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HomeMy WebLinkAbout19-139 - Nordvind Company, LLC - South 196th/200th Street Bridge Repair Project19-139 Council Approval 9/16/19 C-1 AGREEMENT FORM CONTRACT NO. THIS AGREEMENT is made and entered into on this 26ri'day of September , 2019 , by and between ("Contractor"). Now, the City of Tukwila, Washington ("Owner") and Nordv i nd Company, LLC therefore the parties agree as follows: 1. Project. Contractor shall complete all work and furnish all labor, tools, materials, and equipment for the project entitled 196th/200th Street Bridge Repair Project, Project No. 91710406, including all changes to the Work and force account work, in accordance with the Contract Documents, as described in Section 1-04.2 of the Supplemental General Requirements. 2. Payments. Owner shall pay Contractor at the unit and lump sum prices, and by force account as specified in the Proposal according to the Contract Documents as to time, manner, and condition of payment. The payments to Contractor include the costs for all labor, tools, materials and equipment for the Work. 3. Completion Date. Contract time shall commence upon Owner's Notice to Proceed date. The Work under this Agreement shall be completed within the time specified in the Proposal. If the Work under this Agreement is not completed within the time specified, as detailed in the Contract Documents, Contractor shall pay liquidated damages and all engineering inspection and supervision costs to Owner as specified in the Proposal. 4. Attorney's Fees. In the event litigation is commenced to enforce this Agreement, the prevailing party shall be entitled to recover its costs, including reasonable attorney's and expert witness fees. 5. Disclaimer. No liability of Contractor shall attach to Owner by reason of entering into this Agreement, except as expressly provided in this Agreement. 6. Counterparts. This Agreement is executed in two (2) identical counterparts, by the parties, each of which shall for all purposes be deemed an original. CITY OF TUKWILA, WASHINGTON Attest: iw ��\,_t( 20 �°i This dJo day of ✓-t��'" Clerk 0 Approved as to, City Attodey Address for giving notices: t,V �a(''rii) G.cOPo-r1i (Contractor) By: Title: ! rl 't Attest: This 2, n day of 5r PT:M 1L, 2019 Contractor's License No. 1\ Ri)JSS Address for giving notices: tiU)01.ti Rev. 7-30-19 196'1200'" Street Bridge Repair Project Provided o AL-.iders Exchange of WA, Inc. For. usage Condi':ons Agreement see www.bxwa.con - Always Verify Scal. PAYMENT AND PERFORMANCE BOND Bond to City of Tukwila, Washington Bond No. PB00499800160 We, Nordvind Company, LLC , and Philadelphia Indemnity Insurance Company , (Principal) (Surety) a Pennsylvania corporation, and as a surety corporation authorized to become a surety upon Bonds of Contractors with municipal corporations in Washington State, are jointly and severally bound to the City of Tukwila, Washington ("Owner"), in the penal sum of Three Hundred Twenty Thousand Four Hundred & 00/100 Dollars ($ 320.400.00 ), the payment of which sum, on demand, we bind ourselves and our successors, heirs, administrators, executors, or personal representatives, as the case may be. This Payment and Performance Bond is provided to secure the performance of Principal in connection with a contract dated , 20_ , between Principal and Owner for a project entitled 196"1/200th Street Bridge Repair Project, Contract No. 91710406 ("Contract"). The initial penal sum shall equal 100% of the Total Bid Price, including sales tax, as specified in the Proposal submitted by Principal. NOW, THEREFORE, this Payment and Performance Bond shall be satisfied and released only upon the condition that Principal: • Faithfully performs all provisions of the Contract and changes authorized by Owner in the manner and within the time specified as may be extended under the Contract; • Pays all laborers, mechanics, subcontractors, lower tier subcontractors, material men, and all other persons or agents who supply labor, equipment, or materials to the Project; • Indemnifies and holds Owner, its officers, and agents harmless from and against all claims, liabilities, causes of action, damages, and costs for such payments for labor, equipment, and materials by satisfying all claims and demands incurred under the Contract, and reimbursing and paying Owner all expenses that Owner may incur in making good any default by Principal; and • Indemnifies and holds Owner harmless from all claims, liabilities, causes of action, damages and costs, including property damages and personal injuries, resulting from any defect appearing or developing in the material provided or workmanship performed under the Contract. The indemnities to Owner shall also inure to the benefit of the Consulting Engineers and other design professionals retained by Owner in connection with the Project. The liability of Surety shall be limited to the penal sum of this Payment and Performance Bond. No change, extension of time, alteration, or addition to the terms of the Contract or to the Work to be performed under the Contract shall in any way affect Surety's obligation on the Payment and Performance Bond. Surety hereby waives notice of any change, extension of time, alteration, or addition to the terms of the Contract or the Work, with the exception that Surety shall be notified if the Contract time is extended by more than twenty percent (20%). If any modification or change increases the total amount to be paid under the Contract, Surety's obligation under this Payment and Performance Bond shall automatically increase in a like amount. Any such increase shall not exceed twenty-five percent (25%) of the original amount of the Payment and Performance Bond without the prior written consent of Surety. 196'h/200t" Street Bridge Repair Project Rev. 7-30-19 of WA Tnr For usaae Conditions Agreement see www.bxwa.com - Always Verify Scal 756 PHILADELPHIA INDEMNITY INSURANCE COMPANY One Bala Plaza, Suite 100 Bala Cynwyd, PA 19004-0950 Power of Attorney KNOW ALL PERSONS BY THESE PRESENTS: That PHILADELPHIA INDEMNITY INSURANCE COMPANY (the Company), a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, does hereby constitute and appoint Carley Espiritu, Christopher Kinyon, Cynthia L. Jay, Eric A. Zimmerman, James B. Binder, Jamie L. Marques, Karen C. Swanson, Kyle Joseph Howat, Aliceon A. Keltner, Tamara A. Ringeisen, Annelies M. Richie, Heather L. Allen, Jacob T. Haddock, Ally Rombach, Holli Albers, Erica E. Mosley and Brandon K. Bush of Bratrud Middleton Insurance Brokers, Inc. dba Propel Insurance, its true and lawful Attorney - in -fact with full authority to execute on its behalf bonds, undertakings, recognizances and other contracts of indemnity and writings obligatory in the nature thereof, issued in the course of its business and to bind the Company thereby, in an amount not to exceed $50,000,000. This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of Directors of PHILADELPHIA INDEMNITY INSURANCE COMPANY on the l4th of November, 2016. RESOLVED: That the Board of Directors hereby authorizes the President or any Vice President of the Company: (1) Appoint Attorney(s) in Fact and authorize the Attorney(s) in Fact to execute on behalf of the Company bonds and undertakings, contracts of indemnity and other writings obligatory in the nature thereof and to attach the seal of the Company thereto; and (2) to remove, at any time, any such Attorney -in -Fact and revoke the authority given. And, be it FURTHER RESOLVED: That the signatures of such officers and the seal of the Company may be affixed to any such Power of Attorney or certificate relating thereto by facsimile, and any such Power of Attorney so executed and certified by facsimile signatures and facsimile seal shall be valid and binding upon the Company in the future with respect to any bond or undertaking to which it is attached. IN TESTIMONY WHEREOF, PHILADELPHIA INDEMNITY INSURANCE COMPANY HAS CAUSED THIS INSTRUMENT TO BE SIGNED AND ITS CORPORATE SEALTO BE AFFIXED BY ITS AUTHORIZED OFFICE THIS 27 m DAY OF OCTOBER, 2017. (Seal) Robert D. O'Leary Jr., President & CEO Philadelphia Indemnity Insurance Company On this 27th day of October, 2017, before me came the individual who executed the preceding instrument, to me personally known, and being by me duly sworn said that he is the therein described and authorized officer of the PHILADELPHIA INDEMNITY INSURANCE COMPANY; that the seal affixed to said instrument is the Corporate seal of said Company; that the said Corporate Seal and his signature were duly affixed. COMMONWEALTH OF PENy SYLVANI NOTARIAL SEAL Morgan Knapp. Nolary Public Lower M.erwn Iwp.. Monigomary County Aly Commisswn Er picas Serpl. 25. 2021 II INAa abT S (Notary Seal) Notary Public: residing at: My commission expires: Bala Cynwyd. PA September 25, 2021 I, Edward Sayago, Corporate Secretary of PHILADELPHIA INDEMNITY INSURANCE COMPANY, do hereby certify that the foregoing resolution of the Board of Directors and the Power of Attorney issued pursuant thereto on the 27I1 day of October, 2017 are true and correct and are still in full force and effect. I do further certify that Robert D. O'Leary Jr., who executed the Power of Attorney as President, was on the date of execution of the attached Power of Attorney the duly elected President of PHILADELPHIA INDEMNITY INSURANCE COMPANY. In Testimony Whereof I have subscribed my name and affixed the facsimile seal of each Company this < clay of Edward Sayago, Corporate Secretary PHILADELPHIA INDEMNITY INSURANCE COMPANY 20 . 