Owner Controlled Insurance Program Required Set-up Information for Program Administration

Owner/Sponsor
Developer
Company Name:
Contact Person:
Street Address:
Phone:		Fax:
E-Mail:
In-House Claims Representative
Contact Name:
Phone:		Fax:
E-Mail:
OCIP General Contractor
Company Name:
Contact Person:
Street Address:
Phone:		Fax:
E-Mail:
Project Manager:
Phone:		Fax:
E-Mail:
Safety Contact:
Phone:		Fax:
E-Mail:
Claims Reporting Phone Line
Contact Person:
Phone:		Fax:
E-Mail:
OCIP Insurance Agent
Company Name:
OCIP Agent Name:
Street Address:
Phone:		Fax:
E-Mail:
OCIP Insurance Policy Information - Your Agent can assist you with this information
First Named Insured  on Policy:
Second Named Insured  on Policy:
Name of Primary Carrier:
Limits of Insurance
Per Occurance:
General Aggregate:
Completed Ops:
Policy Term:
Self Insured Retention: $		deductible:
OCIP Excess Insurance Policy Information
Name of Excess Carrier:
Limits of Insurance:
Name of Excess Carrier:
Limits of Insurance:
OCIP Excess Insurance Policy Information
Name of Excess Carrier:
Limits of Insurance:
Name of Excess Carrier:
Limits of Insurance:
OCIP Project Information
Name of Project:
Address:
Entity Owning Land:
Type of Project:	Condos     Single Family Homes     Townhomes
	Mixed Use: Retail/Condos     Apartment Building
# of Units:		# of Phases:
Start Date:		End Date:
Hard Construction Cost:			Have you awarded Contracts? Yes No
OCIP Project Information if more than one project under OCIP program [PROJECT 2]
Name of Project:
Address:
Entity Owning Land:
Project Manager:
Phone:		Fax:
E-Mail:
Safety Contact:
Phone:		Fax:
E-Mail:
Claims Reporting Phone Line
Contact Person:
Phone:		Fax:
E-Mail:
Type of Project:	Condos     Single Family Homes     Townhomes
	Mixed Use: Retail/Condos     Apartment Building
# of Units:		# of Phases:
Start Date:		End Date:
Hard Construction Cost:			Have you awarded Contracts? Yes No
OCIP Project Information if more than one project under OCIP program [PROJECT 3]
Name of Project:
Address:
Entity Owning Land:
Project Manager:
Phone:		Fax:
E-Mail:
Safety Contact:
Phone:		Fax:
E-Mail:
Claims Reporting Phone Line
Contact Person:
Phone:		Fax:
E-Mail:
Type of Project:	Condos     Single Family Homes     Townhomes
	Mixed Use: Retail/Condos     Apartment Building
# of Units:		# of Phases:
Start Date:		End Date:
Hard Construction Cost:			Have you awarded Contracts? Yes No

Is this the first OCIP purchased by your organization?	Yes    No
Will you require subs to give insurance bid credits?	Yes    No
Have you begun the bidding process?	Yes    No
If so, did your trade partners include liability insurance in their bids?	Yes    No   Not Sure
Do you wish to include the Loss Control Services provided by Safety Compliance Company with Wrap Up Administration Services?	Yes    No
Please submit only once. The form may take a few moments to process.