Finance Committee

07/30/2021

@ DATE (MM/DD/YYYY,
ACORD CERTIFICATE OF LIABILITY INSURANCE

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

OSHA's Form 300A «rev. 01/2004)
Summary of Work-Related Injuries and Illnesses

All establishments covered by Part 1904 must complete this Summary page, even if no injuries or
illnesses occurred during the year. Remember to review the Log to verify that the entries are complete

Using the Log, count the individual entries you made for each category. Then write the totals below,
making sure you've added the entries from every page of the fog. if you had no cases write "0."

OSHA's Form 300A irev. 01/2004) Year 2019 <>
Summary of Work-Related Injuries and Illnesses US. Department of Labor

Occupational Satety and Health Administration

Form approved OMB no. 1218-0176
All establishments covered by Part 1904 must complete this Summary page, even if no injuries or

illnesses occurred during the year. Remember to review the Log to verify that the entries are complete

OSHA's Form 300A (rev. 01/2004) Year 2018 <>
Summary of Work-Related Injuries and Illnesses 5. enatenent st babes

Occupstional Safery and Heaitn Administration
Form approved OMA no, 1218-0176

All establishments covered by Pan 1304 must complete this Summary page, even if no injuwtes or
liinesses occurred dung Ihe year. Remember to review the Log to vevify that the anines are complete

Certification of Document’s Authenticity
AIA® Document D401™ — 2003

§ C.3.4 Attach a copy of your insurance agent’s verification letter for your organization’s current workers’
compensation experience modification rate and rates for the last three years. See attached

§ C.4 INSURANCE

§ C.4.1 Attach current certificates of insurance for your commercial general liability policy, umbrella insurance policy,
and professional liability insurance policy, if any. Identify deductibles or self-insured retentions for your commercial
general liability policy. See attached

§ C.1,4 Identify key personnel from your organization who will be meaningfully involved with work on this Project and
indicate (1) their position on the Project team, (2) their office location, (3) their expertise and experience, and (4)
projects similar to the Project on which they have worked.

Key personnel for this project will be Randy Franco Project Manager and Michael Gagnon, Project Superintendent.
Both work out of SCMI’s home office located at 2 Townsend West, Unit 3, Nashua, NH.

Project Specific Information

This Exhibit is part of the Contractor’s Qualification Statement, submitted by Schroeder
Construction Management Inc and dated the third day of November in the year Two
Thousand Twenty-one

PROJECT:

IFB0779-1 10321 Waste Line Replacement at the Transit Administration Building
[1 Riverside Street
Nashua, NH 03062

CONTRACTOR'S PROJECT OFFICE:
2 Townsend West, Unit #3, Nashua, NH 03063
TYPE OF WORK SOUGHT

organization was responsible for more than $75,000?
NO
4 filed any lawsuits or requested arbitration regarding a construction project?
NO

§ B.2.3 In the last five years, has your organization, its parent, or a subsidiary, affiliate, or other entity having common
ownership or management; or any of the individuals listed in Exhibit A Section 1,2:

<1 been convicted of, or indicted for, a business-related crime?
NO

2 had any business or professional license subjected to disciplinary action?
NO

Financial and Performance Information

This Exhibit is part of the Contractor's Qualification Statement, submitted by Schroeder
Construction Management Inc and dated the third day of November inthe year Two
Thousand Twenty-one

§ B.1 FINANCIAL

§ B.1.1 Federal tax identification number:

74-3150716

§ B.1.2 Attach financial statements for the last three years prepared in accordance with
Generally Accepted Accounting Principles, including your organization’s latest balance