HomeMy WebLinkAbout25-02 BondsMAR 17 2025 CITY OF OSHKOSH
1- rM UP VUBLM KS
OSHKOSH, WISCONSIN
Contract Number 25-02 Bond Number
Date Bond Executed (Date of Contract or Later) February 28, 2025
PRINCIPAL/CONTRACTOR (Legal Name and Business Address)
Advance Construction, Inc.
2141 Woodale Ave.
Green Bay, WI 54313
SURETY(TES) (Legal Name(s) and Business Address(es))
Great American Insurance Company
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
Type of Organization
Individual —Partnership
X Corporation
State of Incorporation
Penal Sum of Bond
5% 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.
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.
Advance Construction, Inc.
Name of Principal/Contractor
t
Title
Great American Insurance Company
Name of Surety
r
A
Title Deborah Knapp, Attorney n- a
Page 2 of 2
GREAT AMERICAN INSURANCE COMPANY®
Administrative Office: 301 E 4TH STREET 0 CINCINNATI, OHIO 45202 • 513-369-5000 0 FAX 513-723-2740
The number of persons authorized by
this power of attorney is not more than THIRTEEN
No.0 22545
POWER OF ATTORNEY
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 attorneys) -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 INSUfANCE COMPA
Assistant Secretary Divisional Senior rice President
STATE OF OHIO, COUNTY OF HAMILTON - ss: MARK ViCARio (877-37/-2405)
On this 24TH day of SEPTEMBER 2024 , before me personally 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.
r SUSAN A KOHORST
Notary Public
o State of Ohio
My Comm. Expires
May 18, 2025
1
This Power ofAttorney is granted by authority of the following resolutions adopted by the Board of Directors of Grcat American 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 rice
Presidents, or any one of them, be and hereby is authorized, from time to time, to appoint one or moreAttorneys-in-Fact to erectile on behalf of the Company,
as surety, any and all bonds, undertakings and contracts ofsuretyship, or other written obligations in the nature thereof,' to prescribe their respective ditties 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 airy 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,
o- 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 affixed.
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 28 day of February , 2025
t+
Assistant Secretary
S1029AH (03/20)
CONTRACT 25-02 R j1 F,
PROPOSAL
M
The undersigned will begin work as specified after award of the Contract and complete as secified.
T)]'P'I' OF 11U131jC WORKS
I hereby certify that all statements are made in behalf of OsxKO5H, W"SCONS;N
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 true and correct.
-00Y —
Signature
Secretary/Treasurer
(Title, if any)
Subscribed and sworn to before me this 17 day of March , 20 25
r �' p'CARY ••� ':
of ry "Public,or other authorized to administer 3117/26 s
r•
i G 3Z
0...5,����.
(Bidder should not add any conditions or qualifying statements to this Proaa�t�"ierwise the Proposal
may be declared irregular as not being responsive to the Advertisement.)
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 14 of 14
c .I"CV$`§ip;r,
CONTRACT 25-02
ATTACHMENT A MAR
LIST OF PROPOSED SUBCONTRACTORS J.'I lyr ()It PI.JMAC MOORS
OSI KO' SII, 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
G.
PERCENT OF
CONTRACT MOUNT
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).
h-Qd-
Signature of adder
Page 11 of 14
D Fq' OF PUBLIC" WORKS
OSHHOSH, WISC ONSIN
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.
r
/�W/
Name
Brian Joski
Printed Name
Secretary/Treasurer
Title
Advance Construction, Inc.
Company Name
3/17/25
Date
l:\Engineering\Tracy Taylor\Public Works Contracts\Miscellaneous\Disclosure of Ownership Form-2-1- Page 1 of 1
17.doex
City Hall, 215 Church Avenue P.O. Box 1130 Oshkosh, WI 54903-1130 http://www.ci.oShkosh,wl.us
State of Wisconsin
Department of Workforce Development Disclosure of Ownership
Equal Rights Division
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
I hereby state under penalty of perjury that the inrormation, coM4111cu 111 1,1110w.,.,.,.••,..• •� --- - —
accurate according to my knowledge and belief.
