STATE OF LOUISIANA



STATE OF LOUISIANA

DEPARTMENT OF NATURAL RESOURCES

OFFICE OF CONSERVATION

UNDERWATER OBSTRUCTION PROGRAM

CONTRACTOR APPLICATION

The following information is to be submitted for consideration as an approved bidder under La. R.S. 30.101.1 et seq. [Act 666; Underwater Obstruction Program]. Return completed application to:

Mailing Address:

Office of Conservation

Underwater Obstruction Program

PO Box 94275 - Capitol Station

Baton Rouge, LA 70804-9275

Parcel Delivery Address:

Office of Conservation

Underwater Obstruction Program

617 North Third Street

LaSalle Building - 9th Floor

Baton Rouge, LA 70802

Pursuant to LSA R.S. 30.101.6.A(4), all applications are presented to and approved by the Commissioner of Conservation. For questions regarding this application, please call 225/342-5524.

FORM UWO-OR-1

UNDERWATER OBSTRUCTION PROGRAM CONTRACTOR ORGANIZATION REPORT

(INSTRUCTIONS ON PAGE 3)

1. Purpose of Filing (Please Check One)

Initial Filing Annual Re-Filing Change of Address Only Organization Name Change

2. Organization - Name & Mailing Address

|Company Name:       |Phone: (   )       |

|Street Address or P.O. Box:       |Fax: (   )       |

|City, State & ZIP       |E-Mail:       |

3. Contact Person to which ALL correspondence should be directed at the above address:

|Name:       |Title:       |

4. Emergency Contact Person

|Name:       |Phone: (   )       |

|E-Mail:       |Fax: (   )       |

5. Contractor should be eligible for: (please mark one below)

Survey Removal Both

6. Provide a listing/brochure of your equipment available for this type of work.

7. Provide a copy of your current contractor license with the State of Louisiana

8. Attach insurance held by your organization (see attachment ‘A’ for minimum requirements).

9. Each registered organization shall notify this Office, in writing, following the filing of a voluntary petition for bankruptcy under any Chapters of Title 11 (Bankruptcy) of the United States Code (11 U.S.C.) by or against. The notification will indicate the name of the organization and date of filing.

CERTIFICATE: I DECLARE UNDER PENALTIES AS PRESCRIBED IN LRS 30:17, THAT I AM AUTHORIZED TO MAKE THIS REPORT, THAT THIS REPORT WAS PREPARED BY ME OR UNDER MY SUPERVISION AND DIRECTION AND THAT FACTS STATED THEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

________________ ___________ __________

PRINTED NAME TITLE DATE

________________ (___) ___-____

SIGNATURE TELEPHONE

FOR UWO USE ONLY: DATE: ________________ APPROVED BY: __________________

PAGE 2

INSTRUCTIONS

FORM UWO-OR-1: UNDERWATER OBSTRUCTION PROGRAM CONTRACTOR ORGANIZATION REPORT

Who is to file FORM UWO-OR-1: Each entity filing an application to become an approved contractor for the Underwater Obstruction Program within the jurisdiction of the Office of Conservation.

When to file FORM UWO-OR-1: Form UWO-OR-1 must be filed with the Contractor Application submittal or when an organization name is being changed. Initial filing shall be valid for the first calendar year.

FORM UWO-OR-1 must be re-filed annually: The Office of Conservation will notify you before your re-filing date by mailing you a blank Form UWO-OR-1. Update any changes by entering them in the proper areas. SIGN the form and return it to the Office of Conservation in Baton Rouge by January 31.

Specific Items on FORM UWO-OR-1:

1. Check proper block to show purpose of filing

2. This is the official name of your organization as carried on Office of Conservation Records. Address, along with an emergency contact, phone number, etc are required pursuant to R.S. 30:4.B. ALL OF THIS INFORMATION MUST BE PROVIDED.

3. This is the primary contact person.

4. This person will be the contact in case of an emergency (may the same as primary contact).

5. Mark which type of work your company can perform/will bid on.

ATTACHMENT ‘A’

INSURANCE REQUIREMENTS

CERTIFICATE OF INSURANCE

1. GENERAL LIABILITY

A. Minimum limits of $5,000,000 per occurrence.

B. BI/PD/Contractual/Products - Completed Operations/OCP.

C Additional insured - The State of Louisiana, all State Departments, Agencies, Board and Commissions, its officers, directors, agents, and employees are to be included as additional insured with the respect to any work done by the Insured under contract.

A. Watercraft Exclusion deleted or evidence of Protection & Indemnity insurance in minimum amount of $5,000,000 in either instance.

A. Waiver of Subrogation in favor of: The State of Louisiana, all State Departments, Agencies, Board and Commissions, its officers, directors, agents and employees with respect to any work done by the Insured under contract.

2. WORKERS’ COMPENSATION

A. Statutory coverage and Employers Liability.

B. Protection & Indemnity/Jones Act - Maritime in minimum amount of $5,000,000 for crew

C. Employers Liability minimum limits of $1,000,000.

D. Waiver of Subrogation in favor of: The State of Louisiana, all State Departments, Agencies, Board and Commissions, its officers, directors, agents and employees with respect to any work done by the Insured under contract.

E. Longshoremen & Harbor Workers coverage including 905 (b).

F. Outer Continental /shelf Lands Act Endorsement

G. Maritime/Jones Act coverage including TWMC/Transportation, Wages, Maintenance, and Cure.

1. AUTOMOBILE LIABILITY

A. Minimum limits of $1,000,000 per occurrence.

B. Owned/Non Owned/Hired Automobiles.

C. Additional Insured - The State of Louisiana, all State Departments, Agencies, Board and Commissions, its officer, directors, agents and employees are to be included as additional insured with the respect to any work done by the insured under contract.

D. Waiver of Subrogation in favor of : The State of Louisiana, All State Departments, Agencies, Board and Commissions, its officers, directors, agents and employees with respect to any work done by the Insured under contract.

1. PROTECTION & INDEMNITY

A. Waiver of Subrogation in favor of: The State of Louisiana, all State Departments, Agencies, Board and Commissions, its officers, directors, agents, and employees with respect to any work done by the Insured under contract.

A. Additional Insured - The State of Louisiana, all State Departments, Agencies, Board and Commissions, its officers, directors, agents and employees are to be included as additional insured with the respect to any work done by the insured under contract.

A. Minimum limits of $5,000,000 for included Crew/TWMC.

A. ‘As owner of the vessel’ phrase deleted.

A. Any phrase purporting to limit the underwriter’s liability to value of vessel or to that of an owner be deleted.

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