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SEPTA OCIP DRAFT Manual 1/22/15 {Project Name}, {Project City, State}

Owner Controlled Insurance Program (OCIP) {Project Name}

{Project Address}

OCIP Insurance Manual

This Manual is a Contract Document

T A B L E O F C O N T E N T S

of 45 SEPTA OCIP DRAFT Manual 1/22/2015 {Project Name}, {Project City, State}

Table of Content

TABLE OF CONTENTS ............................................................................................................................................. 2

OVERVIEW .................................................................................................................................................................. 3

ABOUT THIS MANUAL ................................................................................................................................................. 3 What This Manual Does ...................................................................................................................................... 4 What this Manual Does NOT Do ....................................................................................................................... 4

OCIP PROJECT DIRECTORY .................................................................................................................................. 5

OCIP ADMINISTRATION.............................................................................................................................................. 5 PROJECT DEFINITIONS ........................................................................................................................................... 6

OCIP INSURANCE COVERAGE .............................................................................................................................. 8

EXCLUDED PARTIES ................................................................................................................................................... 8 EVIDENCE OF COVERAGE .......................................................................................................................................... 8 DESCRIPTION OF OCIP COVERAGES ........................................................................................................................ 8

PRIME CONTRACTOR AND SUBCONTRACTOR REQUIRED COVERAGE ................................................. 10

VERIFICATION OF REQUIRED COVERAGES .............................................................................................................. 10 PRIME CONTRACTOR AND SUBCONTRACTOR MAINTAINED COVERAGES ............................................................... 11 PROPERTY INSURANCE .............................................................................................................................................. 11

PRIME CONTRACTOR AND SUBCONTRACTOR RESPONSIBILITIES ........................................................ 12

PRIME CONTRACTOR AND SUBCONTRACTOR BIDS ................................................................................................. 13 IDENTIFYING PRIME CONTRACTOR, SUBCONTRACTOR AND SUB-SUBCONTRACTOR INSURANCE COSTS ............ 13 ENROLLMENT............................................................................................................................................................ 13 ASSIGNMENT OF PREMIUMS .................................................................................................................................... 14 PAYROLL REPORTS .................................................................................................................................................. 14 SAFETY STANDARDS AND PRIME CONTRACTOR AND SUBCONTRACTOR PREQUALIFICATION ............................... 15 CHANGE ORDER PROCEDURES ............................................................................................................................... 15 INSURANCE COMPANY PAYROLL AUDIT .................................................................................................................. 15 CLOSEOUT AND AUDIT PROCEDURES ..................................................................................................................... 15 OCIP TERMINATION OR MODIFICATION ................................................................................................................... 16

CLAIM PROCEDURES ............................................................................................................................................ 17

GENERAL PROCEDURES .......................................................................................................................................... 17 INVESTIGATION ASSISTANCE ................................................................................................................................... 18 RETURN TO WORK PROGRAM ................................................................................................................................. 18 SAMPLE OFFER OF TEMPORARY ALTERNATIVE POSITION LETTER ................................................................. 20 WORKERS’ COMPENSATION CLAIMS ....................................................................................................................... 18 LIABILITY CLAIMS ...................................................................................................................................................... 22 PROPERTY CLAIMS ................................................................................................................................................... 23 AUTOMOBILE CLAIMS ............................................................................................................................................... 23 POLLUTION CLAIMS .................................................................................................................................................. 23

FORMS ....................................................................................................................................................................... 24

ENROLLMENT APPLICATION - FORM 3 ........................................................................................................ 25 ON-SITE PAYROLL REPORT - FORM 4 ....................................................................................................... 28 NOTICE OF WORK COMPLETION - FORM 5.................................................................................................. 30 EXHIBIT A - EXPERIENCE MODIFICATION RATING EXCEPTION REQUEST ........................................................ 32 EXHIBIT B - EXPERIENCE MODIFICATION RATING EXCEPTION QUESTIONNAIRE .............................................. 33 EXHIBIT C - DRUG AND ALCOHOL TESTING PROGRAM - POLICY AND PROCEDURE .......................................... 36 OLD REPUBLIC CLAIM KIT.......................................................................................................................... 46

Section 1

Section 2

Section 3

Section 4

Section 5 Section 6 Section 7

Section 8

O V E R V I E W


Overview

Welcome to SEPTA’s Owner Controlled Insurance Program (OCIP)

Southeastern Pennsylvania Transportation Authority has arranged for the {Project Name} project to be insured under its Owner Controlled Insurance Program (OCIP). An OCIP is an insurance program for Southeastern Pennsylvania Transportation Authority, The Prime Contractor and all Enrolled Subcontractors that provides certain insurance for Work performed at the Project Site. There are many benefits of Southeastern Pennsylvania Transportation Authority’s OCIP. The OCIP provides more comprehensive coverage than many individual policies. All Enrolled Parties have uniform coverage and uniform limits. Additionally, Southeastern Pennsylvania Transportation Authority has found that an OCIP positively influences overall project safety. However, certain Subcontractors are excluded from this program. These parties are identified in Section 3 of this manual.

You should notify your insurer(s) to endorse your coverage for on-site activities and related costs to be excess and contingent over the OCIP coverage provided under this Program. Each bidder is to bid without the cost of their on-site workers’ compensation, employer’s liability, and general liability primary and excess insurance.

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. Enrollment into the OCIP will take place before you start work on site. Your insurance representative should review this information. Any additional coverage you may wish to purchase will be at your option and expense.

About This Manual Southeastern Pennsylvania Transportation Authority (SEPTA) and Aon Risk Services (Aon) prepared this Insurance Manual. SEPTA is the Sponsor for this OCIP. Aon is the OCIP Administrator for this OCIP. The manual is designed to identify, define and assign responsibilities for the administration of the OCIP for this project.

Section

1

O V E R V I E W


What This Manual Does

This Manual:

Generally describes the structure of the OCIP

Identifies responsibilities of the various parties involved in the Project

Provides a basic description of OCIP coverage

Describes audit and administrative procedures

Provides answers to basic questions about the OCIP

What this Manual Does NOT Do

This Manual does not:

Provide coverage interpretations

Provide complete information about coverages and exclusions

Provide answers to specific claims questions

Refer questions concerning the OCIP, its administration or coverages to the appropriate party identified in the Project Directory in Section 2.

DISCLAIMER:

The information in this manual is intended to outline the OCIP. If any conflict exists between this manual and the OCIP insurance policies, the OCIP insurance policies will govern. If any conflict exists between this manual and the Contract, the Contract controls.

O C I P P R O J E C T D I R E C T O R Y


OCIP Project Directory OCIP Administration

Aon Risk Services, Inc. 625 Liberty Avenue Pittsburgh, PA 15222

Aon Risk Services, Inc. 1120 20th St. NW Suite 600 Washington, DC 20036

Senior Specialists Handling All Matters for Subcontractors: Fred Mesa

(Toll Free Telephone) 866-226-1420 Option 3 (Fax) 800-363-6695 (E-mail) [email protected]

Please show as a regarding on all faxes and emails to Fred Mesa: SEPTA OCIP Customer #570000063725

Program Manager Justin Johnson

(Telephone) 412/594-7581 (Cell) 412/563-5364 (E-mail) [email protected]

Program Administrator Chris Thompson

(Telephone) 202.862.5302 (Fax) 847.953.4324 (E-mail) [email protected]

Claim Consultant Todd Macdermott

(Telephone) 617.457.7654 (Fax) 617.457.7777 (E-mail) [email protected]

SEPTA Project Manager TBD

(Cell) TBD (E-mail) TBD

Project Safety Manager Ron Benson

(Cell) 215.964.4515 (E-mail) [email protected]

Prime Contractor Safety Manager Safety Manager TBD

(Cell) TBD (E-mail) TBD

Section

2

P R O J E C T D E F I N I T I O N S


Project Definitions

The following list includes key OCIP definitions.

OCIP: A “OCIP" or Owner Controlled Insurance Program is a coordinated insurance program providing certain coverages, as defined herein, for SEPTA and eligible Enrolled Parties performing Work at the Project Site.

OCIP Administrator: Aon Risk Services, Inc.

OCIP Insurer: The insurance company (ies) named on a policy or certificate of insurance providing coverage for the OCIP.

OCIP Sponsor: SEPTA

Certificate of Insurance: A document providing evidence of existing coverage for a particular insurance policy or policies.

Eligible Parties/Eligible Subcontractor:

Parties performing labor or services at the Project Site who are eligible to enroll in the OCIP unless it is an Excluded Party.

Enrolled Parties/Enrolled Subcontractor:

Those eligible Subcontractors who have submitted all necessary enrollment information as detailed in Section 6 and have been accepted into the OCIP as evidenced by a Welcome Letter and Certificate of Insurance from the OCIP Administrator.

Section

3

P R O J E C T D E F I N I T I O N S


Excluded Parties/Excluded Subcontractors:

At the discretion of SEPTA, or subject to State regulations, the following parties will be excluded: (1) Hazardous materials remediation, removal and/or transport companies and their consultants; (2) Any Subcontractor performing Structural Demolition that utilizes explosives (3) Architects, engineers, and soil testing engineers, and their consultants; (4) Vendors, suppliers, fabricators, material dealers, truckers, haulers, drivers and others who merely transport, pickup, deliver, or carry materials, personnel, parts or equipment or any other items or persons to or from the Project Site; (5) Subcontractors, and any of their respective Sub-Subcontractors, who do not perform any actual labor on the Project Site; (6) Subcontractors/Vendors performing work under a professional services agreement (e.g. a land surveyor); (7) Subcontractors performing site security or any labor staffing firms; (8) Any parties excluded from participation in the OCIP by law; (9) Any subcontractor who has payroll less than $2,500. (10) SEPTA may include or exclude any parties or entities not specifically identified in this manual at its sole discretion, even if otherwise eligible.

