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HomeMy WebLinkAbout23-12 WWTP Secondary Clarifiers Mortar ReplacementLA i:- DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 AGREEMENT THIS AGREEMENT is by and between the City of Oshkosh, Wisconsin (Owner) and AUGUST WINTER & SONS, INC., (Contractor). Owner and Contractor, in consideration of the mutual covenants set forth herein, agree as follows: 1. WORK Contractor shall complete all work as specified or indicated in the contract documents for City Contract 23-12, WASTEWATER TREATMENT PLANT SECONDARY CLARIFIERS MORTAR REPLACEMENT, 1.1,1. The completed Work of City Contract 23-12 will provide Owner with anew floor mortar layer and adjusted clarifier mechanisms in Secondary Clarifiers Nos. 1 and 3 at the City of Oshkosh Wastewater Treatment Plant. The Work includes the following major items: 1.1.1.1, Removal of 2-inch-thick mortar layer on floor of 120-foot-diameter circular secondary clarifiers. 1.1.1.2. Adjustment of two clarifier mechanism center piers to vertical plumb; adjust of tow clarifier mechanism scraper arms to horizontal true plane. 1.1.1.3. Preparation of clarifiers' concrete floor surface and installation of new mortar layer. 2. ENGINEER 2.1. The Project Work has been designed by Jacobs Engineering Group, Inc. (Engineer), who is to act as Owner's representative, assume all duties and responsibilities, and have the rights and authority assigned to Engineer in the Contract Documents in connection with the completion of the Work in accordance with the Contract Documents. 3, CONTRACT TIMES 3.1. Time of the Essence: All time limits for Milestones, if any, Substantial Completion, and completion and readiness for final payment as stated in the Contract Documents are of the essence of the Contract. 3.2. Days to Achieve Substantial Completion and Final Payment: 3.2.1. The Work shall be Substantially Complete in accordance with Paragraph 15,06 of the General Conditions within 240 days after the date when the Contract Times commence to run. Final Completion of the Work shall be within 60 days of Substantial Completion. 3.3. Liquidated Damages: 3.3.1. Contractor and Owner recognize that time is of the essence of this Agreement and that Owner will suffer financial loss if the Works is not completed withing the times specified above, AGREEMENT 005213-1 DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 5.2.1.2, Upon Substantial Completion, Owner shall pay an amount sufficient to increase total payments to Contractor to ninety-five percent of the Work completed, less such amounts as Engineer shall determine in accordance with Paragraph 15,03 of the General Conditions and less ten percent of Engineer's estimate of the value of Work to be completed or corrected as shown on the tentative list of items to be completed or corrected attached to the certificate of Substantial Completion. 5.3. Final Payment: 53,1. Upon final completion and acceptance of the Work in accordance with Paragraph 15.06 of the General Conditions, the Supplementary Conditions, and the Supplementary Conditions — City of Oshkosh, Owner shall pay the remainder of the Contract Price. 6. INTEREST 6.1. All monies not paid when due as provided in Article 15 of the General Conditions shall bear interest at the rate of one percent per month. 7. CONTRACTOR'S REPRESENTATIONS 7,1, In order to induce Owner to enter into this Agreement, Contractor makes the following representations: 7,1.1. Contractor has examined and carefully studied the Contract. Documents and the other related data identified in the Bidding Documents, 7.12. Contractor has visited the Site and become familiar with and is satisfied as to the general, local, and Site conditions that may affect cost, progress, and performance of the Work. 7.1.3, Contractor is familiar with and is satisfied as to all federal, state, and local Laws and Regulations that may affect cost, progress, and performance of the Work. 7.1.4. Contractor has carefully studied all: (1) reports of explorations and tests of subsurface conditions at or contiguous to the Site and all drawings of physical conditions in or relating to existing surface or subsurface structures at or contiguous to the Site (except Underground Facilities) which have been identified in the Supplementary Conditions as provided in Article 5 of the General Conditions. 