URGENT! PLEASE READ REVISED MONTHLY REQUIREMENTS! INSTRUCTIONS FOR MONTHLY PAYMENT REQUEST REQUIREMENTS & OTHER DOCUMENTS On or before the 20th of Each Month subcontractor pay applications (see attached forms) are due to Summit by 9:00a.m. A properly submitted pay application will contain the following documents: ♦ ♦ ♦ ♦

Request For Payment And Partial Waiver of Lien Schedule Of Values Sworn Statement For Contractor And Subcontractor To Owner Waiver And Release Of Liens (as required)

REQUEST FOR PAYMENT AND PARTIAL WAIVER OF LIEN The bottom part of this form shall serve as YOUR partial waiver of lien release. It is to be completed in its entirety and either notarized or witnessed by two persons. Copies of this form may be made but only documents with ORIGINAL signatures will be accepted. SCHEDULE OF VALUES This form needs to be prepared and returned with the executed Subcontract Agreement. It is to be UPDATED EVERY MONTH and serve as an itemized breakdown of the dollar amount being requested on the REQUEST FOR PAYMENT AND PARTIAL WAIVER AND RELEASE OF LIEN FORM (LINE ‘C’). This will be used by the Project Manager to approve the amount you are requesting to be funded. SWORN STATEMENT FOR CONTRACTOR AND SUBCONTRACTOR TO OWNER This form needs to be completed and submitted by the subcontractor at the time the executed Subcontract Agreement is returned to Summit. Each month the “TOTAL PREVIOUS PAYMENT TO SUPPLIER” and “AMOUNT DUE TO SUPPLIER THIS REQUEST” must be updated and submitted as part of the pay application. As new suppliers/subcontractors are secured, their names are to be added to the list as well. The subcontractors listed must remain on the Sworn Statement until Summit receives a Final Release. WAIVER AND RELEASE OF LIEN The waiver and release forms have become critical documents for owners and their financial institutions. Individual lien releases that correspond to the previous payments should be sent back to Summit within 1-2 days of receiving payment, either by fax or mail. For lower tier subcontractors, release dates should be through the date of the previous month’s subcontractor pay application. If a final payment to a supplier/subcontractor has been made, a final lien release is to be obtained and submitted to Summit. Failure to submit the required lien releases in a timely manner will delay the processing of your next payment. If you are unable to execute the release sent to you with your payment, please contact Summit’s Accounting Department immediately. Summit reserves the right to revise formats of lien releases at any time to incorporate changes required by an owner of a project or as required by State mandates. W-9 FORM This form MUST be returned with your executed SUBCONTRACT AGREEMENT. Failure to submit this form will result in IRS mandatory backup withholding. SALES TAX AFFIDAVIT All lines must be filled out, if you do not remit Sales tax but pay suppliers, please list N/A and note in the blank at the bottom “Sales Tax remitted to suppliers”. If we are audited, you will be required to submit proof at that time. This form must be notarized and return to us prior to the first payment being released. SAMPLE CERTIFICATE OF INSURANCE The sample certificate should be forwarded to your insurance company to insure that proper coverage and endorsements are secured. You are not authorized to report to any of Summit jobsite unless proper proof of insurance has been provided to Summit. Insurance that expires must be replaced immediately. Summit reserves the right to hold payments until proper insurance is on file at our corporate office.

IF YOU HAVE ANY QUESTIONS REGARDING THE ABOVE REQUIREMENTS, PLEASE CONTACT YOUR PROJECT MANAGER IMMEDIATELY. IF YOU NEED ANY ASSISTANCE WITH THE PAY APPLICATION FORMS, PLEASE CONTACT YOUR PROJECT ACCOUNTANT.

