Account Name
Account Contact Name
Account web site address
Contractors License Number:
Are you a member of a trade association?
Producer Name
Account Telephone No:
Account e-mail address Date Completed
Yes No
Enter the percentage of your PAYROLL that emanates from the following operations . Exclude work that you subcontract when determining eligibility percentages. Do not add % of payroll if the activity is part of a primary job. For example, if you do grading as part of putting in a driveway, 100 % of payroll should be allocated to Driveway.
Percentage based on payroll:

Grading of Land - Residential

Grading of Land - Commercial

Grading of Land - Curb to Curb

Excavation

Irrigation or Drainage System Construction

Driveway, Parking Lot or Sidewalk - Paving or Repaving

Street/road construction or reconstruction, including clearing of right-of-way, excavation, filing
or grading (i.e. site preparation)

Street/road paving or repaving or surfacing, including street/road striping

Conduit construction for cables and wires

Telephone, telegraph or cable television line construction (underground only)

Tunneling operations for the installation, service or repair of underground utility lines
 using trenchless excavation construction

Gas mains or connections construction

Water Mains or connections construction including Residential Hook-
Up’s

Water Mains or connections construction excluding Residential HookUp’s

Sewer mains or connections construction including Residential Hook-
Up’s

Sewer Mains or connections construction excluding Residential HookUp’s

Concrete Work
– sound walls, concrete cutting, etc. Do not include pad work

Water Well Drilling

Septic Tank

Asphalt Works, Sand/Gravel Digging, Stone Crushing

Contractor Permanent Yards
If the total is less than 100%, you may be ineligible for the LCA Program.
TOTAL
Describe any other operations:
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
Do you communicate with the USA Dig Alert and the area utility owners that are not members of the USA Dig
Alert prior to all excavation work? If no, you are ineligible for the LICA Program
Yes No
October 2007 Page 1 of 5

Related operations:

Hook-ups for water, sewer or gas? Yes No If yes, indicate type

Airport runways or warming aprons

Any residential finish grading which is not curb to curb?
Yes
Yes
No
No
Are you involved in any of the following operations:

Bridge construction – including bridge culvert and tunneling unless clearance is less than 10 ft. and not more than 20 ft. wide

Concrete Construction of a structural nature and/or foundation work

Dam Construction (reservoirs) except ponding basins

Demolition works except in conjunction with site development work not over 2 stories and clearing land for agricultural purposes

Flood Control or Prevention except in conjunction with site work

Foundation Pouring Work - load bearing

Hauling for others except if incidental (less than 20% of gross receipts)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
How many per year? Commercial % Residential %

Irrigation companies or water-works operations

Levee or Breakwater Construction Except for agricultural irrigation

Oil or gas well drilling, repair or service

On-site Waste Treatment except septic tanks

Pile Driving or Caisson work

Quarry, mining, or asphalt plant operations including gravel digging, stone crushing and asphalt batch plant operations if more than 30% sold to others
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No

Removal of underground petroleum storage tanks

Renting or leasing of owned equipment (power or otherwise) without operator to others

Sewage/Water Treatment Plant Construction other than site grading and excavation

Street or Road Work on Freeway, Bi-ways, connectors or Express Highway construction
Yes
Yes
Yes
Yes
No
No
No
No

Subcontracting other than incidental amounts (less than 25%) as described in the eligibility guidelines Yes No

Surveyors third party Yes No

Tree Pruning or Removal except for clearing land for agricultural purposes or incidental to other site development work

Tunneling except at street crossings unless trenchless
Yes
Yes
No
No

Underpinning buildings

Work done within city-center (downtown) or major metro areas (City of Los Angeles, San Francisco, and
San Diego) unless incidental to operations

Work on hillsides with slopes greater than 20 percent
Yes
Yes
Yes
No
No
No
If Yes to any of the above you may be ineligible for the LICA Program.
1. You operate as:
Construction Manager % General Contractor %
2. Any current or past involvement with wrap-up/OCIP?
Any residential wrap-ups?
Note: Be sure to exclude receipts and payroll from above operations.
October 2007 Page 2 of 5
Subcontractor %
Yes No
Yes No