Print the Name of Authorized Officer
Brian Joski
Authorized O i nIure Date Signed
11
------T3/17125
Corporation, Pa ers1V1p or Sole Proprietorship
Advance Con truction, Inc.
Street Address or P O Box
2141 Woodale Ave
Green Ba
If you have any questions call (608) 266-6861
State Zip Code
WI 54313
--- -1 io n4/1)n14%
BID BOND CITY OF OSHKOSH
Contract Number 25-02
Bond Number (,BAR
Date Bond Executed (Date of Contract or Later) 3/12/2026
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
OSHKOSH, WISCONSIN
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.
CARL BOWERS & SONS CONSTRUCTION CO INC
Name of Principal/Contractor
f � r
MERCHANTS BONDING COMPANY (MUTUAL)
Name of Surety
Page 2 of 2
{Ts Bond #: 492047
E�C-Lil`V]H 1 J
BONDING COMPANY,,,
•
Know All Persons By These Presents, that MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.,
both being corporations of the State of Iowa, dib/a Merchants National Indemnity Company (In California only) (herein collectively called the
"Companies") do hereby make, constitute and appoint, individually,
Michael L Tledt
their true and lawful Attomey(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-Attomey 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 Attorneys -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 Attorney
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 hority hereby given to the
Attorney -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 and/or 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 13th day of March , 2025
{•{{{M{► • �� �•
'•..•�i01YA •..•• •. `�� �.�+++ MERCHANTS BONDING COMPANY (MUTUAL)
.• P t •. • Q �p MERCHANTS NATIONAL BONDING, INC.
.•� �� P0# 0+ • 4?••• Pifl 9 • d/b/a MERCHANTS NATIONAL INDEMNITY COMPANY
Z tn• ^ s y Co.
v°• 2003 ;',a = g'• 1933;
c a
B y
�V�,,
President
STATE OF IOWA
COUNTY OF DALLAS ss.
On this 13th day of March 2025 , before me appeared Larry Taylor, to me personally known, who being by me duly sworn
did say that he Is President of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the
seals affixed to the foregoing Instrument are the Corporate Seals of the Companies; and that the. said instrument was signed and sealed in behalf
of the Companies by authority of their respective Boards of Directors.
�4glAts Penni Miller Commission Number 787952
:: * My Commission Expires
laNA 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 Companies,which is still
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 13th day of March 2025 .
+---•
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.hy�pjtPO ,�•�00 ;�ppp��POq .��.
1933
'♦oa3k ..........;��1�,• •.•day • •'•t,®
POA 0018 (6/24) •••••"'""•��'' • + ® •
Secretary
A �® CERTIFIC�4i'E ®F LIABILITY 1NStJRANCE
DAT3/13/2DIYYYY)
3/13l2025
-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 q j] IRNAL INSURED, the policy(iss) must have ADDITIONAL INSURED provisions or be endorsed.
the ' i conditions of the policy, certain policies may require an endorsement. A statement on
If SUBROGATION IS WAIVED, subject to e' and
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER s ,
Spectrum Insurance Group
OONT
NAME' C Kristin BOeverS --
PHONE i
920-426-2431 nk No):920-385-0866
303 Packerland Dr., Ste Cp
Green Bay WI 54303 x I�UBLi� IC it
L1 C�1ONSIN
EMAIL
AODREs ; kristin.boevers is ectruminsgroup.com
og
INSURERi3) AFFORDING COVERAGE
NAIC it
INSUR_ER_A: SELECTIVE INS CO OF AMER
12572
INSURED CARLS-2
INSURER B : SELECTIVE INS CO OF SC —
1_9259
INSURERC: Evanston Insurance Compapy_— _
Carl Bowers & Sons Construction Co Inc
_
N1844 Maloney Rd
INsuRERo:
Kaukauna WI 54130
INSURER E; --
INSURER F :
e�nvrL+ln�l AIi1�adCD-
COVERAGES GltzKIIrIU1kIC INu[V10r- ;v+a'rrur rV - -
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.