1000 Riverside Ave Suite 800 • Jacksonville, Florida 32204 • (904) 268-5515 • FAX (904) 292-3301

“Project Name” APPLICATION GUIDELINES PLEASE FORWARD THIS TO YOUR ACCOUNTING DEPARTMENT! There is a complete Payment Application Packet attached for your use throughout the project. Please make several copies or scan this into your system for future draw requests. If you can’t locate your copies, please send me a quick email and I can forward the PDF to you, or you can download from our website. PLEASE ONLY USE THESE FORMS. They are project specific and if the request is not on the correct forms, it will be voided and need to be reissued in its entirety. If you have worked with Summit on previous projects, PLEASE DO NOT USE OLD FORMS. Draws can be emailed to me at [email protected] to make the 20th deadline, but Summit requires the original forms to release payment. Forms can be signed in blue, scanned in color and original is not needed. You will receive an Unconditional Partial Release with each payment. It is VERY important to return these upon receipt of your check. The return address is listed on the bottom of the release. Without this release being returned, you will not receive any more payments until we receive it. Your subcontractor/supplier releases are very important in order for you to receive your payments on time. If they are not on the correct form, we can’t accept them. All sub/supplier releases must be Unconditional Partial Releases. Summit doesn’t require any sub/supplier releases for your 1st payment. However, in order to release your 2nd payment, I must receive unconditional partial releases through the date of your 1st draw request. Summit will issue joint checks if needed, but the correct Conditional Partial Release must be provided from your sub/supplier, and a letter on your company letter head requesting the joint check to be issued. If your sub/supplier is requesting a Joint check Agreement, please contact me for the forms that will be needed. Summit will not sign any other companies Joint Check Agreements. A Sworn Statement must be included with each payment application. If you do not have any sub/suppliers, you still will need to complete this form and in the center of the form make a note that states something like “All materials taken from prepaid stock” or that “There are not any subs/suppliers working for your company on this project “. When you complete this form you are sworn that all information is true and accurate, so please be truthful. A Schedule of Values must accompany your draw request. This will need to be updated every month and serves as an itemized breakdown of the dollar amount being requested. This will be used each month by the Project Manager to approve the amount you are drawing for. Summit has implemented a NEW PROCEDURE, You will need to complete and return to us your Sales Tax Affidavit, before your first payment will be made. Attached is a Sample Certificate of Insurance, we must have a correct Insurance Certificate before you can begin working.

We must have a W9 Form on file. Failure to submit this form will result in IRS mandatory 20% backup withholding. You will be sent all the “Final” paperwork closer to the end of the project. Please do not use the regular forms.

“PROJECT NAME” APPLICATION GUIDELINES

Subcontractor Project Information Sheet Please complete this form with Names, Phone Numbers, and Email addresses of the people associated with this project. Subcontractor Name: Project Manager: Phone #: Email: Accounting: Phone #: Email: Lien Releases: Phone #: Email: Certified Payroll: Phone #: Email: Insurance Certificate: Phone #: Email:

Summit Project Team Project Accountant: ___________Phone ________Email________________________________________ Project Administrator: _________Phone________Email________________________________________ Project Manager: _____________Phone________Email________________________________________

REQUEST FOR PAYMENT DRAW (INVOICE) #: DRAW DATE: PERIOD END DATE: AGREEMENT PROJECT: LOCATION:

1000 Riverside Ave Suite 800, Jacksonville, FL 32204 904-268-5515

OFFICE USE ONLY

a)

Amount of original agreement

……………………………………$__________________

b)

Net Change Orders #1 thru #_______

……………………………………$__________________

c)

Revised agreement amount (a+b)

……………………………………$__________________

d)

Work completed to date

e)

Value of stored materials (itemized inventory attached)

f)

Total completed & stored to date (d+e)

………………………………………………$__________________ ………………………… $__________________

…………………………………… $__________________ ……..………. $__________________

g)

Less previous applications (line f from previous draw)

h)

Current application (f-g)

…………………………………. $__________________

i)

Less ________ % retainage (h*%)

…………………………………. $__________________

j)

Less other deductions (State if applicable)

k)

Net amount this request (h-i-j)

l)

Balance to complete agreement (c-f)

m)

