
(A/C, No, Ext):
Broker Phone
E-MAIL
ADDRESS:
Broker Email Address
INSURER A :
Carrier Name
INSURER B :
Carrier Name
INSURER C :
Carrier Name
INSURER D :
Carrier Name
FAX
(A/C, No):
Broker Fax
INSURER(S) AFFORDING COVERAGE
INSURED
Contractor / Subcontractor Name & Address
NAIC #
INSURER E :
INSURER F :
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
A
ADDL SUBR
INSR WVD
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
GENERAL LIABILITY
X
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE
GEN'L
x
OCCUR
X
X
Policy Number
Date
Date
AGGREGATE LIMIT APPLIES PER:
PROPOLICY
ANY AUTO
ALL OWNED
SCHEDULED
AUTOS
X
$1,000,000
X
HIRED AUTOS
UMBRELLA LIAB
X
DED
X
X
Policy Number
Date
Date
X
X
Policy Number
Date
Date
AUTOS
NON-OWNED
AUTOS
X
EXCESS LIAB
D
Combined Single Limit
X
X
C
$2,000,000
$2,000,000
$2,000,000
$1,000,000
$50,000
$5,000
LOC
JECT
AUTOMOBILE LIABILITY
B
LIMITS
Each Occurrence
General Aggregate
Products - Comp Op Agg
Personal & Adv. Injury
Damage to Rented Prem.
Medical Expense
OCCUR
CLAIMS-MADE
Each Occurrence
Aggregate
See Section 4
See Section 4
RETENTION $
X
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
Y/N
X
Policy Number
Date
Date
If yes, describe under
WC STATU-
TORY LIMITS
OTHER
E.L. Each Accident
E.L. Disease - Each Employee
E.L. Disease - Policy Limit
$1,000,000
$1,000,000
$1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Policies above apply to operations in connection with Jill and Frank Fertitta Hall at USC. Hathaway Dinwiddie Construction Company, The University of Southern
California, the OCIP Administrator, and each of their representatives, consultants, officers, agents, employees, each of their Representative's consultants, and all
enrolled parties, regardless of whether or not identified in the Contract Documents or to the Contractor in writing, are included as additional insureds on the above
general liability policies [pursuant to additional insured endorsement CG2010 (11/85) or a combination of both CG 2010 (10/01 or 07/04) and CG 2037 (10/01 or
07/04)] and automobile liability policies. Coverage is primary and non-contributory as respects off-site coverage. Waiver of Subrogation is included for General
Liability and Workers Compensation. General Liability and Workers’ Compensation Coverages apply off-site only.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
The University of Southern California
c/o Hathaway Dinwiddie Construction Company
Address Here
AUTHORIZED REPRESENTATIVE
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05)
The ACORD name and logo are registered marks of ACORD
Exhibit 2 – Sample Additional Insured Endorsement – General Liability
POLICY NUMBER: XXXXXXXXXXXX
CONTRACTOR NAME
COMMERCIAL GENERAL LIABILITY
Sample
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED — OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization:
Hathaway Dinwiddie Construction Company, the University of Southern California, it’s
employees, agents, the University of Southern California's consultant and its consultants, the
OCIP Administrator, and each of their respective officers, agents, and employees
(If no entry appears above, information required to complete this endorsement will be shown in the
declarations as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization
shown in the Schedule, but only with respect to liability arising out of “your work” for that insured by
or for you.
PRIMARY INSURANCE: This insurance will be primary for the additional insured but only with
respect to liability arising out of your work for that additional insured by or for your.
NOTE: This policy to include a WAIVER OF SUBROGATION.
CG 20 10 11 85
Copyright Insurance Services Office Inc., 1984
Exhibit 3 – Sample Additional Insured Endorsement – Auto
POLICY NUMBER
XXXXXXXX
CONTRACTOR NAME
COMMERCIAL AUTO
Sample
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
TRUCKERS COVERAGE FORM
BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM
This endorsement changes the policy effective on the inception date of the policy unless another
date is indicated below.
Endorsement effective
Named Insured
Countersigned by
(Authorized Representative)
SCHEDULE
Who is an insured is changed to include as an "insured" the named insured listed below.
Insurance Company:
Additional Insured: Hathaway Dinwiddie Construction Company, the University of Southern
California, it’s employees, agents, the University of Southern California's consultant and its
consultants, the OCIP Administrator, and each of their respective officers, agents, and
employees
Address:
Description of operations/vehicle As respects to all operations performed for or on behalf of the
Additional Insured
PRIMARY INSURANCE: This insurance will be primary for the additional insured but only with
respect to liability arising out of your work for that additional insured by or for your.
NOTE: This policy to include a WAIVER OF SUBROGATION.
July 1, 2014
Exhibit 4 – MPN Employee Notification English Version
Important Information about Medical Care if you have a
Work-Related Injury or Illness
Initial Written Employee Notification Re: Medical Provider Network
(Title 8, California Code of Regulations, section 9767.12)
California law requires your employer to provide and pay for medical treatment if you are injured at
work. Your employer or their Workers’ Compensation Insurer has chosen to provide this medical
care by using a Workers’ Compensation physician network called a Medical Provider Network (MPN).
