Dir Pwc 100 Form PDF Details

The DIR PWC 100 form is a document used by the California Department of Industrial Relations (DIR) to evaluate the compliance of an employer with workers' compensation laws. The DIR PWC 100 form is broken into five sections, which are: Identification Information, Financial Information, Coverage Analysis and Compliance History, Deductible Payment History, and Retention and Service of Documents. Employers who complete the DIR PWC 100 form will be evaluated on their workers' compensation compliance history, financial stability, and coverage analysis. Completing the DIR PWC 100 form is voluntary for employers in California; however, employers who do not complete the form may be subject to penalties from the DIR.

QuestionAnswer
Form NameDir Pwc 100 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdir 100 form, dir pwc100, pwc100 fill out, pwc application form

Form Preview Example

 

 

 

STATE OF CALIFORNIA – DEPARTMENT OF INDUSTRIAL RELATIONS

 

 

TO:

California Department of Industrial Relations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Division of Apprenticeship Standards

 

 

 

 

AWARDING AGENCY ID NUMBER

 

 

 

 

 

 

 

 

P.O. Box 420603

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

San Francisco, CA 94142

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM:

 

 

 

 

 

 

 

 

 

 

If you do not have an ID number please contact DAS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXTRACT OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PUBLIC WORKS CONTRACT AWARD

.

 

A CONTRACT TO PERFORM PUBLIC WORKS UNDER LABOR CODE SECTION 1777.5 HAS BEEN AWARDED TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. NAME OF GENERAL CONTRACTOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. CONTRACTOR’S LICENSE NO

 

 

3. MAILING ADDRESS (STREET NUMBER OR P.O. BOX)

 

 

 

 

 

 

4. CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. ZIP CODE

 

 

 

 

6. TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

7. GENERAL CONTRACTOR’S CONTACT EMAIL ADDRESS

 

 

 

Application

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8 ADDRESS/LOCATION OF PUBLIC WORKS SITE (INCLUDE CITY AND

 

 

 

 

 

 

 

 

 

 

 

 

Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY):

 

 

 

 

 

 

 

 

9. . NAME OF PROJECT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8a. County

 

 

10. CONTRACT NUMBER

 

 

 

11. PROJECT NUMBER

 

 

 

 

 

 

Award

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. DOLLAR AMOUNT OF CONTRACT AWARD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gov/PWC100

 

 

13 . FIRST ADVERTISED BID DATE

 

ReferenceWeb

 

 

 

12a ESTIMATED TOTAL PROJECT COSTS, IF DIFFERENT FROM

 

 

 

 

14 CONTRACT AWARD DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ITEM 12 (see instructions).

 

 

 

 

 

 

 

 

MONTH DAY

 

YEAR

 

 

MONTH

 

DAY

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. WHICH STATUTE, IF ANY, APPLIES TO THIS PROJECT?

 

 

 

 

 

 

 

the

 

Contract

 

 

 

 

 

 

 

 

 

 

 

 

16. STATE CONSTRUCTION BONDS

 

 

YES

 

NO

 

 

 

 

17. WILL YOU OPERATE A DIR-APPROVED LABOR COMPLIANCE

 

 

If YES, List the Sources and Dollar Amount of Bond Proc ds:

 

 

 

 

 

PROGRAM (LCP) FOR THIS PROJECT?

 

 

SOURCES

 

 

 

 

 

 

DOLLAR AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. IS THERE A PROJECT LABOR AGREEMENT (PLA) ASSOCIATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WITH THIS PROJECT? If yes, please email a copy to cmupla@dir.ca.gov

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

19. STARTING DATE (ESTIMATED OR ACTUAL)

 

 

 

 

.

20. COMPLETION DATE (ESTIMATED OR ACTUAL)

 

 

 

 

 

 

 

 

 

 

Provided24.

use

 

your dir

ca

 

 

 

 

 

 

 

 

 

 

(MM/DD/YYYY)

 

 

 

for

 

 

 

 

 

 

(MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

21. BRIEF DESCRIPTION OF WORK TO BE PERFORMED

 

 

.

 

 

22

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

NEW CONSTRUCTION

REMODELING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALTERATION, DEMOLITION, REPAIR OR MAINTENANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23. CLASSIFICATION OR TYPE OF WORKER (CARPENTER, PLUMBER, ETC.) THAT WILL BE EMPLOYED BY THE CONTRACTOR(S)

 

 

 

submit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. SIGNATURE

https://www

26. TITLE

 

 

 

 

 

 

 

27. DATE

 

 

 

 

 

 

 

lease ist Sub-contractors and their worker classifications

on page 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is language included in the Contract A ard to

effectuate the requirements of

 

 

 

 

 

 

 

 

 

 

 

 

 

sections 1771, 1774, 1775, 1776, 1777.5, 1813, and 1815 of the Labor Code?

 

 

 

YES

 

 

 

NO

 

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. PRINTED OR TYPED NAME

 

 

 

29. E-MAIL ADDRESS

 

 

 

 

 

30. TELEPHONE NUMBERS

 

 

 

 

 

 

 

 

 

 

If different from above, name, title, and contact information of person responsible for carrying out Awarding Body’s LCP or CMU responsibilities.

 

 

31. NAME

 

 

 

 

 

32. TITLE

 

 

 

 

 

 

33. E-MAIL ADDRESS

 

 

 

 

34. TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Duplication of this form is permissible

DIR-PWC 100 (rev. 10/11) successor to the DAS 13 form

EXTRACT OF PUBLIC WORKS CONTRACT AWARD (Continued)

Listing of Sub Contractors

Con. Lic. #

Contractor

Classification of workers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

information

 

 

 

 

 

 

 

 

Application

 

 

 

 

 

ReferenceWeb

Only

Award

 

 

 

 

for

 

gov/PWC100

 

 

 

 

the

 

Contract.

 

 

Provided

use

.

ca

 

 

 

 

 

 

 

 

 

 

 

your

dir

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

Please

 

 

 

 

 

 

 

 

 

 

submit

 

 

 

 

 

 

 

to

https://www

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIR-PWC 100 (rev. 10/11) successor to the DAS 13 form

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