757 PHILADELPHIA INDEMNITY INSURANCE COMPANY One Bala Plaza, Suite 100 Bala Cynwyd, PA 19004-0950 Power of Attorney KNOW ALL PERSONS BY THESE PRESENTS: That PHILADELPHIA INDEMNITY INSURANCE COMPANY (the Company), a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, does hereby constitute and appoint Carley Espiritu, Christopher Kinyon, Cynthia L. Jay, Eric A. Zimmerman, James B. Binder, Jamie L. Marques, Karen C. Swanson, Kyle Joseph Howat, Aliceon A. Keltner, Tamara A. Ringeisen, Annelies M. Richie, Heather L. Allen, Jacob T. Haddock, Ally Rombach, Holli Albers, Erica E. Mosley and Brandon K. Bush of Bratrud Middleton Insurance Brokers, Inc. dba Propel Insurance, its true and lawful Attorney - in -fact with full authority to execute on its behalf bonds, undertakings, recognizances and other contracts of indemnity and writings obligatory in the nature thereof, issued in the course of its business and to bind the Company thereby, in an amount not to exceed $50,000,000. This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of Directors of PHILADELPHIA INDEMNITY INSURANCE COMPANY on the 1411' of November, 2016. RESOLVED: That the Board of Directors hereby authorizes the President or any Vice President of the Company: (1) Appoint Attorney(s) in Fact and authorize the Attorney(s) in Fact to execute on behalf of the Company bonds and undertakings, contracts of indemnity and other writings obligatory in the nature thereof and to attach the seal of the Company thereto; and (2) to remove, at any time, any such Attorney -in -Fact and revoke the authority given. And, be it FURTHER RESOLVED: That the signatures of such officers and the seal of the Company may be affixed to any such Power of Attorney or certificate relating thereto by facsimile, and any such Power of Attorney so executed and certified by facsimile signatures and facsimile seal shall be valid and binding upon the Company in the future with respect to any bond or undertaking to which it is attached. IN TESTIMONY WHEREOF, PHILADELPHIA INDEMNITY INSURANCE COMPANY HAS CAUSED THIS INSTRUMENT TO BE SIGNED AND ITS CORPORATE SEALTO BE AFFIXED BY ITS AUTHORIZED OFFICE THIS 27111DAY OF OCTOBER, 2017. (Seal) Robert D. O'Leary Jr., President & CEO Philadelphia Indemnity Insurance Company On this 27i1' day of October, 2017, before me came the individual who executed the preceding instrument, to me personally known, and being by me duly sworn said that he is the therein described and authorized officer of the PHILADELPHIA INDEMNITY INSURANCE COMPANY; that the seal affixed to said instrument is the Corporate seal of said Company; that the said Corporate Seal and his signature were duly affixed. COMMONWEALTH OF PENNSVI,VANIA NOTARIAL SEAL Morgan Knapp. Notary Public Lower Merlon lap.. Mpn Oo.»nary County AlyCwnmissbnExpnas Sapl. 25. 2021 14wU 1 FL,5Ynv,!NASSOCAPCa1M (Notary Seal) Notary Public: residing at: Bala Cynwyd, PA My commission expires: September 25, 2021 I, Edward Sayago, Corporate Secretary of PHILADELPHIA INDEMNITY INSURANCE COMPANY, do hereby certify that the foregoing resolution of the Board of Directors and the Power of Attorney issued pursuant thereto on the 27i1' day of October, 2017 are true and correct and are still in full force and effect. I do further certify that Robert D. O'Leary Jr., who executed the Power of Attorney as President, was on the date of execution of the attached Power of Attorney the duly elected President of PHILADELPHIA INDEMNITY INSURANCE COMPANY. In Testimony Whereof I have subscribed my name and affixed the facsimile seal of each Company this') - bay of rl^'(..yIk<. 1,,, Edward Sayago, Corporate Secretary PHILADELPHIA INDEMNITY INSURANCE COMPANY Performance 8 Payment Bond C-3 This Payment and Performance Bond shall be governed and construed by the laws of the State of Washington, and venue shall be in King County, Washington. IN WITNESS WHEREOF, the parties have executed this instrument in two (2) identical counterparts this 20th day of September , 20 19 . Nordvind Company, LLC Prir\cipal Philadelphia Indemnity Insurance Company Surety Signature of Authorized Official Signature of Authorized Official By 'Aliceon A. Keltner, Attorney -in -Fact Title Attorney in Fact (Attach Power of Attorney) Name and address of local office of Philadelphia Indemnity Insurance Company agent and/or Surety Company: 1420 5th Ave Suite 3510 Seattle, WA 98101 Surety companies executing bonds must appear on the current Authorized Insurance List in the State of Washington per Section 1-02.7 of the Standard Specifications. 196t/200`h Street Bridge Repair Project Rev. 7-30-19 Client#: 183963 NORDSEWE ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/9/19/2DD/ YYYY) 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER Propel Insurance Seattle Commercial Insurance 601 Union Street, Suite 3400 Seattle, WA 98101-1371 CONTACT Rainey Lindholm PHONE FAX (A/C, No, Ext): 800 499-0933 (A/C, No): 866 577-1326 E-MAIL mine Ilndholm ro elinsurance.com ADDRESS: y' p AF INSURER(S)FORDINGCOVERAGE NAIL# INSURER A : Ohio Security Insurance Company 24082 INSURED Nordvind Sewer Services LLC 1720 Loraine St Enumclaw WA 98023 INSURER B INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSRL SUBR WVD POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL. LIABILITY BKS59648686 04/28/2019 04/28/2020 EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR PREMISESCO(EaoNcurrence) s1,000,000 MED EXP (Any one person) $ 15,000 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE X LIMIT APPLIES ECOT PER: LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE X X LIABILITY ANY AUTO OWNED X SCHEDULED AUTOS D AUNOTN-OWNEOSONLY BAS59648686 04/28/2019 04/28/2020 COMBINEDccident)SILIMIT (Ea a $NGLE 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB O OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/ N N N / A BKS59648686 WA Stop Gap 04/28/2019 04/28/2020 PER STATUTE OTH- ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 A Lesed Rented Equipment BKS59648686 04/28/2019 04/28/2020 $150,000 Limit $1,000 Ded DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) The General Liability, Auto Liability and Umbrella Liability policies include a blanket automatic additional insured endorsement that provides additional insured status only when there is a written contract between the named insured and the entity that requires such status. RE: Operations performed by the Named Insured City of Tukwila is named as Additional Insured per the attached CERTIFICATE HOLDER CANCELLATION City of Tukwila 6300 Southcenter Blvd #212 Tukwila, WA 98188 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 9- "_ ACORD 25 (2016/03) 1 of 1 #S3809071/M3625462 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JMT00 This page has been left blank intentionally. COMMERCIAL GENERAL LIABILITY CG88100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY EXTENSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART INDEX SUBJECT PAGE NON -OWNED AIRCRAFT 2 NON -OWNED WATERCRAFT 2 PROPERTY DAMAGE LIABILITY — ELEVATORS 2 EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) 2 MEDICAL PAYMENTS EXTENSION 3 EXTENSION OF SUPPLEMENTARY PAYMENTS — COVERAGES A AND B 3 ADDITIONAL INSUREDS — BY CONTRACT, AGREEMENT OR PERMIT 3 PRIMARY AND NON-CONTRIBUTORY — ADDITIONAL INSURED EXTENSION 5 ADDITIONAL INSUREDS — EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" 6 WHO IS AN INSURED — INCIDENTAL MEDICAL ERRORS/MALPRACTICE AND WHO IS AN INSURED — 6 FELLOW EMPLOYEE EXTENSION — MANAGEMENT EMPLOYEES NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES 7 FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES 7 KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT 7 LIBERALIZATION CLAUSE 7 BODILY INJURY REDEFINED 7 EXTENDED PROPERTY DAMAGE 8 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US — 8 WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU CG88100413 © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 8 With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. A. NON -OWNED AIRCRAFT Under Paragraph 2. Exclusions of Section I — Coverage A - Bodily Injury And Property Damage Liability, exclusion g. Aircraft, Auto Or Watercraft does not apply to an aircraft provided: 1. It is not owned by any insured; 2. It is hired, chartered or loaned with a trained paid crew; 3. The pilot in command holds a currently effective certificate, issued by the duly constituted authority of the United States of America or Canada, designating her or him a commercial or airline pilot; and 4. It is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the insured other valid and collectible insurance, whether primary, excess (other than insurance written to apply specifically in excess of this policy), contingent or on any other basis, that would also apply to the loss covered under this provision. B. NON -OWNED WATERCRAFT Under Paragraph 2. Exclusions of Section I — Coverage A— Bodily Injury And Property Damage Liability, Subparagraph (2) of exclusion g. Aircraft, Auto Or Watercraft is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) Less than 52 feet long; and (b) Not being used to carry persons or property for a charge. C. PROPERTY DAMAGE LIABILITY — ELEVATORS 1. Under Paragraph 2. Exclusions of Section I — Coverage A— Bodily Injury And Property Damage Liability, Subparagraphs (3), (4) and (6) of exclusion j. Damage To Property do not apply if such "property damage" results from the use of elevators. For the purpose of this provision, elevators do not include vehicle lifts. Vehicle lifts are lifts or hoists used in automobile service or repair operations. 