26WS0011-_Required_Documents.pdf

State of California Solicitation Number: 26WS0011 Department of Veterans Affairs

BIDDER’S CHECKLIST

Floor Care Equipment Preventative Maintenance and Repair Services

The checklist below is a summary of documents to be submitted based on requirements in the Invitation for Bid.

This checklist should be returned with your bid. Place a check-mark or “X” next to each document being submitted. Signatures are required on the documents where specified.

The company name listed on all documents submitted (ex. licenses, permits, certifications, and insurance) must be identical to the company name on the Payee Data Record (STD 204). Failure to submit these documents in the manner prescribed may delay award of Agreements.

Bidder’s Checklist

Bidder Certification

Bid Rate Sheet

Signed Payee Data Record - STD 204

Bidder Declaration - GSPD-05-105

Commercially Useful Function (CUF) Certification, if applicable

Disabled Veteran Business Enterprise (DVBE) Declarations – DGS PD 843, if applicable

Darfur Contracting Act

Contractor Certification Clauses (CCC-4/2017) - The CCC-4/2017 can be found on the Internet at https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List- Folder/Standard-Contract-Language

Valid California city or county business license; or, if a corporation located within the State of California, incorporation documents or letter from the Secretary of State; or, if not a California business, an affidavit that business is in good standing with the State, Province, or Country in which business is headquartered.

Sample Invoice https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard-Contract-Language https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard-Contract-Language

BID/BIDDER CERTIFICATION SHEET

This Bid/Bidder Certification Sheet must be signed and returned along with all the "required attachments" as an entire package. The bid must be transmitted in accordance with IFB instructions.

A. I have read and understand the DVBE participation requirements and have included documentation demonstrating that I have met the participation goals, if goals are included.

B. The undersigned signature certifies under penalty of perjury that they are a duly authorized representative and in compliance with all the requirements of this bid document. The signature below authorizes the verification of this certification.

An Unsigned Bid/Bidder Certification Sheet May Be Cause For Rejection.

1. Company Name 2. Telephone Number 2a. Fax Number

2c. E-MAIL

3. Address

Indicate your organization type:

4. Sole Proprietorship 5. Partnership 6. Corporation

Indicate the applicable employee and/or corporation number:

7. Federal Employee ID No. (FEIN) 8. California Corporation No.

9. Bidder’s Name (Print) 10. Title

11. Signature 12. Date

13. Are you certified with the Department of General Services, Office of Small Business and Disabled Veteran Business Enterprise Services (OSDS) as:

a. California Small Business Yes No

If yes, enter certification number:

b. Disabled Veteran Business Enterprise Yes No If yes, enter your service code below:

NOTE: A copy of your Certification should be included if either of the above items is checked “Yes”.

Date application was submitted to OSDS, if an application is pending:

Completion Instructions for Bid/Bidder Certification Sheet

Complete the numbered items on the Bid/Bidder Certification Sheet by following the instructions below.

Item Numbers

Instructions

1, 2, 2a, 3 Must be completed. These items are self-explanatory.

Check if your firm is a sole proprietorship. A sole proprietorship is a form of business in which one person owns all the assets of the business in contrast to a partnership and corporation. The sole proprietor is solely liable for all the debts of the business.

Check if your firm is a partnership. A partnership is a voluntary agreement between two or more competent persons to place their money, effects, labor, and skill, or some or all of them in lawful commerce or business, with the understanding that there shall be a proportional sharing of the profits and losses between them. An association of two or more persons to carry on, as co-owners, a business for profit.

Check if your firm is a corporation. A corporation is an artificial person or legal entity created by or under the authority of the laws of a state or nation, composed, in some rare instances, of a single person and his successors, being the incumbents of a particular office, but ordinarily consisting of an association of numerous individuals.

7 Enter your federal employee tax identification number.

Enter your corporation number assigned by the California Secretary of State’s Office. This information is used for checking if a corporation is in good standing and qualified to conduct business in California.

9, 10, 11, 12

Must be completed. These items are self-explanatory.

If certified as a California Small Business, place a check in the "Yes" box, and enter your certification number on the line. If certified as a Disabled Veterans Business Enterprise, place a check in the "Yes" box and enter your service code on the line. If you are not certified to one or both, place a check in the "No" box. If your certification is pending, enter the date your application was submitted to OSDS.

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE E-MAIL ADDRESS

Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)

CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

Section 3 – Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.

For Individuals, enter SSN.

If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.

For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.

For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.

CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.

No services performed in California

Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

Section 6 – Paying State Agency Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

California Department of Veterans Affairs CBO

1227 O Street 916-651-2159

Sacramento CA 95814 ophelia.deollas@calvet.ca.gov

Print Form Reset Form

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.