3. Enter the percentage of your payroll and/or sales that emanate from residential or commercial work from the following operations:
Residential site preparation: Rough grading % Finish grading % Soil compaction %
Commercial site preparation:
Building site pad preparation
Foundation form construction
Rough grading % Finish grading %
% Soil stabilization
% Foundation design
Soil compaction
%
%
%
Concrete pouring for foundations Foundation pier hole drilling
3. Indicate the average percentage of your TOTAL payroll or sales during the past 3 years for the following:
Percentages based on: (Check one)
COMMERCIAL WORK
Payroll or Sales
%
INDUSTRIAL WORK
HABITATIONAL WORK
%
%
TOTAL ( THE TOTAL SHOULD EQUAL 100 %.)
Please complete if you do any habitational work.
HABITATIONAL WORK BREAKDOWN
CONDOMINIUMS (High And Low Rise)
MULTI-FAMILY DEVELOPMENTS (including townhouses)
APARTMENTS
TRACT HOUSING
CUSTOM HOMES
%
% NEW or
MAJOR REHAB/
RENOVATION
%
%
%
%
%
+
+
+
+
+
+
% SERVICE OR
MAINTENANCE
%
%
%
%
%
Other % + %
TOTAL ( THE TOTAL SHOULD EQUAL 100 %.) % + %
5. Do you have any future plans related to work involving apartments, condos, townhouses, tract homes, custom homes or homes of unusual design?
If Yes , please describe.
=
=
=
=
=
=
=
=
%
%
%
%
%
%
%
Yes No
6. PAYROLL/GROSS RECEIPTS HISTORY
Year Payroll Subcontractor
Costs
Non
– OCIP
Receipts
Premium Deductible
Anticipated $
Current
1 st Prior
2 nd Prior
3 rd Prior
4 th Prior
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
OPIC Receipts
$
$
$
$
$
$
N/A
$
$
$
$
$
N/A
$
$
$
$
$
October 2007 Page 3 of 5

7. List the states you have worked in during the last 5 years.
8. Have you ever been cited for any OSHA or state labor board violations in the past three years
If yes, please explain:
9. Describe your three largest jobs currently underway or planned for the next year:
Start Date End Date
Year Completed
Description
10. Describe the four largest projects completed in the past five years:
Description
Yes
Value
Value
No
11. Have you ever been named in claims and/or litigation regarding faulty or defective construction or workmanship, including claims due to subsidence or construction defect issues?
If Yes , were you acting as a general or sub-contractor?
Was it a commercial project?
Provide detail on claims/litigation and what loss control measures you implemented for the future.
Was it a habitational project?
Yes No
Yes No
Yes No
Yes No
Yes No 12. Do you have knowledge of any pre-existing act, omission, event; condition or damages to any person or property that may potentially give rise to any future claim or legal action? If Yes , please describe.
13. Do you have an architect on staff?
If Yes , do you carry professional liability insurance?
If No , do you require that the architect carry his/her own professional liability insurance?
14. Do you sub-contract work?
15. Indicate percent of receipts:
16. List the types of work subcontracted.
17. Do you obtain Certificates of insurance from all subcontractors?
18.
Are you named as an additional insured on all subcontractors’ policies?
19. Do require all subcontractors to carry primary limits equal to or greater than their own?
20. Do you use written subcontractor agreements containing hold harmless/indemnity agreements in your favor?
21. . Do you always use them with all your subcontractors?
Yes
Yes No
Yes No
Yes No
%
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
22. Indicate the types of subcontractor agreements you typically sign when you are working for a general.
Standard (AGC, AIA contracts) Custom Other
October 2007 Page 4 of 5

RISK CONTROL
1. Do you have a quality control program?
If Yes , is it? Informal Formal Documented
Yes No
2. Is it a written a written quality control program?
3. Do you retain job files?
Yes
Yes
No
No
If Yes , how long are they retained? years
4. Do you employ a full-time safety director and have a written safety program? Yes No
5. The safety program includes driver selection and training requirements.
6. Do you have a drug testing program?
Yes No
Yes No
SEWER AND WATER – UNDERGROUND UTILITY WORK
1. Do you communicate with the One-Call Service Center and non-members of the center a minimum of 48 hours before the job begins (or per state regulations)?
2. Is the route of excavation white lined before the utility locator arrives on site?
3. Do you do hand digging within 18 inches to 24 inches (depending on state regulations) from the center of the utility line?
4. Do you request new locates for excavations incurring extended time requirements (10 days or more) and following inclement weather?
5. Are photographs or videos taken before and after the excavation?
Yes No
Yes No
Yes No
Yes No
Yes No
HIGH PRIORITY/CRITICAL JOBS
The utility owner needs to be asked if this job is considered a high priority or critical job. Some job examples would be high pressure water or gas pipe, power transmission lines, 15-pair communication cable, Sonet Ring Architecture Fiber Optics, etc.
In addition to the five requirements noted above, do you:
1. Schedule a pre-excavation meeting on the job-site with the facility owner and prime contractor?
2. Utilize pot holing, air knives, or vacuum excavation techniques to verify utility locates? (A substitute for pot holing would be the excavator’s use of state of the art locating equipment).
3. Map the coordinates of the locations in relation to a stationary object(s), such as a tree, building, fence, etc?
Yes No
Yes No
Yes No
Producer’s Signature
Applicant’s Signature
Date
Date
October 2007 Page 5 of 5