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�� , � <br /> � <br /> �...w <br /> i INSUI�Al�'CJE COST CALCULAT�C}N {To be completed by each Contractor of every tier.} F.Q� Z <br /> � Date Project Name ' *# iiioiioo <br /> Contractor=s Name .-- <br /> Address <br /> Work Description � <br /> Contact Phone F� <br /> Payroll Cantact Phone Fax <br /> Federal ID Number Gross Contract/Change Order$ <br /> Self-Performing ContractlChange Order$ CO#(s) <br /> Workers=Camp. Ins. Carrier � Policy Period <br /> Gener'al Liability Ins. Carrier Policy Period <br /> UmbrellalExcess Ins. Carrier � Folicy Periad <br /> NCCI;ID Number *OCIP Contract Code <br /> � ' *(To be Assianed by dCIP Administrator.} <br /> (A) Workers= Compensation Payrol] (Project Site Clnly -Attach additional pages if requiared.) <br /> WC,Classification WC Gade WC Rate%$100 Estimated Payroll Fremium <br /> � � , <br /> , � � <br /> Total Payroll: $ <br /> ;� ' <br /> ` Tatal Premium: $ <br /> 7 ! <br /> Prezniurz�Cred'zts: Zf agplicable: 2%- Safety <$ >= $ <br /> � ; If applicable: 5%-Drug Free �$ >= $ <br /> Must provide copy af,WC Exp. Madifier X % = � (A,� <br /> Dec and Racin�Page{S} <br /> (B} General Liabi�ity {�'roject Site Only}Based upon_,Payroll_Receipts 1$lOQ 1$1,440 <br /> GL Classi�cation GL Cade GL Rate Est. P!R ar Rcpts. Premium <br /> Must pravide capy af GL TOt�I G�., $ � {$} <br /> Rating Paje(s) ! � <br /> � � � <br /> (C) ExcesslUmibrella-Rate:$ Per$ Payrall^Receipts_ $ (C) <br /> �; � , <br /> {I}) Subcantractars Premiums (Attach Form 1'far each subcontractor.} $ {3D} <br /> �I i , � <br /> {E) TOTA,L ALL INSURANCE P�t.EIitIIUIVIS {A+B+C+D) $ (E} <br /> To[al Insurance Premium credits represent the amount of insurance premiums that will be excluded from the contracdchange order amount <br /> and are subjeci to autiit. In the event the Owner elects not to provide the project insurance,a pro rata portion of This amount will be added <br /> to tHe ariginal contracdchange order. <br /> i � <br /> ' � - <br /> Si�ried by: �� � Tit}e- <br /> �, <br /> I ' <br /> ;I , i , <br />