7.1.5. Contractor has considered the information known to Contractor; information commonly known to contractors doing business in the locality of the Site; information and observations obtained from visits to the Site; the Contract Documents; and Site -related reports and drawings identified in the Contract Documents, with respect to the effect of such information, observations, and documents on 1) the cost, progress, and performance of the Work; 2) the means, methods, techniques, sequences, and procedures of construction to be employed by Contractor, including any specific means, methods, techniques, sequences, and procedures of construction expressly required by the Contract Documents; and 3) Contractor's safety precautions and programs. 7.1.6. Contractor does not consider that any further examinations, investigations, explorations, tests, studies, or data are necessary for the performance of the Work at the Contract Price, within AGREEMENT 0052 13 -3 DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 8.2.1.3. Bid Form Signature Pages. 8.2,1,4. Documentation submitted by Contractor prior to Notice of Award. 8.11,4,1,1. List of Proposed Subcontractors, 8.2.1,4,1.2. Disclosure of Ownership, 8.2.1,5. The following which may be delivered or issued on or after the Effective Date of the Agreement and are not attached hereto: 8.2.1.5.1. Notice to Proceed. 8.2.1.5.2. Work Change Directives, 8.2.1,5.3. Change Orders. 8.2.1.5.4. Field Orders, 8.2,1,5,5. Engineer's written interpretations and clarifications. 8.3. The Contract Documents are complementary; what is required by one is as binding as if required by all. In the event any provision in any of the above component parts of this Contract conflicts with any provision in any other of the component parts, the provision in the component part first enumerated above shall govern over any other component which follows it numerically except as may be otherwise specifically stated. 8A, There are no Contract Documents other than those listed above in this Article, 8,5. The Contract Documents may only be amended, modified, or supplemented as provided in Article 3 and Article 11 of the General Conditions and Supplementary Conditions, 9, MISCELLANEOUS 9.1. Terms used in this Agreement will have the meanings stated in the General Conditions and the Supplementary Conditions. 9.2. Successors and Assigns: Owner and Contractor each binds itself, its partners, successors, assigns, and legal representatives to the other party hereto, its partners, successors, assigns, and legal representatives in respect to all covenants, agreements, and obligations contained in the Contract Documents. 9.3. Severability: Any provision or part of the Contract Documents held to be void or unenforceable under any Law or Regulation shall be deemed stricken, and all remaining provisions shall continue to be valid and binding upon Owner and Contractor, who agree the Contract Documents shall be reformed to replace such stricken provision or part thereof with a valid and enforceable provision that comes as close as possible to expressing the intention of the stricken provision. 9.4, Assignment of Contract: AGREEMENT 0052 13 5 DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 IN WITNESS WHEREOF, Owner and Contractor have signed this Agreement in triplicate. One counterpoint each has been delivered to Owner, Contractor, and Engineer. All portions of the Contract Documents have been signed. or identified by Owner and Contractor or on their behalf. This Agreement will be effective on April 26, 2023 (which is the Effective Date of the Agreement). Signed for in behalf of the City of Oshkosh DocuSigned by: zacssai�a�aas... , Mark A. Rohloff, City Manager DocuSigned by: F IA9 Diane M. Bartlett, City Clerk FD ocuSigned by: JJti 32FEe;33T0E87�9 ... Lynn Lorenson, City Attorney FDocuSigned by: ��/- 47-7/ 9 C€€C32�89fr Russ Van Gompel, Director of Finance I hereby certify that the necessary provisions have been made to pay the liability which will accrue under this contract, CONTRACTOR: August Winter & Sons, By: Travis Glennon Title: Assistant Secretary [CORPORATE SEAL] �DocuSlgned by: Attest: S �tbv' HOA06�055529d6F_. Title:Assistant Seereta Address for giving notices: 2323 North Roemer Road Appleton, WI 54911 License No. (Where applicable) Agent for service or process: (If Contractor is a corporation or a partnership, attach evidence of authority to sign.) AGREEMENT 0052 13 - 7 DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 CITY CONTRACT 23-12 OSHKOSH WWTP SECONDARY CLARIFIERS MORTAR REPLACEMENT PROJECT CITY OF