VENDOR CORPORATE PROFILE PROCESSING ... - RR Simmons

VENDOR CORPORATE PROFILE PROCESSING INSTRUCTIONSSince R.R. Simmons negotiates most of its work, vendor capabilities are very important to our clients. While it is notour intent to overwhelm you with this package, the requested information is necessary for our review of yourcompany. The qualification process actually benefits our vendors in the following ways:• Potential increased competitiveness by waiving the price of bonding.• Potential for repeat negotiated/invited bid work.• Expedited purchase agreements and payments.Due to the fact that we do not customize this form for one specific type of service provider, please note that the termVendor is intended to mean Subcontractor, Material Supplier, Design Consultant etc. Complete information as isappropriate to the type of goods and/or services you propose to supply to R.R. Simmons.Please feel free to use any existing standard documentation your company has available in lieu of recreatingthe same information. We do ask though, that you take the time to note "see attached" in the applicableblanks on our form and complete all other questions that are not addressed in your existing information. Acorporate brochure, company history, key personnel resumes, and any additional supplemental information youcould provide would also be appreciated. This optional information provides valuable insight and is very helpful tous when we are selecting team members for projects.The Vendor Corporate Profile package contains the following documents. Brief descriptions, along with instructionsfor completing each have been provided. Once completed, return all documents to us at the above address.Corporate Profile - Contains information regarding your company and its capabilities.Summary Attachments - Includes the following attached letters and provides instructions for you to attachcompany policies, current and completed project information, and current business licenses.It is important to fill in all blanks on these letters except for the boxed information which is intended for your bank,bonding, and insurance representative's use. Please have an officer of your company sign these letters and print theirname and title and your company's full legal name.Bank Reference Letter - Address and send to your bank officer for verification of your deposit and loan accounthistory.Bonding Capacity Verification Letter - Address to your bonding agent for verification of your bonding limits.Insurance Verification Letter - Address to your insurance agent for verification of your insurance information,discounts and Workers' Compensation Experience Modification Rate.R.R. Simmons Insurance Requirements and Sample Certificate of Insurance - Identifies the insurance coverageand limits to be reflected on a Certificate of Insurance to be provided to R.R. Simmons. Material suppliers areaddressed in paragraph E and vendors providing Design Services are addressed in paragraph F. Certificates will beaccepted during the pre-qualification process. Once your company is chosen for a particular project, a projectspecific Certificate will be required.W-9 Form - Provides us with your taxpayer identification number for reporting purposes. If you are an individual orsole proprietor, your social security number should be provided. If you are tax exempt, please complete Part II. Fillin the top section with your full legal company name and address and remember to sign and date the form.Financial Information - Requests a voluntary financial statement and CPA information for consideration ofbonding waiver.

VENDOR CORPORATE PROFILECOMPANY INFORMATIONCompany Name:Main Contact:Main Office Address:Phone Number:Fax Number:E-Mail Address:Website Address:List Counties/States you do business in:SERVICES PROVIDED & EXPERIENCECSI phases/divisions you perform:Qualified Specialties: Construction Only Design Only Design/Construction Maintenance Other (specify)For vendors providing both Design and Construction services:Do you employ a licensed Design Professional on staff?Number of LEED® projects completed?In progress?Number of LEED® Accredited Professionals on staff?If not, provide a list of preferred Design Professionals you will subcontractdesign work to, including names and addresses.Percent of work performed by Own Forces: % No. of employees:Office:Field:Dsgn. Professionals: Yes NoDo you lease any employees or use a temporary service?If yes, from what company? Yes NoSAFETY EXPERIENCEHave you received any OSHA citations or paid an OSHA related fine in the past 3 years? Yes NoIf yes, list OSHA citations, date, cause and fine amount:Date Received: $Date Received: $Date Received: $Company:Contact:Company:Contact:Company:Contact:TRADE/SUPPLIER REFERENCES (list major suppliers)Phone Number:Fax Number:Phone Number:Fax Number:Phone Number:Fax Number:Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 2