2. The following is added to Section IV — Commercial General Liability Conditions, Condition 4. Other Insurance, Paragraph b. Excess Insurance: The insurance afforded by this provision of this endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) If Damage To Premises Rented To You is not otherwise excluded from this Coverage Part: 1. Under Paragraph 2. Exclusions of Section I - Coverage A - Bodily Injury and Property Damage Liability: a. The fourth from the last paragraph of exclusion j. Damage To Property is replaced by the following: Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" (other than damage by fire, lightning, explosion, smoke, or leakage from an automatic fire protection system) CG88100413 to: (i) Premises rented to you for a period of 7 or fewer consecutive days; or (ii) Contents that you rent or lease as part of a premises rental or lease agreement for a period of more than 7 days. Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" to contents of premises rented to you for a period of 7 or fewer consecutive days. A separate limit of insurance applies to this coverage as described in Section III — Limits of Insurance. © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 8 b. The last paragraph of subsection 2. Exclusions is replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section III — Limits Of Insurance. 2. Paragraph 6. under Section 11I — Limits Of Insurance is replaced by the following: 6. Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of "property damage" to: a. Any one premise: (1) While rented to you; or (2) While rented to you or temporarily occupied by you with permission of the owner for damage by fire, lightning, explosion, smoke or leakage from automatic protection systems; or b. Contents that you rent or lease as part of a premises rental or lease agreement. 3. As regards coverage provided by this provision D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) - Paragraph 9.a. of Definitions is replaced with the following: 9.a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with the permission of the owner, or for damage to contents of such premises that are included in your premises rental or lease agreement, is not an "insured contract". E. MEDICAL PAYMENTS EXTENSION If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided by this policy are amended as follows: Under Paragraph 1. Insuring Agreement of Section I — Coverage C — Medical Payments, Subparagraph (b) of Paragraph a. is replaced by the following: (b) The expenses are incurred and reported within three years of the date of the accident; and F. EXTENSION OF SUPPLEMENTARY PAYMENTS — COVERAGES A AND B 1. Under Supplementary Payments — Coverages A and B, Paragraph 1.b. is replaced by the following: b. Up to $3,000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. 2. Paragraph 1.d. is replaced by the following: d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work. G. ADDITIONAL INSUREDS - BY CONTRACT, AGREEMENT OR PERMIT 1. Paragraph 2. under Section 11— Who Is An Insured is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written agreement or permit. Such person or organization is an additional insured but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused in whole or in part by: a. Your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your on going operations for the additional insured that are the subject of the written contract or written agreement provided that the "bodily injury" or "property damage" occurs, or the "personal and advertising injury" is committed, subsequent to the signing of such written contract or written agreement; or CG88100413 © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 8 b. Premises or facilities rented by you or used by you; or c. The maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or d. Operations performed by you or on your behalf for which the state or political subdivision has issued a permit subject to the following additional provisions: (1) This insurance does not apply to "bodily injury", "property damage", or "personal and advertising injury" arising out of the operations performed for the state or political subdivision; (2) This insurance does not apply to "bodily injury" or "property damage" included within the "completed operations hazard". (3) However: Insurance applies to premises you own, rent, or control but only with respect to the following hazards: a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners, or decorations and similar exposures; or (b) The construction, erection, or removal of elevators; or (c) The ownership, maintenance, or use of any elevators covered by this insurance. 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to Paragraph 1.a. above, a person's or organization's status as an additional insured under this endorsement ends when: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. With respect to Paragraph 1.b. above, a person's or organization's status as an additional insured under this endorsement ends when their written contract or written agreement with you for such premises or facilities ends. With respects to Paragraph 1.c. above, this insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property damage". We have no duty to defend an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured as required in Paragraph b. of Condition 2. Duties In the Event Of Occurrence, Offense, Claim Or Suit under Section IV — Commercial General Liability Conditions. CG88100413 © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 4 of 8 2. With respect to the insurance provided by this endorsement, the following are added to Paragraph 2. Exclusions under Section I - Coverage A - Bodily Injury And Property Damage Liability: This insurance does not apply to: a. "Bodily injury" or "property damage" arising from the sole negligence of the additional insured. b. "Bodily injury" or "property damage" that occurs prior to you commencing operations at the location where such "bodily injury or "property damage" occurs. c. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of, or the failure to render, any professional architectural, engineering or surveying services. d. "Bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. e. Any person or organization specifically designated as an additional insured for ongoing operations by a separate ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS endorsement issued by us and made a part of this policy. 3. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. H. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. Condition 4. Other Insurance of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: a. The following is added to Paragraph a. Primary Insurance: If an additional insured's policy has an Other Insurance provision making its policy excess, and you have agreed in a written contract or written agreement to provide the additional insured coverage on a primary and noncontributory basis, this policy shall be primary and we will not seek contribution from the additional insured's policy for damages we cover. CG88100413 © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 8 b. The following is added to Paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreement, or permit issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the additional insured is designated as a Named Insured. Regardless of the written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional insured has been added as an additional insured on other policies. I. ADDITIONAL INSUREDS - EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. 1. The following is added to Condition 2. Duties In The Event Of Occurrence, Offense, Claim or Suit: An additional insured under this endorsement will as soon as practicable: a. Give written notice of an "occurrence" or an offense that may result in a claim or "suit" under this insurance to us; b. Tender the defense and indemnity of any claim or "suit" to all insurers whom also have insurance available to the additional insured; and c. Agree to make available any other insurance which the additional insured has for a loss we cover under this Coverage Part. d. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured. 2. The limits of insurance applicable to the additional insured are those specified in a written contract or written agreement or the limits of insurance as stated in the Declarations of this policy and defined in Section III — Limits of Insurance of this policy, whichever are less. These limits are inclusive of and not in addition to the limits of insurance available under this policy. J. WHO IS AN INSURED - INCIDENTAL MEDICAL ERRORS / MALPRACTICE WHO IS AN INSURED - FELLOW EMPLOYEE EXTENSION - MANAGEMENT EMPLOYEES Paragraph 2.a.