New Vendor Information Packet - PBI Restores

1 New Vendor Information Packet Please return completed documents to Anne Popowski Fax: 410-453-9002. email: SUBCONTRACTOR REQUIRED Information . Company Name:_____. Company Contact:_____. Address: _____. _____. Office #: _____. Mobile #: _____. Fax #: _____ email: _____. Trade: _____. _____. Years in business: _____. Incorporated: yes _____ no _____. Business license #: _____. Federal ID#: _____ or Social Security #: _____. ALSO REQUIRED: Certificate of Insurance (COI) with requirements as outlined on the attached sample COI. Form W-9; also attached. Please submit all invoices by US Mail, Fax or by email to No payment can be made without completion of this form, valid COI and W-9.

2 Payment terms are 30 days from PBI's Receipt of invoice. Questions: Please Call Anne Popowski @ 410-453-9000 Ext. 137. Serving the Mid-Atlantic Region 16 Stenersen Lane, Unit 1A * Hunt Valley, MD 21030. 888-724-7363. Fax: 410-453-9002. General Liability Insurance Requirements PBI Restorations must have on file a Certificate of Insurance from your insurance company naming Popowski Brothers, Inc. T/A PBI Restorations, PBI Disaster Restoration LLC and PBI. Environmental Restoration LLC as the certificate holder. In addition to the certificate, we need a copy of the list of exclusions from your policy (you can send us a copy from your policy OR you can authorized your agent to send us a copy along with the certificate.)

3 If there are NO exclusions on your general liability policy, please have your agent submit the following statement to us along with the certificate There are no exclusions listed on XYZ Contractor's general liability policy #1234567. When you receive notice that your policy is expiring, please have your insurance carrier issue us another certificate immediately. Otherwise, we will hold payment of all invoices until we receive the renewal certificate. PBI updates these General Liability certificates annually. Please renew your General Liability certificate immediately when it expires.

4 WORKERS' COMPENSATION INSURANCE REQUIREMENTS. PBI Restorations must have on file a Certificate of Insurance from your insurance company naming Popowski Brothers, Inc. T/A PBI Restorations, PBI Disaster Restoration LLC and PBI. Environmental Restoration LLC as the certificate holder. Please see attached SAMPLE COI for required coverage limits and proper Certificate Holder names. CONTRACTS AND INVOICES WILL NOT BE PROCESSED UNTIL YOUR. CERTIFICATE OF INSURANCE HAS BEEN RECEIVED. DATE (MM/DD/YYYY). CERTIFICATE OF LIABILITY INSURANCE 6/2/2015. THIS CERTIFICATE IS ISSUED AS A MATTER OF Information ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.

5 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).

6 CONTACT. PRODUCER NAME: Insurance Producer PHONE FAX. (A/C, No, Ext): (A/C, No): E-MAIL. ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC #. INSURER A : AM Best Carrier A VII or better 221199. INSURED INSURER B : Subcontractor INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 2036374924 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.

7 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 ADDL SUBR POLICY EFF POLICY EXP. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS. A X COMMERCIAL GENERAL LIABILITY Policy Number 12/31/2014 12/31/2015 EACH OCCURRENCE $ 1,000,000. DAMAGE TO RENTED. CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $ 50,000. MED EXP (Any one person) $ 5,000. PERSONAL & ADV INJURY $ 1,000,000.

8 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000. PRO- POLICY X JECT X LOC PRODUCTS - COMP/OP AGG $ 2,000,000. OTHER: $. A AUTOMOBILE LIABILITY 12/31/2014 12/31/2015 COMBINED SINGLE LIMIT $ 1,000,000. Policy Number (Ea accident). X ANY AUTO BODILY INJURY (Per person) $. ALL OWNED SCHEDULED BODILY INJURY (Per accident) $. AUTOS AUTOS. NON-OWNED PROPERTY DAMAGE. HIRED AUTOS AUTOS (Per accident) $. $. A X UMBRELLA LIAB X OCCUR Policy Number 12/31/2014 12/31/2015 EACH OCCURRENCE $ 1,000,000. EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000. DED RETENTION $ $.

9 A WORKERS COMPENSATION Policy Number 12/31/2014 12/31/2015 PER OTH- X STATUTE ER. AND EMPLOYERS' LIABILITY Y/N. ANY PROPRIETOR/PARTNER/EXECUTIVE EACH ACCIDENT $ 500,000. OFFICER/MEMBER EXCLUDED? N/A. (Mandatory in NH) DISEASE - EA EMPLOYEE $ 500,000. If yes, describe under DESCRIPTION OF OPERATIONS below DISEASE - POLICY LIMIT $ 500,000. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required). With respects to general liability for ongoing and completed operations performed by the named insured the following are included as additional insureds when required by written contract or agreement: Popowski Brothers, Inc.

10 T/A PBI Restorations; PBI Disaster Restoration, LLC; PBI Environmental Restoration, LLC and Owner along with their respective officers, agents and employees General liability coverage is primary and noncontributory when required by written contract or agreement. See CERTIFICATE HOLDER CANCELLATION. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN. Popowski Brothers, Inc. T/A PBI Restorations; ACCORDANCE WITH THE POLICY PROVISIONS. PBI Disaster Restoration LLC. PBI Environmental Restoration LLC AUTHORIZED REPRESENTATIVE.