Job-To-Date Retainage Held

………………………… $__________________

………………………………….. $__________________ ………………………………….. $__________________

………………………………………………$__________________

CONDITIONAL PARTIAL WAIVER AND RELEASE OF LIEN The undersigned subcontractor acknowledges that there are no additional costs or claims for any extras

This agreement constitutes a partial release of lien to the extent of all monies

or additions for labor or material on the described real estate performed to date, except as authorized by

due and owing, including the cost of additional labor and material for work

signed Change Orders which are included on line "b" below and further certifies that all work performed or

being performed without a signed Change Order up to date hereof, and further

materials installed are in accordance with the approved plans and specifications on the agreement.

is given in accordance with Governing Mechanics Lien Law and the undersigned

The undersigned certifies that all laborers and materialmen with regard to the job have been fully paid

subcontractor certifies that he has paid all laborers and materialmen to the date

and that none of such laborers and materialmen have any claims, demands or claims of lien against said

hereof and this agreement constitutes a sworn affidavit inducing Summit

premises, and the undersigned subcontractor does hereby agree to indemnify and hold harmless

Contracting Group, Inc. to make the payment requested.

Summit Contracting Group, Inc. against any loss or damage, including a reasonable attorney's fee, which it may sustain by reason of placing or filing of liens against said real estate by subcontractor's laborers or materialmen for amounts due them for services performed to date.

SIGNATURE MUST BE NOTARIZED OR WITNESSED BY TWO PERSONS.

Witness the hand and seal of the undersigned this _________ day of _____________________________,20_______ By: Name of Company

Signature

Title

Address

Phone

Before me, the undersigned authority, personally appeared __________________________ who, by me being first duly sworn, did acknowledge that he or she is the ____________________ of _________________________ and as such has the authority to execute this document and that the facts stated therein are true. Dated this _________ date of _______________________, 20________. My Commission Expires: ______________________________________ STATE OF __________________ COUNTY OF __________________

Witness:

________________________________________

___________________________________ ___________________________________

Notary Public

CHECK DELIVERY (CIRCLE ONE) * DELIVER TO JOB SITE * REGULAR MAIL * OVERNIGHT-FEDEX/UPS #____________________________ OFFICE USE ONLY

W-9 (FED ID #)

SWORN STATEMENT

AGREEMENT

INSURANCE

PM APPROVAL

LICENSES/BOND

CO'S

VP APPROVAL

RELEASES

Eff/06-08

REQUEST FOR PAYMENT DRAW (INVOICE) #:

Draw date is the date you submit your draw

DRAW DATE: PERIOD END DATE:

This information can be Found on your agreement

AGREEMENT

Period end date is the last date the work was completed that

PROJECT: LOCATION:

1000 Riverside Ave Suite 800, Jacksonville, FL 32204 904-268-5515

OFFICE USE ONLY

a)

Amount of original agreement

……………………………………$__________________

b)

Net Change Orders #1 thru #_______

……………………………………$__________________

c)

Revised agreement amount (a+b)

……………………………………$__________________

d)

Work completed to date

e)

Value of stored materials (itemized inventory attached)

f)

Total completed & stored to date (d+e)

Only Approved Change orders can be billed /signed & on Summit forms

………………………………………………$__________________ ………………………… $__________________

…………………………………… $__________________

Total Completed & Stored line (f)

……..………. $__________________ from previous draw

g)

Less previous applications (line f from previous draw)

h)

Current application (f-g)

…………………………………. $__________________

i)

Less 10 % retainage (h*%)

…………………………………. $__________________

j)

Less other deductions (2% state if applicable)

k)

Net amount this request (h-i-j)

l)

Balance to complete agreement (c-f)

m)

Job-To-Date Retainage Held

………………………… $__________________

………………………………….. $__________________ ………………………………….. $__________________

………………………………………………$__________________

CONDITIONAL PARTIAL WAIVER AND RELEASE OF LIEN The undersigned subcontractor acknowledges that there are no additional costs or claims for any extras

