HomeMy WebLinkAboutTR Karrels-Senior Center AGREEMENT
THIS AGREEMENT, made on the 22 day of January, 2010, by and between the CITY OF
OSHKOSH, party of the first part, hereinafter referred to as CITY, and T.R. Karrels & Associates,
SC, (1934 Algoma Boulevard, Oshkosh, WI, 54901) hereinafter referred to as the
CONTRACTOR /CONSULTANT,
WITNESSETH:
That the City and the Contractor /Consultant, for the consideration hereinafter named, enter
into the following agreement. The Contractor /Consultant's proposal is attached hereto and reflects
the agreement of the parties except where it conflicts with this agreement, in which case this
agreement shall prevail.
ARTICLE I. PROJECT MANAGER
A. Assignment of Project Manager. The Contractor /Consultant shall assign the following
individual to manage the project described in this contract:
(Thomas R Karrels, P.E.- Owner)
B. Changes in Project Manager. The City shall have the right to approve or disapprove of
any proposed change from the individual named above as Project Manager. The City shall be
provided with a resume or other information for any proposed substitute and shall be given the
opportunity to interview that person prior to any proposed change.
ARTICLE II. CITY REPRESENTATIVE
The City shall assign the following individual to manage the project described in this contract:
(Jon Urben— General Services Director)
ARTICLE III. SCOPE OF WORK
The Contractor /Consultant shall provide the services described in the City's Request for
Proposals and Proposal of the Contractor /Consultant. If anything in the Proposal conflicts with the
Request for Proposals, the provisions in the Request for Proposals shall govern.
The Contractor /Consultant may provide additional products and/or services if such
products /services are requested in writing by the Authorized Representative of the City.
ARTICLE IV. CITY RESPONSIBLITIES
The City shall furnish, at the Contractor /Consultant's request, such information as is needed
by the Contractor /Consultant to aid in the progress of the project, providing it is reasonably
obtainable from City records.
To prevent any unreasonable delay in the Contractor's /Consultant's work the City will
1
examine all reports and other documents and will make any authorizations necessary to proceed
with work within a reasonable time period.
ARTICLE V. TIME OF COMPLETION
The work to be performed under this contract shall be commenced and the work completed on or
before May 1, 2010, unless the parties in writing agree to extend this date.
ARTICLE III. PAYMENT
A. The Contract Sum.
The City shall pay to the Contractor /Consultant for the performance of the contract the sum of
$2,614, adjusted by any changes hereafter mutually agreed upon in writing by the parties hereto.
Fee schedules shall be firm for the duration of this Agreement.
B. Method of Payment. The Contractor /Consultant shall submit itemized monthly
statements for services. The City shall pay the Contractor /Consultant within 30 calendar days after
receipt of such statement. If any statement amount is disputed, the City may withhold payment of
such amount and shall provide to Contractor /Consultant a statement as to the reason(s) for
withholding payment.
C. Additional Costs. Costs for additional services shall be negotiated and set forth in a
written amendment to this agreement executed by both parties prior to proceeding with the work
covered under the subject amendment.
ARTICLE IV. CONTRACTOR TO HOLD CITY HARMLESS
The Contractor covenants and agrees to protect and hold the City of Oshkosh harmless
against all actions, claims and demands of any kind or character whatsoever which may in any way
be caused by or result from the intentional or negligent acts of the Contractor, his agents or assigns,
his employees or his subcontractors related however remotely to the performance of this Contract or
be caused or result from any violation of any law or administrative regulation, and shall indemnify or
refund to the City all sums including court costs, attorney fees and punitive damages which the City
may be obliged or adjudged to pay on any such claims or demands within thirty (30) days of the date
of the City's written demand for indemnification or refund.
ARTICLE V. INSURANCE
The Contractor /Consultant agrees to abide by the attached City of Oshkosh Insurance
Requirements.
ARTICLE VI. TERMINATION
A. For Cause.
If the Contractor /Consultant shall fail to fulfill in timely and proper manner any of the obligations
under this Agreement, the City shall have the right to terminate this Agreement by written notice to
the Contractor /Consultant. In this event, the Contractor /Consultant shall be entitled to compensation
for any satisfactory, usable work completed.