LITIGATION HISTORYAre there any judgments, claims, arbitration proceedings or suits pending or outstanding against yourorganization for its officers?Has your organization filed any lawsuits or requested arbitration regarding construction/designcontracts within the last three years?Has your organization, any of its officers or any officers’ previous organizations ever filed forbankruptcy or Chapter 11 reorganization? Yes No Yes No Yes NoIf the answer to any of these questions is yes, please explain details.BACKLOG INFORMATIONConstruction Value Fee ValueTotal amount of work/fees under contract: $ $Average annual volume - past three years: $Officers/Partners/Owners Names:CORPORATE AUTHORITYTitles:INDIVIDUALS AUTHORIZED TO SIGN (with limits, if applicable):Name Contract Pay Applications Change Orders Lien Waivers$____________ $____________ $____________ $____________$____________ $____________ $____________ $____________$____________ $____________ $____________ $____________$____________ $____________ $____________ $____________Federal Tax IDTotal Business Yrs.Total Business Yrs.Under Current Name Corporation-State Partnership Sole Proprietor Joint VentureList other business names and dates you have operated under in the past 3 years.Operating Dates:Operating Dates:Is your company a certified M.W.B.E.? If so, please provide certificate.This vendor has read and agrees to the terms and conditions of R.R. Simmons’ standard contract subagreement. Yes No Yes NoI certify that this information is true and complete to the best of my knowledge.Signature by OfficerPrinted Name:Corporate Title:Date Signed:Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 3

VENDOR CORPORATE PROFILE - SUMMARY ATTACHMENTSCompany Name:Main Office AddressPhone Number:Fax Number:ATTACH copies of current applicable certificates, or other evidence of certification for the following items. If notcertified, enclose copies of internal policy documents for review.SAFETY POLICY Are you qualified for the 2% worker’s compensation safety Yes Nodiscount?HAZCOM POLICY Do you have a Hazardous Communication Policy? Yes NoDRUG POLICY Are you qualified for the 5% worker’s compensation drug discount? Yes NoEEOC POLICY Does your EEOC Policy comply with Federal regulations? Yes NoQUALITY POLICY Do you have a Quality control program? Yes NoList projects currently under contract and those completed within past three years using the ATTACHED form. If youhave a list which contains the same information in a different format, ATTACH your project list.Please complete the requested information for Bank and Bonding verification and ATTACH.Please attach current copy of audited Financial Statements.Refer to the ATTACHED insurance requirements. Complete and ATTACH the insurance verification letter.List and ATTACH copies of current licenses for the type of work you perform.Professional & Business Licenses: License Holder/Principal: License #’s:QBGCR.R. Simmons privately negotiates most of its work. Vendor capabilities are very important to R.R. Simmons’ clients. Sinceinformation contained in the Vendor Corporate Profile is for R.R. Simmons internal use only, please assist us by providingadditional information suitable for external marketing presentations. This information should include resumes of keypersonnel and marketing brochures.Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 4

REFERENCES - RECENTLY COMPLETED PROJECTS(List at least 5 major projects completed within the past 3 years.Copy this form for additional space.)Company Name:Main Office AddressPhone Number:Fax Number:Project Name:Total Project Construction Value:Location: $Owner:Contact/Phone:General Contractor:Contact/Phone:Architect:Contact/Phone:Your Contract Amt. $ E-Mail Address:Is this a Design/Build Project? Yes No Change Orders: $% complete: _____% Did you provide construction? Yes No Did you provide Design? Yes NoEst. completion date: Is this a LEED certified project? Yes No Est. $’s saved by Value Engineering:$Project Name:Total Project Construction Value:Location: $Owner:Contact/Phone:General Contractor:Contact/Phone:Architect:Contact/Phone:Your Contract Amt. $ E-Mail Address:Is this a Design/Build Project? Yes No Change Orders: $% complete: _____% Did you provide construction? Yes No Did you provide Design? Yes NoEst. completion date: Is this a LEED certified project? Yes No Est. $’s saved by Value Engineering:$Project Name:Total Project Construction Value:Location: $Owner:Contact/Phone:General Contractor:Contact/Phone:Architect:Contact/Phone:Your Contract Amt. $ E-Mail Address:Is this a Design/Build Project? Yes No Change Orders: $% complete: _____% Did you provide construction? Yes No Did you provide Design? Yes NoEst. completion date: Is this a LEED certified project? Yes No Est. $’s saved by Value Engineering:$Project Name:Total Project Construction Value:Location: $Owner:Contact/Phone:General Contractor:Contact/Phone:Architect:Contact/Phone:Your Contract Amt. $ E-Mail Address:Is this a Design/Build Project? Yes No Change Orders: $% complete: _____% Did you provide construction? Yes No Did you provide Design? Yes NoEst. completion date: Is this a LEED certified project? Yes No Est. $’s saved by Value Engineering:$Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 6