This agreement constitutes a partial release of lien to the extent of all monies

or additions for labor or material on the described real estate performed to date, except as authorized by

due and owing, including the cost of additional labor and material for work

signed Change Orders which are included on line "b" below and further certifies that all work performed or

being performed without a signed Change Order up to date hereof, and further

materials installed are in accordance with the approved plans and specifications on the agreement.

is given in accordance with Governing Mechanics Lien Law and the undersigned

The undersigned certifies that all laborers and materialmen with regard to the job have been fully paid

subcontractor certifies that he has paid all laborers and materialmen to the date

and that none of such laborers and materialmen have any claims, demands or claims of lien against said

hereof and this agreement constitutes a sworn affidavit inducing Summit

premises, and the undersigned subcontractor does hereby agree to indemnify and hold harmless

Contracting Group, Inc. to make the payment requested.

Summit Contracting Group, Inc. against any loss or damage, including a reasonable attorney's fee, which it may sustain by reason of placing or filing of liens against said real estate by subcontractor's laborers or materialmen for amounts due them for services performed to date.

SIGNATURE MUST BE NOTARIZED OR WITNESSED BY TWO PERSONS.

Witness the hand and seal of the undersigned this _________ day of _____________________________,20_______

If you want your check sent overnightAddress please list your Before me, the undersigned authority, personally appeared __________________________ who, by me being first duly sworn, did acknowledge that account# and he or she is the ____________________ of _________________________ and as such has the authority to execute thishow document circle youand that the facts stated therein are true. want it delivered!! Dated this _________ date of _______________________, 20________. My Commission Expires: ______________________________________ By:

Name of Company

Signature

STATE OF __________________ COUNTY OF __________________

Witness:

________________________________________

Phone

___________________________________ ___________________________________

Notary Public

CHECK DELIVERY (CIRCLE ONE) * DELIVER TO JOB SITE * REGULAR MAIL * OVERNIGHT-FEDEX/UPS #____________________________ OFFICE USE ONLY

Title

W-9 (FED ID #)

SWORN STATEMENT

AGREEMENT

INSURANCE

PM APPROVAL

LICENSES/BOND

CO'S

VP APPROVAL

RELEASES

Eff/06-08

SUBCONTRACTOR NAME: ____________________

SCHEDULE OF VALUES APPLICATION NO.: APPLICATION DATE: PERIOD TO: ARCHITECT'S PROJECT NO:

In tabulations below, amounts are stated to the nearest dollar. Use Column I on Agreements where variable retainage for line items may apply.

A

B

C

ITEM NO.

DESCRIPTION OF WORK

SCHEDULED VALUE

JOB NAME: JOB NUMBER:

D

E

F

WORK COMPLETED FROM PREVIOUS THIS PERIOD APPLICATION (D + E)

G

MATERIALS PRESENTLY STORED (NOT IN D OR E)

TOTAL COMLETED AND STORED TO DATE (D+E+F)

% (G / C)

H

I

BALANCE TO FINISH (C - G)

RETAINAGE (IF VARIABLE RATE)

Punch (5% of Scheduled Value Total) Clean (5% Scheduled Value Total) GRAND TOTALS

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

Sworn Statement for Contractor and Subcontractor to Owner State of ______________________________ Draw Period Ending: ______________________________ County of ____________________________ The affiant (1)______________________________ being first duly sworn on oath dispossess and says that he/she is the (2)______________________________ of (3)______________________________ who has an agreement with SUMMIT CONTRACTING GROUP, INC., for (4)______________________________ on the following described premises in said county in which located (5) _______________________________________ and owned by (6) ______________________ That for the purpose of said agreement, the following persons have been contracted with and have furnished, or are furnishing and preparing material for, and have done or are doing labor and/or materials on said improvement. That there are not persons with contracts for labor and/or materials for said improvement. That there is due and to become said persons, respectively, the amounts set opposite their names for materials or labor as stated. That all lien waivers provided to Owner are true, correct and genuine and delivered unconditionally and that there is no claim either legal or equitable to defeat the validity of said waivers. That this statement is made to said Owner for the purpose of procuring from said Owner. (7) __________ payment on said contract, and is full, true and complete statement of all such persons, and of the payments paid, due and to become due them. (1) Executor’s Name (2) Executor’s Title (3) Firm Name (4) General Work Description (5) Site Location (6) Owner (7) Payment Type