Prompt return of this fully completed form will prevent delays when processing payments.

Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).

NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.

A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.

Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).

Section 1 – Payee Information Name – Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return.

Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name.

Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level.

Partnerships, Estates/Trusts, or Corporations – enter the entity name as shown on the entity’s federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Mailing Address – The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.

Section 2 – Entity Type If the Payee in Section 1 is a(n)… THEN Select the Box for…

Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships Limited Liability Partnerships (LLP) and, LLC treated as a Partnership Partnerships Estate Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery care, dentistry, etc. LLC that is to be taxed like a Corporation and is medical in nature

Corporation-Medical

Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) LLC that is to be taxed like a Corporation and is legal in nature

Corporation-Legal

Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt Corporation that does not meet the qualifications of any of the other corporation types listed above LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above

Corporation-All Other

Section 3 – Tax Identification Number The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Section 4 – Payee Residency Status Are you a California resident or nonresident?

A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

A partnership is considered a resident partnership if it has a permanent place of business in California.

An estate is a resident if the decedent was a California resident at time of death.

A trust is a resident if at least one trustee is a California resident.

o For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.

For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:

Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov

Section 5 – Certification Provide the name, title, email address, signature, and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is provided, the individual identified as the tax liable party must certify the form. Note: the signee may differ from the tax liable party in this situation if the signee can provide a power of attorney documented for the individual.

Section 6 – Paying State Agency This section must be completed by the state agency/department requesting the STD 204.

Privacy Statement Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000. You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

All questions should be referred to the requesting state agency listed on the bottom front of this form.

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CALIFORNIA DISABLED VETERAN BUSINESS ENTERPRISE (DVBE)

PROGRAM REQUIREMENTS

(Revision Date 7/1/09)

Please read the requirements and instructions carefully before you begin.

AUTHORITY: The Disabled Veteran Business Enterprise (DVBE) Participation Goal Program for State contracts is established in Public Contract Code (PCC), §10115 et seq., Military and Veterans Code (MVC), §999 et seq., and California Code of Regulations (CCR), Title 2, §1896.60 et seq.

The minimum DVBE participation goal is 3% when DVBE goals are deemed mandatory.

INTRODUCTION: The bidder must complete the identified forms and fully document options A, in this document to comply with this solicitation’s DVBE program requirements. Bids or proposals (hereafter called “bids”) that fail to submit all required forms and fully document and meet the DVBE program requirement shall be considered non-responsive, if requirements are deemed mandatory.

Information submitted by the intended awardee to comply with this solicitation’s DVBE requirements will be verified by the State. If evidence of an alleged violation is found during the verification process, the State shall initiate an investigation, in accordance with the requirements of the PCC §10115, et seq., and MVC §999 et seq., and follow the investigatory procedures required by the CCR §1896.80. Contractors found to be in violation of certain provisions may be subject to loss of certification, penalties and/or contract termination.

Only State of California, Office of Small Business and DVBE Services (OSDS), certified DVBEs (hereafter called “DVBE”) who perform a commercially useful function relevant to this solicitation, may be used to satisfy the DVBE program requirements. The criteria and definition for performing a commercially useful function are contained herein on the page entitled Resources & Information.

Bidders are to verify each DVBE subcontractor’s certification with OSDS to ensure DVBE eligibility.

To meet the DVBE program requirements, bidders must complete and fully document the following compliance option when requirements are mandatory:

Option A - Commitment to full DVBE participation - For a bidder who is a DVBE or who is able to meet the commitment to use identified certified DVBE(s) to fulfill the full DVBE participation goal.

OPTION A – COMMITMENT -- Commit to meet or exceed the DVBE participation requirement in this solicitation by Method A1 (bidder is a California certified DVBE) or A2 (bidder is not a California certified DVBE). Bidders must document DVBE participation commitment by completing and submitting the attached Documentation of Disabled Veteran Business Enterprise Program Requirements (CDVA. 840) and the Bidder Declaration (GSPD-05-105) located elsewhere within the solicitation document. Failure to complete and submit the required forms as instructed shall render the bid non-responsive.

At the State’s option prior to award of the contract, a written confirmation from each DVBE subcontractor identified on the Bidder Declaration must be provided. As directed by the State, the written confirmation must be signed by the bidder and the DVBE subcontractor(s). The written confirmation may request information that includes but is not limited to the DVBE scope of work, work to be performed by the DVBE, term of intended subcontract with the DVBE, anticipated dates the DVBE will perform required work, rate and conditions of payment, and total amount to be paid to the DVBE. If further verification is necessary, the State will obtain additional information to verify the above requirements.