VENDOR CORPORATE PROFILE - FINANCIAL ATTACHMENTS AND INFORMATION(This information will be kept confidential.)Company Name:Main Office AddressPhone Number:Fax Number:Please attach a financial statement for the last fiscal year end, preferably audited, including a balance sheet and incomestatement. Submission is voluntary; however, bonding may be waived in evidence of sufficient financial capacity ofprovided. Please keep in mind the added cost of a bond could affect the competitiveness of your proposed price.CPA Name:Phone Number:May we contact CPA with questions? Yes NoFor attached Financial Statements:Are the financial statements for the identical organization named onpage one of this qualification statement? Yes NoIf not, explain the relationship and financial responsibility of theorganization whose financial statements are provided (parent,subsidiary, etc.).Will the organization whose financial statement is attached act asguarantor of the contract for construction?Has your organization ever failed to complete any work awarded to it? Yes No Yes NoRe: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 7

BANK REFERENCE LETTERPlease Complete This Form And Send To Your Bank Officer For VerificationDate: ________________________________________________________________________________________Bank Name Phone #_________________________________________________________________Bank Address Fax #_________________________________________City, State, ZipRE:Dear:Account # ___________________________________________________________Bank Officer’s NameR.R. Simmons is in the process of reviewing our Corporate Profile. As part of the review process, they request referencesfrom our trade contacts, customers, bonding agents and financial institutions. The information received from thereferences will give them a better understanding of our company, and our ability to perform in accordance with contractterms.This letter serves as written authorization to release the following information to R.R. Simmons to assist in the evaluationof our company.Bank to Complete this Box:Deposit Account HistoryType of account(s)______________________Date(s) opened______________________Average balance$_______________Number of returned checks________Bank to Complete this Box:Loan Account HistoryNo. of outstanding loans______Line of Credit yes noDate established$__________Maximum Available$__________Current outstanding balance $__________Secured? yes noCollateral ____________________________Relationship handled as Agreed? yes noBanker Signature:___________________________Banker Name:______________________________If you have any questions, do not hesitate to call me at . Please mail or fax the information to R.R. Simmonsas soon as possible. Thank you for your cooperation in this matter.Sincerely,Printed Name & TitleCompany Name[Enter Vendor Name Here]RETURN RESPONSE TO:R.R. SimmonsAttn.: Corporate Profile Coordinator14025 Riveredge Dr., Suite 550Tampa, Florida 33637Phone: 813-632-1200Fax: 813-632-5500Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 8

BONDING CAPACITY VERIFICATION LETTERPlease Complete This Form And Send To Your Bonding Agent For VerificationDate: ______________________________________________________________________________________Agency Name Phone #_______________________________________________________________Address Fax #_________________________________________City, State, ZipRE:Dear:Account # ___________________________________________________________Bonding Agent’s NameR.R. Simmons is in the process of reviewing our Corporate Profile. As part of the review process, they request referencesfrom our trade contacts, customers, bonding agents and financial institutions. The information received from thereferences will give them a better understanding of our company, and our ability to perform in accordance with contractterms. Please make note that R.R. Simmons requires the surety issuing the bonds to maintain a Best Rating of A, VIII orbetter as part of its acceptance criteria.This letter serves as written authorization to release the following information to R.R. Simmons to assist them in theirevaluation of our company.Bonding Agent to Complete this Box:Surety Name ____________________________Surety Address ____________________________City, State, ZipSurety Best Rating/Financial Size/Date ____________/_______________/______________Bond Line Established Y_____N_____Date___________Bonding Limits ____________/_______________Single Project AggregateBond Rate Structure ____________________________Agent Signature__________________________________Agent Name:______________________________________If you have any questions, do not hesitate to call me at . Please mail or fax the information to R.R. Simmonsas soon as possible. Thank you for your cooperation in this matter.Sincerely,RETURN RESPONSE TO:R.R. SimmonsAttn.: Corporate Profile Coordinator14025 Riveredge Dr., Suite 550____________________________________ Tampa, Florida 33637Printed Name & TitlePhone: 813-632-1200Fax: 813-632-5500Company Name[Enter Vendor Name Here]Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 9