Name of Supplier Contact Person Phone Number

Contracted For

Total Contract Amount With Supplier

Total Previous Payment To Supplier

Amount Due To Supplier This Request

I agree to furnish Waivers of Lien for all labor and materials under my agreement when demanded. ___________________________________ Subcontractors’ Signature

___________________________________ Notary Public Signature

___________________________________ Notary Seal and Stamp

Subscribed and sworn before me this __________ day of _______________ 20 _____

The above sworn statement shall be obtained by the General Contractor before each and every payment.

(1) Name of Person Signing the form

Sworn Statement for Contractor and Subcontractor to Owner Draw Date

State of ______________________________

(3)Company

County of ____________________________ Name

(5)Address of the project

(6)Owner of Draw Period Ending: ______________________________

(2)Title of the person signing the form.

the project

The affiant (1)______________________________ being first duly sworn on oath dispossess and says that he/she is the (2)______________________________ of (3)______________________________ who has an agreement with SUMMIT CONTRACTING GROUP, INC., for (4)______________________________ on the following described premises in said county in which located (5) _______________________________________ and owned by (6) ______________________ That for the purpose of said agreement, the following persons have been contracted with and have furnished, or are furnishing and preparing material for, and have done or are doing labor and/or materials on said improvement. That there are not persons with contracts for labor and/or materials for said improvement. That there is due and to become said persons, respectively, the amounts set opposite their names for materials or labor as stated. That all lien waivers provided to Owner are true, correct and genuine and delivered unconditionally and that there is no claim either legal or equitable to defeat the validity of said waivers. That this statement is made to said Owner for the purpose of procuring from said Owner. (7) __________ payment on said contract, and is full, true and complete statement of all such persons, and of the payments paid, due and to become due them. (1) Executor’s Name (2) Executor’s Title (3) Firm Name (4) General Work Description (5) Site Location (6) Owner (7) Payment Type

Name of Supplier Contact Person Phone Number

Contracted For

Total Contract Amount With Supplier

Total Previous Payment To Supplier

(7) Progress Payment

Amount Due To Supplier This Request

ALL SUBCONTRACTORS & SUPPLIERS MUST BE LISTED ON THIS FORM (Do not include your company on this form)

-Once the sub/supplier is listed on this form, you must continue to list them until a Final Release is received by Summit’s Accounting Dept. (You can find this form in the attached) -Even though no funds may be owed to your suppliers every month, you must still continue to list them on this form until a final is received, and submit an Unconditional Partial Release for each company listed for the previous months draw dates before your next funding will be released. I agree to furnish Waivers of Lien for all labor and materials under my agreement when demanded. ___________________________________ Subcontractors’ Signature

___________________________________ Notary Public Signature

___________________________________ Notary Seal and Stamp

Subscribed and sworn before me this __________ day of _______________ 20 _____

The above sworn statement shall be obtained by the General Contractor before each and every payment.

SALES TAX AFFIDAVIT Project Name: ________________________________________________________ Project Location: ______________________________________________________ Local Jurisdiction In Which the Sales Tax Will be Remitted:

Registration #

County In Which The Sales Tax Will be Remitted:

Registration #

State In Which The Sales Tax Will be Remitted:

Registration #

Printed Name: Company Name: Date: Authorized Signature: The purpose of this affidavit is to provide us documentation that you will pay sales tax on materials purchased for Summit Contracting Group, Inc. for the project referenced above. This document must be signed, notarized and returned to our office with PROOF OF REGISTRATION OF ALL APPLICABLE TAXES prior to the release of your FIRST check. The execution of this document is verification that the above listed company WILL remit sales tax to the appropriate jurisdictions for the above referenced project. PLEASE NOTE: THIS EXECUTED DOCUMENT AND PROOF OF REGISTRATION IS REQUIRED BEFORE RELEASE OF YOUR FIRST CHECK. NO EXCEPTIONS.