Method A1. Certified DVBE bidder:

a. Commit to performing at least 3% of the contract bid amount (unless otherwise specified) with the prime bidder’s firm or in combination with another DVBE(s).

b. Document option intention on the CDVA 840 (Section A) and document DVBE participation on the Bidder Declaration GSPD-05-105.

c. At the State’s option a DVBE bidder working in combination with other DVBEs shall submit proof of its commitment by submitting a written confirmation from the DVBE(s) identified as a subcontractor on the Bidder Declaration. When requested, the document must be submitted to the address or facsimile number specified and within the timeframe identified in the notification. Failure to submit the written confirmation as specified may be grounds for bid rejection.

Method A2. Non-DVBE bidder:

a. Commit to using certified DVBE(s) for at least 3% (unless otherwise specified) of the bid amount.

b. When a bidder commits to less than the required 3% DVBE participation or its commitment may fall below 3% bidder will not be given any incentive points

c. Document option intention on the CDVA 840 (Section A) and document DVBE participation on the Bidder Declaration GSPD-05-105.

d. At the State’s option prior to contract award, a bidder is to submit proof of its commitment by submitting a written confirmation from each DVBE identified as a subcontractor on the Bidder Declaration GSPD-05-105. The awarding department contracting official named in the solicitation may contact each listed DVBE, by mail, fax or telephone, for verification of the bidder’s submitted DVBE information. When requested, the document must be submitted to the address or facsimile number specified and within the timeframe identified in the notification. Failure to submit the written confirmation as specified may be grounds for bid rejection.

RESOURCES AND INFORMATION

STATE: Contact the Department of General Services, Procurement Division (DGS-PD), Office of Small

Business and DVBE Services (OSDS), to obtain a list of certified DVBEs by telephone at (916) 322-5060 for the 24-hour automated telephone system or (916) 375-4940 for the receptionist during normal business hours. This information can also be obtained by searching the online database at www.pd.dgs.ca.gov/smbus. Begin by selecting Certified Firm Inquiry Services and then search by using either the Keyword Search or the Standard Query options.

FEDERAL: Search the U.S. Small Business Administration’s (SBA) Central Contractor Registration (CCR) on-line database at www.ccr.gov/ to identify potential DVBEs and click on the "Dynamic Small Business Search" button. Search options and information are provided on the CCR Dynamic Small Business Search site. First time users should click on the “help” button for detailed instructions.

LOCAL: For a list of local DVBE organizations, please refer to the DVBE Resource Packet that may be accessed online (www.pd.dgs.ca.gov/smbus - select “DVBE Resource Packet”) or obtain a hardcopy by requesting it from DGS-PD Office of Small Business and DVBE Services (see the Resources & Information page provided herein).

The Bidders Declaration (GSPD-05-105) MUST be included with the bid; failure to submit these documents shall render your bid non-responsive if requirements are mandatory.

RESOURCES AND INFORMATION

For questions regarding bid documentation requirements, contact the contracting official at the awarding department for this solicitation. The Department of General Services, Procurement Division (DGS-PD) publishes a Resource Packet to assist bidders in meeting these contract requirements. To obtain this list, please contact the DGS- PD Office of Small Business and DVBE Services and request the “DVBE Resource Packet.”

U.S. Small Business Administration (SBA):

Use the Central Contractor Registration (CCR) on-line database.

Internet contact only –Database: www.ccr.gov/.

FOR:

Service-Disabled Veteran-owned businesses in California (Remember to verify each DVBE’s California certification.)

Local Organizations (see the DVBE Resource Packet available from DGS-PD DVBE Program Section listed below)

FOR:

List of potential DVBE subcontractors

DGS-PD Office of Small Business and DVBE Services (OSDS) 707 Third Street, Room 1-400, West Sacramento, CA 95605 Website: www.pd.dgs.ca.gov/smbus 24-hour automated information

& document requests: (916) 322-5060 Receptionist: (916) 375-4940 Fax: (916) 375-4950

FOR:

Directory of Certified DVBEs Certification Applications Certification Information Certification Status, Concerns

DGS-PD Office of Small Business and DVBE Services 707 Third Street, Room 1-400, West Sacramento, CA 95605 Voice, 8 am-5 pm: (800) 559-5529 Fax: (916) 375-4597

FOR:

DVBE Program Participation Requirements DVBE Program Info. and Statewide Policy DVBE Resource Packet DVBE Business Utilization Plan Small Business/DVBE Advocates

Commercially Useful Function Definition

California Code of Regulations, Title 2, § 1896.61(l):

The term "DVBE contractor, subcontractor or supplier" means any person or entity that satisfies the ownership (or management) and control requirements of §1896.61(f); is certified in accordance with §1896.70; and provides services or goods that contribute to the fulfillment of the contract requirements by performing a commercially useful function.

