Fillable VENDOR PACKET CHECKLIST (Los Rios Community College District)

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VENDOR PACKET CHECKLIST (Los Rios Community College District)

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VENDOR PACKET
CHECKLIST
COMPLETE AND RETURN:
____ Vendor Application
____ Federal Tax Form W-9
____ CA Tax Form(s) as applicable
____ Insurance Certificate and Additional Insured Endorsements as
applicable
RETURN THE ABOVE DOCUMENTS VIA EMAIL:
lrccdpurchase@losrios.edu
Purchasing Revised 12/04/2020
Please note that this application is to be used for goods and services
providers. If your company is a building contractor, please register in
Los Rios CCD’s vendor portal.
Revised 12/04/20
Dear Vendor:
Welcome! Thank you for your interest in doing business with Los Rios Community College. In
accordance with Federal and California state tax laws, backup withholding is required for certain
payments to individuals and business entities. Following please find required forms for reporting and
complete the appropriate form. Return to Los Rios Purchasing Department via email:
Attn: Purchasing Department
lrccdpurchase@losrios.edu
Internal Revenue Code, section 3406(a)(1)(a) requires Taxpayer Identification Number (TIN) (24%
withholding of payments to be made unless valid TIN provided).
California Revenue and Tax Code, section 18662 (7% withholding to non-California individuals or
business entities/corporations without valid TIN. Return the following to Los Rios Purchasing
Department as noted above:
• IRS Form W-9 required to report TIN (Form W-9 instructions)
• Foreign Vendors - IRS Form W-8BEN, W-81MY, W-8ECI, W-8EXP
• Form 590 - Nonresident Withholding Exemption (permanent place of business in California
or qualified to do business through the California Secretary of State)
• Form 587 – Nonresident Withholding Allocation Worksheet (you do not have permanent
place of business in California, you are not qualified to do business through the California
Secretary of State)
If you completed any of the above forms and want to request a waiver or a reduced waiver, the
following forms will need to be completed. Return the original form to the Franchise Tax Board to
obtain a determination letter. Forward a copy of the determination letter to Los Rios Purchasing as
noted above.
• Form 588 – Nonresident Withholding Waiver Request
• Form 589 – Nonresident Reduced Withholding Request
If we do not receive the completed IRS Form W-9, California Form 590 or 587 with a determination
letter from the Franchise Tax Board, backup withholding at 24% for IRS and 7% for the State of
California will begin.
NAME:
FEDERALID#OR
SOCIALSECURITY#
REMITADDRESS(ifdifferent)
PHONE
FAX
EMAIL
WEBSITE
Individual
Partnership
Non Profit
Corporation(ListStateIncorporated)
IsbusinessregisteredintheStateofCalifornia?
Yes No
DATE
‐ / ‐ ‐
NAMEOF
FIRM
MAILINGADDRESS
ORGANIZATION/REGISTRATION
(Checkallthatapply)
AUTHORIZEDCOMPANYREPRESENTATIVES
Name Title/Capacity Email
PROVIDELISTOFCOMMODITIES,EQUIPMENT,SUPPLIESand/orSERVICES
I certify that all statements contained herein are correct.
I understand that this information will be used as a basis
for evaluating my request to receive bid invitations for
purchases. I understand that being placed on the qualified
vendor bid list does not in any way represent an endorsement of
my firm by Los Rios, nor does it relieve my firm of providing
bonds and insurances as required. I further agree to disclose
any known or potential conflicts of interest relating to my
business and Los Rios. I understand the requirements for
fulfilling and invoicing orders. I further certify this firm is an
equal opportunity employer.
___________INITIALS
LRCCD
VENDORAPPLICATION
ReturnsignedcompletedformtoPurchasingviaemail: lrccdpurchase@losrios.edu.
SIGNATURE TITLE
OTHERBUSINESSINFORMATION
DiscountsExtendedPaymentTerms
Refund/Returns
VENDORCERTIFICATION
LOSRIOSPURCHASINGONLY:
www.losrios.edu/purchasing
11/18
NAICS/COMMODITY CODE
______
Revised 12/04/20
INSURANCE REQUIREMENT FOR PERFORMING ON-SITE SERVICES FOR THE
LOS RIOS COMMUNITY COLLEGE DISTRICT
All insurance policies shall include additional insured (AI) endorsement naming the Los Rios Community College District,
its trustees, officers, employees, volunteers, agents, inspectors, project managers, consultants, their employees and each
of them, as additional insured. Alternatively, policy can provide blanket AI endorsement referencing written contract.
The minimum insurance coverage to be obtained by the Vendor is as follows:
Commercial/Comprehensive General Liability Insurance (Insurance Services Organization, Inc. form GL-00-01, Ed. 11-89
or equivalent) (ISO CG 00 0 1):
• Bodily Injury and Property Damage Liability Insurance for Premises and Operations
• Personal Injury for Premises and Operations; Independent Contractors
• Incidental Contracts
• Contractual Liability
• Broad Form Comprehensive General Liability Endorsement (Insurance Services Organization, Inc. form GL-04-04, Ed.
5-81 or equivalent)