STATE OF COUNTY OF The foregoing by identification.

instrument was acknowledge before me this , who is personally known to me or who has produced

day

of

NOTARY PUBLIC:_ Typed Name:_ Commission Expires:_ Commission No:

RETURN TO: Summit Contracting Group, Inc. 1000 Riverside Ave, Suite 800, Jacksonville, FL 32204

,

20

, as

SALES TAX AFFIDAVIT Must be filled in

Project Name: _________________________________________________________ Project Location: _______________________________________________________ Local Jurisdiction In Which the Sales Tax Will be Remitted ___________

Registration # _________________

County In Which The Sales Tax Will be Remitted:___________________

Registration #_________________

State In Which The Sales Tax Will be Remitted: ______ ___________

Registration #__________________

Printed Name: __________________________________________________________

Must be filled in Company Name: ________________________________________________________ Date: _________________________________________________________________

Must be signed

Authorized Signature:____________________________________________________ The purpose of this affidavit is to provide us documentation that you will pay sales tax on materials purchased for Summit Contracting Group, Inc. for the project referenced above. This document must be signed, notarized and returned to our office with PROOF OF REGISTRATION OF ALL APPLICABLE TAXES prior to the release of your FIRST check. The execution of this document is verification that the above listed company WILL remit sales tax to the appropriate jurisdictions for the above referenced project. PLEASE NOTE: THIS EXECUTED DOCUMENT AND PROOF OF REGISTRATION IS REQUIRED BEFORE RELEASE OF YOUR FIRST CHECK. NO EXCEPTIONS. STATE OF __________________ COUNTY OF ________________ The foregoing instrument was acknowledge before me this___________ day of ______________, 20__, by______________________________, who is personally known to me or who has produced _____________________________ as identification. NOTARY PUBLIC:___________________________________ Typed Name:_________________________________________ Commission Expires:___________________________________ Commission No:_______________________________________

INTERIM WAIVER AND RELEASE UPON PAYMENT

STATE OF GEORGIA COUNTY OF ___________

THE UNDERSIGNED MECHANIC AND/OR MATERIALMAN HAS BEEN EMPLOYED BY _SUMMIT CONTRACTING GROUP, INC. TO FURNISH ___________________________(DESCRIBE MATERIALS AND / OR LABOR) FOR THE CONSTRUCTION OF IMPROVEMENTS KNOWN AS ____________ WHICH IS LOCATED IN THE CITY OF ________________, COUNTY OF _____________________, AND IS OWNED BY _________________________________________ AND MORE PARTICULARLY DESCRIBE AS FOLLOWS: JOB NAME: ADDRESS: CITY, STATE, ZIP:

UPON THE RECEIPT OF THE SUM OF $____________________, THE MECHANIC AND/OR MATERIALMAN WAIVES AND RELEAES ANY AND ALL LEINS OR CLAIMS OF LEINS IT HS UPON THE FOREGOING DESCRIBED PROPERTY OR ANY RIGHTS AGAINST ANY LABOR AND / OR MATERIAL BOND THROUGH THE DATE OF __________(DATE) AND EXECEPTING THOSE RIGHTS AND LIENDS THAT THE MECHANIC AND/OR MATERIAL MAN MIGHT HAVE IN ANY RETAINED AMOUNTS, ON ACCOUNT OF LABOR OR MATERIALS, OR BOTH, FURNISHED BY THE UNDERSIGNED TO OR ON ACCOUNT OF SAID CONTRACTOR FOR SAID BUILDING (S) OR PREMISES. GIVEN UNDER HAND AND SEAL THIS _____ DAY OF _______________, 20___.

