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(
BID BOND , WED CITY OF OSHKOSH
Contract Number 25-07
pEPT OF PUBLIC WiSCOONSIN
Date Bond Executed (Date of Contract or Later) 10/28/2024 OSHKOSH,
PRINCIPAL/CONTRACTOR (Legal Name and Business Address)
CARL BOWERS & SONS CONSTRUCTION CO INC
N1844 Maloney Rd
Kaukauna, WI 54130
SURETY(IES) (Legal Name(s) and Business Address(es))
MERCHANTS BONDING COMPANY (Mutual)
PO Box 14498
Des Moines, IA 50306-3498
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
5% of bid amount
The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors,
and assigns to the Owner for the amount of the penal sum identified above if the Owner accepts the bid of this
Contractor within the time specified in the Bid documents or within such time period as may be agreed upon
between the Owner and the Contractor, and the Contractor shall fail to execute the Contract within five (5) business
days of written notice to the Contractor and Surety of Owner's intent to make a claim upon this Bond.
The Surety hereby waives any notice of an agreement between the Owner and Contractor to extend the time in
which the Owner may accept the Bid.
If the Contractor either enters into a contract with Owner in accordance with the terms of the Bid and gives such
bond(s) that may be specified in the Bidding documents for the faithful performance of the Contract and for the
prompt payment of labor, materials, and supplies furnished for the purpose thereof; or pays to the Owner the
difference between the amount specified in the Bid and such larger amount for which the Owner may in good faith
contract with another party to perform the work covered in such Bid, then the Surety and the Contractor shall have
no obligation under this Bond.
Page 1 of 2
Notice to the Contractor or Surety shall be deemed to have been given: (i) upon delivery to an officer or person
entitled to such notice, if hand delivered; or (ii) two (2) business days following deposit in the United States mail,
postage prepaid; (iii) upon delivery by a commercial carrier that will certify the date and time of delivery; or (iv)
upon transmission if by facsimile, e-mail, or other form of electronic transmission. Notices shall be provided to the
Owner, Surety, and/or Contractor at their address as specified on this Bond or to a facsimile, e-mail or other
electronic address that has been provided in writing to the other party to be used for this purpose.
The laws of the State of Wisconsin shall govern the interpretation and construction of this Bond. Winnebago
County shall be the venue for all disputes arising under this Bond. Any provision in this Bond that may conflict
with statutory or other legal requirement shall be deemed deleted herefrom and provisions conforming to the
statutory or other legal requirement shall be deemed incorporated herein.
Gall 60WOr'6 1 -�O,I5 n���KG iorl
Name of Principal/Contractor
Titlear%r! l3oWG16GG/G���'+1/7'r�p5ari��
MERCHANTS BONDING COMPANY (MUTUAL)
Name of Surety
Michael Tiedt (Attomey-ire-Fact)
Page 2 of 2
BONDING COMPANY.
POWER OF ATTORNEY
Know All Persons By These Presents, that MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.,
both being corporations of the State of Iowa, d/b/a Merchants National indemnity Company (in California only) (herein collectively called the
"Companies") do hereby make, constitute and appoint, individually,
Michael L Tiedt
their true and lawful Attoniey(s)-in-Fact, to sign its name as surety(les)and to execute, seal and acknowledge any and all bonds, undertakings,
contracts and other written instruments in the nature thereof, on behalf of the Companies in their business of guaranteeing the fidelity of
persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions
or proceedings allowed by law.
This Power -of -Attorney is granted and is signed and sealed by facsimile under and by authority of the following By -Laws adopted by the Board of
Directors of Merchants Bonding Company (Mutual) on April 23, 2011 and amended August 14, 2015 and April 27, 2024' and adopted by the Board of
Directors of Merchants National Bonding, Inc., on October 16, 2015 and amended on April 27, 2024.
'The President, Secretary, Treasurer, or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and
authority to appoint Attomeys-in-Fact, and to authorize them to execute on behalf of the Company, and attach the seal of the Company thereto,
bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof."
'The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of.Attomey
or Certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations ' of the
Company, and such signature and seal when so used shall have the same force and effect as though manually fixed."
In connection with obligations in favor of the Florida Department of Transportation only, it is agreed that the power and aut horny hereby given to the
Attomey-in-Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction
contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department
of Transportation making payment of the final estimate to the Contractor andior its assignee, shall not relieve this surety company of any of
Its obligations under its bond.
In connection with obligations in favor of the Kentucky Department of Highways only, it is agreed that the power and authority hereby given
to the Attomey-In-Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner -
Department of Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modification or revocation.
In Witness Whereof, the Companies have caused this instrument to be signed and sealed this 28th day of October , 2024 .
STATE OF IOWA
COUNTY OF DALLAS ss.
On this 28th day of
did say that he is Preside
seals affixed to the foregi
of the Companies by auth
,Q �1A( s
0
z
� f
1OWN
-o-
2003
MERCHANTS BONDING COMPANY (MUTUAL)
MERCHANTS NATIONAL BONDING, INC.
dlbia MERCHANTS NATIONAL INDEMNITY COMPANY
By
President
October 2024 , before me appeared Larry Taylor, to me personalty, known, who being by me duly sworn
of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the
3 instrument are the Corporate Seals of the Companies; and that the. said instrument was signed and sealed in behalf
y of their respective Boards of Directors.
Penni Miller
Commission Number 787952
My Commission Expires cayx"�
January 20, 2027 Notary Public
(Expiration of notary's commission
does not invalidate this instrument)
I, Elisabeth Sandersfeld, Secretary of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., do
hereby certify that the above and foregoing Is a true and correct copy of the POWER -OF -ATTORNEY executed by said Componies,which is stilt
In full force and effect and has not been amended or revoked.
In Witness Whereof, I have hereunto set my hand and affixed the seal of the Companies on this 28th day of October' 2024 .
�\i��lia R+�
a•M�r•�
,.�' 4pOj� '•.
, g'
,..,
2003
;:
• . 1933 t •" secretary
. ,+
,
POA 0018 (6124)
�QD CERTIFICATE OF LIABILITY INSURANCE
DATE
A n2MMON4YY'
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 rights to the certificate holder in lieu of such endorsements .
PRODUCER
Spectrum Insurance Group
303 Packerland Dr,, Ste C
Green Bay WI 54303
NAME CT_ Kristin Bocvers _
PHONE 920 426-2431 N FAX 920-385 a$5a
E-MAIL - ---- ——
ADDRESS: kdsfln.boevers s actruminsgroup.com
INSURER(S) AFFORDING COVERAGE
NAIC#
INSURER A: SELECTIVE INS CO OF AMER
12572
INSURED CARLB-2
Carl Bowers & Sons Construction Co Inc
INSURER B : SELECTIVE INS CO OF SC
19259
—
INSURERC:
W844 Maloney Rd
INSURERD:
Kaukauna Wi54130
INSURER E :
INSURER F :
GQVERAGES CERTIFICATE Mt1MRr-R- 1AA7A7AnQR i7GA11*IAM M1 teancD.
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.
