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OCIP Enrollment Form (Form A)
Sound Transit Owner Controlled Insurance Program
For Contractors, Subcontractors, Consultants and Subconsultants Involved in Sound Move Projects

GENERAL INFORMATION

Name of Company:
Type of Entity:	Corporation Partnership LLC Individual Joint Venture
Address:
Address2:
City:
State:		Zip:
Telephone Number:		Fax:
Federal Employer ID:
Administrative Contact Name:
Admin Contact Telephone:
Prime Contractor:

CONTRACT OR SUBCONTRACT INFORMATION

Estimated Start Date:		Estimated Completion Date:
Contract Amount:		Sound Transit Contract Number RTA:
Scope of Work:
Contractor:	Contractor Subcontractor Construction Management Consultant Subconsultant Architect/Engineer

List of Expected Subcontractors / Subconsultants
Subcontractor Name	Subcontract Amount	Description of Subcontract

ENROLLMENT CERTIFICATION

CERTIFICATION AND ASSIGNMENT

We hereby certify that the cost of insurance for those coverages provided by the Owner Controlled Insurance Program (OCIP) have not been included in our contract price. Further, we hereby assign, transfer and set over absolutely unto Sound Transit its right, title and interest to any and all returns of premiums, dividends, discounts, or other adjustments to this OCIP. This assignment shall pertain to the policies as now written and as subsequently modified, rewritten or replaced in Sound Transit’s Insurance companies, including any additional amount or coverages as a result thereof. We also assign our right of cancellation of all Insurance policies provided to us by Sound Transit through the OCIP. This assignment is valid only for Insurance policies where premiums have been paid by Sound Transit on behalf of our firm. We agree that by signing this form, we request enrollment in the OCIP, and that enrollment will be confirmed once Sound Transit’s insurance representative issues the appropriate OCIP certificates. OCIP coverage will become effective at the time our employees first come on to a Sound Move Project Site

We hereby certify that the information set forth herein is true and accurate in all material respects.

Date:		Authorised Representative:
		Title:

If you have questions regarding this form, please direct them to:

Consultants or Contractors:
Contact your Sound Transit Contract Administrator

Subconsultants or Subcontractors:
Contact your primary Consultant or Contractor