(1) of Section II - Who Is An Insured is replaced with the following: (1) "Bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), to a co -"employee" while in the course of his or her employment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co -"employee" or "volunteer worker" as a consequence of Paragraph (1) (a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1) (a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. However, if you are not in the business of providing professional health care services or providing professional health care personnel to others, or if coverage for providing professional health care services is not otherwise excluded by separate endorsement, this provision (Paragraph (d)) does not apply. CG88100413 © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 6 of 8 Paragraphs (a) and (b) above do not apply to "bodily injury" or "personal and advertising injury" caused by an "employee" who is acting in a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, includes the direct supervision of other "employees" of yours. However, none of these "employees" are insureds for "bodily injury" or "personal and advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to cause "bodily injury" or "personal and advertising injury", or caused in whole or in part by their intoxication by liquor or controlled substances. The coverage provided by provision J. is excess over any other valid and collectable insurance available to your "employee". K. NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES Paragraph 3. of Section II - Who Is An Insured is replaced by the following: 3. Any organization you newly acquire or form and over which you maintain ownership or majority interest, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. d. Records and descriptions of operations must be maintained by the first Named Insured. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations or qualifies as an insured under this provision. L. FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES Under Section IV — Commercial General Liability Conditions, the following is added to Condition 6. Representations: Your failure to disclose all hazards or prior `occurrences" existing as of the inception date of the policy shall not prejudice the coverage afforded by this policy provided such failure to disclose all hazards or prior "occurrences" is not intentional. M. KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT Under Section IV — Commercial General Liability Conditions, the following is added to Condition 2. Duties In The Event of Occurrence, Offense, Claim Or Suit: Knowledge of an "occurrence", offense, claim or "suit" by an agent, servant or "employee" of any insured shall not in itself constitute knowledge of the insured unless an insured listed under Paragraph 1. of Section II — Who Is An Insured or a person who has been designated by them to receive reports of "occurrences", offenses, claims or "suits" shall have received such notice from the agent, servant or "employee". N. LIBERALIZATION CLAUSE If we revise this Commercial General Liability Extension Endorsement to provide more coverage without additional premium charge, your policy will automatically provide the coverage as of the day the revision is effective in your state. O. BODILY INJURY REDEFINED Under Section V — Definitions, Definition 3. is replaced by the following: 3. "Bodily Injury" means physical injury, sickness or disease sustained by a person. This includes mental anguish, mental injury, shock, fright or death that results from such physical injury, sickness or disease. CG88100413 © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 7 of 8 P. EXTENDED PROPERTY DAMAGE Exclusion a. of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the following: a. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. Q. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US — WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU Under Section IV — Commercial General Liability Conditions, the following is added to Condition 8. Transfer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against a person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard" provided: 1. You and that person or organization have agreed in writing in a contract or agreement that you waive such rights against that person or organization; and 2. The injury or damage occurs subsequent to the execution of the written contract or written agreement. CG88100413 © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 8 of 8 COMMERCIAL GENERAL LIABILITY CG88601208 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EACH LOCATION GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section 1— Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section I — Coverage C Medical Payments, which can be attributed only to operations at a single "location" owned by or rented to you: 1. A separate Each Location General Aggregate Limit applies to each "location", and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Each Location General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard", and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Each Location General Aggregate Limit for that "location". Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Each Location General Aggregate Limit for any other "location". 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Each Location General Aggregate Limit. B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I — Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section 1— Coverage C Medical Payments, which cannot be attributed only to operations at a single "location" owned by or rented to you: 1. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products -Completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Each Location General Aggregate Limit. C. When coverage for liability arising out of the "products -completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products - completed operations hazard" will reduce the Products -Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Each Location General Aggregate Limit. D. For the purposes of this endorsement, the following definition is added to Section V — Definitions: "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. E. The provisions of Section III - Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. CG 88 60 12 08 Includes copyrighted material of ISO Properties, Inc., with its permission. Page 1 of 1 This page has been left blank intentionally. COMMERCIAL AUTO CA88100110 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE ENHANCEMENT ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. COVERAGE INDEX SUBJECT PROVISION NUMBER ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT 3 ACCIDENTAL AIRBAG DEPLOYMENT 12 AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS 18 AMENDED FELLOW EMPLOYEE EXCLUSION 5 AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE 13 BROAD FORM INSURED 1 BODILY INJURY REDEFINED 21 EMPLOYEES AS INSUREDS (including employee hired auto) 2 EXTENDED CANCELLATION CONDITION 22 EXTRA EXPENSE — BROADENED COVERAGE 10 GLASS REPAIR — WAIVER OF DEDUCTIBLE 15 HIRED AUTO PHYSICAL DAMAGE(including employee hired auto) 6 HIRED AUTO COVERAGE TERRITORY 20 LOAN / LEASE GAP 14 PARKED AUTO COLLISION COVERAGE (WAIVER OF DEDUCTIBLE) 16 PERSONAL EFFECTS COVERAGE 11 PHYSICAL DAMAGE — ADDITIONAL TRANSPORTATION EXPENSE COVERAGE 8 RENTAL REIMBURSEMENT 9 SUPPLEMENTARY PAYMENTS 4 TOWING AND LABOR 7 UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS 17 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US 19 SECTION II — LIABILITY COVERAGE is amended as follows: 1. BROAD FORM INSURED SECTION II — LIABILITY COVERAGE, paragraph A.1. —WHO IS AN INSURED is amended to include the following as an insured: d. Any legally incorporated entity of which you own more than 50 percent of the voting stock during the policy period. However, "insured" does not include any organization that: (1) Is a partnership or joint venture; or (2) Is an insured under any other automobile policy; or (3) Has exhausted its Limit of Insurance under any other automobile policy. Paragraph d. (2) of this provision does not apply to a policy written to apply specifically in excess of this policy. e. Any organization you newly acquire or form, other than a partnership or joint venture, of which you own more than 50 percent of the voting stock. This automatic coverage is afforded only for 180 days from the date of acquisition or formation. However, coverage under this provision does not apply: (1) If there is similar insurance or a self -insured retention plan available to that organization; CA88100110 ©2010 Liberty Mutual Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, with its permission. Page 1 of 7 (2) If the Limits of Insurance of any other insurance policy have been exhausted; or (3) To "bodily injury" or "property damage" that occurred before you acquired or formed the organization. 2. EMPLOYEES AS INSUREDS SECTION II — LIABILITY COVERAGE, paragraph A.1. —WHO IS AN INSURED is amended to include the following as an insured: f. Any "employee" of yours while using a covered "auto" you do not own, hire or borrow but only for acts within the scope of their employment by you. Insurance provided by this endorsement is excess over any other insurance available to any "employee". g. An "employee" of yours while operating an "auto" hired or borrowed under a written contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business and within the scope of their employment. Insurance provided by this endorsement is excess over any other insurance available to the "employee". 3. ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT SECTION II — LIABILITY COVERAGE, paragraph A.1. —WHO IS AN INSURED is amended to include the following as an insured: h. Any person or organization with respect to the operation, maintenance or use of a covered "auto", provided that you and such person or organization have agreed in a written contract, agreement, or permit issued to you by governmental or public authority, to add such person, or organization, or governmental or public authority to this policy as an "insured". However, such person or organization is an "insured": (1) Only with respect to the operation, maintenance or use of a covered "auto"; (2) Only for "bodily injury" or"property damage" caused by an "accident" which takes place after you executed the written contract or agreement, or the permit has been issued to you; and (3) Only for the duration of that contract, agreement or permit 4. SUPPLEMENTARY PAYMENTS SECTION II — LIABILITY COVERAGE, Coverage Extensions, 2.a. Supplementary Payments, paragraphs (2) and (4) are replaced by the following: (2) Up to $3,000 for cost of bail bonds (including bonds for related traffic violations) required because of an "accident" we cover. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the insured at our request, including actual loss of earnings up to $500 a day because of time off from work. 5. AMENDED FELLOW EMPLOYEE EXCLUSION In those jurisdictions where, by law, fellow employees are not entitled to the protection afforded to the employer by the workers compensation exclusivity rule, or similar protection, the following provision is added: SECTION II — LIABILITY, exclusion B.5. FELLOW EMPLOYEE does not apply if the "bodily injury" results from the use of a covered "auto" you own or hire. SECTION III — PHYSICAL DAMAGE COVERAGE is amended as follows: 6. HIRED AUTO PHYSICAL DAMAGE Paragraph A.4. Coverage Extensions of SECTION III — PHYSICAL DAMAGE COVERAGE, is amended by adding the following: If hired "autos" are covered "autos" for Liability Coverage, and if Comprehensive, Specified Causes of Loss or Collision coverage are provided under the Business Auto Coverage Form for any "auto" you own, then the Physical Damage coverages provided are extended to "autos": a. You hire, rent or borrow; or CA 88 10 01 10 ©2010 Liberty Mutual Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, with its permission. Page 2 of 7 b. Your "employee" hires or rents under a written contract or agreement in that "employee's" name, but only if the damage occurs while the vehicle is being used in the conduct of your business, subject to the following limit and deductible: A. The most we will pay for "loss" in any one "accident" or "loss" is the smallest of: (1) $50,000; or (2) The actual cash value of the damaged or stolen property as of the time of the "loss"; or (3) The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality, minus a deductible. B. The deductible will be equal to the largest deductible applicable to any owned "auto" for that coverage. C. Subject to the limit, deductible and excess provisions described in this provision, we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own. D. Subject to a maximum of $750 per "accident", we will also cover the actual loss of use of the hired "auto" if it results from an "accident", you are legally liable and the lessor incurs an actual financial loss. E. This coverage extension does not apply to: (1) Any "auto" that is hired, rented or borrowed with a driver; or (2) Any "auto" that is hired, rented or borrowed from your "employee". For the purposes of this provision, SECTION V — DEFINITIONS is amended by adding the following: "Total loss" means a "loss" in which the cost of repairs plus the salvage value exceeds the actual cash value. 7. TOWING AND LABOR SECTION III — PHYSICAL DAMAGE COVERAGE, paragraph A.2. Towing, is amended by the addition of the following: We will pay towing and labor costs incurred, up to the limits shown below, each time a covered "auto" classified and rated as a private passenger type, "light truck" or "medium truck" is disabled: a. For private passenger type vehicles, we will pay up to $50 per disablement. b. For "light trucks", we will pay up to $50 per disablement. "Light trucks" are trucks that have a gross vehicle weight (GVW) of 10,000 pounds or less. c. For "medium trucks" , we will pay up to $150 per disablement. "Medium trucks" are trucks that have a gross vehicle weight (GVW) of 10,001 — 20,000 pounds. However, the labor must be performed at the place of disablement. 8. PHYSICAL DAMAGE- ADDITIONAL TRANSPORTATION EXPENSE COVERAGE Paragraph A.4.a., Coverage Extension of SECTION III — PHYSICAL DAMAGE COVERAGE, is amended to provide a limit of $50 per day and a maximum limit of $1,500 CA88100110 ©2010 Liberty Mutual Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, with its permission. Page 3 of 7 9. RENTAL REIMBURSEMENT SECTION III — PHYSICAL DAMAGE COVERAGE, A. COVERAGE, is amended by adding the following: a. We will pay up to $75 per day for rental reimbursement expenses incurred by you for the rental of an "auto" because of "accident" or "loss", to an "auto" for which we also pay a "loss" under Comprehensive, Specified Causes of Loss or Collision Coverages. We will pay only for those expenses incurred after the first 24 hours following the "accident" or "loss" to the covered "auto." b. Rental Reimbursement will be based on the rental of a comparable vehicle, which in many cases may be substantially less than $75 per day, and will only be allowed for the period of time it should take to repair or replace the vehicle with reasonable speed and similar quality, up to a maximum of 30 days. c. We will also pay up to $500 for reasonable and necessary expenses incurred by you to remove and replace your tools and equipment from the covered "auto". d. This coverage does not apply unless you have a business necessity that other "autos" available for your use and operation cannot fill. e. If "loss" results from the total theft of a covered "auto" of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided under Paragraph 4. Coverage Extension. f. No deductible applies to this coverage. For the purposes of this endorsement provision, materials and equipment do not include "personal effects" as defined in provision 11. 10. EXTRA EXPENSE - BROADENED COVERAGE Under SECTION III — PHYSICAL DAMAGE COVERAGE, A. COVERAGE, we will pay for the expense of returning a stolen covered "auto" to you. The maximum amount we will pay is $1,000. 11. PERSONAL EFFECTS COVERAGE A. SECTION III — PHYSICAL DAMAGE COVERAGE, A. COVERAGE, is amended by adding the following: If you have purchased Comprehensive Coverage on this policy for an "auto" you own and that "auto" is stolen, we will pay, without application of a deductible, up to $600 for "personal effects" stolen with the "auto." The insurance provided under this provision is excess over any other collectible insurance. B. SECTION V — DEFINITIONS is amended by adding the following: For the purposes of this provision, "personal effects" mean tangible property that is worn or carried by an insured." "Personal effects" does not include tools, equipment, jewelry, money or securities. 12. ACCIDENTAL AIRBAG DEPLOYMENT SECTION III — PHYSICAL DAMAGE COVERAGE, B. EXCLUSIONS is amended by adding the following: If you have purchased Comprehensive or Collision Coverage under this policy, the exclusion for "loss" relating to mechanical breakdown does not apply to the accidental discharge of an airbag. Any insurance we provide shall be excess over any other collectible insurance or reimbursement by manufacturer's warranty. However, we agree to pay any deductible applicable to the other coverage or warranty. 13. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE SECTION III — PHYSICAL DAMAGE COVERAGE, B. EXCLUSIONS, exception paragraph a. to exclusions 4.c. and 4.d. is deleted and replaced with the following: CA88100110 ©2010 Liberty Mutual Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, with its permission. Page 4 of 7 Exclusion 4.c. and 4.d. do not apply to: a. Electronic equipment that receives or transmits audio, visual or data signals, whether or not designed solely for the reproduction of sound, if the equipment is permanently installed in the covered "auto" at the time of the "loss" and such equipment is designed to be solely operated by use of the power from the "auto's" electrical system, in or upon the covered "auto" and physical damage coverages are provided for the covered "auto"; or If the "loss" occurs solely to audio, visual or data electronic equipment or accessories used with this equipment, then our obligation to pay for, repair, return or replace damaged or stolen property will be reduced by a $100 deductible. 14. LOAN / LEASE GAP COVERAGE A. Paragraph C., LIMIT OF INSURANCE of SECTION III — PHYSICAL DAMAGE COVERAGE is amended by adding the following: The most we will pay for a "total loss" to a covered "auto" owned by or leased to you in any one "accident" is the greater of the: 1. Balance due under the terms of the loan or lease to which the damaged covered "auto" is subject at the time of the "loss" less the amount of: a. Overdue payments and financial penalties associated with those payments as of the date of the "loss", b. Financial penalties imposed under a lease due to high mileage, excessive use or abnormal wear and tear, c. Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease, d. Transfer or rollover balances from previous loans or leases, e. Final payment due under a "Balloon Loan", f. The dollar amount of any unrepaired damage which occurred prior to the "total loss" of a covered "auto", g. Security deposits not refunded by a lessor, h. All refunds payable or paid to you as a result of the early termination of a lease agreement or as a result of the early termination of any warranty or extended service agreement on a covered "auto", i. Any amount representing taxes, j. Loan or lease termination fees; or 2. The actual cash value of the damage or stolen property as of the time of the "loss". An adjustment for depreciation and physical condition will be made in determining the actual cash value at the time of the "loss". This adjustment is not applicable in Texas. B. ADDITIONAL CONDITIONS This coverage applies only to the original loan for which the covered "auto" that incurred the loss serves as collateral, or lease written on the covered "auto" that incurred the loss. C. SECTION V — DEFINTIONS is changed by adding the following: As used in this endorsement provision, the following definitions apply: "Total loss" means a "loss" in which the cost of repairs plus the salvage value exceeds the actual cash value. A "balloon loan" is one with periodic payments that are insufficient to repay the balance over the term of the loan, thereby requiring a large final payment. CA88100110 ©2010 Liberty Mutual Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, with its permission. Page 5 of 7 15. GLASS REPAIR - WAIVER OF DEDUCTIBLE Paragraph D. Deductible of SECTION III — PHYSICAL DAMAGE COVERAGE is amended by the addition of the following: No deductible applies to glass damage if the glass is repaired rather than replaced. 16. PARKED AUTO COLLISION COVERAGE (WAIVER OF DEDUCTIBLE) Paragraph D. Deductible of SECTION III — PHYSICAL DAMAGE COVERAGE is amended by the addition of the following: The deductible does not apply to "loss" caused by collision to such covered "auto" of the private passenger type or light weight truck with a gross vehicle weight of 10,000 lbs. or less as defined by the manufacturer as maximum loaded weight the "auto" is designed to carry while it is: a. In the charge of an "insured"; b. Legally parked; and c. Unoccupied. The "loss" must be reported to the police authorities within 24 hours of known damage. The total amount of the damage to the covered "auto" must exceed the deductible shown in the Declarations. This provision does not apply to any "loss" if the covered "auto" is in the charge of any person or organization engaged in the automobile business. SECTION IV — BUSINESS AUTO CONDITIONS is amended as follows: 17. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS SECTION IV- BUSINESS AUTO CONDITIONS, Paragraph B.2. is amended by adding the following: If you unintentionally fail to disclose any hazards, exposures or material facts existing as of the inception date or renewal date of the Business Auto Coverage Form, the coverage afforded by this policy will not be prejudiced. However, you must report the undisclosed hazard of exposure as soon as practicable after its discovery, and we have the right to collect additional premium for any such hazard or exposure. 18. AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT, OR LOSS SECTION IV — BUSINESS AUTO CONDITIONS, paragraph A.2.a. is replaced in its entirety by the following: a. In the event of "accident", claim, "suit" or "loss", you must promptly notify us when it is known to: 1 You, if you are an individual; 2. A partner, if you are a partnership; 3. Member, if you are a limited liability company; 4. An executive officer or the "employee" designated by the Named Insured to give such notice, if you are a corporation. To the extent possible, notice to us should include: (1) How, when and where the "accident" or "loss" took place; (2) The "insureds" name and address; and (3) The names and addresses of any injured persons and witnesses. 19. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US SECTION IV — BUSINESS AUTO CONDITIONS, paragraph A.5., Transfer of Rights of Recovery Against Others to Us, is amended by the addition of the following: If the person or organization has waived those rights before an "accident" or "loss", our rights are waived also. CA 88 10 01 10 ©2010 Liberty Mutual Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, with its permission. Page 6 of 7 20. HIRED AUTO COVERAGE TERRITORY SECTION IV — BUSINESS AUTO CONDITIONS, paragraph B.7., Policy Period, Coverage Territory, is amended by the addition of the following: f. For "autos" hired 30 days or less, the coverage territory is anywhere in the world, provided that the insured's responsibility to pay for damages is determined in a "suit", on the merits, in the United States, the territories and possessions of the United States of America, Puerto Rico or Canada or in a settlement we agree to. This extension of coverage does not apply to an "auto" hired, leased, rented or borrowed with a driver. SECTION V — DEFINITIONS is amended as follows: 21. BODILY INJURY REDEFINED Under SECTION V — DEFINTIONS, definition C. is replaced by the following: "Bodily injury" means physical injury, sickness or disease sustained by a person, including mental anguish, mental injury, shock, fright or death resulting from any of these at any time. COMMMON POLICY CONDITIONS 22. EXTENDED CANCELLATION CONDITION COMMON POLICY CONDITIONS, paragraph A.— CANCELLATION condition applies except as follows: If we cancel for any reason other than nonpayment of premium, we will mail to the first Named Insured written notice of cancellation at least 60 days before the effective date of cancellation. This provision does not apply in those states which require more than 60 days prior notice of cancellation. CA88100110 ©2010 Liberty Mutual Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, with its permission. Page 7 of 7 This page has been left blank intentionally. PROPOSAL (unit price) Contractor's Name AOX4w`rkm (^v*VA71 Contractor's State License No. City of Tukwila Project No. 91710406 To the Mayor and City Council City of Tukwila, Washington The undersigned (Bidder) hereby certifies that he personally examined the location and construction details of Work outlined in the Contract Documents for the City of Tukwila (Owner) project titled 196 m /200m Street Bridge Repair Project, which project includes but is not limited to nynnovm| and vgp|moe0ant of the concrete approach and other associated structures at the 188m/200m Street ridge on the vVaat aide of the Green River between the City of Tukwila and the City of Kent,; and has read and thoroughly understands these Documents which govern all Work embraced inthis improvement and the methods by which payment will bemade for said Work, and thoroughly understands the nature of said Work; and hereby proposes to undertake and complete all Work annbronad in this improvement in accordance with these Contract Documents and at the following schedule mfrates and prices. The Bidder understands that the quantities mentioned herein are approximate onbandanuoubeot to increase or decrease, and hereby proposes to perform all quantities ofwork oseither increased` or decreased in accordance with the Contract Documents. As evidence of good faith, (check one)V bid bond or 0 cash, Ocashier's check, Ocertified check, or postal money order made ��|��e�������T�| B��i��a�ched���. B�daru�eostands that, should this offer be accepted by Owner within ninety (90) calendar days after the day of Bid Opening and the Bidder fails or refuses to enter into on Agreement and furnish the required Payment and Performance Bond and liability insurance within tan /10A calendar days after Notice of Award, the Contract shall be null and void and the Bid Deposit or Bond accompanying this Proposal shall be forfeited and become the property ofOwner osliquidated damages, all nsprovided for inthe Bid Documents. Bidder shall attain PhysicalCompletion ofall Work inall respects within fifty five (65)working days from the date stated in the written Notice to Proceed. If the work is not completed within this time pnhnd. Bidder shall pay liquidated donnogen to Owner as specified in Section 1-08.8 of the Standard Specifications for every working day work is not Physically Complete after the expiration of the Contract time stated above. In addition, Bidder shall compensate Owner for actual engineering inspection and supervision costs and any other legal fees incurred by Owner an m result ofsuch delay. 196111/200111 Street Bridge Repair Project Rev. 7-30'19 * rrn ��� �Q� STREET BRIDGE REPAIR PROJECT -SCHEDWLE A Project No. 91710406 Note, Unit prices for all itemo, all extensions, and the total amount bid must beshown. Where conflict occurs between the unit price and the total amount specified for any item, the unit price shall prevoi|, and totals shall be corrected to conform thereto. For Schedule A. include applicable Sales Tax imthe various Unit and Lump Sum prices. Item No. Item Description Quantity Unit Unit Price Amount ROADWAY 1. Clearing and Grubbing 1 LS \[\JL)D � 10/0o. 2. Controlled Density Fill 65 CY % Ld 6/5aao� 3. Crushed Surfacing Base Course 25 CY too . 