--�
INTR
TYPE OF INSURANCE
ADD
SUBR
POLICY NUMBER
POLICY EFF
MMIoD
POLICY EXP
M /YYYY
LIMITS
A
X
COMMF.RCIALGENERALLIABILITY
CLAIMS MADE [-�] OCCUR
S 2553019
4/1/2024
4/l/2025
EACH OCCURRENCE
s1,000,000
PREMISES JEa occurrence)
$ 500,000
MED EXP (Any oneperson)
$15,000
PERSONAL& ADV INJURY
$1,000,000
GENL
AGGREGATE LIMIT APPLIES PER:
POLICY JEC a LOC
GENERAL AGGREGATE
$ 2,000,000
II
PRODUCTS -COMPIOPAGG
$2,000 000.
$
OTHER:
A
AUTOMOBILE
LIABILITY
S 2553019
411/2024
4/l/2025
tE(,1 Nd ntSINGLELIMff
$1,000,000
BODILY INJURY (Par person)
$
ANY AUTO
OWNED SCHEDULEDBODILY
ONLY AUTOS
Ix
INJURY Per accident
( iAUTOS
S
HIREDAUTOS
ONLY X ANUT�OS ONLY
R(,P.1P %DAMAGE
S
A
X
UMSRELLALIAS
X
OCCUR
S 2553019
4/1/2024
4/1/2025
EACH OCCURRENCE
$5,000,000
AGGREGATE
$ 5 000 000
EXCESS LIAB
CLAIMS -MADE
DED I X I RETENTIONS n
1
$
e
WORKERS COMPENSATION AN EMPLOYERS LIABILITY YIN
ANYPROPRIETORIPARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED? �
NIA
WC 9135809
4/1/2024
4/l/2025
X SSTTA STATUTE ERH__..
E.L. EACH ACCIDENT
$ 500,000
_
E.L. DISEASE - EA EMPLOYEE
_
$ 500,000
(Mandatory In NH)
1P as, describe under
OSCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$500,000
A
A
RentadA-eased Equipment
Installation Floater
S 2553019
S 2553019
4/1/2024
4/1/2024
411/2026
4/1/2025
Equipment Limit
Installation Umit
$300,000
$2,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addltlon Remarks Schedule, may be attached If more space Is required) _
11/4/24 B
Bid (Contract 25-07 West 15th Avenue Reconstruction])
City Of Oshkosh
231 Church Ave
PO Box 1130
Oshkosh WI 54903-1130
t run
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
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
RECEIVED
NOV - 4 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Please review the attached Department of Workforce Development Disclosure of Ownership form. If Item 3 on this
Disclosure of Ownership form applies to your company, you must complete the Disclosure of Ownership form and
upload in the appropriate location on Quest V-Bid.
If Item 3 on the Disclosure of Ownership form does NQT apply to your company, you must complete the
information below and upload this page in the appropriate location on Quest V-Bid.
CERTIFICATION
I certify by my signature below that Item 3 of the attached Disclosure of Ownership form does NOT apply to my
firm, or a shareholder, officer, or partner of my firm.
9-1. M I o;1/!f
'
Printed Name
.5e- G/e4aq /-yetbulee'
Title
eev / Svc.,rey'o S ry9 l /[�fG�i pr7
Company Name
_ 11/4� l2-Z'
Date
L%Engineering\TracyTaylorlPubllcWorks ContractslMis"Uaneous`DsdosureofOwnersNpFonn-2-1- Page I of I
17.doo,
City Hall, 215 Church Avenue P.O. Box 1130 Oshkosh, WI 54903-1130 http://www.ci.oshkosh.wi.us
State of Wisconsin
Department or Workforce Development
Equal Rights Division
Disclosure of Ownership
The statutory authority for the use of this form is prescribed in Sections 66.0903(12)(d), 66,0904(10)(d) and 103.49(7)(d), Wisconsin
Statutes.
The use of this form is mandatory. The penalty for failing to complete this form is prescribed in Section 103.005(12), Wisconsin
Statutes,
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1) (m), Wisconsin Statutes].
(1) On the date a contractor submits a bid to or completes negotiations with a state agency, local governmental unit, or
developer, investor or owner on a project subject to Section 66.0903, 66.0904 or 103.49, Wisconsin Statutes, the
contractor shall disclose to such state agency, local governmental unit, or developer, Investor or owner, the name of
any "other construction business," which the contractor, or a shareholder, officer or partner of the contractor, owns or
has owned within the preceding three (3) years.
(2) The term "other construction business" means any business engaged in the erection, construction, remodeling,
repairing, demolition, altering or painting and decorating of buildings, structures or facilities. It also means any
business engaged in supplying mineral aggregate, or hauling excavated material or spoil as provided by Sections
66.0903(3), 66.0904(2), 103.49(2) and 103.50(2), Wisconsin Statutes,
(3) This form must ONLY be filed, with the state agency project owner, local governmental unit project owner, or
developer, investor or owner of a publicly funded private construction project that will be awarding the contract, if both
(A) and (B) are met.
(A) The contractor, or a shareholder, officer or partner of the contractor:
(1) Owns at least a 25% interest in the "other construction business," indicated below, on the date the contractor
submits a bid or completes negotiations; or
(2) Has owned at least a 25% interest in the "other construction business" at any time within the preceding three
(3) years.
(B) The Wisconsin Department of Workforce Development (DWD) has determined that the "other construction
business" has failed to pay the prevailing wage rate or time and one-half the required hourly basic rate of pay, for
hours worked in excess of the prevailing hours of labor, to any employee at any time within the preceding three (3)
years.
Other Construction Business
Business Name /
V /JA
Street Address or P 0Box
City
State
Zip Code
Business Name
Street Address or P 0 Box
City
State
Zip Code
Business Name
Street Address or P 0 Box
City
State
Zip Code
Business Name
Street Address or P 0 Box
City
State
Zip Code
I hereby state under penalty of perjury that the information, contained In this document, is true and
accurate according to my knowledge and belief.
Print the Name of Authorized Officer W
% 2 // gO e/ "S
Authorized Officer Signature 2 w
Date Signed
Corporation, Partnership or Sole Proprietorship Name
66tr r
Street Address or P 0 Box
City
ka a A -A m
State
[Zip Code
If you have any questions call (608) 266-6861
ERD-7777 (R. 01/2011)
RECEIVED
CONTRACT 25-07
ATTACHMENT A NOV — 4 2024
LIST OF PROPOSED SUBCONTRACTORS DEFT O PUBLIC WORKS
OSI-IKOSH, WISCONSIN
Pursuant to Section 66.29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the Proposed Subcontractors and the class of work to be performed by each. The
CONTRACTOR will be permitted to sublet a portion of the Contract, but shall perform with their
organization work amounting to at least thirty percent (30%) of the original Contract amount.
Work performed by the CONTRACTOR for any Bid Item that had been subcontracted will not be
included towards the thirty percent (30%) calculation.
If the CONTRACTOR shall sublet any part of this Contract, the CONTRACTOR shall be as fully
responsible to the CITY for the acts and omissions of their Subcontractor and of the persons either directly
or indirectly employed by their Subcontractor as they are by acts or omissions of persons directly
employed by themselves. All Subcontractors, if any, shall be listed in the spaces provided on the
Proposal Form and said list shall not be added to or altered without the written consent of the CITY.