Project Site: Generally defined as the “project location” (designated in this manual and more fully identified in the Contract) and adjacent or nearby areas where incidental operations are performed excluding permanent locations of any insured party.

Contract: A written or oral agreement between the Sponsor and the Prime Contractor as well as between the Prime Contractor and Subcontractor, including Sub-Subcontractors of any tier.

Subcontractor: Includes only those persons, firms, joint venture entities, corporations, or other parties that enter into a Contract with SEPTA, its Prime Contractor or its Subcontractors to perform Work at the Project Site.

Welcome Letter: A document issued by the OCIP Administrator, which confirms acceptance/enrollment of the applicant into the OCIP.

Work: Operations, as fully described in the Contract, performed at the Project Site.

O C I P I N S U R A N C E C O V E R A G E


OCIP Insurance Coverage

This chapter provides a brief description of the OCIP Coverage. The Prime Contractor and Subcontractors should refer to the actual OCIP insurance policies for details concerning coverage, exclusions and limitations.

Excluded Parties Excluded Parties are not granted any insurance coverage under the OCIP. Excluded Parties must meet the insurance requirements established in Section 5 and provide evidence of coverage to the Prime Contractor.

Evidence of Coverage Each Enrolled Party will be issued an individual workers’ compensation policy provided by the OCIP Insurer. The OCIP Administrator will provide a Certificate of Insurance as evidence of workers’ compensation, general liability, and excess liability insurance coverage provided to each Enrolled Party. Each Enrolled Party will be added as a named insured to the OCIP general liability insurance policy. The OCIP Insurer will furnish other documents to Enrolled Parties, including claim forms, and will post notices, etc. Copies of the general liability policy will be available upon written request.

Description of OCIP Coverages The following descriptions on these pages provide a summary of coverages ONLY. The Prime Contractor and Subcontractors should refer to the policies for actual terms, conditions, exclusions and limitations.

SEPTA will furnish the following coverages for the benefit of all Enrolled Parties performing Work at the Project Site.

Workers’ Compensation and Employer’s Liability

Insurance Carrier: Old Republic Insurance Company Coverage: Statutory limits required by the workers’ compensation laws of the applicable

jurisdiction, excluding monopolistic states, with Employer’s Liability. Part One - Workers’ Compensation: Statutory Limit Part Two - Employer’s Liability: Annual Limits Per Enrolled Party Bodily Injury by Accident, each accident $ 1,000,000 Bodily Injury by Disease, each employee $ 1,000,000 Bodily Injury by Disease, policy limit $ 1,000,000

Section

4

A separate worker’ compensation policy will be issued to each Enrolled Party.

O C I P I N S U R A N C E C O V E R A G E


This policy does not cover off-site operations.

Commercial General Liability

Insurance Carrier: Old Republic Insurance Company Coverage: Third Party Bodily Injury and Property Damage Liability. Limits of Liability Shared by All Enrolled Parties General Aggregate Per Project $ 4,000,000 Products/Completed Operations Aggregate Per Project $ 4,000,000 Personal and Advertising Injury Limit $ 2,000,000 Each Occurrence Limit $ 2,000,000 Fire Damage Legal Liability (any one fire) $ 300,000 Medical Expense Limit (any one person) $ 10,000 This insurance will NOT provide coverage for products liability to any vendor, supplier, off-

site fabricator, material dealer or other party for any product manufactured, assembled or otherwise worked upon away from the Project Site.

This policy does not cover off-site operations. Twelve (12) years or Statute of Repose, whichever is less, Products & Completed

Operations Extension beyond final acceptance of the entire Project with a single non-reinstated aggregate limit.

The policy contains exclusions. Please see the policy for a complete list of exclusions.

Excess Liability Insurance Carriers: Various Carriers

Limits of Liability Shared by All Enrolled Parties Each Occurrence Limit $ 200,000,000 Products/Completed Operations Aggregate Per Project $ 200,000,000 Annual General Aggregate Limit Per Project $ 200,000,000

Policy follows form (provisions, coverages, exclusions, etc.) of underlying Commercial General Liability and Employer’s Liability policy wording.

This policy does not cover off-site operations.

Property of Prime Contractors and Subcontractors Note: The Prime Contractor and Subcontractors are advised to arrange their own insurance

for rented, owned, leased or borrowed equipment and materials not intended for

inclusion in the Project. Neither the Builders Risk policy nor the OCIP will cover Prime

Contractor or Subcontractor property.

A single general liability policy will be issued for all Enrolled Parties with all Enrolled Parties Named as Insureds

Single excess liability policies will be issued for all Enrolled Parties.

S U B C O N T R A C T O R - R E Q U I R E D C O V E R A G E


Prime Contractor and Subcontractor Required Coverage

The Prime Contractor, Subcontractors and all Sub-Subcontractors are required to maintain coverage to protect against losses that occur away from the Project Site or that are otherwise not covered under the OCIP. All Prime Contractor Certificates of Insurance must be submitted to SEPTA prior to Mobilization.

The Prime Contractor, Subcontractors and Sub-Subcontractors are required to maintain insurance coverage for the duration of the Contract that protects SEPTA from liabilities. These liabilities may arise from the Prime Contractor or Subcontractor’s operations performed away from the Project Site, from operations not covered by the OCIP, or from operations performed by Excluded Parties. The OCIP places Subcontractors into one of two main categories: Enrolled Parties or Excluded Parties.

Enrolled Parties are to provide evidence of Workers’ Compensation, General Liability and Excess/umbrella liability insurance for off-site activities and Automobile Liability and any other insurance in accordance with the insurance specifications in the Contract. See Sections 3 for the definition of Enrolled Parties.

Excluded Parties must provide evidence of Workers’ Compensation, General Liability, Excess/umbrella liability, Automobile Liability, and any other insurance in accordance with the insurance specifications in the OCIP Insurance Exhibit for all activities including both on-site and off-site activities as per the insurance specifications in the Contract. See Sections 3 for the definition of Excluded Parties.

Verification of Required Coverages The Prime Contractor shall provide verification of insurance to SEPTA prior to mobilization and within three (3) days of any renewal, change or replacement of coverage. Refer to the OCIP Insurance Exhibit of your Contract for complete insurance requirements.

The Prime Contractors is responsible for monitoring their Subcontractors’ Certificates of Insurance. Subcontractors are responsible for monitoring their Sub-Subcontractor’s Certificates of Insurance. SEPTA reserves the right to disapprove the use of Prime Contractors or Subcontractors that are unable to meet the insurance requirements, or who do not meet other SEPTA policy requirements.

Section

5

See OCIP Insurance Exhibit to the Contract.

S U B C O N T R A C T O R - R E Q U I R E D C O V E R A G E


The limits of liability shown in the OCIP Insurance Exhibit for the insurance required of the Prime Contractor, Subcontractors and Sub-Subcontractors are minimum limits only and are not intended to restrict the liability imposed on the Prime Contractors or Subcontractors for work performed under their Contract.

Failure of any Enrolled Party or any Excluded Party from the SEPTA OCIP program to file the required Certificates of Insurance will not relieve such party of its responsibility to carry and maintain such insurance. SEPTA and its representatives have the right to stop work or prevent any non-enrolled Subcontractor or Subcontractor of any tier from entering the Project Site until the Subcontractor's Certificate of Insurance has been submitted and approved. Denial of site access for this reason will not result in an acceptable claim for "cause for delay."

Prime Contractor and Subcontractor Maintained Coverages The OCIP Insurance Exhibit to the Contract details insurance requirements for Enrolled and Excluded Party(s). The “Personal Property Insurance” section below applies to both Enrolled and Excluded Parties.

Personal Property Insurance Enrolled and Excluded Parties must provide their own insurance for owned, leased, rented and borrowed equipment, whether such equipment is located at a Project Site or “in transit”. Prime Contractors and Subcontractors are solely responsible for any loss or damage to their personal property including, without limitation, property or materials created or provided under their Contract until installed at the Project Site, Prime Contractor and Subcontractor tools and equipment, scaffolding and temporary structures.

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


Prime Contractor and Subcontractor Responsibilities

Throughout the course of the Project, The Prime Contractor and Subcontractors will be responsible for reporting and maintaining certain records as outlined in this section.

The Prime Contractor, Subcontractor and its Sub-Subcontractors are required to cooperate with SEPTA and its OCIP Administrator with all aspects of OCIP operation and administration. The responsibilities of the Prime Contractor, Subcontractors and Sub-Subcontractors include, but are not limited to the following:

Comply with all aspects of SEPTA's safety program.

Provide each Subcontractor and Sub-Subcontractor with a copy of this OCIP Insurance Manual by including it in all Contracts.

Complete all Forms in order to Enroll in the OCIP within 5 days of your award of the Contract on the project or no less than 45 days before mobilization and assure each Subcontractor and Sub-Subcontractor enrolls in the OCIP within these timeframes.

Provide timely evidence of required insurance to SEPTA.

Notify the OCIP Administrator and SEPTA’s Project Team of all Subcontractors and Sub-Subcontracts awarded (first tier and subsequent tiers). Subcontractors shall cause all Sub-Subcontractors to submit Forms 3.

Maintain and report monthly payroll records.

Comply with all OCIP claim procedures.

Notify the OCIP Administrator immediately of any insurance cancellation or non-renewal of your own and Sub-Subcontractor-required insurance.