As defined in MVC §999, a person or an entity is deemed to perform a "commercially useful function" if a person or entity does all of the following:

Is responsible for the execution of a distinct element of the work of the contract.

Carries out the obligation by actually performing, managing, or supervising the work involved.

Performs work that is normal for its business services and functions.

Is not further subcontracting a portion of the work that is greater than that expected to be subcontracted by normal industry practices.

A contractor, subcontractor, or supplier will not be considered to perform a commercially useful function if the contractor's, subcontractor's, or supplier's role is limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of disabled veteran business enterprise participation.

STATE OF CALIFORNIA – Department of Veterans Affairs

DOCUMENTATION OF DISABLED VETERAN BUSINESS ENTERPRISE PROGRAM

REQUIREMENTS

CDVA 840 (REV. 7/2009)

A. Designation Of Option –Complete the applicable section and attach the required supporting documentation.

You are advised to read all instructions carefully prior to completing this form. Remember that only California certified DVBEs who can provide related goods and/or services may be used to satisfy these program solicitation requirements. DVBEs must perform a commercially useful function. During contract performance, all requests for substituting DVBEs subcontractors must be made in accordance with the provisions of California Code of Regulations, Title 2, §1896.64(c).

OPTION A – I commit to meeting the full DVBE Agreement participation requirement.

Complete: CDVA 840, Section A (check the box on this form) and sign and submit the bidders declaration (GSPD 05-105).

Checking every box of your elected compliance option does not guarantee that your bid will be deemed compliant.

OPTION A: COMMITMENT TO DVBE AGREEMENT PARTICIPATION

CDVA 840 included with bid

Designated the Commitment Option in Section A – Checked the box of the form CDVA 840

Bidder Declaration form GSPD-05-105 completed and included with bid

Proposed DVBE participation meets or exceeds the 3% requirement (unless a different percentage is specified)

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CERTIFICATES OF INSURANCE

DATE (MM/DD/YY) / /

PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS

NO RIGHT UPON THE CERTIFICATE HOLDER. THIS COVERAGE DOES NOT AMEND,

EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.

COMPANIES AFFORDING COVERAGE

COMPANY

A

INSURED COMPANY

B

COMPANY

C

COMPANY

D

COVERAGES

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 CONDIDTION 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.

TYPE OF INSURANCE

POLlCY NUMBER

POLICY

EFFECTIVE

DATE

(MM/DD/YY)

POLICY

EXPIRATION

DATE

(MM/DD/YY)

LIMITS

GENERAL LIABILITY GENERAL AGGREGATE $

COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $

CLAIMS

MADE

OCCUR PERSONAL & ADV INJURY $

OWNER AND CONTRACTOR’S PROT EACH OCCURRENCE $

FIRE DAMAGE (Any one fire) $

MED EXP (Any one person) $

AUTOMOBILE LIABILITY

COMBINED SINGLE LIMIT $

ANY AUTO

ALL OWNED AUTOS BODILY INJURY (Per person) $

SCHEDULED AUTOS

HIRED AUTOS BODILY INJURY (Per accident) $

NON-OWNED AUTOS

PROPERTY DAMAGE $

GARAGE LIABILITY

AUTO ONLY - EA ACCIDENT $

ANY AUTO OTHER THAN AUTO ONLY:

EACH ACCIDENT $

AGGREGATE $

EXCESS LIABILITY

EACH OCCURRENCE $

UMBRELLA FORM AGGREGATE $

OTHER THAN UMBRELLA FORM $

WORKERS COMPENSATION AND

EMPLOYERS’ LIABILITY

STATUTORY LIMITS

THE PROPRIETOR/ EACH ACCIDENT $

PARTNERS/ EXECUTIVE

OFFICERS ARE:

INCL DISEASE - POLICY LIMIT $

EXCL DISEASE - EACH EMPLOYEE $

OTHER

DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS

The State of California, its officers, agents, employees and servants are hereby named as additional insured but only with respect to work performed for the State of California.

CERTIFICATE HOLDER

ATTENTION:

BID NO.

STATE OF CALIFORNIA

P.O. Box 4038 Sacramento, CA 95812-4038

CANCELLATION

SHOULD ANY OF THE ABOVE-DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE

THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE

CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE

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

RESPRESENTATIVES.

AUTHORIZED REPRESENTATIVE

I hereby certify under penalty of perjury that the foregoing is true and correct.

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SAMPLE

Insurance Sample