This MPN is administered by First Health and Gallagher Bassett Services, Inc. (GB). Your
employer/employer name’s workers’ compensation carrier is Old Republic General Insurance Company.
This notification tells you what you need to know about the MPN program and describes your rights in
obtaining medical care for work-related injuries and illnesses.
•
What is a MPN?
A Medical Provider Network (MPN) is group of health care providers (physicians and other medical
providers) used to treat workers injured on the job. Each MPN must include a mix of doctors specializing
in work-related injuries and doctors with expertise in general areas of medicine.
Your employer or Gallagher Bassett will select your initial medical provider and thereafter the
MPN regulations allow employees to have a choice of provider(s).
•
How do I find out which doctors are in my MPN?
The PRE-INJURY/ILLNESS MPN contact for your MPN is:
Name: Christy Foote
Title:
Address: 225 S. Lake Avenue, Suite 900, Pasadena, CA 91101
Telephone Number: (626) 683-5221
Email Address: cfoote@orcpg.com
The MPN contact listed in this notification will be able to answer your questions about the MPN and will
help you obtain a regional list of all MPN doctors in your area. At minimum, the regional listing must
include a list of all MPN providers within 15 miles of your workplace and/or residence or a list of all MPN
providers within the county where you live and/or work. You may choose which list you wish to receive.
You can get the list of MPN providers by calling the MPN contact or by going to our website at
www.talispoint.com/cvty/gbmpn. You may also locate a MPN doctor by calling Gallagher Bassett
Managed Care Services at 1-800-370-0594. At the voice prompts, please select Option 6, then Option 2.
To locate a pharmacy that is most convenient for you, please contact First Script at 1-866-445-7344. Or
you may locate a pharmacy by going to our website at www.firstscript.com. On our website you will see
LOCATE A PHARMACY. Just enter your zip code and a pharmacy listing will display.
Your employer has identified the following Gallagher Bassett Services, Inc. (GB) to be the POSTINJURY/ILLNESS MPN Contact for all employees:
For Southern California Claims
Gallagher Bassett Services, Inc.
P.O. Box 9875, Calabasas, CA 91372
Telephone Number: 866-444-8379
You also have the right to a complete listing of all of the MPN providers upon request.
•
What happens if I get injured at work?
July 1, 2014
In case of an emergency, you should call 911 or go to the closest emergency room.
If you are injured at work, notify your employer as soon as possible. Your employer will provide you
with a claim form. When you notify your employer that you have had a work-related injury, your
employer or Gallagher Bassett will make an initial appointment with a doctor in the MPN.
•
How do I choose a provider?
After the first medical visit, you may continue to be treated by this doctor, or you may choose another
doctor from the MPN. You may continue to choose doctors within the MPN for all of your medical
care for this injury. If appropriate, you may choose a specialist or ask your treating doctor for a referral to
a specialist. If you need help in choosing a doctor you may call the MPN Contact listed above.
•
Can I change providers?
Yes. You can change providers within the MPN for any reason, but the providers you choose should
be appropriate to treat your injury.
•
What standards does the MPN have to meet?
The MPN has providers in all California counties with the exception of Alpine, Trinity, Mono, and
Mariposa counties.
The MPN must give you a regional list of providers that includes at least three physicians in each
specialty commonly used to treat work injuries/illnesses in your industry. The MPN must provide
access to primary physicians within 15 miles and specialists within 30 miles. If you live in a rural area
there may be a different standard.
The MPN must provide initial treatment within 3 days. You must receive specialist treatment within
20 days of your request. If you have trouble getting an appointment, contact your claims adjuster at
Gallagher Bassett or the MPN Contact identified in this Notice.
•
What if there are no MPN providers where I am located?
If you are a current employee living in a rural area or temporarily working or living outside the MPN
service area, or you are a former employee permanently living outside the MPN service area, the MPN
or your treating doctor will give you a list of at least three physicians who can treat you. The MPN
may also allow you to choose your own doctor outside of the MPN network. Contact your MPN Contact
identified in this notice for assistance in finding a physician or for additional information.
•
What if I need a specialist not in the MPN?
If you need to see a specialist that is not available in the MPN, you have the right to see a specialist
outside of the MPN.
•
What if I disagree with my doctor about medical treatment?
If you disagree with your doctor or wish to change your doctor for any reason, you may choose another
doctor within the MPN.
If you disagree with either the diagnosis or treatment prescribed by your doctor, you may ask for a
second opinion from another doctor within the MPN. If you want a second opinion, you must contact the
MPN and tell them you want a second opinion. The MPN should give you at least a regional MPN
provider list from which you can choose a second opinion doctor. To get a second opinion, you must
choose a doctor from the MPN list and make an appointment within 60 days. You must tell the MPN
Contact of your appointment date, and the MPN will send the doctor a copy of your medical
records. You can request a copy of your medical records that will be sent to the doctor.
If you do not make an appointment within 60 days of receiving the regional provider list, you will not be
allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this
treating physician.
July 1, 2014
If the second opinion doctor feels that your injury is outside of the type of injury he or she normally
treats, the doctor's office will notify your employer or insurer. You will get another list of MPN doctors
or specialists so you can make another selection.