EXHIBIT AMINIMUM INSURANCE REQUIREMENTSThe word “Vendor” used herein refers to a Subcontractor, Material Supplier or Design Consultant, as applicable,based on the Agreement executed between R. R. Simmons Construction Corporation and the Vendor. The term“subvendor” or “subsubvendor” refers to the Vendor’s subcontractor, subsubcontractor, subconsultant orsubsubconsultant as applicable.Vendor is to secure, and pay for all insurance required by this Agreement from an insurer acceptable to R. R.Simmons Construction Corporation in such amounts as required by this Agreement but not less than that required bythe Contract Documents, and such other insurance coverages as may be required by the Contract Documents asapplicable to the WORK required under this Agreement, prior to commencing WORK. All liability insurancepolicies, other than Workers' Compensation and Employers' Liability Insurance and Professional Liability policies(for Vendors and/or their subvendors or subsubvendors providing design services) shall name R. R. SimmonsConstruction Corporation as an additional insured (including Completed Operations) using ISO Endorsements CG2010 (11/85 edition) or CG2026 (11/85 edition). All Coverage afforded the additional insured shall be primary andnon-contributory as respects any other insurance carried by the additional insured. The use of any other form toprovide additional insured coverage will require the prior approval of R. R. Simmons Construction Corporation. Allpolicies shall contain severability of interests provisions, and a waiver of subrogation in favor of R.R. SimmonsConstruction Corporation. Vendor shall provide the R. R. Simmons Construction Corporation with evidence of thisinsurance and of the Vendor's compliance with this requirement by providing the endorsement form or by listing thisendorsement on the face of the ISO Certificate.All certificates of insurance and policies shall contain provisions that thirty (30) days written notice by registered orcertified mail shall be given to R. R. Simmons Construction Corporation of any cancellation, intent not to renew, orreduction in the policies' coverages, except in the application of the aggregate limits provisions. The 30 daycancellation notice is required on all certificates for all required coverages and shall not include wording such as“will endeavor” to give notice, and failure to do so imposes “no obligation”. This notice may be certified by strikingthe words “endeavor to” and “but failure to do so will impose no obligation or liability of any kind upon thecompany, its agents or representatives”, or by providing a unqualified cancellation notice provision in the commentssection of the certificate of insurance or a separate endorsement. If any insurance provided pursuant to thisAgreement expires prior to the completion of the WORK or all warranty periods required by this Agreement,renewal certificates of insurance shall be furnished by Vendor to R.R. Simmons Construction Corporation thirty (30)days prior to the date of expiration.Vendor shall supply R. R. Simmons Construction Corporation, upon request, with certified copies of all insurancepolicies required to be furnished by Vendor herein. In the event of a reduction of the aggregate limit of any policy,the Vendor shall immediately take steps to have the aggregate limit reinstated to the full extent permitted under suchpolicy. All insurance coverages of Vendor shall be primary to any insurance or self-insurance program carried byR. R. Simmons Construction Corporation applicable to this WORK. Further, if requested, certified true copies ofthe renewal policies shall also be furnished by Vendor to R. R. Simmons Construction Corporation at least 30 daysprior to expiration.Should at any time the Vendor not maintain the insurance coverages required in this Agreement, R. R. SimmonsConstruction Corporation may cancel the Agreement or at its sole discretion shall be authorized to purchasecoverages and charge the Vendor for comparable coverages purchased. R. R. Simmons Construction Corporationshall be under no obligation to purchase such insurance, nor shall it be responsible for the coverages purchased orthe insurance company/companies used. The decision of R. R. Simmons Construction Corporation to purchase suchinsurance coverages shall in no way be construed to be a waiver of its rights under this Agreement.Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 12

