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Ofc Form 26 - Work Certificate For Contractors Before Beginning Their Work On Public Projects - New Hampshire Department Of Transportation

Subcontractor/Lower-Tier/Consultant Name:_________________________

Project Name: ________________________________________

Project Number: ______________________________________

WORK CERTIFICATE for CONTRACTORS

BEFORE BEGINNING THEIR WORK on PUBLIC PROJECTS

Certification Requirements of RSA 21-I:80 and RSA 228:4-b

By New Hampshire law, before any work is done on any major state project or any work on any

highway, bridge or other construction, reconstruction, alteration or maintenance project, each

contractor, subcontractor and independent contractor shall complete and sign this form and provide

the following documents:

1. Attach a certificate of your current workers’ compensation insurance coverage, naming

NH Department of Transportation, Office of Federal Compliance, 7 Hazen Drive, Concord, NH

03302-0483 as the certificate holder, showing coverage specific for work within the State of New

Hampshire. [Note that any person directly performing work on a project must be covered by

such workers’ compensation coverage under RSA 281-A, and you will not permit or direct any

person excluded from your coverage to work on the project.]

2. Provide below an estimate of the total number of workers anticipated to be employed on the project

during the contract period, and a number of days (8-hour periods), applied to each insurance

classification code applicable to the work to be performed:

Number of workers

Days

Classification code & description of work

[Attach additional sheets as necessary]

OFC Form 26 (Rev: January 4, 2016)

Ofc Form 26 - Work Certificate For Contractors Before Beginning Their Work On Public Projects - New Hampshire Department Of Transportation