4 � H�A� Approach 1/2 | P8�4�2 r pproao n� 1�O TON �� �,~ / � �7ay. 5. NOT USED 0. Cement Conc. Traffic Curb and Gutter OO LF 40 2 4t'%� � BRIDGE 7. Mobilization 1 LS UD Ei Structure Surveying 1 L8 \ ' 0,)D � 9. Type Progress Schedule 1 LS '500 10. Unexpected Site Changes Est FA $10.000.00 $10'000.00 11. Resolution ofUtility Conflicts Est FA $5.000D0 $5.000.00 12. SPCCP|on 1 LS 13. Temporary Erosion & Sediment Control and Water Pollution Prevention (including SVVPPP Implementation) 1 LS 4!1 14. Project Temporary Traffic Control, Min. Bid $50.000 1 LS 15. Removal ofStructures and Obstructions 1 LS 16. Savvnutting 2300 IN -FT \(} 17. Concrete Pavement Seat Incl. Dowel Bars 1 LS 5-, Ob 18. Bridge Approach Slab 205 GY �Z.� 19. Expansion Joint GvstennConnpr�aaion See|-Superotr. ' 1 LS \�0J3 (o»b »0 / '``' - 20. Cast -In -Place Conc. Barrier 25 LF 5W 21. Traffic Pedestrian Barrier 50 LF 22. Conduit Pipe 4|n. [}iom. 55 LF 23. Conduit Pipe 2In. [)ionn. 120 LF 0, � SIDEWALK 196111/200m8trae Bridge Repair Project Rev. 8-13-19 196111/200m8trae Bridge Repair Project Rev. 8-13-19 Proposal P-3 TRAFFIC CONTROL DEVICES 25. Paint Line 350 LF to. ROADSIDE DEVELOPMENT DEVELOPMENT 26. Property Restoration Est FA $5,000.00 $5,000.00 Schedule A Total 31-0i 4i,t). TOTAL BID PRICE $ 32-0, 40), 19-* 1961172001h Street Bridge Repair Project Rev. 8-13-19 Proposal P-4 Bids Submitted on Computer Printouts Bidders, at their option, in lieu of hand writing in the unit prices in figures in ink on the Bid forms above, may submit an original computer printout sheet with their bid, as long as the following requirements are met: 1. Each sheet of the computer printout must contain the exact same information as shown on the hard - copy bid form — Project Name, Schedule Name, column headings — in the order shown, totals, etc. 2. The computer printout of the Bid Proposal must have the exact certification language shown below, signed by the appropriate officer of the firm. 3. If a computer printout is used, the bidder must still execute that portion of the unit price Bid form which acknowledges the Bid Guaranty, Time of Completion, and all addenda that may have been issued, etc. If any of these things are missing or out of order, the bid may be rejected by the Owner. The unit and lump sum prices shown on acceptable printouts will be the unit prices used to tabulate the Bid and used in the Contract if awarded by the City. In the event of conflict between the two, unit Bid prices will prevail over the extended (Total) prices. If the Bid submitted by the bidder contains both the form on these Bid Proposal sheets, and also a computer printout, completed according to the instructions, the unit bid prices shown on the computer printout will be used to determine the bid. Put this certification on the last sheet of the Bid computer printout, and sign: (YOUR FIRM'S NAME) certifies that the unit prices shown on this complete computer print-out for all of the bid items contained in this Proposal are the unit and lump sum prices intended and that its Bid will be tabulated using these unit prices and no other information from this print-out. (YOUR FIRM'S NAME) acknowledges and ag ees that the total bid amount shown will be read as its total bid and further agrees that the official total Bid a ountyw I be determined by multiplying the unit Bid prices shown in this print-out by the respective estimated quan tie shown on the Bid form then totaling all of the extended amounts. Signed: Title: Date: 196" 7200`h Street Bridge Repair Project Rev. 7-30-19 Proposal P-5 By signing behow/. Bidder acknowledges receipt and understanding of the following Addenda to the Bid Documents: Addendum No. Date of Receiot Addendum No. 1 ?/n/' I / 3 2 4 Date of Receipt NOTE: Failure to acknowledge receipt ofAddenda may beconsidered aoan irregularity in the Bid Proposaland Owner reserves the right bndetermine whether the bid will be disqualified By signing ba|ovv. Bidder certifies that Bidder has reviewed the insurance provisions ofthe Bid Documents and will provide the required coverage. |tiaunderstood that Owner may accept or rejectmUbkds. The Surety Company which will furnish the required Payment and Performance Bond is (Name) (Address) \ Signature of Authorized Official: / A r �. ���^ Printed Name and Title:o�"'~ |e� �'�/°+�5«(> ^^ ['�� ' ,y Joint Venture /Corporation »`u, C' / .\ Phone No.: 7./^l YZ5' 5�44 Date: |�3»(\i This address and phone number is the one to which e8 communications regarding this proposal should be sent. 1. firm under which business istransacted; proposal must be executed by a partner. If the Bidder is a corporation, proposal must be executed in the corporate name by the president orvice-president (or any other corporate officer accompanied uyevidence u/ uuuxx/y to sign). 2. A bid must be received on all items. If either m unit price or an extension is |aft blank (but not both) for a bid item, the Owner will multiply or divide the available entry by the quantitv, as applicable, and enter it on the bid form. If there is no unit price or extension for one or more bid item(s), the proposal will be rejected. 196117200"' Street Bridge Repair Project Rev. 7-3O19 P-6 BID SECURITY Bid Deposit: The undersigned Principal hereby deposits a Bid Deposit with the City of Tukwila in the form of a cash deposit, certified or cashier's check, or postal money order in the amount of S 1 oto varM dollars ($ ). -OR- Bid Bond: The undersigned, Nordvind Company, LLC (Principal), and Philadelphia Indemnity Insurance Company (Surety), are held and firmly bound unto the City of Tukwila (Owner) in the penal sum of Five Percent (5%) of Bid Amount dollars ($ 5% of Bid Amount ), which for the payment of which Principal and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and severally. The liability of Surety under this Bid Bond shall be limited to the penal sum of this Bid Bond. Conditions: The Bid Deposit or Bid Bond shall be an amount not less than five percent (5%) of the total bid, including sales tax and is submitted by Principal to Owner in connection with a Proposal for 196th/200th Street Bridge Repair Project, Project No. 91710406, according to the terms of the Proposal and Bid Documents. Now therefore, a. If the Proposal is rejected by Owner, or b. If the Proposal is accepted and Principal shall duly make and enter into an Agreement with Owner in accordance with the terms of the Proposal and shall furnish a bond for the faithful performance of said Project and for the payment of all persons performing labor or furnishing materials in connection therewith, with Surety or Sureties approved by Owner, then this Bid Security shall be released; otherwise it shall remain in full force and effect and Principal shall forfeit the Bid Deposit or Surety shall immediately pay and forfeit to Owner the amount of the Bid Bond, as penalty and liquidated damages. The obligations of Surety and its Bid Bond shall be in no way impaired or affected by any extension of time within which Owner may accept bids; and Surety does hereby waive notice of any such extension. Signed and dated this 20th day of August Nordvind C mpa,n , LLC pal Signature of Authorized Official Title Name and address of local office of agent and/or Surety Company: ,2019 . Philadelphia Indemnity Insurance Company Surety By Attar ey in Fact (Attach Power of Att Cynth a L. Jay Philadelphia Indemnity Insurance Company 1420 5th Ave Suite 3510 Seattle, WA 98101 196111"/200`" Street Bridge Repair Project Rev. 7-30-19 PrnvirlPrl hn Rnilriorc RvrhannP of WA Tnr Pnr ncan, rnnrlitinnc AnrPPmPnf RPP www hxwa rnm - Alwavc VPrifv Pral Proposal (continued) P-7 Surety companies executing bonds must appear on the current Authorized Insurance List in the State of Washington per Section 1-02.7 of the Standard Specifications. 196`'I200"' Street Bridge Repair Project Rev. 7-30-19 NON~COLLUS|ONCJECLAFAJ|ON STATE [)FVVAGH|NGTON \ ) ss. COUNTY OF KING ) The undersigned, being first duly ovvorn, on oath states that the peraon, firrn, ossociation, portnenahip, jointvanture. or corporation named in the Bid Proposal has (have) not, either directly or indireotk/, entered into any agneemnent, participated in any co||usion, or otherwise taken any action in restraint of free competitive bidding in connection with the City of Tukwila project named 196m/200m Street Bridge Repair Project, Project No. 91710406. | i � Name ofFirm / / / 1� Signature ofAuthorized Official Title v Signed and sworn to before me on this { \1-k\ day of , d \0 Signature of Notary Public in and for the State of Washington, residing at Mvappointment expires: � ` ����/vw�`^. � � _'M ~*_ �"I � u v Toe _ _ v.��_� �� �'-.v .'_, ooax: NOTICE TO ALL BIDDERS 1-800-424-9071 The U.S. Department of Transportation (UGDOT)operates the above toll -free "hotline" Monday through Friday, 8:00 a.m. to 5:00 p.nm., eastern time. Anyone with knowledge of possible bid rig0ing, bidder ooUusion, or other fraudulent activities should use the "hotline" to report such activities. The "hotline" is part ofUSDOT`s continuing effort to identify and investigate highway construction contract fraud and abuse and is operated under the direction of the U8DOT Inspector General. All information will be treated confidentially and caller anonymity will be respected. 