SUMMIT CONTRACTING GROUP, INC (Company/Organization/Individual) ____________________________ (SEAL) (SIGNATURE) _________________________________ WITNESS _________________________________ ADDRESS NOTICE: WHEN YOU EXECUTE AND SUBMIT THIS DOCUMENT, YOU SHALL BE CONCLUSIVELY DEEMED TO HAVE BEEN PAID IN FULL THE AMOUNT STATED ABOVE, EVEN IF YOU HAVE NOT ACTUALLY RECEIEVED SUCH PAYMENT, 60 DAYS AFTER THE DATE STATED ABOVE UNLESS YOU FILE EITHER AN AFFIDAVIT OR NONPAYMENT OR A CLAIM OF LIEN PRIOR TO THE EXPIRATION OF SUCH 60 DAY PERIOD. THE FAILURE TO INCLUDE THIS NOTICE LANGUAGE ON THE FACE OF THE FORM SHALL RENDER THE FORM UNENFORCEABLE AND INVALID AS A WAIVER AND RELASE UNDER O.C.G.A. SECTION 4414-366.

Return to: Summit Contracting Group, Inc., 1000 Riverside Ave Suite 800, Jacksonville, FL 32204

INSURANCE SPECIFICATIONS Before commencing the work, the Subcontractor shall procure and retain at it(s) own expense until completion and final acceptance of the work, the following minimum coverages and limits. Such coverage should be placed in insurance companies who have at least an A.M. Best company rating of A-. Insurance certificate must include: A. WORKERS’ COMPENSATION AND EMPLOYER’S LIABILITY INSURANCE 1. Workers’ Compensation and Occupational Disease Coverage in accordance with the laws of the State within whose jurisdiction the work is performed. In the event that the work of this contract falls within the purview of the United States Longshoremen’s and Harbor Workers’ Compensation Act, the Jones Act or the Federal Employer’s Liability Act, the Subcontractor(s) shall extend his insurance coverage to provide and maintain in full force and effect during the period covered by this subcontract, insurance against the liability imposed under either or both of these Acts as applicable. 2. Employer’s Liability Coverage within minimum limit of: $1,000,000 Bodily Injury by Accident $1,000,000 Bodily Injury by Disease $1,000,000 Bodily Injury by Disease Each Employee B. COMMERCIAL GENERAL LIABILITY INSURANCE including but not limited to the following coverages: 1. Premises/Operations Liability. 2. Products/Completed Operations Hazards Included. 3. Contractual Liability Coverage Included. 4. Broad Form Property Damage Liability Included. 5. Per Project Aggregate 6. The Limits of Insurance shall be at least as follows: $2,000,000 General Aggregate Limit (Other than Products/Completed Operations) $2,000,000 Products/Completed Operations Aggregate Limit $1,000,000 Personal and Advertising Injury Limit $1,000,000 Each Occurrence Limit C. BUSINESS AUTOMOBILE INSURANCE including the following coverages: 1. Owned Vehicles. 2. Hired Vehicles. 3. Non-owned Vehicles. 4. Each of the above listed coverages shall provide coverage in the following minimum limits of liability: $1,000,000 Bodily Injury and Property Damage Per Occurrence; Combined Single Limit D. COMMERCIAL UMBRELLA/EXCESS LIABILITY CAN BE INCLUDED TO EXTEND THE REQUIRED LIMITS Before commencing work, the Subcontractor shall furnish a certificate of insurance showing that the above required insurance is in force, stating policy numbers, date effective & expiration, and limits of liability thereunder, and further providing that the insurance(s) will not be canceled or changed prior to, at least, 30 days (10 days for nonpayment) after written notice of such cancellation has been given to the Contractor as evidenced by return receipt of registered or certified letter. Said certificate is to state that the policies described therein have been endorsed to provide Summit Contracting Group, Inc. as well as any other parties as required under the contract, as Additional Insureds on a Primary and Noncontributory basis to the General Liability, Auto, and Umbrella; and included on a Waiver of Subrogation under the General Liability, Auto, Workers’ Compensation and Umbrella for any and all work performed under contract to them. The certificate shall also show State(s) covered under the Workers Compensation, which is to include the state where work is being performed; and the name and address of project/job being performed. Summit Contracting Group, Inc. 1000 Riverside Avenue, Suite 800 Jacksonville, FL 32204