Signed, final waivers of lien will need to be provided to the CITY prior to the release of the final retainage
to the CONTRACTOR.
When a Subcontractor and the class of work to be performed are not listed, it shall be considered that the
Bidder will perform the work themselves.
NAME OF PROPOSED
SUBCONTRACTOR
A / Pi )(
V;'1104
CLASS OR ITEMS OF WORK
PERCENT OF
CONTRACT AMOUNT
I hereby certify that the use of the name(s) of the above Proposed Subcontractor(s) was with the
knowledge and consent of the said Subcontractor(s).
FRhature:..
Page 18 of 21
PIECEWED
CONTRACT 25-07 NOV - 4
PROPOSAL 2024
DEPTOFPUBI_I; ,
The undersigned will begin work as specified after award of the Contract and coM'pliftea%specified.
I hereby certify that all statements are made in behalf of
GOl/I i slddf9 4iD064rl e'Ff"%
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of��b
a Partnership consisting of ; or
an individual trading as ; of
the City of ; State of
That I have examined and carefully prepared this Proposal from the Plans and Specifications and have
checked the same in detail before submitting this Proposal; that I have full authority to make such
statements and submit this Proposal in (its) (their) behalf; and that said statements are true and correct.
i
(Title, if any)
Subscribed and sworn to before me this 1/ th day of ,VOyGlMbei' , 20 Z41
ADAM CART. BOWERS
Notary Public, or other authorized to administer Notary Public
State of Wisconsin
(Bidder should not add any conditions or qualifying statements to this Proposal as otherwise the Proposal
may be declared irregular as not being responsive to the Advertisement.)
Accompanying this Proposal is a Bid Bond in the amount of S- % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 21 of 21
ARAIA Document A31 OTM .2010
CONTRACTOR:
(Name, legal status and addr�sss)
PTS CONTRACTORS, INC,
4075 Eaton Road
Green Bay, WI 54311
OWNER:
(Nance, legal status and address)
CITY OF WAUKESHA
201 Delafield Street, Waukesha, WI 53188
BOND AMOUNT: Five
o Amount Amount bid
SURETY:
(Nance, legal status and principal place
of business)
LIBERTY MUTUAL INSURANCE COMPANY
175 Berkeley Street
Boston, MA 02116
RECEIVE)
NOV - 4 26 .t
DEPT OF PUBLIC Wolty >
OSHKOSH, WISCONSIN
This document has Important legal
consequences. Consultation with
an attorney Is encouraged with
respect to its completion or
modification.
.Any singular reference to
Contractor, Surety, Owner or
other party shall be considered
plural where applicable.
PROJECT:
(1lrance, location or address, and Project number, if anj9
2024 Area 7 Flood Mitigation Storm Sewer, Waukesha, Wl Project Number, if any:
The Contractor and Surety are bound to the Owner in the amount set forth above, for the payment of which the
Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and
severally, as provided herein. The, conditions of this Dond are such that if the Owner accepts the bid of the Contractor
within the time specified in the bid documents, or within such time period as may be agreed to by the Owner and
Contractor, and the Contractor either (1) enters into a contract with the Owner in accordance with the tens of such
bid, and gives such bond or bonds as may be specified in the bidding or Contract Documents, with a surety admitted
in the jurisdiction of the Project and otherwise acceptable to the Owner, for the faithful performance of such Contract
and for the prompt payment of labor and material furnished in the prosecution thereof; or (2) pays to the Owner the
difference, not to exceed the amount.of this Bond, between the Amount specified in said bid and such larger amount
for which the Owner may in good faith contract with another party to perform the work covered by said bid, then this
obligation shall be null and void, otherwise to remain in full force and effect. The Surety hereby waives any notice of
an agreement between the Owner and Contractor to extend the time in which the Owner may accept the bid. Waiver of
notice by the Surety shall not apply to any extension exceeding sixty (60) days in the aggregate beyond the time for
acceptance of bids specified in the bid documents, and die Owner and Contractor shall obtain the Surety's consent for
an extensionbeyond sixty (60) days.
If this Bond is issued in connection with a subcontractor's bid to a Contractor, the term Contractor in this c�ttt
be deemed to be Subcontractor and the terni Owner shall be deemed to be Contractor.. ` �� t j,..•••'','r"•••.
When thus Bond has been furnished to comply with a statutory or other legal requirement in the locatrlStlre Project;49j
any provision in this Bond conflicting with said statutory or legal requirement shall be deemed delet'etere�
provisions conforming to such statutory or other legal requirement shall be deemed incorporated he><ginVhf Sa '
furnished, the intent is that this Bond shall be construed as a statutory bond and not as a common law�b qn .Z�
Signed and sealed this 1st day of November, 2024 •'scQNS�N.••' `�
PTS CONTRAC RS, INC. , t )972••••.
(Principal
o itness)
vilness)
(Title) Steve C. Horn, Vice-Presr en
LIBERTY MUTUAL INSURANCE COMPANY
IS rety tNSU
(Title) Roxanne Jensen, Attorney in Fact 1912
0
~d`�ssACHUg" .dad'
AIA Document A310TM' - 2010. Copyright 01963, 1970 and 2010 by The American Institute of Architects. All rights reserved. coal No. 0099
Liberty
Mutual.
SURETY
This Power of Attorney limits the acts of those named herein, and they have no authority to
bind the Company except In the manner and to the extent herein stated,
Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company
West American Insurance Company
POWER OF ATTORNEY
Certificate No: 8209723.354019
KNOWN ALL PERSONS BY THESE PRESENTS: That The Ohio Casualty Insurance Company is a corporation duly organized under Hie laws of the State of New Hampshire, that
Liberty Mutual Insurance Company is a corporation duly organized under the laws of the Stale of Massachusetts, and West American Insurance Company is a corporation duly organized
under the laws of the State of Indiana (herein collectively called the "Companies'), pursuant to and by authority herein set forth, does hereby name, constitute and appoint, Brian
Krause, Kelly Cody, Marc Sacia, Roxanne Jensen, Trudy A. Szalewski
nil ut ute city or Milwaukee state of Wl each individually if there be more than one named, Its true and lawful attorney -in -fact to make,
execute, seal, acknowledge and deliver, for and Ton behalf as surety and as its act and deed, any and all undertakings, bonds, recognizances and other surely obligations, in pursuance
of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper
persons.
IN WITNESS WHEREOF, this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed
thereto this 3rd dayof Aprf) , 2023 .
a`ni
c
m State of PENNSYLVANIA
rn County of MONTGOMERY ss
Liberty Mutual Insurance Company
Ay INSUpq P�tY INsp INSU,pq The Ohio Casualty Insurance Company
J~J3`o�o�Tay"toJ�rpMokl �R9y� �4apPorr4}oyc'ce West American Insurance Company
1912 " 1919 M
r s o o 1991 0
*u' Nola y°� NAMP+yr`��a�'o B
* * M+ f y:
David M. Carey, Assistant Secretary
On this 3rd day of April , 2023 before me personally appeared David M. Carey, who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance
m Company, The Ohio Casualty Company, and West American Insurance Company, and that he, as such, being authorized so to do, execute the foregoing instrument for the purposes
> therein contained by signing on behalf of the corporations by himself as a duly authorized officer.
,71
U
.N
To
1
i�
I a)
Pru
jG
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my notarial seal at Plymouth Meeting, Pennsylvania, on the day and year first above written.
yp, PAST
orf:I' fi<1 commonwealth of Pennsylvania . Nolary Seal �
L P Terosa Pestelio, Notary PuMro?��-N
OF hlonlgomery county
My commission expires Mama 28, 2025 B
T Commission number 1126014 y
+�� Member, PeansytvaNaAssocianon of Notaries ker,"P=stlIa—,Notary Public
This Power of Attorney is made and executed pursuant to and by authority of the following By-laws and Authorizations of The Ohio Casualty Insurance Company,
Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows:
Liberty Mutual
ARTICLE IV— OFFICERS: Section 12. Power of Attomey.
Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President, and subject to such limitation as the Chairman or the
President may prescribe, shall appoint such atlomeys-in-fact, as may be necessary to act in behalf of the Corporation to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Such attomeys-in-fact, subject to the limitations set forth in their respective powers of attomey, shall.
have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so executed, such
instruments shall be as binding as if signed by the President and attested to by the Secretary. Any power or authority granted to any representative or attomey-in-fact under Hie
provisions of this article may be revoked at any time by the Board, the Chairman, the President or by the officer or officers granting such power or aulhorty.
ARTICLE XIII — Execution of Contracts: Section 5. Surety Bonds and Undertakings,
Any officer of the Company authorized for that purpose in writing by the chairman or the president, and subject to such limitations as the chairman or Hie president may prescribe,
shall appoint such attomeys-in-fact, as may be necessary to act in behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings,
bonds, recoglthrices and other surety obligations. Such attomeys-in-fact subject to the limitations set forth in their respective powers of attorney, shall have full power to bind the
Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so executed such instruments shall be as binding as if
signed by the president and attested by the secretary.
Certificate of Designation — The President of the Company, acting pursuant to the Bylaws of the Company, authorizes David M. Carey, Assistant Secretary to appoint such attomeys4n-
fact as may be necessary to act on behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety
obligations.
Authorization — By unanimous consent of the Company's Board of Directors, the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the
Company, wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds, shall be valid and binding upon the Company with
the same force and effect as though manually affixed.
1, Renee C. Llewellyn, the undersigned, Assistant Secretary, The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company do
hereby certify that the original power of attorney of which the foregoing is a full, true and correct copy of the Power of Attorney executed by said Companies, is in full force and effect and
has not been revoked, j h
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this S 1 day of / kV . , 2024 .
P� INS U� Poaf INS& a 1NSU,q
JhJ3`oaeO�rFoyc'in �Or°oaPOR�ro'Pgyn w 3`oPPo�r�•`nt�
r 1912 o c 1919 1991
~4-j1�9ACMU%•da y��NAMPB�`a�c r rNauNf• a� By.
Renee C. Llewellyn, Assistant Secretary
LMS-12e73 LMIC OCIC WAIC Munl Co 02r21
RECEIVED
NOV — 4 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
Please review the attached Department of Workforce Development Disclosure of Ownership form. If Item 3 on this
Disclosure of Ownership form applies to your company, you must complete the Disclosure of Ownership form and
upload in the appropriate location on Quest V-Bid.
If Item 3 on the Disclosure of Ownership form does NOT apply to your company, you must complete the
information below and upload this page in the appropriate location on Quest V-Bid.
CERTIFICATION
I certify by my signature below that Item 3 of the attached Disclosure of Ownership form does NOT apply to my
firm, or a shareholder, officer, or partner of my firm.
Name
Steve C. Horn
Printed Name
Vice -President
Title
PTS Contractors Inc
Company Name
Nov 4 2024
Date
I:\Engineering\Tracy Taylor\Public Works Contracts\ Miscellaneous \Disclosure of ownership Ponn_2-1- Page 1 of 1
17.docx
Ciiv Hnll_ 915 Church Avenue P.O. Box 1 130 Oshkosh, WI 54903-1130 http://www.cl.oshkosh.wi.us
State of Wisconsin
Department of Workforce Development
Equal Rights Division
Disclosure of Ownership
The statutory authority for the use of this form is prescribed in Sections 66.0903(12)(d), 66.0904(10)(d) and 103.49(7)(d), Wisconsin
Statutes.
The use of this form is mandatory. The penalty for failing to complete this form is prescribed in Section 103.005(12), Wisconsin
Statutes.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1) (m), Wisconsin Statutes],
(1) On the date a contractor submits a bid to or completes negotiations with a state agency, local governmental unit, or
developer, investor or owner on a project subject to Section 66,0903, 66.0904 or 103,49, Wisconsin Statutes, the
contractor shall disclose to such state agency, local governmental unit, or developer, investor or owner, the name of
any "other construction business," which the contractor, or a shareholder, officer or partner of the contractor, owns or
has owned within the preceding three (3) years.
(2) The term 'other construction business" means any business engaged in the erection, construction, remodeling,
repairing, demolition, altering or painting and decorating of buildings, structures or facilities. It also means any
business engaged in supplying mineral aggregate, or hauling excavated material or spoil as provided by Sections
66.0903(3), 66.0904(2), 103.49(2) and 103.50(2), Wisconsin Statutes.
(3) This form must ONLY be filed, with the state agency project owner, local governmental unit project owner, or
developer, investor or owner of a publicly funded private construction project that will be awarding the contract, if both
(A) and (B) are met.
(A) The contractor, or a shareholder, officer or partner of the contractor:
(1) Owns at least a 25% interest in the "other construction business," indicated below, on the date the contractor
submits a bid or completes negotiations; or
(2) Has owned at least a 25% interest in the "other construction business" at any time within the preceding three
(3) years.
(B) The Wisconsin Department of Workforce Development (DWD) has determined that the "other construction
business" has failed to pay the prevailing wage rate or time and one-half the required hourly basic rate of pay, for
hours worked in excess of the prevailing hours of labor, to any employee at any time within the preceding three (3)
years.
Other Construction Business
_ .._. __, ... ..l—I JJ ,IM,,,y %J, NU, Jury Ura< Me inrormation, contained in this document, is true and
accurate according to my knowledge and belief.
Print the Name of Authorized Officer
Authorized Officer Signature
Corporation, Partnership or Sole Proprietorship Name
Date Signed
Street Address or P O Box
City
If you have any questions call (608) 266-6861
;=Rn_7777iR nvgnii�
State I Zip Code
RECEIVED
CONTRACT 25-07
ATTACHMENT A NOV - 4 2024
DEPT OF PUBLIC WORKS
LIST OF PROPOSED SUBCONTRACTORS OSI-KOSH, WISCONSIN
Pursuant to Section 66.29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the Proposed Subcontractors and the class of work to be performed by each. The
CONTRACTOR will be permitted to sublet a portion of the Contract, but shall perform with their
organization work amounting to at least thirty percent (30%) of the original Contract amount.
Work performed by the CONTRACTOR for any Bid Item that had been subcontracted will not be
included towards the thirty percent (30%) calculation.
If the CONTRACTOR shall sublet any part of this Contract, the CONTRACTOR shall be as fully
responsible to the CITY for the acts and omissions of their Subcontractor and of the persons either directly
or indirectly employed by their Subcontractor as they are by acts or omissions of persons directly
employed by themselves. All Subcontractors, if any, shall be listed nn the spaces provided on the
Proposal Form and said list shall not be added to or altered without the written consent of the CITY.
Signed, final waivers of lien will need to be provided to the CITY prior to the release of the final retainage
to the CONTRACTOR.
When a Subcontractor and the class of work to be performed are not listed, it shall be considered that the
Bidder will perform the work themselves.
NAME OF PROPOSED
SUBCONTRACTOR
r16 � j C- r
4,QA /Ci
AL- C)L
CLiiASS O''R ITEMS OF WORK
A-< PLA-
PERCENT OF
CONTRACT AMOUNT
/4, p7a
t
z
I hereby certify that the use of the name(s) of the above Proposed Subcontractor(s) was with the
knowledge and consent of the said Subcontractor(s).
Signature of Bidder
Page 18 of 21
MEWED
CONTRACT 25-07
PROPOSAL NOV - 4 ?_024
The undersigned will begin work as specified after award of the Contract and complete As,speeeif(ejlks
I hereby certify that all statements are made in behalf of
PTS Contractors, Inc
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of Wisconsin
a Partnership consisting of ; or
an individual trading as ; of
the City of ; State of
That I have examined and carefully prepared this Proposal from the Plans and Specifications and have
checked the same in detail before submitting this Proposal; that I have full authority to make such
statements and submit this Proposal in (its) (their) behalf; and that said state ents are trite and correct.
Signature
Vice -President
(Title, if any)
Subscribed and sworn to before me this 4 day of Nov. 20 24
toSets*#eee•
- df� OPP-
"IV ) r
Notary Public, or other authorized to administer
w
0 do
tp 60 %
m
w
•
�O '••••Osseo••';•
(Bidder should not add any conditions or qualifying st�fte�lgts to �W Proposal as otherwise the Proposal
may be declared irregular as not being responsive to the 'Nftisement.)
Accompanying this Proposal is a Bid Bond in the amount of 5 % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 21 of 21
RECEIVED
NOV - 4 2024
BID BOND DEPT OF PUBLIC WORK:CITY OF OSHKOSH
OSHKOSH, WISCONSIN
Contract Number 25-07
Bond Number
Date Bond Executed (Date of Contract or Later) October 22, 2024
PRINCIPAL/CONTRACTOR (Legal Name and Business Address) Type of Organization
Advance Construction, Inc. _Individual —Partnership
2141 Woodale Ave. XCorporation
Green Bay, WI 54313
State of Incorporation
SURETY(IES) (Legal Name(s) and Business Address(es)) Penal Sum of Bond
Great American Insurance Company 5% of amount bid
301 E. Fourth St.,
Cincinnati, OH 45202
OWNER (Legal Name and Business Address)
CITY OF OSHKOSH
215 Church Avenue
PO Box 1130
Oshkosh, Wisconsin 54903-1130
OBLIGATION
The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors,
and assigns to the Owner for the amount of the penal sum identified above if the Owner accepts the bid of this
Contractor within the time specified in the Bid documents or within such time period as may be agreed upon between
the Owner and the Contractor, and the Contractor shall fail to execute the Contract within five (5) business days of
written notice to the Contractor and Surety of Owner's intent to make a claim upon this Bond.
The Surety hereby waives any notice of an agreement between the Owner and Contractor to extend the time in which
the Owner may accept the Bid.
If the Contractor either enters into a contract with Owner in accordance with the terms of the Bid and gives such
bond(s) that may be specified in the Bidding documents for the faithful performance of the Contract and for the
prompt payment of labor, materials, and supplies furnished for the purpose thereof; or pays to the Owner the
difference between the amount specified in the Bid and such larger amount for which the Owner may in good faith
contract with another party to perform the work covered in such Bid, then the Surety and the Contractor shall have
no obligation under this Bond.
Page 1 of 2
Notice to the Contractor or Surety shall be deemed to have been given: (i) upon delivery to an officer or person
entitled to such notice, if hand delivered; or (ii) two (2) business days following deposit in the United States mail,
postage prepaid; (iii) upon delivery by a commercial carrier that will certify the date and time of delivery; or (iv)
upon transmission if by facsimile, e-mail, or other form of electronic transmission. Notices shall be provided to the
Owner, Surety, and/or Contractor at their address as specified on this Bond or to a facsimile, e-mail or other electronic
address that has been provided in writing to the other party to be used for this purpose.
The laws of the State of Wisconsin shall govern the interpretation and construction of this Bond. Winnebago County
shall be the venue for all disputes arising under this Bond. Any provision in this Bond that may conflict with
statutory or other legal requirement shall be deemed deleted herefrom and provisions conforming to the statutory
or other legal requirement shall be deemed incorporated herein.
Name of Princi ontractor
Title
Great American Insurance Company
Name of Surety
Title Deborah Knapp, Attorney -In- a.,
Page 2 of 2
GREAT AMERICAN INSURANCE COMPANY®
Administrative Office: 301 E 4TH STREET • CINCINNATI, OHIO 45202 • 513-369-50DO 18 FAX 513-723-2740
The number of persons authorized by
this power of attorney is not more than THIRTEEN
POWER OF ATTORNEY
No.O 22545
KNOW ALL MEN BY THESE PRESENTS: That the GREATAMERICAN INSURANCE COMPANY, a corporation organized and existing under
and by virtue of the laws of the State of Ohio, does hereby nominate, constitute and appoint the person or persons named below, each individually if more than
one is named, its true and lawful attomey-in-fact, for it and in its name, place and stead to execute on behalf of the said Company, as surety, any and all bonds,
undertakings and contracts of suretyship, or other written obligations in the nature thereof; provided that the liability of the said Company on any such bond,
undertaking or contract of suretyship executed under this authority shall not exceed the limit stated below.
Name
KIMBERLY ASCHENBACH
BRIAN REIMER
DEBORAH KNAPP
DILLON HOLEWINSKI
RHONDA KLUESSENDORF
ZACHARY KAISER
ANNEMARIE WILLBANKS
LYNN CLAUSEN
SHELLEY RADATZ
NICHOLAS JULIAN
ANDREW WEISHEIPL
CHRISTEEN CARNEY
Address Limit of Power
LAYNE SELIN ALL
$100,000,000
ALL OF
MENASHA, WISCONSIN
This Power of Attorney revokes all previous powers issued on behalf of the attomey(s)-in-fact named above.
IN WITNESS WHEREOF the GREAT AMERICAN INSURANCE COMPANY has caused these presents to be signed and attested by its appropriate
officers and its corporate seal hereunto affixed this 24TH day of SEPTEMBER 1 2024
Attest GREAT AMERICAN INSUJLANCE COMP
Assistant Secretary Divisional Senior ice President
STATE OF OHIO, COUNTY OF HAMILTON - ss: MARK VICARIO (877-377-2405)
On this 24TH day of SEPTEMBER 2024 , before mepersonally appeared MARK VICARIO, tome known,
being duly swom, deposes and says that he resides in Cincinnati, Ohio, that he is a Divisional Senior Vice President of the Bond Division of Great American
Insurance Company, the Company described in and which executed the above instrument; that he knows the seal of the said Company; that the seal affixed to the
said instrument is such corporate seal; that it was so affixed by authority of his office under the By -Laws of said Company, and that he signed his name thereto
by like authority.
SUSAN A KOHORST
Notary Public
State of Ohio
Ay Comm. Expires
Aay 18, 2025
This Power ofAttomey is granted by authority of the following resolutions adopted by the Board of Directors of GreatAmerican Insurance Company
by unanimous written consent dated June 9, 2008,
RESOLVED: That the Divisional President, the several Divisional Senior Vice Presidents, Divisional Vice Presidents and Divisonal Assistant Hice
Presidents, or anyone of them, be and hereby is authorized, from time to time, to appoint one or more Attorneys -in -Fact to execute on behalf of the Company,
as surety; any and all bonds, undertakings and contracts of suretyship, or other written obligations in the nature thereof to prescribe their respective duties and
the respective limits of their authority; and to revoke any such appointment at any time.
RESOLVED FURTHER: That the Company seal and the signature of any of the aforesaid officers and any Secretary or Assistant Secretary of the
Company may be affixed by facsimile to any power of attorney or certificate of either given for the execution of any bond, undertaking, contract of suretyship,
or other written obligation in the nature thereof, such signature and seal when so used being hereby adopted by the Company as the original signature of such
officer and the original seal of the Company, to be valid and binding upon the Company with the same force and effect as though manually efj-rxed.
CERTIFICATION
I, STEPHEN C. BERAHA, Assistant Secretary of Great American Insurance Company, do hereby certify that the foregoing Power of Attorney and
the Resolutions of the Board of Directors of June 9, 2008 have not been revoked and are now in full force and effect.
Signed and sealed this 22nd day of October 2024
Assistant Secretary
S1029AH (03120)
RECEIVED
NOV — 4 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
Please review the attached Department of Workforce Development Disclosure of Ownership form. If Item 3 on this
Disclosure of Ownership form applies to your company, you must complete the Disclosure of Ownership form and
upload in the appropriate location on Quest V-Bid.
If Item 3 on the Disclosure of Ownership form does NOT apply to your company, you must complete the
information below and upload this page in the appropriate location on Quest V-Bid.
CERTIFICATION
I certify by my signature below that Item 3 of the attached Disclosure of Ownership form does NOT apply to my
firm, or a shareholder, officer, or partner of my firm.
Name
Glenn Joski
Printed Name
President
Title
Advance Construction, Inc.
Company Name
11 /4/24
Date
I:\Engineering\Tracy Taylor\ Public Works Contracts\Miscellaneous\Disclosure of ownership Fonn 2-1- Page 1 of 1
17.dooc
City Hall, 215 Church Avenue P.O. Box 1 130 Oshkosh, WI 54903-1130 http://www.ci.oshkosh.wi.us
State of Wisconsin
Department of Workforce Development
Equal Rights Division
Disclosure of Ownership
The statutory authority for the use of this form is prescribed in Sections 66.0903(12)(d), 66.0904(10)(d) and 103.49(7)(d), Wisconsin
Statutes.
The use of this form is mandatory. The penalty for failing to complete this form is prescribed in Section 103.005(12), Wisconsin
Statutes.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1) (m), Wisconsin Statutes].
(1) On the date a contractor submits a bid to or completes negotiations with a state agency, local governmental unit, or
developer, investor or owner on a project subject to Section 66.0903, 66.0904 or 103.49, Wisconsin Statutes, the
contractor shall disclose to such state agency, local governmental unit, or developer, investor or owner, the name of
any `other construction business," which the contractor, or a shareholder, officer or partner of the contractor, owns or
has owned within the preceding three (3) years.
(2) The term 'other construction business" means any business engaged in the erection, construction, remodeling,
repairing, demolition, altering or painting and decorating of buildings, structures or facilities. It also means any
business engaged in supplying mineral aggregate, or hauling excavated material or spoil as provided by Sections
66.0903(3), 66.0904(2), 103.49(2) and 103.50(2), Wisconsin Statutes.
(3) This form must ONLY be filed, with the state agency project owner, local governmental unit project owner, or
developer, investor or owner of a publicly funded private construction project that will be awarding the contract, if both
(A) and (B) are met.
(A) The contractor, or a shareholder, officer or partner of the contractor:
(1) Owns at least a 25% interest in the "other construction business," indicated below, on the date the contractor
submits a bid or completes negotiations; or
(2) Has owned at least a 25% interest in the "other construction business" at any time within the preceding three
(3) years.
(B) The Wisconsin Department of Workforce Development (DWD) has determined that the 'other construction
business" has failed to pay the prevailing wage rate or time and one-half the required hourly basic rate of pay, for
hours worked in excess of the prevailing hours of labor, to any employee at any time within the preceding three (3)
years.
Other Construction Business
Business Name
NONE
Street Address or P O Box
City
TState
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
I hereby state under penalty of perjury that the information, contained in this document, is true and
accurate according to my knowledge and belief.
Print the Name of Authorized Officer
Advance Construction, Inc.
Authorized O i e ' gnat
Date Signed
11 /4/24
Corporation, Partnership Sole Proprietorship Name
Advance ConstruQMn, Inc.
Street Address or P O Box
City
State
I Zip Code
2141 Woodale Ave
Green Bay
iWI
154313
If you have any questions call (608) 266-6861
RECEIVED
CONTRACT 25-07 NOV - 4 2024
ATTACHMENT A
DEPT OF PUBLIC WORKS
LIST OF PROPOSED SUBCONTRACTORS OSHKOSH, WISCONSIN
Pursuant to Section 66.29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the Proposed Subcontractors and the class of work to be performed by each. The
CONTRACTOR will be permitted to sublet a portion of the Contract, but shall perform with their
organization work amounting to at least thirty percent (30%) of the original Contract amount.
Work performed by the CONTRACTOR for any Bid Item that had been subcontracted will not be
included towards the thirty percent (30%) calculation.
If the CONTRACTOR shall sublet any part of this Contract, the CONTRACTOR shall be as fully
responsible to the CITY for the acts and omissions of their Subcontractor and of the persons either directly
or indirectly employed by their Subcontractor as they are by acts or omissions of persons directly
employed by themselves. All Subcontractors, if any, shall be listed in the spaces provided on the
Proposal Form and said list shall not be added to or altered without the written consent of the CITY.
Signed, final waivers of lien will need to be provided to the CITY prior to the release of the final retainage
to the CONTRACTOR.
When a Subcontractor and the class of work to be performed are not listed, it shall be considered that the
Bidder will perform the work themselves.
NAME OF PROPOSED
SUBCONTRACTOR
CLASS OR ITEMS OF WORK
I hereby certify that the use of the name(s) of the
knowledge and consent of the said Subcontractor(s).
Signature of B der
PERCENT OF
CONTRACT AMOUNT
above Proposed Subcontractor(s) was with the
Page 18 of 21
RECEIVED
CONTRACT 25-07 NOV - 4 2024
PROPOSAL
DEPT OF PUBLIC W
ORK
The undersigned will begin work as specified after award of the Contract and com�ple°t�a?;'5�ifiesd.
I hereby certify that all statements are made in behalf of
Advance Construction, Inc.
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of Wisconsin
a Partnership consisting of ; or
an individual trading as - ; of
the City of ; State of
That I have examined and carefully prepared this Proposal from the Plans and Specifications and have
checked the same in detail before submitting this Proposal; that I have full authority to make such
statements and submit this Proposal in (its) (their) behalf; and that said statements are t and correct.
Signature
President
Subscribed and sworn to before me this 4 day of November
(Title, if any)
2024
`` IIII IIIIII,,,,,/'''
ip
*ary lic, or other authorized to administer 3/17/26 _ NOTARY
;A BLIG
(Bidder should not add any conditions or qualifying statements to ti 1�fierwise the Proposal
df'P
may be declared irregular as not being responsive to the Advertisement `f """"""����`
Accompanying this Proposal is a Bid Bond in the amount of 5 % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 21 of 21
Contract Number 25-07 Bond#; FD03290
Date Bond Executed (Date of Contractor Later) 10117/2024
PRINCIPAWCONTRACTOR (Legal Name and Business Address)
DORNER, INC.
E506 Luxemburg Road
Luxemburg, WI 54217
SURETY(IES) (Legal Name(s) and Business Address(es))
Fidelity And Deposit Company Of Maryland
1299 Zurich Way, 5th Floor
Schaumburg, IL 60196-1056
OWNER (Legal Name and Business Address)
CITY OF OSHKOSH
215 Church Avenue
PO Box 1130
Oshkosh, Wisconsin 54903-1130
OBLIGATION
RECEIVED
CITY OF OSHKOSH
NOV li.
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Type of Organization
Individual ❑Partnership
✓ Corporation
State of Incorporation
WI
Penal Sum of Bond
Five Percent Of Amount Bid
The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors
and assigns to the Owner for the amount of the penal sum identified above if the Owner accepts the bid of this
Contractor within the time specified in the bid documents or within such time period as may be agreed upon
between the Owner and the Contractor, and the Contractor shall fail to execute the Contract within five (5) business
days of written notice to the Contractor and Surety of Owner's intent to make a claim upon this Bond.
The Surety hereby waives any notice of an agreement between the Owner and Contractor to extend the time in
which the Owner may accept the bid.
If the Contractor either enters into a contract with Owner in accordance with the terms of the bid and gives such
bond(s) that may be specified in the bidding documents for the faithful performance of the Contract and for the
prompt payment of labor, materials and supplies furnished for the purpose thereof; or pays to the Owner the
difference between the amount specified in the bid and such larger amount for which the Owner may in good faith
contract with another party to perform the work covered in such bid, then the Surety and the Contractor shall have
no obligation under this Bond.
Notice to the Contractor or Surety shall be deemed to have been given: (i) upon delivery to an officer or person
entitled to such notice, if hand delivered; or (ii) two (2) business days following deposit in the United States mail,
postage prepaid; (III) upon delivery by a commercial carrier that will certify the date and time of delivery; or (iv)
upon transmission if by facsimile, email or other form of electronic transmission. Notices shall be provided to the
Owner, Surety and/or Contractor at their address as specified on this Bond or to a facsimile, email or other
electronic address that has been provided in writing to the other party to be used for this purpose.
The laws of the State of Wisconsin shall govern the interpretation and construction of this Bond. Winnebago
County shall be the venue for all disputes arising under this Bond. Any provision in this Bond that may conflict
with statutory or other legal requirement shall be deemed deleted herefrom and provisions conforming to the
statutory or other legal requirement shall be deemed incorporated herein.
w
DORNER, INC. Fidelity And Deposit Company Of Marylapd. .
Name of Principal/Contractor Name of Surety
ORN
i�
Title .s �,sj•; % -In-fTi aConnieSmith, omeyact
:N m;�
-,,�,Otis � ti%
�.��11111,111100<
ZURICH AMERICAN INSURANCE COMPANY
COLONIAL AMERICAN CASUALTY AND SURETY COMPANY
FIDELITY AND DEPOSIT COMPANY OF MARYLAND
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That the ZURICH AMERICAN INSURANCE COMPANY, a corporation of the State of New
York, the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, a corporation of the State of Illinois, and the FIDELITY
AND DEPOSIT COMPANY OF MARYLAND a corporation of the State of Illinois (herein collectively called the "Companies"), by
Robert D. Murray, Vice President, in pursuance of authority granted by Article V, Section 8, of the By -Laws of said Companies, which are
set forth on the reverse side hereof and are hereby certified to be in full force and effect on the date hereof, do hereby nominate, constitute,
and appoint Michael J. DOUGLAS, Connie SMITH, Chris STEINAGEL, Christopher M. KEMP, Robert DOWNEY, Kory
MORTEL and Eliot MOTU, all of Hudson, Wisconsin, Its true and lawful agent and Attorney -in -Fact, to make, execute, seal and deliver,
for, and on its behalf as surety, and as its act and deed: any and all bonds and undertakings, and the execution of such bonds or
undertakings In pursuance of these presents, shalt be as binding upon said Companies, as fully and amply, to all intents and purposes, as if
they had been duly executed and acknowledged by the regularly elected officers of the ZURICH AMERICAN INSURANCE COMPANY at
Its office in Now York, New York., the regularly elected officers of the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY
at its office in Owings Mills, Maryland,, and the regularly elected officers of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND
at its office in Owings Mills, Maryland., in their own proper persons.
The said Vice President does hereby certify that the extract set forth on the reverse side hereof is a true copy of Article V, Section 8, of
the By -Laws of said Companies, and is now in force.
IN WITNESS WHEREOF, the said Vice -President has hereunto subscribed his/her names and affixed the Corporate Seals of the said
ZURICH AMERICAN INSURANCE COMPANY, COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, and
FIDELITY AND DEPOSIT COMPANY OF MARYLAND, this 27th day of November, A.D. 2019.
SEAL5
�WIwiW'
ATTEST:
ZURICH AMERICAN INSURANCE COMPANY
COLONIAL AMERICAN CASUALTY AND SURETY COMPANY
FIDELITY AND DEPOSIT COMPANY OF MARYLAND
By: Robert D. Murray
Vice President
By: Dawn E, Brown
Secretary
State of Maryland
County of Baltimore
On this 27th day of November, A.D. 2019, before the subscriber, a Notary Public of the State of Maryland, duty commissioned and qualified, Robert D.
Murray, Vice President and Dawn E. Brown, Secretary of the Companies, to me personally known to be the individuals and officers described in and who
executed the preceding instrument, and acknowledged the execution of same, and being by me duly swam, deposeth and saith, that he/she is the said officer of
the Company aforesaid, and that the seals affixed to the preceding instrument are the Corporate Seals of said Companies, and that the said Corporate Seals and
the signature as such officer wore duly affixed and subscribed to the said instrument by the authority and direction of the said Corporations,
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my Official Seal the day and year first above written.
``,arr1 Ittt�t
dj'�t\11'I •t
;5•. nuv� }��� Constance A. Dunn, Notary Public
ri+�Rrf;�{�o���•� My Commission Expires: July 9, 2023
htntnu�
EXTRACT FROM BY-LAWS OF THE COMPANIES
"Article V, Section 8, Attorneys-fn-Fact, The Chief Executive Officer, the President, or any Executive Vice President or Vice President
may, by written instrument under the attested corporate seal, appoint attomeys-in-fact with authority to execute bonds, policies,
reeognizances, stipulations, undertakings, or other like instruments on behalf of the Company, and may authorize any officer or any such
attomey-in-fact to affix the corporate seal thereto; and may with or without cause modify of revoke any such appointment or authority at any
time."
CERTIFICATE
I, the undersigned, Secretary of the ZURICH AMERICAN INSURANCE COMPANY, the COLONIAL AMERICAN CASUALTY
AND SURETY COMPANY, and the FIDELITY AND DEPOSIT COMPANY OF MARYLAND, do hereby certify that the foregoing
Power of Attorney Is still in full force and effect on the date of this certificate; and I do further certify that Article V, Section 8, of the By -
Laws of the Companies is still in force.
This Power of Attorney and Certificate may be signed by facsimile under and by authority of the following resolution of the Board of
Directors of the ZURICH AMERICAN INSURANCE COMPANY at a meeting duly called and held on the 15th day of December 1998.
RESOLVED: "That the signature of the President or a Vice President and the attesting signature of a Secretary or an Assistant Secretary
and the Seal of the Company may be affixed by facsimile on any Power of Attomey,..Any such Power or any certificate thereof bearing such
facsimile signature and seal shall be valid and binding on the Company."
This Power of Attorney and Certificate may be signed by facsimile under and by authority of the following resolution of the Board of
Directors of the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY at a meeting duly called and held on the Sth day of
May, 1994, and the following resolution of the Board of Directors of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND at a
meeting duly called and hold on the I Oth day of May, 1990,
RESOLVED: "That the facsimile or mechanically reproduced seal of the company and facsimile or mechanically reproduced signature
of any Vice -President, Secretary, or Assistant Secretary of the Company, whether made heretofore or hereafter, wherever appearing upon a
certified copy of any power of attorney issued by the Company, shall be valid and binding upon the Company with the same force and effect
as though manually affixed.
INJEaTiMONy WHEREOF, I have hereunto subscribed my name and aflxed the corporate seals of the said Companies,
thls,`11t_h __dgy`f October 2024,
NAL
By: Brian M. Hodges
Vice President
TO REPORT A CLAIM WITH REGARD TO A SURETY BOND, PLEASE SUBMIT A COMPLETE DESCRIPTION
OF THE CLAIM INCLUDING THE PRINCIPAL ON THE BOND, THE BOND NUMBER, AND YOUR CONTACT
INFORMATION TO:
`Zurich Surety Claims
1299 Zurich Way
Schaumburg, IL 60196-1056
www.renortsfolaim 04urichna.com
800-626-4577
TO:
FROM:
SUBJECT:
ALL CONTRACTORS
ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
DISCLOSURE OF OWNERSHIP FORM
RECEIVED
NOV - 4 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Please review the attached Department of Workforce Development Disclosure of Oznership form. If Item 3 on this
Disclosure of Ownership form applies to your company, you must complete the Disclosure of Ownership form and
upload in the appropriate location on Quest V-Bid.
If Item 3 on the Disclosure of Ownership form does NOT apply to your company, you must complete the
information below and upload this page in the appropriate location on Quest V-Bid.
CERTIFICATION
I certify by my signature below that Item 3 of the attached Disclosure of Ownership form does NOT apply to my
firm, or a shareholder, officer, or partner of my firm.
. Q&44�z 4t-' ,-
Name
Daniel Dorner
Printed Name
President
Title
Dorner Inc.
Company Name
11 /4/24
Date
I:\Engineering\Tracy Taylor\Pub] ic Works Cunt racts\Miscellnneous\Disclosure of Ownershlp Form 2.1- Page 1 of 1
17.docx
City Hall, 215 Church Avenue P.O. Box 1 130 Oshkosh, WI 54903-1 130 http://www.cl,oshkosh.wl.us
RECEIVED
CONTRACT 25-07 NOV - 4 2024
ATTACHMENT A
DEPT OF PUBLIC WORKS
LIST OF PROPOSED SUBCONTRACTORS OSHKOSH, WISCONSIN
Pursuant to Section 66,29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the Proposed Subcontractors and the class of work to be performed by each. The
CONTRACTOR will be permitted to sublet a portion of the Contract, but shall perform with their
organization work amounting to at least thirty percent (30%) of the original Contract amount.
Work performed by the CONTRACTOR for any Bid Item that had been subcontracted will not be
included towards the thirty percent (30%) calculation.
If the CONTRACTOR shall sublet any part of this Contract, the CONTRACTOR shall be as fully
responsible to the CITY for the acts and omissions of their Subcontractor and of the persons either directly
or indirectly employed by their Subcontractor as they are by acts or omissions of persons directly
employed by themselves. All Subcontractors, if any, shall be listed in the spaces provided on the
Proposal Form and said list shall not be added to or altered without the written consent of the CITY.
Signed, final waivers of lien will need to be provided to the CITY prior to the release of the final retainage
to the CONTRACTOR.
When a Subcontractor and the class of work to be performed are not listed, it shall be considered that the
Bidder will perform the work themselves.
NAME OF PROPOSED
SUBCONTRACTOR
U.z,�'mati
�V2 7K L L
"Rr
(�%sc l�Nrvd �tiey�r�J,yG
CLASS OR ITEMS OF WORI<
'
4f'-m ,. / L.�y!, Plek
�LE19i2z�v(, ��2u�9/3srG
PERCENT OF
CONTRACT AMOUNT
/40
<l o
I hereby certify that the use of the name(s) of the above Proposed Subcontractor(s) was with the
knowledge and consent of the said Subcontractor(s).
Q 4.,., j
Signature of Bidder
Page 18 of 21
RECEIVED
CONTRACT 25-07 NOV - 4 2024
PROPOSAL
DEPT OF PUBLIC WORKS
The undersigned will begin work as specified after award of the Contract and c6mp�e�e�jfiNpeci led.
I hereby certify that all statements are made in behalf of
Dorner Inc.
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of Wisconsin
a Partnership consisting of
an individual trading as
the City of
; State of
; or
of
That I have examined and carefully prepared this Proposal from the Plans and Specifications and have
checked the same in detail before submitting this Proposal; that I have full authority to make such
statements and submit this Proposal in (its) (their) behalf; and that said statements are true and correct.
f1 .1I n
President
Signature
(Title, if any)
Subscribed and sworn to before me this 3 day of N OV-e-mboef- f 20 &A
A/1 . in, f N r%
Notary Public, or other authorized to administer
N
(Bidder should not add any conditions or qualifying statements to this Pr
may be declared irregular as not being responsive to the Advertisement.)
Accompanying this Proposal is a Bid Bond in the amount of % of the total
called for in the Official Notice to Contractors.
AU
BLIG
at101A�'evlid, as
Page 21 of 21