Common use of ’ Compensation Insurance and Disability Benefits Requirements Clause in Contracts

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jsp); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jsp); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of a contract or any contract renewal. A contractor will not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Bid submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this section at any time during the term of the Contract shall be considered a breach of the terms of the Contract and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use the Contract and their officers, agents, and employees to avail themselves of all remedies available under the Contract , at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. . Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of of, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this Attachment at any time during the term of the Contract shall be considered a breach of the terms of the Contract and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use the Contract and their officers, agents, and employees to avail themselves of all remedies available under the Contract, at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxxx://xxx.xxx.xx.xxx/); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook. Group 79050 - Media Buying Services (Statewide) Group 79050 - Media Buying Services (Statewide) Attachment 8 - Report of Contract Usage Contractor Name: 0 Contract Reporting Period (Dates) 0 Contract Number: 0 Grand Total $ - Contractor's Invoice # Invoice Date Ordering Entity PO # Contract # (if applicable) Type of Authorized User Authorized User Name of Media Campaign Type of Media Placed Entity Name Media Purchased From Net Cost of Media Purchased Contractor's Commission Total Commission Total Amount Invoiced Sample: XYZ456 10/2/2018 5456456 PS12345 SUNY SUNY Brockport My Brother's Keeper Challenge Social - Facebook Facebook $ 5,000.00 5% $ 250.00 $ 5,250.00 23171 Attachment08_ReportofContractUsage 1 of 3 Group 79050 - Award 23171 Attachment 11 - Business Automobile Liability Insurance Attestation In the event that your firm does not currently possess all Business Automobile Liability Insurance as required by Attachment 4 – Insurance Requirements, Section B.2., of the Contract, your firm will be required to complete the attached attestation and this attestation must be signed by an individual who is authorized to bind the organization in a contract. Please return a signed, original hard copy of the attestation, signed in black or blue ink, with the other insurance documents to the designated contact listed on Page 1 of the Request for Proposals.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of a Bid or any contract renewal. A Bidder will not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Bid submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this Attachment at any time during the term of any Contract resulting from this Solicitation shall be considered a breach of the terms of any Contract resulting from this Solicitation and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use any Contract resulting from this Solicitation and their officers, agents, and employees to avail themselves of all remedies available under any Contract resulting from this Solicitation, at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: •  Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); •  Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or •  Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or •  Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: •  Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); •  Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or •  Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook. Group 30310-23123, Vehicle and Equipment Parts and Related Product Attachment 3 – Report of Contract Usage Enter information for this report in the cells below. The information entered below will be prepopulated on the Contract Usage tab. Contractor Name: NYS Contract Number: Contract Reporting Period (Dates): Contract Usage Sheet Definitions Column Name Definition Contract Number: Contractor's Contract number issued by OGS (e.g., PC12345) Contractor's Invoice Number Number on Contractor's invoice to ordering entity Contractor's Invoice Date Date on Contractor's invoice to ordering entity Authorized User Order Number Number on ordering entity's purchase order, or other ordering document Authorized User Order Date Date on the ordering entity's purchase order, or other ordering document Authorized User Entity Name Name of the entity (e.g., NYS agencies, political subdivisions, local governments, public authorities, public school and fire districts, public and nonprofit libraries, and certain other nonpublic/nonprofit organizations) that issued the purchase order, or other ordering document. Region/ Facility/ Location Name Region, facility, or location associated with the entity "State" or "Non-State" Entity See "State Agency List" tab of this workbook Ship to Authorized User County County where the Product was delivered (or provided over-the-counter) Ship to Authorized User City City (village/town/etc.) where the Product was delivered (or provided over-the-counter) Contractor Location Name Name of the Contractor or Subcontractor location that sold the Product to the Authorized User. Contractor Location County County where the Contractor or Subcontractor Location is located. Contractor Location City City (village/town/etc.) where the Contractor or Subcontractor Location is located. Lot Number Contract Lot (i.e., Lot 1 or Lot 2) under which the Product was sold. Contract Part Group Number Number of the Contract Part Group (e.g., 22) under which the Product was sold. See list of Parts Groups below. Contract Part Group Description Description of the Contract Part Group (e.g., Steering) under which the Product was sold. See list of Parts Groups below. Contractor's Part Number Contractor's code that uniquely identifies the Product. Part or Service Description Contractor's description of the Product. OEM Name Name of the manufacturer of the Product. OEM Part Number Manufacturer's code that uniquely identifies the Product. Commonly Stocked or Direct Order Enter "Commonly Stocked" or "Direct Order," to identify how the Product was acquired by the Contractor

