SECTION 5

STATE REQUIRED CONTRACT PROVISIONS

ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?

INSRLTR

DATE (MM/DD/YYYY)

INSURED

POLICY EFFECTIVEDATE (MM/DD/YY)

POLICY EXPIRATIONDATE (MM/DD/YY)POLICY NUMBER LIMITSTYPE OF INSURANCE

GENERAL LIABILITY

AUTOMOBILE LIABILITY

GARAGE LIABILITY

EXCESS/UMBRELLA LIABILITY

WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY

OTHER

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION

DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN

NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL

IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR

REPRESENTATIVES.

AUTHORIZED REPRESENTATIVE

INSURER A:

INSURER B:

INSURER C:

INSURER D:

INSURER E:

EACH OCCURRENCE $DAMAGE TO RENTEDPREMISES (Ea occurence)COMMERCIAL GENERAL LIABILITY $

CLAIMS MADE OCCUR MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $PRO-JECTPOLICY LOC

COMBINED SINGLE LIMIT(Ea accident)

$ANY AUTO

ALL OWNED AUTOS BODILY INJURY(Per person)

$SCHEDULED AUTOS

HIRED AUTOS BODILY INJURY(Per accident)

$NON-OWNED AUTOS

PROPERTY DAMAGE(Per accident)

$

AUTO ONLY - EA ACCIDENT $

ANY AUTO EA ACC $OTHER THANAUTO ONLY: AGG $

EACH OCCURRENCE $

OCCUR CLAIMS MADE AGGREGATE $

$

DEDUCTIBLE $

RETENTION $ $WC STATU-

TORY LIMITSOTH-ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $If yes, describe underSPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $

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 MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATIONONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.

INSURERS AFFORDING COVERAGE NAIC #

COVERAGES

CERTIFICATE HOLDER CANCELLATION

ACORD 25 (2001/08) © ACORD CORPORATION 1988

CERTIFICATE OF LIABILITY INSURANCE

ADD'LINSRD

PRODUCER

$

City of Los AngelesOffice of the City Administrative Officer, Risk Management200 North Main Street, Room 1240Los Angeles, CA 90012

Re

v 02/2012

Sheet o

f

CD

OT

Pro

ject Nu

mb

er (s): D

BE

Sub

con

tractor:

FE

IN N

um

ber: _______________________________

To

wn

(s) of:

Ad

dress:

Sub

mitted

By:

Is this D

BE

firm a 1

st or 2

nd

tier sub

con

tractor?

1st

2n

d*

Origin

al Bid

($):

Do

llar amo

un

t sub

con

tracted to

this D

BE

firm ($

):

Do

llar amo

un

t requ

ested fo

r CR

ED

IT fo

r this D

BE

Firm

($):

**

Is Th

is item

P

artial Y

es No

Firm

Ty

pe C

od

e

***

Qu

antity

and

U

nit o

f item

as bid

Co

ntract

Un

it Price

Qu

antity an

d

Un

it for item

Su

bco

ntracted

Sub

con

tract U

nit P

riceT

otal Item

price

sub

con

tracted

To

tal item p

rices cred

ited to

the

sub

con

tractor ****

If any

of th

e items ab

ov

e are check

ed Yes as to

Partia

l, please u

se the sp

ace pro

vid

ed o

r use an

attachm

ent to

offer

an exp

lanatio

n o

f the w

ork

invo

lved. A

lso p

lease iden

tify w

ho

is respo

nsib

le for th

e remain

der o

f the p

artial items.

*** Firm

Ty

pe C

od

e: S (su

bco

ntracto

r), M (m

anu

facturer), P

(sup

plier), T

(truck

ing), V

(services)

**** Th

e credited

amo

un

t inclu

des ad

justm

ents fo

r sup

ply item

s (60

%) o

r items fu

rther su

bco

ntracted

to N

ON

-DB

E firm

s.

On

ly certified

DB

E firm

s and

on

ly for w

ork

wh

ich th

ey have b

een certified

for w

ill be ap

pro

ved b

y CD

OT

tow

ard th

e goal. D

epartm

ent's D

BE

directo

ry is availab

le on

CT

DO

T's w

ebsite o

r by callin

g 86

0-5

94

-21

71

Signatu

re of P

rime C

on

tractor, T

itleSign

ature o

f Sub

con

tractor, T

itleD

ate

After th

is sub

mittal is ap

pro

ved b

y the D

epartm

ent, an

y pro

po

sed ch

anges to

it mu

st be su

bm

itted to

the D

eaprtm

ent fo

r app

roval.

Date

Item N

um

ber &

Descrip

tion

CO

NN

ECTIC

UT D

EPA

RTM

ENT O

F TRA

NSP

OR

TATIO

N (C

TDO

T)

PR

E-AW

AR

D D

BE C

OM

MITM

ENT A

PP

RO

VA

L REQ

UEST

TO B

E SUB

MITTED

WITH

IN TH

E TIME FR

AM

E IND

ICA

TED IN

THE B

ID D

OC

UM

ENTS

* Th

e CD

OT

prefers 1

st tier sub

con

tractors; h

ow

ever, credit fo

r 2n

d tier D

BE

firms w

ill be ap

pro

ved

pro

vid

ed th

is page is sign

ed b

y b

oth

the p

rime an

d th

e DB

E firm

, the 1

st tier sub

con

tractor is id

entified

, the exten

t of th

e 2n

d tier w

ork

is clearly iden

tified, an

d th

e prim

e m

akes th

e assertion

that regard

less of its arran

gemen

t with

the 1

st tier sub

con

tractor, th

is DB

E firm

will b

e used

and

its replacem

ent is

sub

ject to th

e con

ditio

ns o

f the D

BE

specificatio

n an

d co

ntract req

uirem

ents.

** P

lease be ad

vised th

at by

sub

mittin

g this fo

rm yo

u (th

e prim

e) agree that th

e

Cred

ited am

ou

nt w

ill be th

e amo

un

t of co

mm

itmen

t to th

e pro

ject by

you

An

y DB

E T

ruck

ing firm

(T) n

om

inated

on

this fo

rm m

ust self p

reform

no

t less than

30

% o

f their co

ntract valu

e.