AODL SUER POLICY EFF POLICY EXP LIMITS
TYPE OF INSURANCE POLICY NUMBER M MIDD
X COMMERCIAL GENERAL LIABILITY S 2653019 -0!1/2024 -0/112025 EACHOCCURRENCE _ $ 1,000,000
DAMAG 0 TE
CLAIMS -MADE � OCCUR PREMISES Ea occurrsnco $
MED EXP (Any one person) $15.000
rA
PERSONAL & ADV INJURY $1,0000,000 _
- - —000
GEN'L AGGREGATE LIMIT APPLIES PER
J PR LOGPRODUCTS
POLICY Llxl
GENERALAGGREGATE $ 2,000,
- COMP/OPAGG $2,000 000
A
OTHER:
AUTOMOBILE LIABILITY
S 2553019
4/1/2024
4/1/2025
COMBINEOSIN LELIMIT
(Eaaccident)—$
1,000,000_
BODILY INJURY (Per person)
$
—
X ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
X AUTOS ONLY X AUTOS ONLDY
BODILY INJURY (Par accident)
--
$ _
PROPERTY DAMAGE
r accident
$ -____--
A
B
X
UMBRELLA LIAR
EXCESS LIAR
XIOCCUR
CLAIMS -MADE
NIA
S 2553019
WC9135809
4/1/2024
4/1/2024
4/1/2025
4/V2025
EACH OCCURRENCE
$ 5,006,000
AGGREGATE
S 5,000 _
X gTATUTE7EMPLOYEE
$
__
DED X RETENTIONS
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETORIPARTNERIEXECUTIVE a
OFFICERIMEMSEREXCLUDED4
E.L. EACH ACCEE
$ 500,000 -_
E.L. DISEASE -
$ 500,000 _
A
A
C
(Mandatory In NH)
If yes, describe Under
DESCRIPTION OF OPERATIONS below
RentedlLeasedEquipmant
Installation Floater
Pollution Liability
S 2553019
S 2553019
CPLMOL127826
4H12024
4/1/2024
12/2/2024
4/1/2025
411/2025
12/2/2026
E.L. DISEASE -T
FquippmenlLlmit
InstallationLimit
Pollution Limit
$ 500.000
$300,000
$2,000,000
$1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may he attached if more spaco is required)
3/17/26 Bid (Contract 25-02 Nebraska Street Sanitary Interceptor Sewer Construction)
City of Oshkosh
231 Church Ave
PO Box 1130
Oshkosh WI54903
SHOULD ANY OF THE; ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ATH ORIZED REPRESENTATIVE
., 4 n a a gnat Arn0n 11nRPnRATinti- All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
CONTRACT 25-02
PROPOSAL
MAR I r 20125
The undersigned will begin work as specified after award of the Contract and complete as specified.
DEFT OF PUBLIC WORKS
I hereby certify that all statements are made in behalf of
Carl Z-Owe'15 t Joys 4
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of 1^4'5C,00? ' /,17
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.
oc'zg—nature
56
(Title, if any)
Subscribed and sworn to before me this + *h day of A ✓ C h • 2��
80 BOWERS
Nota Public, or er 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 J % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 14 of 14
CONTRACT 25-02
ATTACHMENT A MAR 177 2025
LIST OF PROPOSED SUBCONTRACTORS DEPT Or PUBLIC WORKS
{?SHKO�SH, 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
M4"� G
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).
Page 11 of 14
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
I?I;IT tll,,1't1j3I,=C WORKS
OSHKOSH, WI SCCONSIN
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.
Printed Name
Title
Company Name
Date
b \ Hngineering\Tmey Taylor\Public Works Contrads\Miscellaneuus\Disclosure of ownership Form_2-1- Page I of I
17.doa
City Hall, 215 Church Avenue P.O. Box 1130 Oshkosh, WI 54903-1130 http://www.ci.oshkosh.wi.us
State of Wisconsin
Department of Workforce Development Disclosure of Ownership
Equal Rights Division
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 (8) are met.
(A) The contractor, or a shareholder, officer or partner of the contractor:
(1) Owns at least a 26% 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 NO
Street Address or P O Box
City
State
Z�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
t , t
Zip Code
nd
m
I hereby state under penalty of perjury that the information, contained in this docuen , is rue a
d dblif
accurate accordrn tom knowle a an e e .