If you disagree with the second opinion, you may ask for a third opinion. If you request a third opinion,
you will go through the same process you went through for the second opinion.
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider
list, then you will not be allowed to have a third opinion with regard to this disputed diagnosis or
treatment of this treating physician.
If you disagree with the third opinion doctor, you may ask for an Independent Medical Review (IMR).
Your employer or MPN contact person will give you information on requesting an Independent Medical
Review and a form at the time you request a third opinion.
If either the second or third opinion doctor agrees with your need for a treatment or test, you will be
allowed to receive that medical service from a provider inside the MPN, including the second or third
opinion physician.
If the Independent Medical Reviewer supports your need for a treatment or test you may receive the
treatment recommended by the IMR physician from a doctor inside or outside of the MPN.
•
What if I am already being treated for a work-related injury before the MPN begins?
Your employer or insurer has a Transfer of Care Policy administered by Gallagher Bassett, which will
determine if you can continue being temporarily treated for an existing work-related injury by a
physician outside of the MPN before your care is transferred into the MPN.
If you have properly predesignated a primary treating physician, you cannot be transferred into
the MPN. (If you have questions about predesignation, ask your supervisor.) If your current doctor is
not or does not become a member of the MPN, then you may be required to see a MPN physician.
If your employer decides to transfer you into the MPN, you and your primary treating physician must
receive a letter notifying you of the transfer.
If you meet certain conditions, you may qualify to continue treating with a non-MPN physician for
up to a year before you are transferred into the MPN. The qualifying conditions to postpone the transfer
of your care into the MPN are in the box below.
Can I Continue Being Treated By My Doctor?
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or
continuity of care) for up to a year if your injury or illness meets any of the following conditions:
•
(Acute) The treatment for your injury or illness will be completed in less than 90 days;
•
(Serious or chronic) Your injury or illness is one that is serious and continues for at least
90 days without full cure or worsens and requires ongoing treatment. You may be allowed to be
treated by your current treating doctor for up to one year, until a safe transfer of care can
be made.
•
(Terminal) You have an incurable illness or irreversible condition that is likely to cause
death within one year or less.
•
(Pending Surgery) You already have a surgery or other procedure that has been authorized by
your employer or insurer that will occur within 180 days of the MPN effective date, or the
termination of contract date between the MPN and your doctor.
July 1, 2014
You can disagree with your employer’s decision to transfer your care into the MPN. If you don’t want
to be transferred into the MPN, ask your primary treating physician for a medical report on whether you
have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN.
Your primary treating physician has 20 days from the date of your request to give you a copy of his/her
report on your condition. If your primary treating physician does not give you the report within 20 days
of your request, the employer can transfer your care into the MPN and you will be required to use a
MPN physician.
You will need to provide a copy of the report to Gallagher Bassett if you wish to postpone the
transfer of your care. If you or your employer disagrees with your doctor’s report on your condition, you
or your employer can dispute it. See the complete transfer of care policy for more details on the dispute
resolution process.
For a copy of the entire transfer of care policy, ask your MPN Contact.
•
What if I am being treated by a MPN doctor who decides to leave the MPN?
Your employer or insurer has a written “Continuity of Care” policy that will determine whether you can
temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer
participating in the MPN.
If your employer decides that you do not qualify to continuing your care with the non-MPN provider, you
and your primary treating physician must receive a letter of notification.
If you meet certain conditions, you may qualify to continue treating with this doctor for up to a year
before you must switch to MPN physicians. These conditions are set forth in the box above, “Can I
Continue Being Treated By My Doctor?”
You can disagree with your employer’s decision to deny you Continuity of Care with the terminated
MPN provider. If you want to continue treating with the terminated doctor, ask your primary treating
physician for a medical report on whether you have one of the four conditions stated in the box above
to see if you qualify to continue treating with your current doctor temporarily.
Your primary treating physician has 20 days from the date of your request to give you a copy of his/her
medical report on your condition. If your primary treating physician does not give you the report
within 20 days of your request, the employer can transfer your care into the MPN and you will be
required to use a MPN physician.
You will need to provide a copy of the report to Gallagher Bassett if you wish to postpone the
transfer of your care into the MPN. If you or your employer disagrees with your doctor’s report on your
condition, you or your employer can dispute it. See the complete Continuity of Care policy for more
details on the dispute resolution process.
For a copy of the entire Continuity of Care policy, ask your MPN Contact.
•
What if I have questions or need help?
•
MPN Contact: You may always contact the MPN Contact if you need help or an explanation
about your medical treatment for your work-related injury or illness.
Name: Christy Foote
Address: 225 S. Lake Ave, Suite 900, Pasadena, CA 91101
Telephone Number: (626) 683-5221
Email address: cfoote@orcpg.com
•
Employer’s MPN website: www.talispoint.com/cvty/gbmpn. You may also locate a
MPN doctor by calling Gallagher Bassett Managed Care Services at 1-800-370-0594.
At the voice prompts, please select Option 6, then Option 2.