196 1h /2001h Street Bridge Repair Project Rev. 7-30-1e P-9 RESPONSIBLE BIDDER DETERMINATION FORM Attach additional sheets as necessary to fully provide the information required. Name of Bidder: CE.Avirie Address of Bidder: Rio purl 1-1E, /=....rtuvi (Awl WO ctg2Z- c,v) tw City State Zip Code Contractor's License No. AolliWSI 951 C:7 WA State UBI No. 4e) 4:-/P 'gat/ Dept. of L&I License Bond Registration No. exl Worker's Comp. Acct. No. - 144- 001 Bidder is a(n): 0 Individual 0 Partnership 0 Joint Venture 0 Incorporated in the state of 11`1/9 List business names sed by Bidder during the past 10 years if different than above: Bidder has been in business continuously from 2015 Year Bank Reference PrroC FlAtArl 1VIA C3, 7 ft7 . 94-3 Bank Account Officer Officer's Phone No. No. of regular full-time employees: Number of projects in the past 10 years completed: 10 ahead of schedule 10 on schedule behind schedule Bidder has had experience in work comparable to that required for this Project: As a prime contractor for 5' years. As a subcontractor for 5 years. List the supervisory personnel to be employed by the Bidder and available for work on this project (Project Manager, Principal Foreman, Superintendents, and Engineers): Name Title cAtvi uu 0 (1,29q,C4. STN5t •E,)11-1 PAL 14 lAm.ivtivn How Long With Bidder 3 4- 1961h/200th Street Bridge Repair Project Rev. 7-30-19 14(.4in LL4.1.,vFxf 2.9R P-10 Name the Surveyor to be used on this Project, who ill directly supervise all surveying activities. Attach a resume outlining the experience and q cations of the Surveyor. Is the Surveyor licensed in the State of Washington (a PLS)? Yes 11 No Surveyor's Name: tekfillfiffa;D VAT-0 S List all those projects, of similar nature and size, completed by Bidder within the past 10 years. Include a reference for each. Any attached preprinted project listing must include all this information. Bidder must have at least 10 years experience working on projects of similar nature and size. Year Project Name Completed 7.01 JAYA („Lil)cC41 '2,17 oq 4,2)o. si (A), Contract Amount a_ Loo.fIYl201i dj) • 44 MUMA ADA) 7,Ake 15-4 oda. e- '1L4V) UPIVO 041') evo, e r(IdzAvick. 50.3, 4`• Owner/Reference Name and Phone V1)10 ; A no tv,) 04a : 24, 241, 3234 cive(AL 4t5 415 ex4,17 urn opcoo., 253, 49u, Goon& 544A6 ; TALvto p 405. G1GC > cor7 waio fpfoik.' 3& a. F15, 343 t/Y4 Iwo) filiv): 34). 453 List all projects undertaken in the last 10 years which have resulted in partial the Contract by arbitration or litigation in the courts: Name of Client and Project Contract Amount Total Claims Arbitrated or Litigated or final settlement of Amount of Settlement of Claims Bidder, or any representative or partner thereof, ever failed to complete a contract? No 0 Yes If yes, give details: I -its Bidder ever had any Payment/Performance Bonds called as a result of its work? t\No 0 Yes If yes, please state: Project Name Contracting Party Bond Amount 1961"/200111 Street Bridge Repair Project Rev. 7-30-19 Responsible Bidder Determination Form P-11 HtBidder ever been found guilty of violating any State or Federal employment laws? I No 0 Yes If yes, give details: Has Bidder for protection under any provision of the federal bankruptcy laws or state insolvency lawsl\� No El Yes If yes, give details: Has any adverse legal judgment been rendered against Bidder inthe past 5years? No [] Yes If yes, Qk/e details: Has Bidder or any of its employees filed any claims with Washington State VVorknnon'a Compensation or oƒh i naDom company for accidents resulting in fatal injury or dismemberment in the past 5 years? /No 0 Yes If yes, please state: The undersigned warrants under p alty of Perjury that the foregoing information is true and accurate to the best of his/her knov 4e. TIKe)undersigned authorizes the City of Tukwila to verify all information contained herein. Signature of Bidder Title: 19611,/2001h Street Bridge Repair Project Rev. 7-3O1S P-12 PROPOSED EQUIPMENT AND LABOR SCHEDULE (Use additional sheets if required) Equipment to be used: DESCRIPTION/TYPE YEAR CONDITION OWN/RENT L4943'6t- 1,0 0 (two A.A9 (LA-vii.11-4(*. Ni 1 5 G-IvP ) v1171 k (14U( N4-01C, 2411 6-1A-10 OtA/11 -114,tig- lflo GAA, owl) Labor to be used: ,21)&j,i1TK VIA-4 afa illtitk 0/405Z Id 070 Name of Bidder Signature of Authorized Official 614,, Title 196"'/200'h Street Bridge Repair Project Rev, 7-30-19 P-13 PROPOSED SUBCONTRACTORS Name of Bidder ^nD/17111 In accordance with RCW 39.30.060 as amended, every bid that totals $1 million or more shall include below the names of the subcontractors with whom the Bidder, if awarded the contract, will subcontract for performance of the work of: HVAC (heating, ventilation, and air conditioning); plumbing as described in chapter 18.106 RCW; and electrical as described in chapter 19.28 RCW, or to name itself for the work. The Bidder shall not list more than one subcontractor for each category of work identified, unless subcontractors vary with bid alternates, in which case the Bidder must indicate which subcontractor will be used for which alternate. Failure of the Bidder to submit as part of the bid the names of such subcontractors or to name itself to perform such work or the naming of two or more subcontractors to perform the same work shall render the prime contract bidder's bid nonresponsive and, therefore, void. The successful Bidder must have the written permission of the Owner to make any change to this list. Percent of total bid to be performed by Bidder 15 Schedule/Bid Item Numbers % of Name Subcontractor will perform Total Bid (A)1 (11 r1/tvf Spj Pile Int. 4 4- 1961h/200th Street Bridge Repair Project Rev. 7-30-19 584 PHILADELPHIA INDEMNITY INSURANCE COMPANY One Bala Plaza, Suite 100 Bala Cynwyd, PA 19004-0950 Power of Attorney KNOW ALL PERSONS BY THESE PRESENTS: That PHILADELPHIA INDEMNITY INSURANCE COMPANY (the Company), a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, does hereby constitute and appoint Carley Espiritu, Christopher Kinyon, Cynthia L. Jay, Eric A. Zimmerman, James B. Binder, Jamie L. Marques, Karen C. Swanson, Kyle Joseph Howat, Aliceon A. Keltner, Tamara A. Ringeisen, Annelies M. Richie, Heather L. Allen, Mary S. Norrell, Jacob T. Haddock and Brandon K. Bush of Bratrud Middleton Insurance Brokers, Inc. dba Propel Insurance , its true and lawful Attorney -in -fact with full authority to execute on its behalf bonds, undertakings, recognizances and other contracts of indemnity and writings obligatory in the nature thereof, issued in the course of its business and to bind the Company thereby, in an amount not to exceed $50,000,000. This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of Directors of PHILADELPHIA INDEMNITY INSURANCE COMPANY on the 1411' of November, 2016. RESOLVED: That the Board of Directors hereby authorizes the President or any Vice President of the Company: (1) Appoint Attorney(s) in Fact and authorize the Attorney(s) in Fact to execute on behalf of the Company bonds and undertakings, contracts of indemnity and other writings obligatory in the nature thereof and to attach the seal of the Company thereto; and (2) to remove, at any time, any such Attorney -in -Fact and revoke the authority given. And, be it FURTHER RESOLVED: That the signatures of such officers and the seal of the Company may be affixed to any such Power of Attorney or certificate relating thereto by facsimile, and any such Power of Attorney so executed and certified by facsimile signatures and facsimile seal shall be valid and binding upon the Company in the future with respect to any bond or undertaking to which it is attached. IN TESTIMONY WHEREOF, PI-IILADELPFI1A INDEMNITY INSURANCE COMPANY HAS CAUSED TI-IIS INSTRUMENT TO BE SIGNED AND ITS CORPORATE SEALTO BE AFFIXED BY ITS AUTHORIZED OFFICE THIS 27TH DAY OF OCTOBER, 2017. (Seal) Robert D. O'Leary Jr., President & CEO Philadelphia Indemnity Insurance Company On this 2711i day of October, 2017, before me came the individual who executed the preceding instrument, to me personally known, and being by me duly sworn said that he is the therein described and authorized officer of the PHILADELPHIA INDEMNITY INSURANCE COMPANY; that the seal affixed to said instrument is the Corporate seal of said Company; that the said Corporate Seal and his signature were duly affixed. ��1 `" r J11t'1cnnEn, rxR Ft d k i. .• ., c�.rw.roxnie`rusir»4W'L' (Notary Seal) Notary Public: residing at: My commission expires: Bala Cynwyd, PA September 25, 2021 I, Edward Sayago, Corporate Secretary of PHILADELPHIA INDEMNITY INSURANCE COMPANY, do hereby certify that the foregoing resolution of the Board of Directors and the Power of Attorney issued pursuant thereto on the 271h day of October, 2017 are true and correct and are still in full force and effect. I do further certify that Robert D. O'Leary Jr., who executed the Power of Attorney as President, was on the date of execution of the attached Power of Attorney the duly elected President of PHILADELPHIA INDEMNITY INSURANCE COMPANY. In Testimony Whereof I have subscribed my name and affixed the facsimile seal of each Company this day of Edward Sayago, Corporate Secretary PHILADELPHIA INDEMNITY INSURANCE COMPANY ,20