Print the Name of Authorized Officer
Authorized Officer Signature
Date Signed /
Corporation, Partnership or Sole Proprietorship Name
Gv 3�jet4 e- ®h
/1 v Grs ®ems
Street Address or P O Box City State F%Pc,,ode
NiVil had Kma*ataf� 3o
v a G
If you have any questions call (608) 266-686i
ERD-7777 (R. 01/2011)
��► 0
Contract Number 25-02
E)F lyr OF PUBLIC WORKS
Bond Number FD03366
Date Bond Executed (Date of Contract or Later) 3/04/2026
PRINCIPAL/CONTRACTOR (Legal Name and Business Address)
DORNER, INC.
E606 Luxemburg Road
Luxemburg, W154217
SURETY(IES) (Legal Names) and Business Address(es))
Fidelity And Deposit Company Of Maryland
1299 Zurich Way, 6th 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
CITY OF OSHKOSH
Type of Organization
F1Individual 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.
Fidelity And Deposit Company_Of Ma land
DORNER INC. 0 ► Y p Maryland
Name of Principal/Contractor `���� �.�``� E ���� Name of Surety
0 01
EAR,
973 ' =
Title �''i, ''•C.b!� '• ��btle Connie Smith, Attorney -In -fact
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, ilia 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 ilia "Companies"), by
Robert D. Murray, Vice President, In pursuance of authority granted by Article V, Section 8, of ilia 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, Koty
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, shall 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 New York, New York,, ilia 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.
`�"yuias�o�
('
`^ $1BAL
v�
ATTEST:
ZURICH AMERICAN INSURANCE COMPANY
COLONIAL AMERICAN CASUALTY AND SURETY COMPANY
FIDELITY AND DEPOSIT COMPANY OF MARYLAND
By; Robert D. Murray
Vice Presldent
By; Daiwi E. Brown
Secretary
State of Maryland
County of Baltimore
On this 271h day of November, A.D. 2019, before ilia subscriber, a Notary Public of the State of Maryland, duly conuuissioned and qualified, Robert D.
Murray, Vice President and Down E. Brown, Secretary of Ilia Companies, to me personally known to be the individuals and otYicers described in and who
executed the preceding instrument, and acknowledged the execution of some, and being by me duly sworn, deposolli and saith, that hasho is the said officer of
ilia Company aforesaid, and flint die seals affixed to die preceding Instrument are the Corporate Seals of said Companies, and that ilia said Corporate Seals and
the signature as such officer were duly affixed and subscribed to die sold instrument by the authority and direction of die sold Corporations.
iN TESTIMONY WHEREOF, I have horeunto set my hand and affixed my Official Seal the day and year first above written.
Constance A. Dunn, Notary Public
My Commission Expires: July 9, 2023
CONTRACT 25-02 MARI =1 2025
PROPOSAL
DEPT OF PUBLIC WORKS
The undersigned will begin work as specified after award of the Contract and comp e&A'9s 9&1&
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 ; 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 sa' statements are true and correct.
r„ c,
President
Subscribed and sworn to before me this
e
CO . ,p
Notary Public, or other authorized to administer y •y�'•.,� �Qlr I C ��.�
% 0 1..•....•.w'�g�
Signature
(Title, if any)
20-a-5 _.
(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 5 % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 14 of 14
CONTRACT 25-02 MAR 17 2025
ATTACHMENT A D13I1, oi" PUBLIC WORKS
OSHKOSH, WISCONSIN
LIST OF PROPOSED SUBCONTRACTORS
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
SovsuHF.�s
Me&
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).
Pai RJ
onature of Bidder
Page 11 of 14
0.
SH1C0 S%\, 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.
1
Daniel Dorner
Printed Name
President
Title
Dorner Inc.
Company Name
3/17125
Date
h\engineering\Tracy Taylor\Public Works Contracts\Miscelloneous\Dlsclosure of Ownership Form-2-1- Page I of 1
17.docx
City Hall, 215 Church Avenue P.O. Box 1130 Oshkosh, WI 54903-1130 http://www,cl,oshkosh.wi.us