July 1, 2014
•
Division of Workers’ Compensation (DWC): If you have concerns, complaints or questions
regarding the MPN, the notification process, or your medical treatment after a work-related
injury or illness, you can call DWC’s Information and Assistance at 1-800-736-7401. You can
also go to DWC’s website at www.dir.ca.gov/dwc and click on “medical provider networks”
for more information about MPNs.
•
Independent Medical Review: If you have questions about the Independent Medical
Review process contact the Division of Workers’ Compensation’s Medical Unit at:
P.O. Box 71010
Oakland, CA 94612
510-286-3700 or 800-794-6900
Keep this information in case you have a work-related injury or illness.
July 1, 2014
Exhibit 4 – MPN Employee Notification Spanish Version
Información importante sobre atención médica en caso de lesión o
enfermedad relacionada con el trabajo
Comunicación escrita inicial para el empleado - Ref: Red de Proveedores Médicos
(Artículo 9767.12 del Código Regulatorio de California, Título 8)
La legislación de California establece que su empleador debe proporcionarle y pagarle la atención
médica para el tratamiento de cualquier lesión sufrida en el trabajo. Su empleador o su
Aseguradora de Indemnización del Trabajador optó por brindar dicha atención médica a través de una
red de médicos denominada Red de Proveedores Médicos (MPN, por sus siglas en inglés). Esta MPN es
administrada por First Health y Gallagher Bassett Services, Inc. (GB). Su empleador /la aseguradora de
indemnización del trabajador de su empleador es Old Republic General Insurance Corporation. Este
aviso contiene la información que necesita sobre el programa MPN y describe su derecho a recibir.
•
¿Qué es una MPN?
Una Red de Proveedores Médicos (MPN) es un grupo de proveedores de cuidados de salud (médicos y
otros proveedores de salud) usados por para el tratamiento de las lesiones laborales. Cada red MPN
debe estar integrada por un grupo de médicos especializados en lesiones laborales y médicos con
experiencia en las áreas generales de la medicina.
Su empleador o Gallagher Bassett seleccionarán su proveedor médico inicial y las disposiciones de la
MPN permiten que en adelante los empleados seleccionen el o los proveedores.
•
¿Cómo averiguo qué médicos pertenecen a mi red MPN?
El contacto MPN para PRE-LESIÓN/ENFERMEDAD de su MPN es:
Nombre: Christy Foote
Domicilio: 225 S. Lake Ave, Suite 900, Pasadena, CA 91101
Número de teléfono: (626) 683-5221
Dirección de correo electrónico: cfoote@orcpg.com
La persona de contacto de la red MPN que figura en esta lista podrá responder sus preguntas sobre la
MPN y lo ayudará a obtener una lista regional de todos los médicos de la red MPN de su zona. Como
mínimo, la lista regional debe incluir a todos los proveedores de la red que se encuentren dentro de un
radio de 15 millas de su lugar de trabajo y/o residencia o una lista de todos los proveedores de la red
MPN del condado en el que vive y/o trabaja. Usted puede elegir qué lista desea recibir.
Puede obtener una lista de los proveedores de la red MPN llamando por teléfono a la persona de contacto
de la MPN o visitando el sitio Web: www.talispoint.com/cvty/gbmpn. Usted también puede localizar a
un doctor de la MPN llamando a servicios de cuidados administrados de Gallagher Bassett al
1-800-370-0594. Cuando la voz le indique las distintas opciones, seleccione la opción 6 y luego la
opción 2.
Para buscar la farmacia más conveniente para usted, por favor llame a First Script al 1-866-445-7344. O
visite nuestra página web: www.firstscript.com. En la página Web verá BUSCAR FARMACIA
(LOCATE A PHARMACY). Sólo debe ingresar su código postal y se desplegará una lista de farmacias.
Su empleador ha establecido a Gallagher Bassett Services, Inc. (GB) como el Contacto
MPN para POS-LESIÓN /ENFERMEDAD de todos los empleados:
For Southern California Claims
P.O. Box 9875, Calabasas, CA 91372
Telephone Number: 866-444-8379
July 1, 2014
Si usted lo desea puede solicitar una lista completa de todos los proveedores de la MPN.
•
¿Qué sucede si me lesiono en el trabajo?
En caso de una emergencia, debe llamar al 911 o dirigirse a la sala de emergencias más próxima.
Si usted se lesiona en el trabajo, notifique a su empleador lo antes posible. Su empleador le entregará un
formulario de reclamo. Cuando usted notifica a su empleador que ha sufrido una lesión relacionada con el
trabajo, su empleador o Gallagher Bassett realizan una primera cita con un médico de la MPN.
•
¿Cómo elijo un proveedor?
Después de la primera visita médica, puede continuar el tratamiento con el mismo médico o puede elegir
a otro profesional de la red MPN. Usted podrá cambiar de médico dentro de la red MPN cada vez que lo
desee durante el tratamiento de la lesión. Si corresponde, puede consultar a un especialista o pedirle a su
médico tratante una derivación para ver a un especialista. Si necesita ayuda para elegir un médico,
puede comunicarse con el Contacto MPN que figura arriba.
•
¿Puedo cambiar de proveedores?
Sí. Puede cambiar de proveedores dentro de la red MPN siempre que lo desee, pero los proveedores que
elija deben ser idóneos para tratar su lesión.