• Products and Completed Operations which shall be in the amount of not less than a combined single limit of One
Million Dollars ($1,000,000) per occurrence for one or more persons injured and property damaged on an
occurrence form insurance policy. The aggregate limit of liability for products and completed operations shall not
be less than Three Million Dollars ($3,000,000) for Type A, Two Million Dollars ($2,000,000) for Type B.
• Any combination of General Liability and Excess Liability Coverage can be combined to meet the Aggregate.
Business Automobile Liability Policy Insurance (Insurance Serving Organization, Inc. form CA 00 0 1 or equivalent):
• Protection against loss as a resul
t of liability to others caused by an accident and resulting in bodily injury and/or
property damage, arising out of the ownership or use of any automobile the limits of liability shall not be less than
One Million Dollars ($1,000,000) combined single limit each accident for bodily injury and property damage
combined.
Workers' Compensation and Employers' Liability Insurance:
• The Vendor shall be a qualified self-insurer or shall carry full Workers' Compensation and Employers' Liability
insurance coverage, either through the State Compensation Insurance Fund or a standard approved policy
obtained from a licensed insurance carrier for all persons employed, either directly or through subcontractors, in
carrying out the work under this Contract in accordance with the "Workers' Compensation and Insurance Act,"
Divi
sion IV thereof. Employers' limits of liability shall be the prevailing statutory limits of liability.
• If no (zero) employees, complete Sole Proprietor form
The Vendor shall provide a Certificate of Insurance and required endorsements to comply with this section at least 15
days prior to commencement of work under this contract. The certificate shall state that LRCCD will be given 30 days
notice of any material change or cancellation in coverage.
Purchasing Revised 10/31/2018
Los Rios Community College District
TYPES OF CONTRACT SERVICE
Insurance Type*
A. Specialized Services:
Asbestos Abatement/Environmental/Air Quality
Food Services and Catering
Hazardous Waste Services
High Voltage Services
International Study Travel Abroad
Medical Services (including optical and laboratory)
Professional Services (Accountants, Actuaries, Architects, Attorneys, Engineers,
Financial Services, Insurance, Surveyors, Technology/Cyber/Software as Service)
Special Events, Community Services, Transportation Services
Other (please specify)__________________________________________________
B. Build
ing, Grounds and Maintenance Services:
Building and Grounds Maintenance (Electrical, HVAC, painting, plumbing, roofing, etc.)
Ele
vator Maintenance
Groundskeepers
Janitor/Custodial
Tree Removal/Trimming
Roadway/Parking Lot Striping
Repair, Installation, and Independent Contractors Services:
Carpet Installation and Cleaning
Door and Window Services
Floor Installation, Cost Estimators, Schedule Consultants
Independent services contracts (grants writers, professional speakers, trainers, and
facilitators, report writers, and evaluation/assessment reports)
Locksmith Services
Shower/Tub and Tile Repair
Garage Door Installation, Fence Repairs
*Referen
ces Insurance Coverage and Limits
The above l
ist is not all inclusive of contract services. The District reserves the right to change limit requirements
based on specific services to be performed.
Purchasing Revised 10/31/2018
Los Rios Community College District
INSURANCE COVERAGE AND LIMITS
Type of Contract
Comm’l
General Liab.
Business
Auto Liab.
Professional
Liab.
Workers’
Compensation
A or B
√
√
√
Professional Service
(Architects Engineers,
doctors*)
√
√
√
√
√ = Coverage normally required in contract situation
* = License required by governmental agency
INSURANCE COVERAGE LIMITS
Coverage
Basis
Type A
Type B
(CGL) (Additional Insured)
Occurrence
Aggregate
$1,000,000
$3,000,000
$1,000,000
$2,000,000
(Additional Insured)
Occurrence
$1,000,000
$1,000,000
Workers’ Compensation (WC)
Statutory
Occurrence
Statutory Limit
$1 mil/$1 mil
/$1 mil
Statutory Limit
$1 mil/$1 mil
/$1 mil
Professional Liability (PL)
Aggregate
$2,000,000
$2,000,000
N/A
**Technology E&O, PL
Occurrence
Aggregate
$2,000,000
$2,000,000
N/A
**Cyber Liability (Vendor)
Occurrence
Aggregate
$2,000,000
$2,000,000
N/A
Builders’ Risk (BR)
(Additional Insured
Occurrence
Completed Project Value
Property (Installation Floater)
Contract
Value
Additional Insured or Loss Payee
Full Replacement – No Coinsurance
w/MCS 90 Filing (Additional
Occurrence
$5,000,000
$5,000,000
Pollution/Environmental
Occurrence
Aggregate
$5,000,000
$5,000,000
$1,000,000
$2,000,000
**Technology/Cyber for IT vendors that have access to private/personal information about the District,
student, employee, etc.
The above list is not all inclusive of contract services. The District reserves the right to change limit
requirement’s based on specific services to be performed.
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Completed 28 January 2021

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