ATTACHMENT II. The Application includes the forms listed below. These must be completed and submitted in accordance with the Network requirements:

ATTACHMENT II

Application Submission Punch List - Conversion Network

The Application includes the forms listed below. These must be completed and submitted in accordance with the Network requirements:

RFQ Application Submittal Form (Form CN-1)

Contractor Information Form (including license information) (Form CN-2)

Quality-Customer Reference Form (Form CN-3)

Lead Distribution Area Form (CN-4)

Safety Survey Form (CN-5)

*

The above information constitutes a complete application.

Acceptance -Conversion Network

Provide With Acceptance to Network

Executed Network Agreement

Certificates of Insurance* for: 1) Worker's Compensation & Employer's Liability,

2) Commercial General Liability, 3) Excess Liability Insurance, 4) Professional Liability,

5) Commercial Automobile Liability, 6) Employee Crime Liability

* (Insurance carriers must be licensed in CT and the applicable Company and its affiliates must be named as additional insured's.)

ATTACHMENT II

RFQ Application Submittal Form (CN-1) - Conversion Network Application

I

of

(Applicant's Name)

(Company Name)

hereby apply to participate in the Conversion Network(s) of the following company or companies:

(Please check one category:)

SCG

CNG

Both SCG and CNG

The following completed forms are included with this application:

* Contractor Information Form (Form CN-2)

* Quality-Customer Reference Form (Form CN-3)

* Lead Distribution Area Form (Form CN-4)

* Safety & Health Form (Form CN-5)

I understand that submission of this application does not guarantee participation but rather

will be used as part of a review process to determine eligibility.

Name of Applicant:

(Applicant's Written name)

Title:

Signature of Applicant:

Form 1 of 5

CN-1 8/ 9/ 13

ATTACHMENT II

Contractor Information Form (CN-2) - Conversion Network Application

Please provide the following information.

Company's Legal Name:

Office Phone No.:

Address - Main Office:

Office Fax Number:

CT Tax Identification Number

Office Email Address:

Principal Contact:

Principal's Cell Number:

Principal's Title:

Principal's Email Address:

Primary CT Heating License Holder

Heating Equipment Installed

(please specify)

CT Heating License Number

(Primary Holder)

24 Hour Answering service?

(Yes or No)

License Type(s)

Expiration Date

No. of Full Time Office Staff:

Periodic Training of Licensed

Technicians

Foreign Languages ( Please

specify, if none Enter "None" )

Form 2 of 5

CN- 2 8/ 9 /13

Statement of Quality & Customer Reference Form (CN-3) --- Conversion Network Application

ATTACHMENT II

Company Name:

I. Company's Statement of Quality (Brief) :

II. Are you a member of the Better Business Bureau (BBB)*?

Yes

If Yes, Current Grade:

* BBB membership is not required for Network participation. Non member companies will not be adversely affected.

No

III. Customer References:

(Please provide contact information of five (5) or more recent customer references , including equipment installed, fuel type and installation dates. References may be contacted by the Companies )

Customer Name

Street Address

Town

State

Zip Code

Phone Number

List Equipment

installed

Fuel type

Install date

1

2

3

4

5

6

7

Note: As part of this Application, references may be contacted to determine customer satisfaction with your company and the equipment installation.

Lead Distribution Area Form (CN-4) - Conversion Network Application

ATTACHMENT II

I.

Company Name:

II.

Type of installations for which you would like to receive leads.

Furnaces

Boilers

Both

III.

Is your company available for evening/emergency installations?

Yes

No

IV.

Number of installation crews to be used.

V.

Check (X) the Company Program(s) and municipalities where you want to perform conversions.

CNG Program

SCG Program

ALL CNG Municipalities

ALL SCG Municipalities

Or Selected Municipalities

Or Selected Municipalities

Avon

Branford

Berlin

Bridgeport

Bloomfield

Clinton

Canton

East Haven

East Hartford

Easton

Farmington

Fairfield

Glastonbury

Guilford

Granby

Hamden

Greenwich

Madison

Hartford

Milford

Hebron

New Haven

Manchester

North Branford

Mansfield

North Haven

New Britain

Old Saybrook

Rocky Hill

Trumbull

Simsbury

Westbrook

Unionville

West Haven

West Hartford

Weston

Wethersfield

Westport

Windsor

Woodbridge

CN-4 8/9/13

RFQ Application Submittal is requested as soon as possible.

Safety and Health Form (CN-5) - Conversion Network Application

Safety and Health Form (CN-5) - Conversion Network Application

Company Name: Address: City, State and Zip Code: Company Contact:

Telephone #: E-Mail Address:

Fax #: Completed by:

1) In the table below, provide the three most recent full years of incident information for your company.

Year Average Exposure Number of Incident Rate # of Lost Incidence # of EMR # of # of Hours Recordable of Recordable Workday Rate of Lost Lost (Must be Fatalities Employees Cases Cases Cases Workday Workdays Verifiable)

Cases

(A) (B) (C) (D) (E) (F) (G) (H) (I) (J)

GUIDANCE IN FILLING OUT THE TABLE

(A) YEAR: List the three most recent full calendar years. If less than a year please specify months. (B) Average # of Employees: List the average # of employees who worked during the year. (C) Exposure Hours: List the total number of hours worked during the year by all company employees. (D) Number of Recordable Cases: List the total number of OSHA Recordable cases that occurred in that year. (E) Incidence Rate of Recordable Cases: Number of Recordable Cases X 200,000

Total Exposure Hours

A lost workday case will be defined as any Recordable case that results in death or lost workdays with days away (G) Incidence rate of lost workday cases: Number of Recordable Cases X 200,000

Total Exposure Hours (H) Number of Lost Workdays:

List the total number of lost workdays experienced by all employees due to injury or job-related illness during the year. (I) EMR- Experience Modification Rate: We require verification for the EMR. Any of the following methods would be acceptable. *A letter from your insurance agent, insurance carrier, or state fund (on their letterhead), verifying the EMR listed above

* A copy of the last three (3) years' experience rating calculations sheets, which your insurance carrier should forward to you annually. (J) Number of Fatalities: List the total number of fatalities that resulted from occupational injuries or illnesses.

Deaths that occur in the workplace but are not the result of occupational injuries or illnesses should not be included.

2) Are all documents pertaining to this questionnaire available for auditing? YES NO If No: Please explain:

3) Does your company hold documented onsite safety meetings (Tailgate/toolbox/pre-job}? If Yes, describe type of meeting and frequency:

Form 5 of 5

Is Documentation available? YES NO

Safety and Health Form (CN-5) - Conversion Network Application

4) Does your company perform regular equipment checks on all equipment?

YES NO

If yes, are records available and maintained? YES NO

5) Does your company require the following personal protective equipment on a construction site?

YES NO

YES NO

Comments:

7) Indicate the circumstances in which your company's employees may be subject to alcohol/drug screening.

Pre-Employment Reasonable Cause/Suspicion Periodic

Follow Up Random Post Accident

Return to Duty Other: (explain) 8) Do you provide a formal, documented safety orientation for each newly hired worker?

YES _NO

9) After completing this survey, do you have any additional comments to offer? Comments:

10. Date Completed:

11. Name of Individual Completing Questionnaire:

12. Signature of Individual Completing Questionnaire: CN-5 8/9/13

Form 5 of 5