•
¿Qué estándares tiene que cumplir la MPN?
La MPN cuenta con proveedores en todos los condados de California con la excepción de los condados de
Alpine, Trinity, Mono y Mariposa.
La MPN debe proporcionarle una lista regional de proveedores que incluya por lo menos tres médicos de
cada una de las especialidades más comunes en el tratamiento de lesiones/enfermedades laborales
frecuentes en su industria. La MPN debe posibilitarle el acceso a médicos primarios dentro de un radio
de 15 millas y especialistas dentro de las 30 millas. Si usted vive en una zona rural, es posible que se
apliquen otros estándares.
La MPN debe brindar el tratamiento inicial dentro de los 3 días. Debe recibir tratamiento de un
especialista dentro de los 20 días siguientes a la solicitud. Si tiene problemas para conseguir una cita,
póngase en contacto con su ajustador de reclamos de Gallagher Bassett o con la persona de contacto
de la MPN identificada en este Aviso.
•
¿Qué sucede si no hay proveedores de la red MPN en mi lugar de residencia?
Si usted es un empleado actual que vive en una zona rural o trabaja o vive temporalmente fuera de un área
de servicios de la red MPN o si es un ex-empleado que reside permanentemente fuera del área de
servicios de la red MPN, la red MPN o su médico tratante le proporcionarán una lista de al menos tres
médicos que puedan realizarle el tratamiento. La red MPN también puede autorizarlo a elegir su propio
médico fuera de la red MPN. Comuníquese con la persona de contacto de la MPN identificada en este
aviso para solicitar ayuda para encontrar un médico o para obtener información adicional.
•
¿Qué sucede si mi lesión requiere una especialidad que no figura en la red MPN?
Si necesita un especialita que no está disponible a través de la red MPN, usted tiene derecho a consultar a
un especialista fuera la red.
•
¿Qué sucede si no estoy de acuerdo con mi médico en cuanto al tratamiento?
Si no está de acuerdo con su médico o desea cambiar de médico por alguna razón, puede elegir otro
profesional dentro de la red MPN.
July 1, 2014
Si no está de acuerdo con el diagnóstico o tratamiento prescripto por cierto médico, puede solicitar
una segunda opinión de otro médico de la red MPN. Si desea una segunda opinión, debe ponerse en
contacto con la MPN y comunicar que quiere recibir una segunda opinión. La red MPN deberá entregarle
una lista de proveedores MPN regionales de la que usted podrá elegir un médico para obtener una
segunda opinión. Para recibir una segunda opinión, debe elegir un médico de la lista de la MPN y
concertar una cita dentro de los 60 días. Debe informarle a su contacto de la MPN la fecha de su cita y
la red MPN le enviará al médico una copia de su historia clínica. Si usted lo desea, puede solicitar una
copia de la historia clínica que se le enviará al médico.
Si no programa una cita dentro de los 60 días de recibir la lista de proveedores regionales, ya no podrá
pedir una segunda o tercera opinión con respecto a este diagnóstico o tratamiento en discusión de su
médico tratante.
Si el médico al que le pidió la segunda opinión considera que su lesión no está comprendida en el tipo de
lesiones que normalmente atiende, el médico informará oportunamente a su empleador o aseguradora.
Usted recibirá otra lista de médicos o especialistas de la red MPN para que pueda volver a elegir.
Si no está de acuerdo con la segunda opinión, puede pedir una tercera opinión. Si solicita una tercera
opinión, deberá realizar el mismo trámite que realizó para obtener la segunda opinión.
Recuerde que si no programa una cita dentro de los 60 días de recibir otra lista de proveedores de la
MPN, ya no podrá pedir una tercera opinión con respecto al diagnóstico o tratamiento en discusión de su
médico tratante.
Si no está de acuerdo con la tercera opinión, puede solicitar una Revisión Médica Independiente (IMR).
Su empleador o persona de contacto de la MPN le facilitará la información necesaria para solicitar una
Revisión Médica Independiente y un formulario cuando solicite una tercera opinión.
Si el médico que emite la segunda o la tercera opinión considera que usted necesita tratamiento médico o
examinación, se lo autorizará a recibir atención médica por parte de un proveedor de la red MPN,
incluyendo al médico que dio la segunda o la tercera opinión.
Si el Revisor Médico Independiente está de acuerdo con que usted necesita tratamiento o examinación,
usted podrá recibir el tratamiento recomendado por éste por parte de un médico dentro o fuera de la red
MPN.
•
¿Qué sucede si ya estoy recibiendo tratamiento por una lesión laboral antes de que se
habilite la cobertura de la red MPN?
Su empleador o aseguradora cuenta con una Política de transferencia de cuidados administrada por
Gallagher Bassett, que determinará si usted puede continuar temporalmente el tratamiento de una lesión
de trabajo con un médico que no pertenece a la red MPN antes de transferir la atención a la red MPN.
Si usted ha predesignado correctamente a un médico tratante primario, no podrá ser transferido a la red
MPN. (Si tiene preguntas sobre la predesignación, consulte a su supervisor). Si su médico actual no
pertenece a la red MPN o no ingresa a la red, es posible que usted deba consultar a un médico de la red
MPN.