Have a Pennsylvania Workers' Compensation Experience Modification Factor (EMR) not exceeding 1.25. If the Prime Contractor, Subcontractor or Sub-Subcontractor has an EMR higher than 1.25, they must complete the EMR Exception Request (Attached Exhibit A) and EMR Exception Questionnaire (Attached Exhibit B) in accordance with the OCIP Exhibit. These Exhibits may also be found at the end of this document. If the Prime Contractor, Subcontractor or Sub-Subcontractor has an EMR higher than 1.70, a special exception will need to be granted by the carrier for them to be enrolled into the OCIP. If the Prime Contractor's or Subcontractor's domicile state is not Pennsylvania, their applicable Experience Modification Factor will be used, (i.e., Interstate (NCCI) for Maryland, New Jersey's state-specific modification, etc.).

Section

6



It shall be mandatory for the Prime Contractor and all Subcontractors to participate in the Drug and Alcohol Testing Program ("Program") in order to perform work on this project and each shall be responsible for the payment of drug and alcohol testing services for their respective employees. The mandatory Program is to include (i) pre-employment testing prior to being permitted on the project site; (ii) "reasonable suspicion" based testing when an employee is suspected of being impaired on duty; and (iii) post-accident/incident testing which involves any employee who is injured during the course and scope of their employment onsite or involved in an accident/incident in the course of job duties which involves use of heavy equipment, power tools or other dangerous instruments, or under working conditions which result in an injury or substantial property damage or disruption to the project. Please see the Exhibit C to this manual for information on the Drug Testing requirements.

Prime Contractor and Subcontractor Bids SEPTA provides workers’ compensation, general liability and excess liability insurance for all Enrolled Parties under the OCIP for Work performed at the Project Site. The section below describes the procedures for bidding and how OCIP insurance amounts are paid. The OCIP Administrator can also help with this calculation.

Identifying Prime Contractor, Subcontractor and Sub-Subcontractor Insurance Costs Prime Contractors, Subcontractors and each Sub-Subcontractor shall bid the Project “net” of on-site insurance costs due to eligibility for the OCIP. Prime Contractor and Subcontractors shall exclude the Cost of OCIP Coverage from its bid, and ensure that each Sub-Subcontractor of every tier excludes the cost of OCIP coverage from their respective bids. The costs of OCIP coverage is defined as the amount of Prime Contractor’s, Subcontractor’s and its Sub-Subcontractors’ reduction in insurance costs due to eligibility for OCIP coverages. The costs of OCIP coverage includes reduction in insurance premiums, related taxes and assessments, markup on the insurance premiums and losses retained through the use of the self-funded program, self-insured retention, or deductible program. The cost of OCIP coverage must include expected losses within any retained risk. Prime Contractor and Subcontractor must deduct the cost of OCIP coverage for all Sub-Subcontractors in addition to their own cost of OCIP coverage. Change Orders must also be priced to exclude the cost of OCIP coverage.

Enrollment Each Prime Contractor, Subcontractor and Sub-Subcontractor shall provide details about its Sub-Subcontractors as necessary for OCIP enrollment. All of the information requested on the Enrollment Application form (Aon Form 3) in Section 8 is required for enrollment. This form must be completed and submitted to the OCIP Administrator prior to mobilization to obtain coverage under the OCIP.

The OCIP Administrator will issue to each Enrolled Party a Welcome Letter and an OCIP Certificate of Insurance acknowledging acceptance of the applicant into the OCIP. The OCIP Insurer will issue a separate workers’ compensation policy to each Enrolled Party.

See Section 8 for sample OCIP forms.

See Section 2 for information on contacting the OCIP Administrator.



Note: Enrollment is not automatic! Enrollment into the OCIP is required, but not automatic. Access to the Project Site will not be permitted until enrollment is complete. Eligible Prime Contractors, Subcontractors and Sub-Subcontractors MUST complete the enrollment forms and submit them to the OCIP Administrator who will confirm complete enrollment into the OCIP. If a Prime Contractor, Subcontractor or Sub-Subcontractor obtains access to the site, with or without SEPTA’s knowledge, OCIP coverage will not be provided if they are not enrolled. Unenrolled/excluded Subcontractors do not have any insurance coverage under the OCIP.

Assignment of Premiums SEPTA pays the cost of the OCIP insurance coverage. All Enrolled Parties will assign, to SEPTA, all adjustments, refunds, premium discounts, dividends, costs or any other monies due from the OCIP insurer(s). Prime Contractors and Subcontractors will assure that Sub-Subcontractors has executed such an assignment. The Enrollment Application form (Aon Form 3) supplied in Section 8 will be used for this purpose.

Payroll Reports Under SEPTA’s OCIP, the final payroll is determined by an audit by the OCIP insurer. This is required by the Pennsylvania Compensation Rating Bureau (PCRB) to calculate your Workers’ Compensation Experience Modification. By the 10th of each month every Enrolled Party must submit to the OCIP Administrator an On-Site Payroll Report (Aon Form 4) identifying total man-hours and total payroll for all work performed at the Project Site. This report shall classify the labor expended at each Project Site according to the Standard Workers’ Compensation Insurance Classification and included in the Subcontractor’s Enrollment Form (Aon Form 3). The Monthly Payroll Report should include the “straight-time” payroll and the “straight-time” portion of any “overtime” payroll for all OCIP qualified employees (which includes employees and any person working directly or indirectly or on behalf of an Enrolled Party), including on-site supervisors and on-site clerical personnel. A monthly payroll report must be submitted for each month, including “zero (0) payroll” for those months in which no on-site labor was expended, until completion of the Work under each Contract. For those Subcontractors performing Work under multiple Contracts, a separate On-Site Payroll Report (Aon Form 4) is required for each Contract.

Note: Failure to submit the payroll report, along with any other OCIP form, as required, may result in the withholding of payments until required documentation is received, reviewed and approved.

See Section 8 for the On-site Payroll Report form.



Safety Standards and Prime Contractor and Subcontractor Prequalification

Each Prime Contractor, Subcontractor and Sub-Subcontractor is required to have a written safety program and to provide a designated competent safety representative who is on-site in accordance with the safety specifications included in the OCIP Insurance Exhibit to the Contract.

Subcontractors must pre-qualify their Sub-Subcontractors for compliance with required safety standards. Sub-Subcontractors that are incapable of meeting the minimum safety standards do not possess the required minimum occupational safety and health qualifications required to work on SEPTA’s Projects. All Subcontractors shall meet and/or exceed all SEPTA and OSHA Safety Standards.

Change Order Procedures Prime Contractors, Subcontractors and all Sub-Subcontractors are to price Change Orders to exclude the Insurance Costs that are covered in the OCIP, unless otherwise directed by SEPTA.

Insurance Company Payroll Audit Each Enrolled Party is required to maintain 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. 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 and will have an impact on the future Experience Modifiers (EMR) of your firm. All Enrolled Parties shall make available their books, vouchers, contracts, documents, and records, of any and all kinds, to the auditors of the OCIP insurance carrier(s) or SEPTA’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 or longer as required by Law.

Closeout and Audit Procedures Submit the Notice of Work Completion form (Aon Form 5) when a Subcontractor and/or Sub-Subcontractor has completed its Work at the Project Site and no longer has on-site workers. The Aon Form 5 form will initiate the final payroll report and audit of payroll and man-hours by the OCIP Insurer. A copy of the AON Form 5 with instructions on the proper method for completion is found in Section 8. It is important to note that once the Work of the Subcontract is completed and the AON Form 5 has been submitted, the Subcontractor will be responsible to provide its own insurance, for example, should the Subcontractor return to the Project Site, for any reason, they will do so under the Subcontractor’s own insurance program and must provide the Prime Contractor with a Certificate of Insurance showing the Subcontractor’s own coverage as detailed in the Contract.

In addition to completing all other requirements of the Contract, SEPTA will not release final payment until all necessary forms have been submitted and accepted by the OCIP Administrator.

Safety Standards establish minimum standards for Prime Contractor and Subcontractor safety programs. SEPTA’s Safety Standards are provided to all participants during the bidding process.



OCIP Termination or Modification SEPTA reserves the right to terminate or modify the OCIP or any portion thereof with written notice. If SEPTA exercises this right, Prime Contractor and Subcontractors will be provided notice as required by the terms of their individual Contracts. At its option, SEPTA may procure alternate coverage or may require the Prime Contractor and Subcontractors to procure and maintain alternate insurance coverage.

In the event the Prime Contractor or Subcontractor is required to provide alternate insurance, due to termination of the OCIP, the final insurance cost will recognize the cost to furnish such insurance. Subcontractor must submit evidence of the cost of the alternate insurance to SEPTA if requested.

C L A I M P R O C E D U R E S


Claim Procedures

This section describes basic procedures for reporting various types of Claims: workers’ compensation, Liability, and damage to the Project.

General Procedures All Prime Contractors and Subcontractors of every tier will instruct employees and other persons working directly or indirectly on the Subcontractor’s behalf to report all injuries, occupational-related illnesses, property damage or any other incident of any type to the SEPTA Site Safety Manager and/or the Prime Contractor Safety Manager.

The SEPTA Site Safety Manager or the Prime Contractor Safety Manager’s contact information can be found in Section 2 of this manual.

When completing the Accident Forms, please use the following information so that it is coded correctly.

• Worker’s Compensation Policy Number – Specific to each Contractor/Subcontractor

• General Liability Policy Number – A3LGI5001500 • Location Code – TBD

Medical bills should be sent to the following address:

Gallagher Bassett Services PO BOX 23812

Tucson, AZ 85734

Immediately call the SEPTA Site Safety Manager or the Prime Contractor Safety Manager in the event of the following:

• Any injury for which an ambulance is called • Injury to head or neck • Possible injury to back or spinal cord • Unconscious employee • Possible blindness • Amputation of limbs • Fatality • Heart attack or stroke • Hospitalization

Section

7



• Property damage – all damage to property should be reported to include public property, tenant property and property of vendors

Investigation Assistance All Parties will assist in the investigation of any incident(s) involving injury to persons or damage to property. All Parties 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.