ABCCONT-01

VCANDAMIO DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

8/17/2015

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT NAME: PHONE (A/C, No, Ext): E-MAIL ADDRESS:

PRODUCER

Acentria, Inc - Jacksonville Office 4634 Gulfstarr Dr Destin, FL 32541

FAX (A/C, No):

INSURER(S) AFFORDING COVERAGE INSURER A : Insurance INSURED

NAIC #

Company of the West

27847

INSURER B : INSURER C :

Subcontractor Name & Address ***NAME MUST MATCH CONTRACT***

INSURER D : INSURER E : INSURER F :

COVERAGES

CERTIFICATE NUMBER:

REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR

A

ADDL SUBR INSD WVD

TYPE OF INSURANCE

X

POLICY EFF POLICY EXP (MM/DD/YYYY) M MM/DD/YYYY) MM/DD/YYYY (MM/DD/YYYY) MM/DD/YYYY

POLICY NUMBER

COMMERCIAL GENERAL LIABILITY CLAIMS-MADE

X

X

OCCUR

X POLICY NUMBER

04/21/2015 04/21/2016

X XCU Included X Contractual GEN'L AGGREGATE LIMIT APPLIES PER: PROPOLICY X JECT LOC

LIMITS

EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence)

$

MED EXP (Any one person)

$

PERSONAL & ADV INJURY

$

GENERAL AGGREGATE

$

PRODUCTS - COMP/OP AGG

$

ANY AUTO ALL OWNED AUTOS

X

HIRED AUTOS

X

UMBRELLA LIAB

1,000,000 50,000 5,000 1,000,000 2,000,000 2,000,000

$

OTHER: AUTOMOBILE LIABILITY

A

$

X X X

X POLICY NUMBER

04/21/2015 04/21/2016

SCHEDULED AUTOS NON-OWNED AUTOS

COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person)

$

1,000,000

$

BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident)

$

EACH OCCURRENCE

$

$

A

A

EXCESS LIAB

X

OCCUR CLAIMS-MADE

X RETENTION $ DED WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

X

X POLICY NUMBER

04/21/2015 04/21/2016

AGGREGATE

$ $

X Y/N N/A

X POL# /LIST STATES COVERED

04/21/2015 04/21/2016

PER STATUTE

OTHER

E.L. EACH ACCIDENT

$

E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT

POL# /AMOUNT TO COVER ANY 04/21/2015 04/21/2016 Per Location Minimum

A INSTALLATION FLOATER A NO LESS THAN 100,000

LOSSES OF STORED MATERIAL 08/17/2015 08/17/2016 Per Disaster Minimum

$

1,000,000 1,000,000 1,000,000 100,000 100,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

RE: PROJECT/JOB & ADDRESS | Certificate holder [and include other parties if required under the contract] is included as Additional Insured on Primary and Noncontributory basis with respect to the General Liability including Completed Operations, Auto Liability and (if needed) Umbrella Liability; and under a Waiver of Subrogation on the General Liability, Auto Liability and Workers Compensation. The Workers' Compensation policy provides coverage to this contractor and its employees in the State(s) of ___________. Cancellation Notice to the holder: 30 days except 10 days for non-payment of premium.

CERTIFICATE HOLDER

CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE

SUMMIT CONTRACTING GROUP INC 1000 Riverside Ave, Suite 800 Jacksonville, FL 32204

ACORD 25 (2014/01)

© 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD