USAID_DBA_Application.pdf

USAID – Application 11-15-10 Edition

Form-1

Application for Defense Base Act Insurance eMail: usaiddbains@aon.com

SINGLE SOURCE CONTRACT

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Complete A unless there is an existing policy whereby application is being used to add a new contract or task order; Skip to B, add existing AWAC policy #

A. Contractor Information: Federal ID # or Soc. Sec. #:

Business Information (headquarters) Insurance Brokers & other third parties

Applicant/Insured/ (as stated in your

Complete this section to authorize another third party such as a broker, agent, or consultant to be copied on our direct communications to you. Third parties will not be copied if this section is blank.

USAID Contract)

Company Name & dba:

Contact Name & Title:

Address:

City, State, Zip Code, Country:

Telephone:

Fax:

E.mail Address:

Indicate your Organization’s Structure:

Corporation

Joint Venture

Partnership

Sole Proprietor S-Corporation

Other_

Independent Consultant / Contractor

B. Contract Information: USAID Prime Contract No.: USAID Task Order No (if applicable):

Date Contract Awarded: Existing policy No. (If applicable)

Scope of Work: Contract Period:

Proposed Contract Price $:

Applicant is a Prime or Sub-contractor: If Subcontractor, Name of Prime Subcontract No.

Overseas Start Date: If this is a policy renewal, please provide renewal date

Policy will be effective for 12 months from start date or date application received, which ever is later. If you need space to report additional contracts, please list them on a separate sheet. Fill in “see attached” in the contract number space above.

C. Exposure / Premium Calculation

Remuneration Employee Information – Indicate Annual remuneration as defined below.

For the purposes of this contract, Employee Remuneration is defined as salary plus overseas recruitment incentives, post differential and danger pay, but excludes per diem, housing allowance, travel expenses, temporary quarters allowance, education allowance, and other miscellaneous post allowances. Final remuneration will be adjusted at annual final audit.

1.Type of Contract (Services, Construction, or

Security Guards) 2. Remuneration US Nationals

Remuneration Third Country National (TCN)

Remuneration Cooperating Country National (CCN)

Local Nationals (LN)

Total Employee Remuneration

(DBA Rate Per $100)

Services - $2.00 Construction - $4.50

Security - $7.50

3. Estimated Total Premium

Notes:

1. If more than one category of work is to be performed, this should be pro-rated among all applicable categories. Clerical stays with category.

2. Any US Citizens or legal resident of the United States or any person hired in the United States.

3. Note: No Minimum, Subject to final audit at end of annual policy period – additional task orders will be included in the same policy and remuneration audited.

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D. Country Locations/Job Sites

Country City

Policy Instructions:

Once completed, email to Aon USAID eMail: usaiddbains@aon.com

Aon will review same day and accept if complete and verify coverage has been bound within 24 hours.

Contacts: Premium Payment:

Fred Robinson Primary Administrator Support & Policy Servicing

(o) 415-486-7516, (f) 415-486-7059

Fred.Robinson@aon.com

Back-up Angela Falcone

(o) 415-486-7000

OR Ellen Rowan Program Administrator

(o) 202-862-5306, (f) 202-429-8530

Ellen.Rowan@aon.com

Back-up Chris Thompson

(o) 202-862-5302

Verification of coverage – certificate LS241 will be provided with acceptance with Aon invoice for immediate payment.

Payment due immediately. If payment is not received within 10 days of receipt of invoice, policy will be canceled flat.

“Contracting Officer to obtain (and file) a copy of DBA coverage from each USAID contractor for which contract performance is to occur outside of the U.S. This is to be obtained before any overseas work begins.

E. Signature Block : I verify the information presented above and attachments are correct and submit application for coverage to be bound:

Applicant: / Insured / Company

Name of Authorized

Signor:

Signature:

(please print)

Title: Date:

Company

Countersigned at: Aon Risk Insurance Services West, Inc. License #0363334

Dated: By: Title:

Policy Term: At the end of the policy period the insured, will be provided final audit computation worksheet and adjustment of premium will be processed.

AWAC Policy #:

mailto:Fred.Robinson@aon.com mailto:Ellen.Rowan@aon.com

USAID DBA WAIVER LIST

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Waivers are quite old and many are outdated. Economies and political changes have occurred in many countries which impact the viability of Workers Compensation programs overseas and delivery of such benefits. Consequently, contractors (and subcontractors) are required to determine the existence of valid Workers Compensation programs in those foreign countries in which work is to be performed under a U.S. Government contract. This is mandatory before reliance on any of the country waivers listed.

Albania Antigua Armenia Azerbaijan Bahamas Bangladesh Barbados Belarus Belize Benin Bolivia Bosnia & Herzegovina Botswana Brazil Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Chad Chile Colombia Costa Rica Cote d’Ivoire Croatia

Czech Republic Democratic Republic of the Congo Montenegro Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Estonia Ethiopia Fiji Gambia Georgia Ghana Grenada Guatemala Guinea Guinea-Bissau Haiti Honduras Hungary India Indonesia

Israel Italy Jamaica Jordan Kazakhstan Kenya Korea Krygyzstan Latvia Lebanon Lesotho Liberia Lithuania Macedonia Madagascar Malawi Mali Mauritania Mauritius Mexico Moldova Mongolia Morocco Mozambique Namibia

Nepal New Caledonia Nicaragua Niger Nigeria Oman Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Russian Federation Rwanda

St. Christopher and Nevis

St. Lucia

St. Vincent Senegal Serbia

Seychelles

Sierra Leone

Slovak Republic

Slovenia

Somalia South Africa Sri Lanka Sudan Swaziland Syria Tajikistan Tanzania Thailand Togo Tonga Tunisia Turkey Turkmenistan Uganda Ukraine Uruguay Uzbekistan Vietnam Western Samoa Yemen Yugoslavia Zambia Zimbabwe