2
B. For Convenience.
The City may terminate this contract at any time by giving written notice to the Contractor /Consultant
no later than 10 calendar days before the termination date. If the City terminates under this
paragraph, then the Contractor /Consultant shall be entitled to compensation for any satisfactory
work performed to the date of termination.
This document and any specified attachments contain all terms and conditions of the
Agreement and any alteration thereto shall be invalid unless made in writing, signed by both parties
and incorporated as an amendment to this Agreement.
In the Presence of: CONTRACTOR /CONSULTANT
I 11
By: �' d2Z,`/a -,7 7\ ai/r f �S
(Seal of Contractor (Specify Title)
if a Corporation.)
By:
(Specify Title)
CITY OF OSHKOSH
By:
‘,e4i/1
Mark A. Rohloff, Cit Manager
(Wives)
■
III AK _0111111h W
(Wi.$) Pamela R. Ubrig, City Cle
APPOVED: I hereby certify that the necess-
f ary provisions have been made to
% pay the liability which will accrue
., I. t ;♦t� under this contract.
ity Attorne
werzi2r7
"UityXomptroller
3
•
e n g i n e e' s
T .R. Karrels & associates sc
a r ch i t e c is
Interior Building Alterations
Senior Center
January 20, 2010
Jon Urben,
Thank you for allowing us to provide a proposal on the Senior Center Alterations Project. T.R. Karrels &
Associates, SC are known for providing well detailed construction documents followed by construction
observation and project close out services.
Per your walk thru on January 12, 1010, with John, Kim and Mark Ziemer we understand we are to:
• Provide all drawings required to renovate an existing space into a new computer classroom.
• Drawings are to be detailed to the extent required for city inspectors and city personnel to build from.
Details for a hard bid package is not required.
• Provide services during construction and close out documents as required by city inspections.
Not included would be:
Design of HVAC, electrical, and plumbing systems.
To help you understand the work involved we have listed below the major tasks.
Major Tasks:
Lead Arch Arch
• Initial Site Visit 1.5 1.5
• Update CAD Draft Base Plan 1.0 1.5
• Two (2) Preliminary Layouts 1.0 5.0
• Working Drawings to Submit for Plan Approval 1.0 12.0
(Brian Noe @ City)
• City Inspection - Answer Concerns 1.0
• Site Visits During Construction (2) Trips 2.0
• Completion Statement 1.0
• Submittal Forms City / State Forms 1.0 1.0
9.5 21.0
Hourly rates for Services:
Lead Architect $80 9.5 hrs $ 760
Architect / CAD $74 21 hrs $1554
Administrative / Printing $ 300
Total: $2614
Proposed fee would not exceed $2614. We look forward to hearing from you; please don't hesitate to call with
any questions.
Thomas R Karrels, P.E.
Owner
1934 Algoma Blvd 1 Oshkosh WI 54901 1 P 920.426.4470 1 F 920.426.8847
CITY OF OSHKOSH
CONTRACTOR'S INSURANCE AND WITH NO BOND REQUIREMENTS
The Contractor shall not commence work under this contract until the
Contractor has obtained all insurance required under this paragraph
and such insurance has been approved by the Owner, nor shall the
Contractor allow any Subcontractor to commence work on subcontract
until all similar insurance required of the Subcontractor has been
obtained and approved.
I. INSURANCE REQUIREMENTS FOR CONTRACTOR— LIABILITY, BONDS &
PROPERTY
A. Commercial General Liability coverage at least as broad as
Insurance Services Office Forms #CG 00 01 07 98 and #CG 25
03 11 85, including coverage for Products Liability,
Completed Operations, Contractual Liability, and
Explosion, Collapse, Underground coverage with the
following minimum limits:
1. General aggregate limit (other than
Products - Completed Operations) per project $2,000,000
2. Products - Completed Operations aggregate 2,000,000
3. Personal and Advertising Injury limit 1,000,000
4. Each Occurrence limit 1,000,000
5. Fire Damage limit — any one fire 50,000
6. Medical Expense limit — any one person 5,000
7. Watercraft Liability, (Protection & Indemnity
coverage) if the project work includes
the use of, or operation of any watercraft, then
Watercraft Liability insurance must be in force with
a limit of $1,000,000 per occurrence for Bodily
Injury and Property Damage.