Return to Work Program Purpose:

SEPTA is committed to providing a safe work place for both its employees and the Prime Contractor and Subcontractors’ employees; facilitating prompt quality medical care in the event of a work related injury; and pursuing modified alternate duty to minimize the risks and financial burdens to its workforce.

SEPTA has a ”Return To Work” (RTW) program, which will be implemented by the Prime Contractor and each Subcontractor. The Prime Contractor and each Subcontractor will provide a Modified Alternate Duty Opportunity for an employee who has sustained a work related injury or illness and is medically unable to perform all or any part of his / her normal duties during all or any part of the normal workday or shift.

This applies to the Prime Contractor and all Subcontractors of all tiers on the project.

The program must include, but not be limited to:

• Immediate reporting of all work related injuries to SEPTA.

• All injured employees will be provided with an approved medical treatment facility listing where appropriate, or a recommended panel listing. If there is any doubt as to where to go for treatment, the injured employee must contact SEPTA.

• Prime Contractor and Subcontractors need to communicate to the injured employee and physician, SEPTA’s Return To Work Program and facilitate Modified Alternate Duty with physicians and the employee.

• The injured employee must provide the SEPTA Safety Manager, Project Managers and the Prime Contractor Safety Manager copies of all medical notes, to include a statement on work capacity.

• Modified Alternate Duty assignments must comply with all medical limitations as outlined by a physician.

• SEPTA’s Safety Manager, Project Managers and the Prime Contractor Safety



Manager all must be informed of the modified alternate duty assignment, anticipated length of alternate duty, and the restrictions.

• The injured employee is not to assume normal work activities unless there is medical documentation releasing them to their normal duties and presented to SEPTA’s Safety Manager and the Prime Contractor Safety Manager.

Responsibilities:

The following will define the reporting responsibilities of each party involved in the OCIP for Return to Work.

Prime Contractor and Subcontractor – A successful return to work program requires the cooperation and accountability of all your employees.

• Failure of a Prime Contractor or Subcontractor of all tiers to provide Modified Alternate Duty to an injured worker may result in a $1,500 weekly assessment against the Prime Contractor or Subcontractor of all tiers until the injured employee is returned to work in either a modified alternate duty position or full duty. Fines will be issued via deduct change order or any other method deemed appropriate by the OCIP Sponsor to any Prime Contractor or Subcontractor of all tiers who fails to return an injured worker to work in accordance with the outlined requirements.

• Ensure that your employees understand SEPTA’s RTW program and clarify any procedures that are unclear.

• Your employees are to report all injuries, even minor incidents, immediately within established reporting protocols.

• Your employees are to work closely with SEPTA and your managers/supervisors and communicate all necessary information regarding their ability to return to work.

• Your employees are to provide the physician with the information, including the RTW program, necessary to help them determine how and when they can return to work.

• Your employees are to work within their medically stated limitations.

• Your employees are to help co-workers stay focused and provide a positive environment when they return to modified alternate duty.

Supervisor / Manager – Supervisors / Managers play a key role in the success of the return to work program. They must implement and manage the program.

• Understand and support SEPTA’s written policies / procedures.

• Complete the Accident Forms immediately after the incident as per the Incident



Management and Reporting Procedures (attached).

• Facilitate treatment with the injured employee.

• Coordinate modified alternate duty with the injured employee within the injured employee’s work abilities as per the medical documentation. This work can take place on any project the employer is working on.

• Monitor the injured employee’s progress on modified alternate duty and provide weekly updates to the SEPTA’s Safety Manager and the Prime Contractor Safety Manager

Insurance Carrier Team – Are responsible for the daily claim handling.

• Coordinate medical care and return to work issues.

• Contact and communicate with the treating physician following each office visit.

• Manage issues related to claim file resolution.

• Analyze losses and recommend corrective action.

Sample Offer of Temporary Alternative Position Letter (To be used for out-of-work employee who has now been released for work with restrictions) Dear Employee:

(Contractor or Owner Name) is extending an offer of temporary transitional employment.

We are aware that you are medically cleared for work with restrictions. The task requirements of the offered position are within the scope of your current physical limitations.

You are being offered a position as a ___________________. This temporary transitional employment is subject to the limitations described on the attached medical report from ________________. The wages you will be paid are $__________ per hour. The work hours are _______________.

You are expected to return to work in the transitional position as described above on __________________ (date) at _________ am/pm. Please report directly to ________________________ at the __________project/site located at __________________.

Any questions regarding this temporary position offer should be directed to ___________ immediately.



YOUR FAILURE TO REPORT TO WORK AS OUTLINED ABOVE MAY RESULT IN THE TERMINATION OF YOUR WORKER’S COMPENSATION BENEFITS.

Sincerely,

SEND CERTIFIED, RETURN RECEIPT REQUESTED, AND REGULAR MAIL

Workers’ Compensation Claims The main responsibility for any Party is to provide immediate medical care. Any incident(s) must be immediately reported to the SEPTA Safety Manager and/or the Prime Contractor Safety Manager.

Prime Contractor’s and Subcontractors’ on-site personnel will follow these procedures if any employee (or any other person performing work directly or indirectly on behalf of a Subcontractor) is involved in an incident that caused or could have caused an injury.

1. Medical Care All employees involved in jobsite injury are required to treat with a designated healthcare provider from the Provider Panel. The Provider Panel is enclosed with this manual and is posted at the jobsite. In the event of an emergency, the injured worker should be transported to the nearest hospital emergency room. The main responsibility for any Prime Contractor or Subcontractor's on-site personnel is to first see that the injured worker receives immediate medical care. a. REQUIRED FORMS: The Pennsylvania Workers’ Compensation Act

also requires signature on the following forms be presented to every employee at the time of hire and immediately after an injury or as soon as possible (under the circumstances of the injury). Copies of the required form listed below are included with this manual. Signed forms should remain on file with the employer and should be made available upon request by Old Republic/Gallagher Bassett. 1. Rights and Duties Acknowledgement of the Employer for Work Related Injury or Occupational Illness; and

2. Onsite Medical First Aid Facility and Offsite Treatment:

If there is an onsite first aid facility all employees (or any other person performing work directly or indirectly on behalf of a Prime contractor or Subcontractor) must immediately report the incident and be evaluated on site. After being evaluated, if offsite treatment is needed it will be coordinated by SEPTA’s Safety Manager and/or the Prime Contractor Safety Manager. Transportation will be provided by the injured worker’s employer. If there is not an onsite first aid facility, all offsite treatment will be coordinated through SEPTA’s Safety Manager and/or the Prime Contractor Safety Manager. All Prime Contractors and Subcontractors are responsible for transporting their own employees (or any other person performing work directly



or indirectly on behalf of a Prime Contractor or Subcontractor) for offsite treatment. All Prime Contractors and Subcontractors must immediately report any incident to SEPTA’s Safety Manager and/or the Prime Contractor Safety Manager. Every incident must be reported no matter how minor.

3. All Prime Contractors and Subcontractors must cooperate with SEPTA’s safety

team to complete the “Incident Investigation Form” the same day. The SEPTA Safety Manager or the Prime Contractor Safety Manager will follow the procedures established at the start of the job to ensure that all claims are immediately filed with the proper OCIP Insurer.

4. Modified alternate/light duty is mandatory. Prime Contractors, Subcontractors

and its Sub-Subcontractors are required to provide modified alternate/light duty based upon the work restrictions provided by the treating physician, no exceptions.

5. After each doctor visit the injured worker must submit originals of all medical

documentation to include return to work notes, inquiries or correspondence to the onsite first aid facility. If there is not a first aid facility onsite all documentation must be submitted to the SEPTA Safety Manager and/or the Prime Contractor Safety Manager.

6. An injured party will not be allowed to return to the project site unless they have

provided the SEPTA site Safety Manager and/or the Prime Contractor Safety Manager with the proper return to work note, either full duty or modified alternate/light duty.

7. Prime Contractors and Subcontractors that report a claim late, 24 hours from

the date and time they became aware of it, that results in SEPTA being assessed a fine by the State WC Commission or greatly impact the exposure on the claim due to the late reporting may be fined up to $5,000.00.

Liability Claims Prime Contractors and Subcontractors must immediately report all incidents at the Project Site involving the public, tenants, and visitors to the SEPTA Safety Manager and/or the Prime Contractor Safety Manager. As soon as the on-site personnel become aware of the incident or occurrence, they must:

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

2. Prime Contractors and Subcontractors are to coordinate with the SEPTA’s

safety team to complete the “Liability Incident Report Form” the same day.

3. The SEPTA Safety Manager or the Prime Contractor Safety Manager will



follow the procedures established at the start of the job to ensure that all claims are immediately filed with the proper Insurance Carrier.

4. Immediately send all subsequent inquires or correspondence about an insured

loss or claim, including a summons or other legal documents, to the SEPTA Safety Manager immediately. This is required to avoid a default being entered against the defendants. Please send all correspondence to carrier, with a copy to the Aon Claim Consultant, ASAP so counsel can be retained, appearance filed and can respond on behalf of the defendants timely.

Property Claims Report any damage to your work or the work of any other Subcontractor to the Site Safety Manager.

Automobile Claims Automobile claims are not covered under the OCIP Program.