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: •  Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); •  Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or •  Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or •  Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: •  Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); •  Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or •  Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage workers’ compensation and disability insurance or a legal exemption to OGS will result in a rejection Contractor not being considered for this Piggyback Contract or renewal of any contract renewalsame. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at before this Piggyback Contract can be executed by the time of policy renewal, contract renewal and upon requestCommissioner. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of a Bid or any contract renewal. A Bidder will not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Bid submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of a Bid or any contract renewal. A Bidder will not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Bid submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this Attachment at any time during the term of any Contract resulting from this Solicitation shall be considered a breach of the terms of any Contract resulting from this Solicitation and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use any Contract resulting from this Solicitation and their officers, agents, and employees to avail themselves of all remedies available under any Contract resulting from this Solicitation, at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.. GROUP 40440-23166 Vehicles, Class 1-8 (Statewide) Attachment 3 Group 40440-23166, VEHICLES, Class 1-8 (Statewide) Attachment 3: Report of Contract Usage DO NOT ADD, REMOVE OR REARRANGE ANY COLUMNS OR ROWS. Enter Contractor information below. Contract Group & Award Number: Group 40440, Award 23166 Contract Number: Contract Sales Period: Contractor Company Name: Contact Name: Contact E-Mail: Contact Phone Number: Award 23166 Contract Report of Contract Usage - Vehicle Data DO NOT ADD, REMOVE OR REARRAGE ANY COLUMNS OR ROWS. Contract Number Mini-Bid Number Contractor Order Number Vehicle Order Date Order Cancellation Date (if applicable) Authorized User Purchase Order Number Authorized User Entity Name Region/ Facility/ Location Name (if applicable) Indicate "State" or "Non-State" Entity (see "State Agency" tab) Ship to County PC12345 2345 1233 5/20/2019 00000 Xxxxxxxxx CSD Non-State Schenectady PC12345 2491 1234 6/15/2019 7891011 NYS Department of Transportation DOT Region 5 Buffalo State Erie PC12345 2555 1235 7/15/2019 00000 Xxxxxx County Department of Public Works Non-State Albany PC12345 2678 1236 7/18/2019 99810 Saratoga County Non-State Saratoga Chassis or Single OEM Vehicle Data Equipment Type Equipment Description Model Year (if applicable) OEM/Make (if applicable) Model/Model Code (if applicable) VIN (if known at time of completing report) NYS Base MSRP (including Options + all OEM fees) NYS Discount (%) NYS Base Price NYS Aftermarket Components Price Single OEM Vehicle Sedan 2020 Dodge Charger 12223444557889876 $31,000.00 17.00% $27,900.00 Chassis 20k Chassis Cab 2019 Navistar International 7300 SFA 4X4 11223344556677800 $60,000.00 25.50% $59,847.00 $1,000.00 Body Tandem Axle Dump Body 2019 N/A N/A $0.00 Complete Vehicle Tandem Axle Dump Truck 2019 Navistar International 7300 SFA 4X4 11223344556677899 $60,000.00 28.30% $59,830.20 $1,000.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Body Data NYS Price for Vehicle OEM/Make (if applicable) Model/Model Code (if applicable) NYS Base Price NYS Aftermarket Components Price NYS Price for Vehicle Total NYS Contract Price for Complete Vehicle $27,900.00 $0.00 $27,900.00 $60,847.00 N/A N/A $0.00 $60,847.00 $0.00 Viking Proline 1415LW $45,000.00 $1,000.00 $46,000.00 $46,000.00 $60,830.20 Viking Proline 1415LW $45,000.00 $1,000.00 $46,000.00 $106,830.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals, whether the governmental agency is having the work done or is simply issuing the permit, license or contract. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection the Contractor not being considered for this Contract or renewal of any contract renewalsame. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Contract submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this section at any time during the term of the Contract shall be considered a breach of the terms of the Contract and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use the Contract and their officers, agents, and employees to avail themselves of all remedies available under the Contract, at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.. Signature Page