The acceptance by R. R. Simmons Construction Corporation of any certificates of insurance evidencing theinsurance coverages and limits required in this Agreement does not constitute approval or agreement by R. R.Simmons Construction Corporation that the insurance requirements have been met or that the insurance policiesshown on any certificates of insurance are in compliance with the requirements of this Agreement.No services shall commence on the Project unless and until the required Certificates of Insurance are received, thisAgreement has been executed and performance is due pursuant to the Project Schedule. Vendor shall require each ofits subvendors and subsubvendors to procure and maintain, until the applicable warranties expire, insurance of thetypes and to the limits specified in this Exhibit A, unless such insurance requirement for the subvendor orsubsubvendor is expressly waived in writing by R R. Simmons Construction Corporation.The amounts and types of insurance shall conform to the following minimum requirements with the use of InsuranceServices Office (ISO) forms (sample attached) and endorsements or broader where applicable. The insurancecompany must be have a minimum “A” – Class VIII or higher in Best’s Key Rating Guide for Property andCasualty, unless otherwise approved by R.R. Simmons Construction Corporation. All deductibles to be $5,000.00or less unless otherwise stated, and are the responsibility of the Vendor:A. Workers' Compensation and Employers' Liability Insurance shall be maintained by Vendor during theterm of a project agreement, for all employees engaged in Work under the agreement, in accordance withthe laws of the state of Florida. The limits of coverage shall not be less than:Workers' Compensation Florida Statutory RequirementEmployers' Liability $100,000 Limit each accident$500,000 Limit disease aggregate$100,000 Limit disease each employeeThe insurance company shall waive its Rights of Subrogation against R. R. Simmons ConstructionCorporation. In addition, if labor is subcontracted or leased employees are utilized, a Certificate ofInsurance reflecting Workers’ Compensation coverage must be provided by either the Leasing Company orSubcontractor. Leasing Companies must include an “alternate employer” endorsement for the vendor.B. Commercial General Liability Insurance shall be maintained by Vendor. Coverage shall include, but notbe limited to, premises and operations, personal injury, contractual liability pertaining to indemnification orhold harmless agreements with R. R. Simmons Construction Corporation, per project aggregate,independent contractors, broad form property damage including products and completed operationscoverages and shall not exclude coverage for the "x" (explosion) "c" (collapse) and "u" (underground)property damage liability exposures. Coverage shall not be excluded or restricted for “construction defect”,nor for the installation of any product, including but not limited to EIFS or other exterior finishing systems,by or on behalf of the Vendor. The Completed Operations Coverage shall be maintained for this project fornot less than one (1) year following completion and acceptance by R. R. Simmons ConstructionCorporation, unless otherwise extended by the requirements of the contract documents. Limits of coverageshall not be less than the following for Bodily Injury, Property Damage and Personal Injury CombinedSingle Limits:General Aggregate $1,000,000Products-Completed Operations Aggregate $1,000,000Personal and Advertising Injury $500,000Each Occurrence $500,000Fire Damage $50,000Medical Payments, each person $5,000Per Project Aggregate Limits$ same as aboveThe aggregate limits shall be separately applicable to each project through per project aggregate orthe use of an endorsement approved by R. R. Simmons Construction Corporation. The InsuranceCompany shall waive its Rights of Subrogation against R. R. Simmons Construction Corporation.Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 13