It is the sole responsibility of each Party 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 SEPTA’s Site Safety Manager or the Prime Contractor Safety Manager. Each Party shall cooperate in an investigation of all automobile accidents (accidents involving other vehicles, injury to an individual, or damage to the public or property). They must also be reported to the SEPTA Site Safety Manager and/or the Prime Contractor Safety Manager.

Pollution Claims The OCIP general liability policy provides limited pollution coverage.

Any circumstance where hazardous materials are identified or is inadvertently spilled onsite must be reported to SEPTA’s on site personnel. Report claims immediately by notifying the SEPTA Safety Manager, the Prime Contractor Safety Manager, and each Party’s insurer of any known or suspected pollution incidents. Each Party shall cooperate in the investigation of all incidents.

F O R M S


Forms

This section contains the forms needed for administration of the OCIP.

Aon Form 3 Enrollment Application

Aon Form 4 Payroll Report

Aon Form 5 Notice of Work Completion

Exhibit A Experience Modification Rating Exception Request

Exhibit B Experience Medication Rating Exception Questionnaire

Exhibit C Drug and Alcohol Testing Program – Policy and Procedure

Old Republic Claim Kit

Note

For assistance in completing these forms, please contact the OCIP Insurance Administrator – Aon Risk Services: Fred Mesa Phone: 866-226-1420 Option 3 Fax: 800-363-6695 (E-mail) [email protected]

Section

8

F O R M S


Form-3

Enrollment Application - Form 3 Numbers reference attached instructions

{Project Name}

Page 1 of 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-1a or Form-1b, 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..) Company Name & dba: Contact Name & Title:

2

3

Address: City, State Zip Code: Telephone: Fax: E.mail Address:

Indicate your Organization’s Structure: 4 Corporation

Joint Venture Partnership Sole Proprietor

S-Corporation Other _____________________________

B. CONTRACT INFORMATION: Contract No.: 1

{Project Name}

Date Contract Awarded: 2

Description of Work: 3

Proposed Contract Price $: 4 Are you Submitting a bid to SEPTA Construction: 6 Yes No Amount of Self Performed Work $: 5 If No, identify to whom: 7

Start Date:

7

Actual Estimated

Completion Date:

8

Actual Estimated

C. Contacts: (Complete if Applicable)

Position 1 Name & Title 2 Phone 3 Fax 4 Email address Project Mngr: Res. Engineer: Insurance: Contract Admin: Payroll: Claims: Safety Rep: Provide Location of payroll records if different

than Corporate address: 5

Phone: City, State, Zip Code: Fax:

D. workers’ compensation Insurance Information for Work Described Above: (attach a separate sheet if necessary)

a State

b Class Code

c Description

d Man-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 Risk ID Number Rating Bureau Anniversary Rating Date 1 2 3 4

Your current WC Insurance Carrier: 5

Policy #: 6 Effective Date: 7 Expiration Date: 8

F O R M S


Form-3

Enrollment Application - Form 3 Numbers reference attached instructions

{Project Name}

Page 2 of 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.

PLEASE NOTE: If additional Subcontractors are identified / anticipated after your enrollment is complete, please notify Aon as soon as possible.

1 Subcontractor

2 Subcontract

Amount

3 Contact Person

4 Address

5 Phone # /

Fax # / Email

6 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 If yes, please provide address: 2

Please check if: Any aircraft used on this project Any watercraft used on this project 3

Please indicate if labor from the following sources will be used: Employee Leasing Firm Temporary Labor Agency 4 5 6 7 H. W A R R A N T Y A P P L I C A B L E T O P R O G R A M I N S U R A N C E C O V E R A G E

1 Premiums for this Program are the responsibility of SEPTA 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 SEPTA. 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 SEPTA are assigned to SEPTA.

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 excluded within my bid, the insurance costs for the coverage provided by SEPTA. 6 The statements in this insurance application are true to the best of my knowledge.

I. Signature Block : I verify the information presented above and attachments are correct: Name: Date: (please print) Title: Signature: Note: Information can be submitted on-line at www.aonwrap.aon.com. Please contact your Administration Staff to obtain a user ID and Password.

Fax (no coversheet Fred Mesa Phone: 866-226-1420 Option 3 needed) or Mail to: SEPTA OCIP Customer #570000063725 Fax: 800-363-6695 Aon Risk Services, Inc. 4 Overlook Point

Lincolnshire, IL 60069

Or Email: [email protected]

Form-3

Enrollment Application - Form 3 INSTRUCTIONS

{Project Name}

Page 3 of 3

http://www./aonwrap.aon.com

F O R M S


This form must be completed and submitted by each successful Prime Contractor and Subcontractor of any tier prior to Site mobilization for each contract awarded. The Prime Contractor and Subcontractor will submit the completed form to Aon Risk Services. Upon receipt of this form, Aon will issue to the Prime 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 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 primary office location. 3 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. 4 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. B. Contract Information 1 Enter the Contract Number or Purchase Order Number that was included in SEPTA’s originating documentation. 2 Supply the Date this Contract was awarded to your organization. 3 Provide a brief description of the work you will be performing at the project site. 4 Identify the total amount of your contract. 5 Identify the amount of work that you anticipate will be self-performed. 6 Check the appropriate box that identifies if you contract directly with SEPTA or are a Subcontractor. 7 If you are a Subcontractor, identify the entity with who you are under contract. 8 Enter the Date you anticipate starting work and then mark whether the date provided is actual or estimated. 9 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. 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 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 the work identified in B2. (Most states use a 4 digit Number) c Enter the workers’ compensation class code description that applies to the work identified in D1b. d Enter the estimated Man-hours required to complete the described work by workers’ compensation class code. e 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. 2 Total all estimated Man-hours for each class code. Be sure to include information from additional pages if used. 3 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 (Information relates to your corporation’s existing coverage; identify each modification factor that applies.) 1 Enter the State that the Modification Information applies to. 2 Enter your Bureau File Number also referred to as your Risk Identification Number. This number can also be found on your Modification worksheets. 3 Enter the Bureau Rating Agency. In most states this is NCCI. 4 Provide your Company’s Anniversary Rating Date. Information can be located on your bureau’s WC Experience Modification worksheets. 5 Identify your insurance carrier for workers’ compensation Coverage. 6 Provide your workers’ compensation Policy Number. 7 Provide the effective date of your workers’ compensation policy. 8 Provide the expiration date of your workers’ compensation policy. F. Subcontractor Information (Provide the following information for each Subcontractor that will be performing work at the project site. Use additional sheets, if necessary.) 1 Identify the name of the Subcontracting firm. 2 Provide the estimated value of the Subcontracted activity. 3 Provide a contact name, preferably the project manager, for the Subcontractor. 4 Provide the mailing address for the Subcontractor. 5 Provide the phone number for the Subcontractor. 6 Provide the date the Subcontractor is scheduled to begin work. G. Enrollment Questions 1 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. 2 Mark the box or boxes that apply. Contemplate only work performed under this contract. 3 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.

F O R M S


Form-4

On-Site Payroll Report - Form 4 Numbers reference attached instructions

{Project Name}

Page 1 of 2

Complete a Separate Form for Each Contract with SEPTA. Your report is due to the Aon Insurance Administrator, identified below, no later than the 10th day of the succeeding month.

Complete this report even though no work was performed; enter zero (0) for the Reportable Payroll. Delay in providing this report may result in payments being withheld.

A. REPORT IDENTIFICATION

Period Beginning: 1 Period Ending:

2 Year: 3

Contractor: 4

Under Contract with:

5

Contract #:

6 {Project Name}

B. ACTIVITY REPORT

a State

b Workers’

Compensation Class Code

c Work Description

d Man-Hours

e Gross Payroll

f Reportable Payroll *

1

TOTALS: 2

3

4

* Do not include premium (excess) overtime wages, use straight time wage rates only. You must also comply with all rules set forth by the Workers Compensation Bureau in the state in which the work is performed.

C. ADDITIONAL DATA REQUIREMENTS :

1.

2.

3.

D. Signature Block : I verify the information presented above and attachments are correct: Name: Date: (please print) Title: Signature:

CHECK IF THIS IS YOUR LAST PAYROLL REPORT. COMPLETE AN AON FORM-5 “NOTICE OF WORK COMPLETION” AND INCLUDE WITH THIS PAYROLL REPORT.

Note: Information can be submitted on-line at www.aonwrap.aon.com. Please contact your Administration Staff to obtain a user ID and Password.

Fax (no coversheet Fred Mesa Phone: 866-226-1420 Option 3 needed) or Mail to: SEPTA OCIP Customer #570000063725 Fax: 800-363-6695 Aon Risk Services, Inc. 4 Overlook Point Lincolnshire, IL 60069 Or Email: [email protected]


F O R M S


Form-4

On-Site Payroll Report - Form 4 INSTRUCTIONS

{Project Name}

Page 2 of 2 The Prime Contractor and every Subcontractor of any tier performing work at the Project Site for each Contract awarded must complete this form each month. The Prime Contractor/Subcontractor must attach the completed report to their monthly pay request in order to receive interim payment. Prime Contractors will be responsible for the submission of this form by their Subcontractors. Aon Risk Services can forward a supply of these forms to your company upon request. A. Report Identification 1 Fill in the month and day for the beginning of the period you are reporting on. 2 Fill in the month and day for the ending of the period you are reporting on. 3 Fill in the year that applies to the reporting period. 4 Enter the name of your firm. 5 If you are a Subcontractor, identify the name of the firm you are contracted to. If you are a Prime Contractor enter N/A 6 Provide your Contract Number B. Activity Report 1 For each workers’ compensation Class Code that applies to work performed during the reporting period, provide the following

information: a Identify the state in which the work was performed. b Identify the workers’ compensation Class Code that applies to the work performed during the period. (Most states use a four digit No.) c Provide a brief description of the work by class code. d Identify the number of Man-hours worked by your employees for each applicable class code. e Provide the Gross Payroll paid to your employees. This should include overtime pay and vacation pay. f Determine the Reportable Payroll. Reportable Payroll does not include the premium portion of any overtime pay (i.e. 45 hours X

$10.00/hr = 450.00 do not include the premium overtime pay of $5.00 for the 5 hours of overtime) 2 Total the Man-hours provided on the payroll report. 3 Total the Gross Payroll provided. 4 Total the Reportable Payroll.

C. Additional Data Requirements: If questions are listed in this section of the form, they are unique to this project. Please refer to the Insurance Manual.

D. Signature Block: This form must be signed by a representative of your company with the authority to Verify the information is correct. Note: Information can be submitted on-line at www.aonwrap.aon.com. Please contact your Administration Staff to obtain a user ID and Password.


F O R M S


Form-5

Notice of Work Completion - Form 5 Numbers reference attached instructions

{Project Name}

Page 1 of 2 A. General Information

Contractor: 1

Under Contract with:

2

Contract #:

3 {Project Name}

Description of Work Performed: 4

Date Work Completed: 5

Date this Contract Completed: 6

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

City, State, Zip Code:

Contact/Phone #:

C. Signature Block The undersigned acknowledges request for termination of Coverage under the CIP 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 SEPTA with a Certificate of Insurance showing our own Coverage as detailed in our contract.

SIGNED BY: 1

Name & Title Date

APPROVED BY: 2

SEPTA (Name & Title) Date

Fax (no coversheet Fred Mesa Phone: 866-226-1420 Option 3 needed) or Mail to: SEPTA OCIP Customer #570000063725 Fax: 800-363-6695 Aon Risk Services, Inc. 4 Overlook Point Lincolnshire, IL 60069 Or Email: [email protected]

F O R M S


Form-5

Notice of Work Completion - Form 5 INSTRUCTIONS

{Project Name}

Page 2 of 2

This form will be completed and returned to the CIP Administrator by the Prime Contractor or Subcontractor whenever work is completed for each Contract. This form will initiate the final payroll audit process for the Prime 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 Provide the name of the Contractor completing their work. 2 Provide the name of the Entity this Contractor has a contract with. 3 Enter the contract number for the work being completed. 4 Provide a brief description of the work being completed. 5 Provide the Date the Work was completed. 6 Provide the Date the Contract was completed, if other the work completion date.

B. Work Completion 1a Enter the name of each Subcontractor that performed work for you that has also completed their work. b Enter Subcontractors Contract Number. c Provide a brief description of their work. d Provide the Date they completed their work. 2 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 This form must be signed by a representative of your company with the authority to Verify that the information is correct. 2 Have this form approved by the Construction Manager for the Project Site.

F O R M S


Exhibit A EXPERIENCE MODIFICATION RATING EXCEPTION REQUEST

1. Experience Modification Rate (EMR) – The Prime Contractor and all Subcontractors must have a Pennsylvania

Workers’ Compensation Experience Modification not to exceed 1.25. If the Prime Contractor has an EMR over 1.25 or would like to use a Subcontractor with an EMR above 1.25, the Prime Contractor will be required to complete the below exception request form. This exception request will be reviewed by SEPTA, the OCIP Administrator, and/or the OCIP Insurance Carrier. If approved, suggestions may be made to revise the subcontractor’s safety plan, safety personnel staffing, safety training, or other safety related procedures. If the Prime Contractor’s or any Subcontractor’s domicile state is not Pennsylvania, their applicable Experience Modification will be used.

EMR Exception Request Subcontractor Name Awarding Contractor Jobsite Start Date On-Site Scope of Work Duration of Work Contract Value of Work Estimated Payroll Estimated Man-hours Experience Mod Identify any other SEPTA project the Subcontractor has worked on

Is there a specific reason why the EMR is over 1.25?

Please list subcontractor safety staffing procedures

Please list subcontractor safety training procedures

Please Complete the attached questionnaire and submit it along with this Exception Request Form.

F O R M S


Exhibit B

EXPERIENCE MODIFICATION RATING EXCEPTION QUESTIONNAIRE Company Name:

Company Type (Prime Contractor, Mechanical, etc.):

Address: Telephone

No.:

RESOURCES 1. Name of company Safety and Health Contact: Title: 2. What percent of this person’s time is spent on safety

and health related matters? % 3. What professional safety and health certifications does

this person hold (e.g., CSP, PE, CIH)? 4. How many other full-time safety and health

representatives are employed by your company? 5. Name of Site Specific Safety Representative: Title: What percent of this person’s time is spent on safety

and health related matters? % Submit copy of Safety Representative’s qualifications

with completed questionnaire. 6. Does your company have a written procedure to ensure

that adequate safety and health program resources, such as budget, equipment, training, and manpower are included in each project bid? If yes, submit a copy with completed questionnaire. Yes No

SAFETY AND HEALTH PROGRAM ELEMENTS 1. Does your company have a written safety, health, and

accident prevention program (SP)? If yes, submit a copy with your completed questionnaire. Yes No

2. Does your company have a written procedure to ensure safety and health issues are preplanned into each project and work operation (e.g., job hazard analysis, checklists, etc.)? If yes, submit a copy with the completed questionnaire or reference page number in the SP. Yes No Page No.

3. Does your company have a written safety incentive program that will be implemented on this project? If yes, submit a copy with the completed questionnaire or reference page number in the SP. Yes No Page No.

F O R M S


4. Does your company have a written accident/incident investigation procedure? If yes, submit a copy with the completed questionnaire or reference page number in the SP. Yes No Page No.

5. Does your company have a written safety and health training program? If yes, submit a copy with the completed questionnaire or reference page number in the SP. Yes No Page No.

If yes, does the program include the following? New employee/project orientation. Yes No Page No. Weekly “toolbox” meetings. Yes No Page No. Daily job briefings. Yes No Page No. Supervisor safety training. Yes No Page No. Task specific training. Yes No Page No. OSHA required training. Yes No Page No. Other Yes No Page No. 6. Does your company have a written procedure to

ensure that only employees who are qualified by training and experience are allowed to operate equipment, tools, machinery, and vehicles? If yes, submit a copy with the completed questionnaire or reference page number in the SP. Yes No Page No.

7. Does your company designate and train competent people as required by the applicable OSHA standards (e.g., excavations, scaffold, erection, etc.)? Yes No Page No.

8. Does your company have a written procedure to audit projects to ensure all projects are in compliance with applicable laws, requirements, etc.? If yes, submit a copy with the completed questionnaire or reference page number in the SP. Yes No Page No.

9. Does your company have a written procedure to screen subcontractors based on their past safety performance? If yes, submit a copy with the completed questionnaire or reference page number in the SP. Yes No Page No.

OSHA CITATIONS 1. Has your company received any Federal or State

Plan OSHA citations within the last 3 years? Yes No 2. If the answer to question 1 is yes, how many of each

of the following types of citations have you received? Willful Imminent danger Serious Other than serious De minimus Give a brief description of the nature of the citation(s), or attach a copy of the citation(s). ACCIDENT AND ILLNESS STATISTICS 20( ) 20( ) 20( )

F O R M S


Year Year Year 1. How many man-hours has your company worked in

each of the last 3 years? 2. How many OSHA recordable injuries did your

company experience in each of the last 3 years? 3. Based on the below listed formula (a), what are your

incident rates for each of the last 3 years? If the rates are above the current national average, the bid may be disqualified.

4. How many lost time accidents has your company experienced in each of the last 3 years?

5. Based on the below listed formula (b), what is your lost workday case rate for each of the last 3 years? If the rates are above the current national average, the bid may be disqualified.

6. How many fatalities has your company experienced in each of the last 3 years?

7. Submit a copy of your OSHA 300 logs for the last 3 years with your completed questionnaire.

(a) Number of injuries and illnesses x 200,000 Man-hours worked (b) Number of lost time injuries and illnesses x

200,000 Man-hours worked WORKERS’ COMPENSATION EXPERIENCE MODIFICATION RATE 20( ) 20( ) 20( ) Year Year Year Submit, on your insurance company letterhead, your

Workers’ Compensation Experience Modification Rate for each of the last 3 years with your completed questionnaire.

Is there any additional information you feel we need to properly evaluate your company’s safety and health program? If yes, please explain below or attach additional sheets.

Name of Person Completing Questionnaire (Please Print):

Signature of Person Completing Questionnaire: Title: Date:

F O R M S


Exhibit C: Drug and Alcohol Testing Program – Policy and Procedure

It shall be mandatory that all Contractors participate in the Drug and Alcohol Testing Program (“Program”) in order to perform work on this project. The mandatory Program is to include (i) pre-employment testing prior to being permitted on the project site; (ii) “reasonable suspicion” based testing when an employee is suspected of being impaired on duty; and (iii) post-accident/incident testing which involves any employee who is injured during the course and scope of their employment onsite or involved in an accident/incident in the course of job duties which involves use of heavy equipment, power tools or other dangerous instruments, or under working conditions which result in an injury or substantial property damage or disruption to the project.

WORKNET Drug & Alcohol Services (hereinafter “WORKNET”) will be the Third Party Administrator of the Program for the SEPTA OCIP Projects (hereinafter “OCIP Projects”). The following are the procedures which must be adhered to by all contractors:

• As a Contractor is enrolled in the OCIP Project, AON shall be responsible to notify

WORKNET via email the Contractor enrollment information form. AON is responsible to mail/fax/email the Employee Information Packet to the Contractor. The information in the packet will include Contractor contact information, phone numbers, cell telephone numbers, Designated Employer Representative (DER) name, alternate DER and mailing address. See Attachment A.

• WORKNET will email or fax the Drug Testing Agreement Form (See Attachment A) to the

Contractor only if not received in the initial starter packet from AON. The Contractor is responsible for emailing or faxing a completed/signed Drug and Alcohol Testing Agreement Form back to WORKNET immediately after receiving the paperwork.

• WORKNET will send each Contractor via email or fax the Authorization Form for drug

and alcohol testing.

• The Authorization Form must be filled in by an employer representative and signed by an employer representative. It is then given to the employee to take to the collection site for their drug test. The employer must check the appropriate boxes on the Authorization Form (i.e., the particular OCIP Project the testing is being administered for; the reason to test, etc.) If the employee does not have the Authorization Form when presenting to the collection site, the employee will not be tested, but instead turned away and sent back to the collection site for the completed Authorization Form.

• Procedures for receiving negative test results. Test results will be either (i) called and

mailed; (ii) faxed to a confidential fax; or (iii) emailed to the Designated Employer Representative (DER). If you do not receive a result within 72 hours of the testing, then you must contact WORKNET at (610) 916-4781. The DER or Alternate DER may call for results however you must have the employees name and social security number to retrieve test results over the telephone.

• Instant Drug Testing will be conducted for all reasons to test.

• All urine specimen collections and Breath Alcohol Testing will be conducted at the

following certified drug testing facilities:

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South Philadelphia Roxborough Memorial Hospital One Reed Street 5800 Ridge Avenue, Suite 234 Philadelphia, PA 19147 Philadelphia, PA 19128 Mon.-Fri. 7:30 am to 5 pm Mon.-Fri. 8 am to 4:30 pm

Huntingdon Valley King of Prussia Mason Mill Business Park II 170 N. Henderson Road, Suite 306 1800 Byberry Road, Suite 705 King of Prussia, PA 19406 Huntingdon Valley, PA 19006 Ph: 610.337.1558 Ph: 215.947.5005 Mon.-Fri. 7:30 am to 4:30 pm Mon.-Fri. 8 am to 4 pm

Langhorne Reading 360 N. Oxford Valley Road 3225 N. 5th Street Highway Langhorne, PA 19047 Reading, PA 19605 Ph: 215.943.9000 Ph: 610.939.2391 Mon.-Fri. 7:30 pm to 5 pm Mon.-Thurs. 8 am to 5 pm Fri. 7 am to 4 pm Lester Philadelphia 100 Diplomat Drive, Bay 1 Broad and Vine Streets Lester, PA 19113 Mail Stop 101 Ph: 610.521.6880 Philadelphia, PA 19102 Mon.-Thurs. 7:30 am to 8 pm Ph: 215.762.8525 Fri. 7:30 am to 5 pm; Sat. 9 am to 2 pm Mon.-Fri. 7:30 am to 5 pm

Toms River Camden 368 Lakehurst Road, Suite 206 300 S. Benson and Broadway, Suite 101 Toms River, NJ 08755 Camden, NJ 08103 Ph: 732.557.9980 Ph: 856.338.0350 Mon.-Fri. 8 am to 5 pm Mon.-Fri. 7:30 am to 5 pm

Pennsauken Stratford 9370 Route 130 N., Suite 200 37 S. White Horse Pike Pennsauken, NJ 08110 Stratford, NJ 08084 Ph: 856.662.0660 Ph: 856.435.2680 Mon.-Fri. 7:30 am to 5 pm Mon.-Fri. 8 am to 4:40 pm

Burlington Pureland 2103 Burlington-Mt Holly Road 510 Heron Drive, Suite 108 Burlington, NJ 08016 Swedesboro, NJ 08085 Ph: 609.747.1891 Ph: 856.467.8550 Mon.-Fri. 8 am to 5 pm Mon.-Fri. 7:30 am to 5 pm

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Lancaster North Lancaster South 4237 Oregon Pike 241 Rohrerstown Road, Suite 200 Ephrata, PA 17522 Lancaster, PA 17601 Ph: 717.859.5002 Ph: 717.431.1770 Mon.-Thurs. 8 am to 5 pm Mon.-Thurs. 8 am to 5 pm Fri. 8 am to 4 pm Fri. 8 am to 4 pm

Harrisburg Mechanicsburg 6301 Grayson Road, Suite 9 6108 Carlisle Pike Harrisburg, PA 17111 Mechanicsburg, PA 17050 Ph: 717.920.5910 Ph: 717.691.9560 Mon.-Fri. 8 am to 5 pm Mon. & Wed. 7 am to 5 pm;

Tues. & Thursday 8 am to 5 pm Fri. 7 am to 4 pm

Note: All hours of operation may be subject to change without notice. In the event the employer has more than five (5) employees that need testing at the same time, the employer should call the clinic to obtain a time suitable to both.

• A Contractor’s employee must present the completed signed Drug and Alcohol

Testing Authorization Form to the representative at the designated drug testing facility. If the employee of the Contractor does not have the completed signed Authorization Form, they shall not be tested until the employee furnishes the proper completed signed Authorization Form. At the time of the test, the employee of the Contractor must also present a valid Photo ID to the testing facility representative.

WORKNET will provide all Drug Testing Custody and Control Forms for five (5) panel testing and split specimen collection kits to the collection facility. The 5-panel drug test will include the following controlled substances: Marijuana Metabolites, Cocaine Metabolites, Amphetamines, Opiates and Phencyclidine.

Once the urine specimen collection process has begun the employee may NOT leave the WORKNET site until the entire process is fully completed. If the employee leaves collection site without given permission to do so by the collection site, such action will be deemed a REFUSAL to test. Once the urine specimen collection process is completed, the employee of the Contractor will be given the donor copy of the Custody and Control Form. The Donor will then be instructed to provide the Employer Custody and Control Form to his/her supervisor or the Safety Manager. The Employer copy of the Custody and Control Form will be placed in a sealed envelope by the collector at the collection site. Under no circumstances should the employee open the sealed envelope.

All specimens that require confirmation testing shall be sent to a SAMHSA Certified Testing Laboratory. It may take a minimum of 24 to72 hours for test results to be returned to WORKNET from the laboratory. The Contractor is responsible for checking for the test results if not received within a reasonable time frame. WORKNET will contact the Contractor for any laboratory confirmed “Negative” test results. Once the Medical Review Officer (MRO) has discussed the “Non-negative” results (i.e., Positive or Inconclusive) with the employee, the Contractor will be notified. REASONS/LOCATIONS FOR TESTING:

PRE-EMPLOYMENT drug testing is to be performed at the designated collection site.

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POST ACCIDENT/INCIDENT and INJURY drug and breath alcohol testing is to be performed at the designated collection site. The employee must tell the collection site that they were injured while performing work on the OCIP Project, and present the completed signed Authorization Form to the clinic personnel. For purposes of the Program, any confirmatory breath alcohol test result having a level greater than .04 is considered a “Positive” result.

REASONABLE SUSPICION based drug and alcohol testing is to be performed at the designated collection site. The Authorization Form is required for this type of testing. For purposes of the Program, any confirmatory breath alcohol test result having a level greater than .04 is considered a “Positive” result.

The testing facility is to treat any determination of "REFUSAL to TEST” by any employee as a “Positive” result, and will immediately notify WORKNET. The testing facilities will invoice WORKNET monthly for all drug and alcohol contracted services. WORKNET will invoice the Prime Contractor directly for each drug and alcohol screen. Payment is required within 45 days of receipt of the invoice. Cost associated with the drug testing program is as follows:

Test Type Charge*

Instant Drug Test – Negative Test Result

$55.00

Instant Drug Test - “Inconclusive” Test Result with Lab based Confirmation Testing

$59.00

Breath Alcohol Test – Screen

$30.00

Breath Alcohol Test – Confirmation Additional

$30.00

*Must utilize designated collection site for this OCIP Project. You may not use another collection site.

All specimen data will be made available to the appropriate member of the Contractor through WORKNET.

F O R M S


Attachment A

Employee Screening Program Information

Introduction SEPTA for their OCIP Projects has agreed to utilize WORKNET Drug & Alcohol Services (hereinafter “WORKNET”) to provide drug testing. Drug and Alcohol testing is a requirement all Contractors must participate in to work on SEPTA’s OCIP Projects. The Contractor shall be termed as the Employer of the Employee being tested for the purposes of this document. The employer is ultimately responsible for payment of drug and alcohol testing services. Drug Testing WORKNET will utilize an “instant test” for the initial screen followed up by a laboratory based gas chromatography / mass spectrometry (“GC/MS”) confirmation test for all “Inconclusive” drug test result. WORKNET has contracted with WORKNET to perform the drug and alcohol testing for the SEPTA OCIP Projects. No other collection sites can be utilized for this project. Employees must have a “Negative” initial drug screen before they can complete the Project Safety Orientation for the project and begin work on site. WORKNET will report results directly to the Designated Employer Representative (DER). WORKNET will process “Inconclusive” tests in the following manner: After testing is completed, any employee with an “Inconclusive” result will be privately informed, by the employer, that the screen conducted was inconclusive and needs to be further tested at the laboratory. In addition, the employee will be informed by the employer that based on project requirements, he/she cannot be permitted on to the site until the test is reported as “Negative” from a federally certified laboratory. At such time that further testing on an “Inconclusive” test result is returned from the laboratory as “Negative”, the employer will be notified and the employee will be cleared to receive the Project Safety Orientation and to begin work. When the DER receives a result from the Medical Review Officer (MRO) that states “Positive Dilute”, the DER shall treat the result as a verified Positive result. The employee shall not be able to take another drug test based on the fact that the specimen was diluted. When the DER receives a result from the MRO that states a “Negative Dilute” drug test, the company shall do the following:

• If the MRO directs the DER to conduct a recollection under direct observation (i.e., because the creatinine concentration of the specimen was equal to or greater than 2mg/dL, but less than or equal to 5 mg/dL), the DER shall have the employee do so unannounced and immediately.