Si su empleador decide transferirlo a la red MPN, usted y su médico tratante primario deben recibir un
aviso de la transferencia.
Si usted reúne determinados requisitos, podrá continuar el tratamiento con un médico que no
pertenece a la red MPN durante un máximo de un año antes de ser transferido a la red MPN. En el
recuadro que aparece a continuación encontrará cuáles son las condiciones requeridas para posponer la
transferencia de su atención de salud a la red MPN.
July 1, 2014
¿Puedo seguir tratándome con mi médico?
Es posible que usted pueda seguir tratándose con un proveedor que no pertenezca a la red
MPN (por la política de transferencia de cuidados o continuidad de cuidados) durante un
máximo de un año si su lesión o enfermedad se encuadra dentro de alguna de las condiciones
siguientes:
•
(Agudo): el tratamiento de su lesión o enfermedad se completará en menos de 90 días;
•
(Cuadro grave o crónico): su lesión o enfermedad es grave y se prolonga durante 90
días por lo menos, sin que se cure por completo o se agrava y requiere tratamiento
continuo. Es posible que usted obtenga autorización para seguir el tratamiento con su
médico tratante actual hasta que se pueda hacer una transferencia segura del cuidado.
•
(Enfermedad terminal): usted tiene una enfermedad incurable o un cuadro
irreversible con probabilidad de causarle la muerte dentro de un año o menos.
•
(Pendiente de cirugía): su empleador o aseguradora ya ha autorizado la realización de
una cirugía u otra práctica que tendrá lugar dentro de los 180 días de la fecha efectiva
de la red MPN o de la fecha de terminación del contrato entre la MPN y su médico.
Usted puede no estar de acuerdo con la decisión de su empleador de transferir su tratamiento a la red
MPN. Si usted no quiere ser transferido a la red MPN, solicite a su médico tratante primario un informe
médico que indique que usted está comprendido en alguno de los cuatro cuadros especificados arriba para
poder calificar para un aplazamiento de su transferencia a la red MPN.
Su médico tratante primario tiene 20 días a partir de la fecha de su solicitud para entregarle una copia del
informe de su estado de salud. Si su médico tratante primario no le entrega el informe dentro de los 20
días de su pedido, el empleador podrá transferir sus cuidados de salud a la red MPN y usted deberá
utilizar los servicios de un médico de la red.
Usted deberá entregar una copia del informe a Gallagher Bassett si desea aplazar la transferencia de sus
cuidados de salud. Si usted o su empleador no están de acuerdo con el informe del médico sobre su
estado de salud, usted o su empleador pueden objetarlo. Para obtener más información sobre el
procedimiento de resolución de disputas, consulte la política completa sobre transferencia de cuidados.
Puede obtener una copia completa de la política de transferencia de cuidados a través de su persona de
contacto de la red MPN.
•
¿Qué sucede si estoy en tratamiento con un médico de la red MPN que desea dejar de
pertenecer a la red?
Su empleador o la aseguradora tienen una política escrita de "Continuidad del cuidado" que determinará
si usted puede continuar temporalmente el tratamiento de su lesión laboral con su médico si éste
deja de pertenecer a la red MPN.
Si su empleador decide que usted no reúne los requisitos para continuar con su tratamiento médico con el
proveedor que no pertenece a la red MPN, usted y su médico tratante primario deben recibir una carta de
comunicación.
Si usted reúne ciertas condiciones de salud, puede calificar para continuar el tratamiento con este médico
durante un máximo de un año antes de que deba empezar a atenderse con médicos de la red MPN. Estas
condiciones de salud se detallan en el cuadro anterior: “¿Puedo seguir tratándome con mi médico?”
July 1, 2014
Usted puede no estar de acuerdo con la decisión de su empleador de denegar su solicitud de continuidad de
cuidados con un proveedor que deja de pertenecer a la red MPN. Si usted quiere continuar tratándose con un
médico que termina su relación laboral, pídale a su médico tratante primario un informe médico en el que se
señale que usted está comprendido en alguno de los cuatro cuadros especificados anteriormente para ver si
usted reúne los requisitos para seguir tratándose temporalmente con su médico actual.
Su médico tratante primario tiene 20 días a partir de la fecha de su solicitud para entregarle una copia del
informe médico de su estado de salud. Si su médico tratante primario no le entrega el informe dentro de
los 20 días de su pedido, el empleador podrá transferir sus cuidados de salud a la red MPN y usted deberá
utilizar los servicios de un médico de la red.
Usted deberá entregar una copia del informe a Gallagher Bassett si desea aplazar la transferencia de sus
cuidados de salud a la MPN. Si usted o su empleador no están de acuerdo con el informe del médico
sobre su estado de salud, usted o su empleador pueden objetarlo. Para obtener más información
sobre el procedimiento de resolución de disputas, consulte la política completa sobre continuidad de
cuidados.
Puede obtener una copia completa de la política de continuidad de cuidados a través de su persona de
contacto de la red MPN.
•
¿Qué sucede si tengo preguntas o necesito ayuda?
•
Contacto MPN: usted puede comunicarse con la persona de contacto de la red MPN
siempre que necesite ayuda o una explicación sobre su tratamiento médico por lesión o
enfermedad laboral.
Nombre: Christy Foote
Domicilio: 225 S. Lake Ave, Suite 900, Pasadena, CA 91101
Número de teléfono: (626) 683-5221
Dirección de correo electrónico: cfoote@orcpg.com
Sitio Web de la MPN del empleador: www.talispoint.com/cvty/gbmpn. Usted también puede localizar a
un doctor de la MPN llamando a servicios de cuidados administrados de Gallagher Bassett al
1-800-370-0594. Cuando la voz le indique las distintas opciones, seleccione la opción 6 y luego la opción 2.
•
División de Indemnización del Trabajador (DWC): si tiene alguna duda, queja o pregunta
relacionada con la red MPN, el proceso de notificación o su tratamiento médico por lesión o
enfermedad laboral, puede llamar al Centro de Información y Ayuda de la división DWC al
1-800-736-7401. También puede visitar el sitio de la DWC www.dir.ca.gov/dwc y hacer clic en
“redes de proveedores médicos” para recibir más información sobre las redes MPN.
•
Revisión Médica Independiente: si tiene preguntas sobre el proceso de Revisión Médica
Independiente, escriba a la Unidad Médica de la División de Indemnización del Trabajador:
P.O. Box 71010
Oakland, CA 94612
510-286-3700 ó 800-794-6900
Conserve esta información para utilizarla en caso de lesión o enfermedad laboral.
MPN Employee Acknowledgement Form
California Medical Provider Network (MPN)
Acknowledgement Form
I have received the information that tells me how to obtain medical care within the GBMCS MPN under
DWC Approval # 36-6067575-1584.
I understand that if medical care is needed for a work-related injury I must be treated by an approved
doctor to qualify for benefits. Approved doctors are either a physician in the Medical Provider Network
or my predesignated personal physician.
In case of an emergency, I understand that I should call 911 or go to the closest emergency room.
(Signature)
(Date)
(Printed Name)
I live at
(Street Address)
(City)
(State)
(Zip Code)
Name of Employer
************************************************************
Red de Proveedores Médicos (MPN) de California
Formulario de acuse de recibo
He recibido la información que me dice cómo obtener el cuidado médico dentro del GBMCS MPN bajo
Aprobación DWC * 36-6067575-1584.
Entiendo que si necesito atención médica por una lesión relacionada con el trabajo, la misma debe ser
tratada por un médico aprobado para tener cobertura de los beneficios. Un médico aprobado puede ser un
médico de la Red de Proveedores Médicos o mi médico personal predesignado.
En caso de emergencia, entiendo que debo llamar al 911 o dirigirme a la sala de emergencias más próxima.
(Firma)
(Fecha)
(Nombre en letras de imprenta)
Vivo en
(Dirección, calle)
(Ciudad)
(Estado)
(Código postal)
Nombre del empleador
{Insert Date} To:
From:
Re:
GBMCS MPN
“Unless you predesignate a physician or medical group, your new work injuries arising on or after
12/31/2011 will be treated by providers in a new Medical Provider Network, GBMCS MPN. If you have an existing
injury, you may be required to change to a provider in the new MPN. Check with your claims adjuster. You may obtain
more information about the MPN from the workers' compensation poster or from your employer.”
You can get the list of MPN providers by calling the MPN contact or by going to our website at
www.talispoint.com/cvty/gbmpn . You may also locate a MPN doctor by calling Gallagher Bassett Managed Care
Services at 1-800-370-0594. At the voice prompts, please select Option 6, then Option 2.
To locate a pharmacy that is most convenient for you, please contact First Script at 1-866-445-7344. Or you may
locate a pharmacy by going to our website at www.firstscript.com. On our website you will see LOCATE A
PHARMACY. Just enter your zip code and a pharmacy listing will display.
********************************************************
Para:
De:
Ref.:
GBMCS MPN
"Salvo que usted pre-designe un médico o grupo médico, toda lesión laboral nueva que se produzca a partir del
12/31/11 deberá tratarse con proveedores de la nueva Red de Proveedores Médicos, GBMCS MPN. Si usted tiene
una lesión preexistente, quizá tenga que cambiar de proveedor y empezar a atenderse con uno de la nueva red MPN.
Consulte con su liquidador de reclamos. Puede obtener más información sobre la MPN en el aviso del seguro de
riesgos de trabajo o a través de su empleador".
Usted persigue consiguen la lista de abastecedores MPN llamando el contacto de MPN o por ir a nuestro sitio Web en
www.talispoint.com/cvty/gbmpn . También puede localizar a un médico de la red MPN llamando a Servicios de
Atención Administrada Gallagher Bassett Managed Care Services al 1-800-3700594. Cuando escuche las opciones del menú, elija la Opción 6, luego elija la Opción 2.
Para buscar una farmacia que le quede cómoda, comuníquese con First Script al 1-866-445-7344. También
puede buscar una farmacia que le convenga visitando nuestro sitio web en www.firstscript.com. En nuestro sitio
web encontrará la opción LOCATE A PHARMACY (BUSCAR FARMACIA). Lo único que tiene que hacer es
ingresar su código postal y en la pantalla aparecerá una lista de farmacias.
Old Republic Construction Insurance Agency, Inc., CLS #0799319
Old Republic Construction Insurance Agency of New York, Inc., #668042
MPN IMPLEMENTATION VERIFICATION FORM
Once the required MPN notices have been distributed, please complete and return this form to ORCPG. Please note, this form is for ORCPG’ tracking
purposes only and does NOT replace your own record of MPN notice distribution. The items marked with an asterisk (*) are required.
* Employer Name (print or type):
* Address:
* Employer Email Address:
* Workers’ Compensation Policy Number:
Employer Requirements:
In compliance with Title 8, California Code of Regulations §§9767.12 and 9767.16, Employer, named above, verifies that it has posted the MPN
Notification in a conspicuous location at the worksite(s) for convenient viewing by employees, and distributed the MPN Implementation Notice and/or the
Notice of Change of MPN, as required, in English, and also in Spanish to Spanish-speaking employees, on the Distribution Date shown below, to each of
its current employees located in California. Employer also confirms that it will distribute the MPN Implementation Notice and Your Workers’
Compensation Benefits notice to each new employee hired after the Distribution Date shown below.
* Distribution Date: MM/DD/YYYY *
(Example: 7/21/2008)
(The MPN is deemed implemented after the required notices have been posted and distributed to employees)
* Name of Employer Representative:
* Title:
By signing below, the authorized Employer Representative acknowledges that the Employer
Requirements for MPN implementation has been completed.
* Signature of authorized Employer Representative:
* Signature Date:
* Phone Number
Send this completed
MPN Implementation Verification Form to ORCPG:
By e-mail to:
CFoote@orcpg.com,
By mail to:
Old Republic Construction Program Group – Christy Foote
225 S. Lake Ave, Suite 900, Pasadena, CA 91101
By fax:
(626) 683-5197
Exhibit 5 – Designated Medical Clinic
Clinic
US Healthworks Medical Group
1400 S. Grand Ave., Suite 611
Los Angeles, CA 90015 (213) 745-6106
Hours: M-F 8am – 5pm
Directions from Project Site
1.
2.
3.
4.
5.
W Jefferson Blvd
Turn left onto S Figueroa St - 1.5 mi
Turn right onto W Pico Blvd - 0.2 mi
Take the 3rd right onto S Grand Ave - 0.2 mi
Arrive at 1400 S. Grand Ave. on your left
USC Insurance Manual Fertitta Hall 11‐14‐14 58
Clinic Option #2
US Healthworks Medical Group
3430 Garfield Avenue
Commerce, CA 90040 (323) 722-8481
Hours: 24 Hours, 7 Day each week for First Visit
Follow up Hours M-F 7am to 6pm
Exhibit 6 – Treatment Authorization Form
OLD REPUBLIC CONSTRUCTION PROGRAM GROUP/GALLAGHER BASSETT
USC Owner Controlled Insurance Program (client #006138)
VDN No: 2224049
Treatment Authorization
Complete & Provide to injured employee before sending to clinic.
Employee Name: _______________________________________________________________________________________________
Contractors/Employer Name: _____________________________________ Trade: _______________________________
Project Contact Name/Phone: __________________________________________________________________________
Service Requested
Date of Injury: ________________________ Time of Injury: ______________________ Last Work Date: _______________________
Injured Body Part: __________________________________________________________________________________
Injury Treatment: Yes
Alternative Work Available: Yes
Post Accident Drug Testing: Yes
This certifies that the above named individual is employed on an Owner Controlled Insurance Program Project. Workers’
Compensation coverage is provided by Old Republic. Please provide appropriate evaluation and treatment, and bill to address
below. Return To Work Program in place; employers to provide light/restricted duty work, if authorized by treating
physician.
You are authorized to release results of the Post Accident Drug Testing to (a) the employer; (b) the OCIP
WC Insurance Company and their representative(s); (c) the Owner’s Representatives and (c) the OCIP
Administrator.
Project Contact Name/ Title: ______________________________________________________________________________________
Authorized by: ________________________________________________________
Date: _________________________________
THIS SECTION MUST BE COMPLETED BY THE ATTENDING PHYSICIAN
Diagnosis: ______________________________________________________________________________________________
_______________________________________________________________________________________________________
1. Is the Employee able to return to work?
Full Duty: ________
Restricted Duty: _________
Total Disability: ___________
If restricted duty was selected, briefly describe restrictions: ______________________________________________
2. Will employee require any follow up treatment?
Yes
No
If Yes was selected, when is the next scheduled visit?
Date: __________________
Time:__________________
3. I am aware of the restrictions placed on me by the treating Physician:
Employees Name (Please Print): ___________________________________________________________________
Employees’ Signature: ___________________________________________________________________________
Physicians’ Name (Please Print): ___________________________________________________________________
Treatment Bills should be sent to:
Questions should be referred to:
P.O. Box 23812
Tucson, AZ 85734
Gallagher Bassett Services / Calabasas
Toll Free #: (866) 444-8379
Drug Screening Bills should be sent to the injured worker’s employer.

Jill and Frank Fertitta Hall Insurance Manual

Transcription

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