General Liability insurance shall be issued or renewed on an “occurrence” form. If the General Liabilityinsurance required herein is unavailable to vendor on an occurrence form and is issued or renewed on a"claims made" form, as opposed to the "occurrence" form, the retroactive date for coverage shall be no laterthan the commencement date of the Project and shall provide that in the event of cancellation or nonrenewal,the discovery period for insurance claims (Tail Coverage) shall be unlimited.C. Automobile Liability Insurance shall be maintained by Vendor as to the ownership, maintenance, and useof all owned, non-owned, leased or hired vehicles with limits of not less than:Bodily Injury Liability$500,000 Limit each person$500,000 Limit each accidentProperty Damage Liability $500,000 Limit each accident - or -Bodily Injury andProperty Damage Liability$500,000 Combined single limit each accidentThe Insurance Company shall waive its Rights of Subrogation against R. R. Simmons ConstructionCorporation.D. Umbrella Liability Insurance or Excess Liability Insurance shall not be less than $1,000,000 eachoccurrence and aggregate. Coverage shall be in excess of the Employers Liability, Commercial GeneralLiability and Automobile Liability coverages required herein and shall include all coverages on a"following form" basis. Coverage shall drop down as primary on the exhaustion of any aggregate limit.The aggregate limits shall apply separately to each Project, and the specific project aggregate limits shall beevidenced by the use of an endorsement approved by R. R. Simmons Construction Corporation. If theUmbrella coverage does not allow for the above per Project General Aggregate limit, the UmbrellaAggregate limit shall be a minimum of $2,000,000. The Insurance Company shall waive its Rights ofSubrogation against R. R. Simmons Construction Corporation.E. Transportation Insurance shall be maintained by Vendors providing shipments of supplies valued inexcess of $100,000. Such insurance shall be purchased in an amount equal to the full value of the sellingprice of the shipment. Coverage must be placed using a company and form acceptable to R. R. SimmonsConstruction Corporation. The Insurance Company shall waive its Rights of Subrogation against R. R.Simmons Construction Corporation.F. If Design Services are to be provided by Vendor’s direct personnel, Vendor must provide evidence ofProfessional Liability Insurance. If Design Services are to be provided by a subcontractor orsubconsultant to Vendor, the Vendor must provide evidence of Contingent Professional Liability Insurance,and provide evidence of coverage by the subcontractor or subconsultant. The minimum requirements forProfessional Liability Insurance shall be as follows:Professional Liability Insurance shall be maintained by Vendor and Vendor’s subcontractor orsubconsultant that provides design services, insuring its legal and contractual liability arising out of theperformance of professional services under design agreements. Such insurance shall have limits of not lessthan $1,000,000 each claim and aggregate. Any deductible applicable to any claim shall be the soleresponsibility of the Vendor and shall not be greater than $50,000.00 each claim. Vendor must make everyattempt to continue this coverage for a period of not less than three (3) years after completion of its servicesto R. R. Simmons Construction Corporation provided such coverage is reasonably available atcommercially affordable premiums. For the purpose of this Agreement, “reasonably available” and“commercially affordable” shall mean that more than half the design professionals practicing in this state inthis discipline are able to obtain such coverage. The retroactive date for coverage during this three-yearperiod shall not be later than the commencement date of the Project. Such Professional Liability Insurancemay be provided through an endorsement to the Vendor’s General Liability policy as long as coverage istrue Professional Liability coverage including economic damages, and not limited to “bodily injury” and“property damage”. The Vendor or Vendor’s subcontractor or subconsultant shall promptly submitCertificates of Insurance providing for an unqualified written notice of any cancellation of coverage orreduction in limits, other than the application of the aggregate limits provision. In the event of a reductionin the aggregate limits of any policy, the Vendor or Vendor’s subcontractor or subconsultant shallimmediately take steps to have the aggregate limit reinstated to the full extent permitted under such policy.Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 14