OSHKOSH 3.1.3. Bidder is familiar with and is satisfied as to all federal, state and local. Laws and Regulations that may affect cost, progress, and performance of the Work. 3.1.4. Bidder has carefully studied all: i) reports of explorations and tests of subsurface conditions at or contiguous to the Site and all drawings of physical conditions in or relating to existing surface or subsurface structures at or contiguous to the Site (except Underground Facilities) which have been identified in Paragraph 5,03 through 5.05 of the Supplementary Conditions; and ii) reports and drawings of Hazardous Enviromnental Conditions that have been identified in Paragraph 5.06 of the Supplementary Conditions. 3.1.5. Bidder has obtained and carefully studied (or accepts the consequences for not doing so) all additional or supplementary examinations, investigations, explorations, tests, studies and data concerning conditions (surface, subsurface and Underground Facilities) at or contiguous to the Site which may affect cost, progress, or performance of the Work or which relate to any aspect of the means, methods, techniques, sequences, and procedures of construction to be employed by Bidder, including applying the specific means, methods, techniques, sequences, and procedures of construction expressly required by the Bidding Documents to be employed by Bidder, and safety precautions and programs incident thereto. 3.1,6. Bidder does not consider that any further examinations, investigations, explorations, tests, studies, or data are necessary for the determination of this Bid for performance of the Work at the price(s) Bid and within the tunes and in accordance with the other terms and conditions of the Bidding Documents. 3.1.7. Bidder is aware of the general nature of work to be performed by Owner and others at the Site that relates to the Work as indicated in the Bidding Documents. 3.1.8. Bidder has correlated the infoi7zlation known to Bidder, information and observations obtained from visits to the Site, reports and drawings identified in the Bidding Documents, and all additional examinations, investigations, explorations, tests, studies, and data with the Bidding Documents, 3.1.9. Bidder has given Owner mitten notice of all conflicts, errors, ambiguities, or discrepancies that Bidder has discovered in the Bidding Documents, and the written resolution thereof by Engineer is acceptable to Bidder. 3.1.10. The Bidding Documents are generally sufficient to indicate and convey understanding of all terms and conditions for the performance of the Work for which this Bid is submitted. BID FORM PW\JA\C9X37801\C9X39400 0041 13 - 2 FEBRUARY 24, 2023 ©COPYRIGHT 2023 JACOBS DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 CITY CONTRACT 23-12 OSHKOSH WWTP SECONDARY CLARIFIERS MORTAR REPLACEMENT PROJECT CITY OF OSHKOSH 6. TIME OF COMPLETION 6,1, Bidder agrees that the Work will be substantially complete and will be completed and ready for final payment in accordance with Paragraph 15.06 of the General Conditions and Section 00 73 00, Supplementary Conditions — City of Oshkosh, on or before the dates or within the number of calendar days indicated in the Agreement. 6.2. Bidder accepts the provisions of the Agreement as to liquidated damages in the event of failure to complete the Work within the Contract Times. 7, ATTACHMENTS TO THIS BID 7.1, The following documents are attached to and made a condition of this Bid: 7.1.1, Required Bid security in the foim of electronic Bid Bond on the form required by the City of Oshkosh in the amount equal to 5 percent of the total bid amount. 7.1.2. List of Proposed Subcontractors, 7.1.3. Bid Form Signature Pages, 7.1.4, Disclosure of Ownership Form. 8, DEFINED TERMS 8,1, The terms used in this Bid with initial capital letters have the meanings stated in the Instructions to Bidders, the General Conditions, and the Supplementary Conditions. BID FORM PW\JA\C9X37801\C9X39400 0041 13 - 4 FEBRUARY 24, 2023 ©COPYRIGHT 2023 JACOBS DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 A Joint Venture Joint Venturer Name: CITY CONTRACT 23-12 OSHKOSH WWTP SECONDARY CLARIFIERS MORTAR REPLACEMENT PROJECT CITY OF OSHKOSH �1iIN By: (Signature ofjoint venture Name (typed or printed): Title: SEAL) — attach evidence of authority to sign) (Each joint venturer must sign. The manner of signing for each individual, partnership, and corporation that is a party to the joint venture should be in the manner indicated above.) Bidder's Business Address: 2323 N. Roemer Road Appleton, WI 54911 PhoneNo.: 920-739-8881 FAXNo,: 920-739-2230 BID SUBMITTED on April 3 .2023 Wisconsin Contractor's License No.: Master Plumber: 871958, HVAC: 120264 Contractor's License Class (where applicable): N/A 10, SUPPLEMENTS A. The supplements listed below, following "End of Section", are part of this specification. 