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of a Bid or any contract renewal. A Bidder will not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Bid submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this Section at any time during the term of this Piggyback Contract shall be considered a breach of the terms of this Piggyback Contract and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use this Piggyback Contract and their officers, agents, and employees to avail themselves of all remedies available under this Piggyback Contract, at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of a Bid or any contract renewal. A Bidder will not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Bid submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this Attachment at any time during the term of any Contract resulting from this Solicitation shall be considered a breach of the terms of any Contract resulting from this Solicitation and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use any Contract resulting from this Solicitation and their officers, agents, and employees to avail themselves of all remedies available under any Contract resulting from this Solicitation, at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxxxxxxxxxxxxxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxxxxxxxxxxxxxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbookxxxx://xxx.xxx.xx.xxx/content/main/Employers/requirements-businesses-applying-government- permits-licenses-contracts.pdf.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of a Bid or any contract renewal. A Bidder will not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Bid submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this Attachment at any time during the term of any Contract resulting from this Solicitation shall be considered a breach of the terms of any Contract resulting from this Solicitation and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use any Contract resulting from this Solicitation and their officers, agents, and employees to avail themselves of all remedies available under any Contract resulting from this Solicitation, at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jsp); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jsp); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of an award or any contract renewal. A Piggyback Contract will not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Bid submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this section at any time during the term of this Piggyback Contract shall be considered a breach of the terms of this Piggyback Contract and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use this Piggyback Contract and their officers, agents, and employees to avail themselves of all remedies available under this Piggyback Contract, at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for Piggyback contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original Piggyback contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any Piggyback contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, Piggyback contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jsp); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.U-

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. The failure to comply with the requirements of this Attachment at any time during the term of this Contract shall be considered a breach of the terms of this Contract and shall allow the People of the State of New York, the New York State Office of General Services, any entity authorized by law or regulation to use this Contract and their officers, agents, and employees to avail themselves of all remedies available under this Contract, at law or in equity. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.. Instructions GROUP 72002 ‐ Fleet Maintenance Services (Statewide)

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any a contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/079/07 or later), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: •  Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); •  Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or •  Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or •  Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: •  Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); •  Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or •  Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.. Signature Page

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of a Bid or any contract renewal. A Bidder will not be awarded a Contract unless proof of workers’ compensation and disability insurance is provided to OGS. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of Bid submission, policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.. ATTACHMENT 5 – Report of Contract Usage This Spreadsheet is included as a separate document. ATTACHMENT 6 – Guaranteed Analysis This Document is included as a separate document. ATTACHMENT 7 – Approved MWBE Utilization Plan

’ Compensation Insurance and Disability Benefits Requirements. Sections 57 and 220 of the New York State Workers’ Compensation Law require the heads of all municipal and state entities to ensure that businesses applying for contracts have appropriate workers’ compensation and disability benefits insurance coverage. These requirements apply to both original contracts and renewals. Failure to provide proper proof of such coverage or a legal exemption will result in a rejection of any contract renewal. Proof of workers’ compensation and disability benefits coverage, or proof of exemption must be submitted to OGS at the time of policy renewal, contract renewal and upon request. Proof of compliance must be submitted on one of the following forms designated by the New York State Workers’ Compensation Board. An XXXXX form is not acceptable proof of New York State workers’ compensation or disability benefits insurance coverage. Proof of Compliance with Workers’ Compensation Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With with No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icpocreport/overview.jspxxx.xxx.xx.xxx); • Form C-105.2 (9/07), Certificate of Workers’ Compensation Insurance, sent to OGS by the Contractor’s insurance carrier upon request, or if coverage is provided by the New York State Insurance Fund, they will provide Form U-26.3 to OGS upon request from the Contractor; or • Form SI-12, Certificate of Workers’ Compensation Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office, or • Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance, available from the Contractor’s Group Self-Insurance Administrator. Proof of Compliance with Disability Benefits Coverage Requirements: • Form CE-200, Certificate of Attestation for New York Entities With with No Employees and Certain Out of State Entities, That New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (xxxx://xxx.xxx.xx.xxx/content/ebiz/icdbpoc/DBpocFileReq.jspxxx.xxx.xx.xxx); • Form DB-120.1, Certificate of Disability Benefits Insurance, sent to OGS by the Contractor’s insurance carrier upon request; or • Form DB-155, Certificate of Disability Benefits Self-Insurance, available from the New York State Workers’ Compensation Board’s Self-Insurance Office. An instruction manual clarifying the New York State Workers’ Compensation Law requirements is available for download at the New York State Workers’ Compensation Board’s website, xxxx://xxx.xxx.xx.xxx. Once on the site, click on the Employers/Businesses tab and then click on Employers’ Handbook.