• If the MRO reports the result as a negative dilute and when the creatinine concentration of

the dilute specimen is greater than 5 mg/dL, the DER shall direct the employee to take another unannounced test immediately.

F O R M S


Recollection of the specimen shall not be collected under direct observation unless there is another basis to support a directly observed collection. When the DER receives the second result after the initial Negative Dilute result and the result is again Negative Dilute, the DER shall accept this result (unless the MRO asks for another collection under direct observation). If the MRO requires another recollection, the employee must do so immediately. If the result is “Positive”, WORKNET will initiate the MRO review. The MRO is a medical Doctor that has specific training in the area of Drugs of Abuse. The MRO’s role is to make a final determination of the test result, taking into consideration the laboratory report and telephone interview with the donor, as well as any prescription documentation that may be provided. WORKNET will follow these guidelines for the MRO review when processing tests for this Project:

• The MRO staff will contact the donor a minimum of three (3) times within 24 hours of receipt of the “Positive” test result. If the donor has not called the MRO staff, then the MRO staff shall contact the DER for assistance in having the donor contact the MRO.

• After the MRO speaks to the donor via telephone, and the donor states they have a valid prescription, the donor has five (5) business days to provide that documentation or have the prescribing doctor contact the MRO. If a valid prescription that matches to the drug in question is provided, the MRO can overturn the result to a “Negative” result.

• After 10 days of receipt of the “Positive” drug test result from the laboratory, if the donor has not returned the MRO’s telephone call, the drug test results will then be given to the DER.

Once the result is finalized:

• The MRO staff will contact the DER with the result via the telephone. The result will then be mailed and/or faxed to the DER.

• Drug test results shall only be released to the contractor/subcontractor/general manager and/or pertinent DER for this Project. Written authorization from the donor of the urine specimen and/or breath alcohol test shall be required for any other identity requesting drug and/or alcohol results.

• Federal, state, and/or local authorities will be able to obtain the drug and/or alcohol test results only with a subpoena unless there is law requiring disclosure of the results per the Federal, state, and/or local authorities.

• The procedure to release drug and/or alcohol test results revert to 49 CFR Part 40 of the federal guidelines.

• A Drug Test Analysis Report will be sent to SEPTA, Conner Strong & Buckelew, AON and/or The Selzer Company upon request.

F O R M S


Alcohol Testing The following protocols shall be implemented when the reason/basis to test for alcohol is either Post Accident/Incident/Injury or Reasonable Suspicion. The employee shall be transported by the employer to the designated WORKNET. All Alcohol Tests shall be conducted utilizing certified Evidential Breath Testing (EBT) devices. Any initial result of .04 bac or greater will result in an initial Positive finding and require a confirmatory test to be conducted after 15 minutes (but no longer than 30 minutes). Any confirmatory test greater than .04 bac is a Positive result and will be reported to the WORKNET immediately. Results are reported directly to the DER, contractor/subcontractor/general manager and/or pertinent designated representatives of this Project. Any employee testing greater than .04 bac will not be permitted to return to the project. Authorization Form The Authorization Form, which will be emailed to the contractor, must be presented to the collection site that is established for the SEPTA OCIP Projects in order to obtain a drug and alcohol test. The employer will receive the Authorization Form via email from WORKNET after the account has been established. Your employee will be sent back to you for the proper Authorization Form if not presented at the time of testing. The Authorization Form will have your company name already filled in for you. The employer must complete and sign the form along with checking the correct OCIP Project box. A supervisor from the employer MUST sign the authorization form. Reasons to Test: Pre-employment – Drug Only Post-Accident/Incident/Injury – Drug and Breath Alcohol Testing Reasonable Suspicion/Cause – Drug and Breath Alcohol Testing Fee Schedule:

Drug Test:

WORKNET shall use a 5-panel Drug Test instant onsite test kit which includes Marijuana Metabolites, Cocaine Metabolites, Opiate including Heroin, Amphetamines/Methamphetamines, and Phencyclidine (PCP)

Instant Drug Test – Negative Result $55.00 Instant Drug Test – Inconclusive (non-Negative)

Includes Confirmatory Lab Based Test for Instant Test $59.00 Possible additional test(s) of the urine that the MRO may deem necessary, only after speaking with the Donor and the Company is as follow: Split Specimen Test $175.00 D&L Isomer – Amphetamines $150.00

F O R M S


Collection Site: The following sites are the only sites that are permitted to be utilized:

South Philadelphia Roxborough Memorial Hospital One Reed Street 5800 Ridge Avenue, Suite 234 Philadelphia, PA 19147 Philadelphia, PA 19128 Mon.-Fri. 7:30 am to 5 pm Mon.-Fri. 8 am to 4:30 pm

Huntingdon Valley King of Prussia Mason Mill Business Park II 170 N. Henderson Road, Suite 306 1800 Byberry Road, Suite 705 King of Prussia, PA 19406 Huntingdon Valley, PA 19006 Ph: 610.337.1558 Ph: 215.947.5005 Mon.-Fri. 7:30 am to 4:30 pm Mon.-Fri. 8 am to 4 pm

Langhorne Reading 360 N. Oxford Valley Road 3225 N. 5th Street Highway Langhorne, PA 19047 Reading, PA 19605 Ph: 215.943.9000 Ph: 610.939.2391 Mon.-Fri. 7:30 pm to 5 pm Mon.-Thurs. 8 am to 5 pm Fri. 7 am to 4 pm Lester Philadelphia 100 Diplomat Drive, Bay 1 Broad and Vine Streets Lester, PA 19113 Mail Stop 101 Ph: 610.521.6880 Philadelphia, PA 19102 Mon.-Thurs. 7:30 am to 8 pm Ph: 215.762.8525 Fri. 7:30 am to 5 pm; Sat. 9 am to 2 pm Mon.-Fri. 7:30 am to 5 pm

Toms River Camden 368 Lakehurst Road, Suite 206 300 S. Benson and Broadway, Suite 101 Toms River, NJ 08755 Camden, NJ 08103 Ph: 732.557.9980 Ph: 856.338.0350 Mon.-Fri. 8 am to 5 pm Mon.-Fri. 7:30 am to 5 pm

Pennsauken Stratford 9370 Route 130 N., Suite 200 37 S. White Horse Pike Pennsauken, NJ 08110 Stratford, NJ 08084 Ph: 856.662.0660 Ph: 856.435.2680 Mon.-Fri. 7:30 am to 5 pm Mon.-Fri. 8 am to 4:40 pm

Burlington Pureland 2103 Burlington-Mt Holly Road 510 Heron Drive, Suite 108 Burlington, NJ 08016 Swedesboro, NJ 08085 Ph: 609.747.1891 Ph: 856.467.8550 Mon.-Fri. 8 am to 5 pm Mon.-Fri. 7:30 am to 5 pm

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Lancaster North Lancaster South 4237 Oregon Pike 241 Rohrerstown Road, Suite 200 Ephrata, PA 17522 Lancaster, PA 17601 Ph: 717.859.5002 Ph: 717.431.1770 Mon.-Thurs. 8 am to 5 pm Mon.-Thurs. 8 am to 5 pm Fri. 8 am to 4 pm Fri. 8 am to 4 pm

Harrisburg Mechanicsburg 6301 Grayson Road, Suite 9 6108 Carlisle Pike Harrisburg, PA 17111 Mechanicsburg, PA 17050 Ph: 717.920.5910 Ph: 717.691.9560 Mon.-Fri. 8 am to 5 pm Mon. & Wed. 7 am to 5 pm;

Tues. & Thursday 8 am to 5 pm Fri. 7 am to 4 pm

Note: All hours of operation may be subject to change without notice. If you have more than three employees that need testing call the clinic to obtain a time suitable to both.

Note: All hours of operation may be subject to change without notice. The employer must fill out information on next page to set up the Drug and Alcohol Program. A delay in sending the completed form back to WORKNET will mean a delay in Pre-employment testing. The employer must fill in the proper OCIP Form below. If the employer is working on multiple sites only one form is necessary to start the Program. It is extremely important that when the employee presents for testing that the employer make sure to check the proper OCIP project on the Authorization Form.

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WORKNET Drug & Alcohol Services Employee Screening Program Contact Information

SEPTA OCIP Project Company Name: Mailing Address: Physical Address: Telephone #: Fax #: Confidential □ Yes □ No DER: Cell phone #: Email address required: Alternate DER: Cell phone #: Email address: □ Billing Same as Above

Billing Contact: Billing Address: By signing below, I authorize WORKNET to conduct the drug testing and/or alcohol testing for workers on the SEPTA OCIP Project. I agree to abide with the Policy & Procedure and the Employee Screening Information Program. I also agree to the price specified in the Employee Screening Program Information. I agree to pay the invoice from WORKNET within 45 days of receipt.

Name:

Signature:

Title:

Date:

Fill this sheet out immediately and fax to WORKNET (717) 412-9761. Once WORKNET receives this completed form the Account Manager will send you your Authorization Forms. Please contact WORKNET Drug & Alcohol Services @ 610.916.4781, if you have any questions. Thank you. Cara Faessen, Program Manager and Rita M. Lebo, Director.