The Vendor or Vendor’s subcontractor or subconsultant shall promptly submit a certified, true copy of thepolicy and any endorsements issued or to be issued on the policy if requested by R. R. SimmonsConstruction Corporation. The Insurance Company shall waive its Rights of Subrogation against R. R.Simmons Construction Corporation.G. Pollution Liability Insurance is required for all Vendors bringing materials or equipment on to a jobsite.This insurance must cover the release of any pollutants at the jobsite arising from the use of such materialsor equipment. Limits of liability for this insurance shall not be less that $100,000 per occurrence, and maybe provided as an endorsement to the General Liability policy. In the event that a Vendor is actuallyinvolved in environmental remediation or any other type of handling of pollutants arising out of the siteitself, an actual Pollution Liability policy will be required at limits of not less than $1,000,000 peroccurrence and include R. R Simmons Construction Corporation as an additional insured. The InsuranceCompany shall waive its Rights of Subrogation against R. R. Simmons Construction Corporation.Re: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 15

ACORD CERTIFICATE OF INSURANCE Issue DatePRODUCERABC Insurance AgencyINSUREDXYZ COMPANY1 MAIN STREETANYTOWN, USA 12345THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANDCONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATEDOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THEPOLICIES BELOW.COMPANYLETTERCOMPANYLETTERCOMPANYLETTERCOMPANYLETTERCOMPANYLETTERCOMPANIES AFFORDING COVERAGEA World Wide Insurance CompanyBCDEGrand Insurance CompanyCOVERAGESTHIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED OT THE INSURED NAMED ABOVE FOR THE POLICYPERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOWHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.CO LTRAAABTYPE OF INSURANCEGENERAL LIABILITYCOMMERCIAL GENERALLIABILITYCLAIMS MADE OCCURINDEPENDENT CONTRACTCOVERAGECONTRACTUAL LIABILITYPER PROJECT AGGREGATEAUTOMOBILE LIABILITYANY AUTOALL OWNED AUTOSSCHEDULED AUTOSHIRED AUTOSNON-OWNED AUTOSGARAGE LIABILITYUMBRELLA FORMOTHER THAN UMBRELLA FORMWORKER’S COMPENSATIONANDEMPLOYERS LIABILITYPOLICY NUMBER123456782345678934567890POLICY EFFECTIVEDATE (MM/DD/YY)POLICY EXPIRATIONDATE (MM/DD/YY)LIMITSGENERAL AGGREGATE---------------- -------------------------PRODUCTS-COMP/OP AGG.------------------------------------------PERSONAL & ADV.INJURY------------------------------------------EACH OCCURRENCE------------------------------------------FIRE DAMAGE (Any one Fire)------------------------------------------EACH OCCURRENCE------------------------------------------AGGREGATESTATUTORY LIMITS------------------------------------------EACH ACCIDENT------------------------------------------DISEASE-POLICY LIMIT------------------------------------------DISEASE-EACH EMPLOYEE$1, 000,000----------------------$1,000,000----------------------$ 500,000----------------------$ 500,000----------------------$ 50,000----------------------MED. EXPENSE(any one Person) $ 5,000COMBINED SINGLE$ 500,000LIMIT----------------------------------------------------------------BODILY INJURY$(Per Person)----------------------------------------------------------------BODILY INJURY$(Per Accident)----------------------------------------------------------------PROPERTY DAMAGE $$1,000,000----------------------$1,000,000----------------------$ 100,000----------------------$ 500,000----------------------$ 100,000OTHERProfessional Liability * *if required Each Claim $1,000,000DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMSCANCELLATION: Cancellation or any other material change in these policies adversely affecting the interests of the policies named parties in such insurance shallnot be effective until 30 days after written notice thereof to R.R. Simmons Construction Corporation.R.R. Simmons Construction Corporation is named as an Additional Insured (including Completed Operations) on all liability policies (other than W/C, Employers Liability Ins,and Prof. Liab.) using ISO Endorsements CG 2010 (11/85 edition) or CG2026 (11/85 edition) All policies contain severability of interests provisions, and Waiver ofSubrogation in favor R.R. Simmons Construction Corporation.CERTIFICATE HOLDERCANCELLATIONR.R. Simmons Construction Corporation14025 Riveredge Drive, Suite 550Tampa, FL 33637SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVORTOMAIL 30 * DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TOTHE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION ORLIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS ORREPRESENTATIVES.AUTHORIZED REPRESENTATIVERe: CN Vendor Corporate Profile Package 20077 2/14/2007 11:31:01 AM PAGE 16