1. List of Proposed Subcontractors. 2. Disclosure of Ownership. END OF SECTION BID FORM PW\JA\C9X37801\C9X39400 0041 13 - 6 FEBRUARY 24, 2023 ©COPYRIGHT 2023 JACOBS DocuSign Envelope ID: 8BE3EEDD-A2EF449C-A98B-517450A59976 BondNo. 301122G PAYMENTBOND MAY 10 2023 CITY OF OSHKOSH -- _ DEPT Or' PUBLIC WORKS Contract Number 23-12 05gKOS11, WISCONSIN Date Bond Executed (Date of Contract or Later) May 4, 2023 PRINCIPAL/CONTRACTOR (Legal Name and Business Address) August Winter & Sons, Inc. 2323 N. Roemer Road, PO Box 1896 Appleton, WI 54911 SURETY(IES) (Legal Name(s) and Business Address(es)) Ohio Farmers Insurance Company P.O. Box 5001 Westfield Center, OH 44251 - 5001 OWNER (Legal Name and Business Address) CITY OF OSHKOSH 215 Church Avenue PO Box 1130 Oshkosh, Wisconsin 54903-1130 OBLIGATION Type of Organization Individual —Partnership X Corporation State of Incorporation Wisconsin Penal Sum of Bond $580,000.00 The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors and assigns to the Owner to pay for labor, materials and equipment furnished for use in the performance of the Contract identified above, which is incorporated herein by reference, subject to the following terms. If the Contractor promptly makes payment of all sums due to claimants, and defends, indemnifies and holds harmless the Owner from all claims, demands, liens or suits by any person or entity seeking payment for labor, materials or equipment furnished for use in the performance of the Contract, then the Surety and the Contractor shall have no obligation under this Bond. If there is no Owner Default to pay the Contractor as required under the Contract for work performed or to perform or complete any material term of the Contract, then the Surety(ies) obligation under this Bond shall arise after the Owner has promptly notified the Contractor and the Surety of claims, demands, liens or suits against the Owner or the Owner's property by any person or entity seeking payment for labor, materials or equipment furnished for use in the performance of the Contract and tendered defense of such claims, demands, liens or suits to the Contractor and the Surety. DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 State of Minnesota } } ss. County of Hennepin } On this 4th day of May 2023, before me personally came Kelly Nicole En hg auser to me known, who being by me duly sworn, did depose and say that she is the Attorney -in -Fact of Ohio Farmers Insurance Company described in and which executed the above instrument; that she knows the seal of said corporation; that the seal affixed to said instruments is such corporate seal, that it was so affixed by order of the Board of Directors of said corporation, and that she signed her name to it by like order.•. ,:.... !;`_'': HEATHEH R. GOEDTEL Notary Public State of Minnesota MY Commission Expires Oa ���1J' iI �4:---%_ January 31,202s Notary Public DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 Bond No, 301122G PERFORMANCE BOND Contract Number 23-12 Date Bond Executed (Date of Contractor Later) May 4, 2023 MAY 1, 0 2023 CITY OF OSHKOSH OSHKOSH, WI5CONSN, PRINCIPAL/CONTRACTOR (Legal Name and Business Address) August Winter & Sons, Inc. 2323 N. Roemer Road, PO Box 1896 Appleton, WI 54911 SURETY(IES) (Legal Name(s) and Business Address(es)) Ohio Farmers Insurance Company P.O. Box 5001 Westfield Center, OH 44251 - 5001 OWNER (Legal Name and Business Address) CITY OF OSHKOSH 215 Church Avenue PO Box 1130 Oshkosh, Wisconsin 54903-1130 OBLIGATION Type of Organization Individual —Partnership X Corporation State of Incorporation Wisconsin Penal Sum of Bond $580,000.00 The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors and assigns to the Owner for payment of the sum shown above or the performance of the Contract identified above, which is incorporated herein by reference. This Bond shall cover any work performed during initial construction and any warranty period required by the Contract. If there is no Owner Default to pay the Contractor as required under the Contract for work performed or to perform or complete any material term of the Contract, then the Surety(ies) obligation under this Bond shall arise after; 1. The Owner provides notice to the Contractor and Surety that the Owner is considering declaring the Contractor in default of the Contract. Within five (5) business days of the Owner's notice, either the Contractor or the Surety may request a conference with the Owner to discuss such default and the remedy therefor. If a conference is requested, the conference shall be scheduled to take place at Owner's principal place of business or another agreed upon location within five (5) business days of DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 The above obligation is void if the Contractor performs and fulfills all the terms, conditions and agreements of the Contract and any authorized modifications during the term of the original Contract and any extensions thereof. Notice to the Surety is waived for any modifications agreed upon by Owner and Contractor. August Winter & Sons, Inc. Name of Principal/Contractor TitleGT Ohio Farmers Insurance Company Name of Surety Title Kelly icole Enghauser, Attorney -in -Fact DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 AGENCY CUSTOMER ID: LOC #: �►c uKr�► ADDITIONAL KCMAKKS 5UHtUULG rage Z Of AGENCY NAMEDINSURED August Winter & Sons, Inc. Willis Towers Watson Midwest, Inc. P 0 sox 1896 POLICYNUMBER Appleton,WI 549121896 see Page 1 CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Builder's Risk Flood Limits: Zone A $1,000,000 Limit; $100,000 Deductible Zone B, Zone X Shaded, Zone X-500 $2,500,000 Limit; $50,000 Deductible Zone C or Zone X Unshaded $5,000,000 Limit; $25,000 Deductible Cost Breakdown - $580,000; $83,000 Labor; $31,000 Materials; $466,000 Subcontracts Project Address - 233 N. Campbell Road, Oshkosh, WI 54956 Start date - May 15, 2023 Completion date - November 30, 2023 Project Description: Wastewater Treatment Plant Secondary Clarifiers Mortar Replacement AWS Job #: 69223 Originally Issued: 04-2023 City of Oshkosh is included -as Additional Insured as respects to General Liability, Auto Liability and Umbrella/Excess Liability for acts caused by AWS in the performance of their work to which the written contract requiring insurance applies. ACORD 101 (2008/01) r+n 119Uw 1UZ)C1Vtlt The ACORD name and logo are registered marks of ACORD SR IDs 24106443 BATCHs2962948 CERTs W28914550 DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 COMMERCIAL GENERAL LIABILITY sured will be limited to such minimum required result in a claim. To the extent possible, such limits. For the purposes of determining whether notice should include: this limitation applies, the minimum limits required (a) How, when and where the 'occurrence" by the written contract or agreement will be con- or offense took place; sidered to include the minimum limits of any Um- (b) The names and addresses of any injured brella or Excess liability coverage required for the persons and witnesses; and additional insured by that written contract or agreement. This provision will not increase the (c) The nature and location of any injury or limits of insurance described in Section III — Limits damage arising out of the 'occurrence" or Of Insurance. offense. b. The insurance provided to such additional insured (2) If a claim is made or "suit" is brought against does not apply to: the additional insured: (1) Any "bodily injury", "property damage" or (a) Immediately record the specifics of the "personal injury" arising out of the providing, claim or "suit' and the date received; and or failure to provide, any professional archi- (b) Notify us as soon as practicable and see tectural, engineering or surveying services, to it that we receive written notice of the including: claim or "suit' as soon as practicable. (a) The preparing, approving, or failing to (3) Immediately send us copies of all legal pa - prepare or approve, maps, shop draw- pers received in connection with the claim or ings, opinions, reports, surveys, field or- "suit', cooperate with us in the investigation ders or change orders, or the preparing, or settlement of the claim or defense against approving, or failing to prepare or ap- the "suit', and otherwise comply with all policy prove, drawings and specifications; and conditions. (b) Supervisory, inspection, architectural or (4) Tender the defense and indemnity of any engineering activities, claim or "suit' to any provider of other insur- (2) Any "bodily injury" or "property damage" ante which would cover such additional in - caused by "your work" and included in the sured for a loss we cover. However, this con - "products -completed operations hazard" un- dition does not affect whether the insurance less the written contract or agreement specifi- provided to such additional insured is primary tally requires you to provide such coverage to other insurance available to such additional for that additional insured during the policy insured which covers that person or organiza- period. tion as a named insured as described in Par- c. The additional insured must comply with the fol- agraph 4., Other Insurance, of Section IV — lowing duties: Commercial General Liability Conditions. (1) Give us written notice as soon as practicable of an 'occurrence" or an offense which may Page 2 of 2 0 2017 The Travelers Indemnity Company. All rights reserved. CG T8 08 DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 POLICY NUMBER: CUP-5J80755A-22-26 ISSUE DATE: 10/01/2022 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED PERSON OR ORGANIZATION - NOTICE OF CANCELLATION OR NONRENEWAL PROVIDED BY US This endorsement modifies insurance provided under the following:' ALL COVERAGE PARTS INCLUDED IN THIS POLICY CANCELLATION: SCHEDULE Number of Days Notice: WHEN WE DO NOT RENEW (Nonrenewal): Number of Days Notice: PERSON OR ORGANIZATION: ANY PERSON OR ORGANIZATION TO WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OR NONRENEWAL OF THIS POLICY WILL BE GIVEN, BUT ONLY IF: 1. YOU SEND US A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF THE CANCELLATION OR NONRENEWAL OF THIS POLICY} AND 2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS SCHEDULE, ADDRESS: THE ADDRESS FOR THAT PERSON OR ORGANIZ- ATION INCLUDED IN SUCH WRITTEN REQUEST FROM YOU TO US, PROVISIONS A. If we cancel this policy for any legally permitted reason other than nonpayment of premium, and a number of days is shown for Cancellation in the Schedule above, we will mail notice of cancellation to the person or organization shown in such Schedule. We will mail such notice to the address shown in the Schedule above at least the number of days shown for Cancellation in such Schedule before the effective date of cancellation. 30 B. If we do not renew this policy for any legally permitted reason other than nonpayment of premium, and a number of days is shown for When We Do Not Renew (Nonrenewal) in the Schedule above, we will mail notice of nonrenewal to the person or organization shown in such Schedule. We will mail such notice to the address shown in the Schedule above at least the number of days shown for When We Do Not Renew (Nonrenewal) in such Schedule before the effective date of nonrenewal. IL T4 00 05 19 0 2019 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 DocuSign Envelope ID: 8BE3EEDD-A2EF-449C-A98B-517450A59976 TRAVELER J ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 06 R3 (00) - 001 POLICY NUMBER: UB-0L000336-22-26-E NOTICE OF CANCELLATION TO DESIGNATED PERSONS OR ORGANIZATIONS The following is added to PART SIX —CONDITIONS: Notice Of Cancellation To Designated Persons Or Organizations If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice to each person or organization at Its listed address at least the number of days shown for that person or organiza- tion before the cancellation is to take effect. You are responsible for providing us with the information necessary to accurately complete the Schedule below. If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or address of such designated person or organization provided to us is not accurate or complete, we have no responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation. SCHEDULE Name and Address of Designated Persons or Organizations: ANY PERSON OR ORGANTIZATION WITH WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OF THIS POLICY WILL BE GIVEN, BUT ONLY IF: 1. YOU SEE TO IT THAT WE RECEIVE A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF THE CANCELLATION OF THIS POLICY; AND 2, WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS ENDORSEMENT. ADDRESS: "THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN SUCH WRITTEN REQUEST FROM YOU TO US. All other terms and conditions of this policy remain unchanged. Number of Days Notice 30 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No, Insured Premium $ Insurance Company Countersigned by ST ASSIGN: Page n of 1 0 2013 The Travelers Indemnity Company. All rights reserved.