8. Products - Completed Operations coverage must be
carried for two years after completion of work.
B. Automobile Liability coverage at least as broad as
Insurance Services Office Form #CA 00 01 07 97, with
minimum limits of $1,000,000 combined single limit per
accident for Bodily Injury and Property Damage, provided
on a Symbol #1 -Any Auto basis.
C. Workers' Compensation as required by the State of
Wisconsin, and Employers Liability insurance with
sufficient limits to meet underlying Umbrella Liability
insurance requirements.
If applicable for the work coverage must include Maritime
(Jones Act) or Longshoremen's and Harbor Workers Act
coverage.
D. Umbrella Liability providing coverage at least as broad as
the underlying Commercial General Liability, Watercraft
Liability (if required), Automobile Liability and
Employers Liability, with a minimum limit of $2,000,000
each occurrence and $2,000,000 aggregate, and a maximum
self - insured retention of $10,000.
E. Aircraft Liability, if the project work includes the use
of, or operation of any aircraft or helicopter, then
Aircraft Liability insurance must be in force with a limit
of $3,000,000 per occurrence for Bodily Injury and
Property Damage including Passenger liability and
including liability for any slung cargo.
F. Also, see requirements under Section III.
G. Bond Requirements - NONE
II. INSURANCE REQUIREMENTS FOR SUBCONTRACTOR
A. All subcontractors shall be required to obtain Commercial
General Liability (if applicable Watercraft liability),
Automobile Liability, Workers' Compensation and Employers
Liability, (if applicable Aircraft liability) insurance.
This insurance shall be as broad and with the same limits
as those required per Contractor requirements contained in
Section I. above.
III. APPLICABLE TO CONTRACTORS /SUBCONTRACTORS /SUB -SUB CONTRACTORS
A. Acceptability of Insurers. Insurance is to be placed with
insurers who have a Best's Insurance Reports rating of no
less than A- and a Financial Size Category of no less than
Class VI, and who are authorized as an admitted insurance
company in the state of Wisconsin.
B. The City of Oshkosh, the City of Oshkosh's elected or
appointed officials, and employees shall be named as
additional insureds on all Liability policies for
liability arising out of project work.
C. Certificates of Insurance acceptable to the City of
Oshkosh shall be submitted prior to commencement of the
work to City Clerk - City of Oshkosh. These certificates
shall contain a provision that coverage afforded under the
policies will not be canceled or non renewed until at
least 30 days' prior written notice has been given to the
City of Oshkosh.
4tc1 CERTIFICATE OF LIABILITY INSURANCE OP ID LS
TRKAR-1 01 27 10
PRODUCER • ! • II* • • • .
Hughes Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
40 W. 6th Ave ! HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. 0. Box 298 I ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Oshkosh WI 54903
Phone: 920-426-2431 Fax :920-426-4514 INSURERS AFFORDING COVERAGE NA1C #
INSURED N!:ORrRA General Casualty
, NSLERFEE.1)
T R Karrels & Associates SC N0LER r EL 0
1934 Algoma Blvd LT,
Oshkosh WI 54901
COVERAGES
THE THE POLICIES Or INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR T-IE POLICY PERIOD INDICATED NOTWITHSTANDING
ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR GTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED CR
MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN >5 SUBJECT Ta ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS
INSR ADM. POUCY EFFECTIVE POLICY EXPIRATION
LTR INSRD TYPE OF INSURANCE POLICY NUMBER OATE IMINIIDDIYYYY DATE iMMFDD/YYYYI LIMITS
GENERAL LIABILITY EACt• OC,CEARENC1 1000000
DAMAGE TO k ENT ET)
A X ;OMME FECIA1 GENERAL LAEll « CCS 0791403 01/13/10 01/13/11 300000
CLAIMS MADE X Cr CCLE ME ,) peN5C,' S 5000
X Business Owners 1000000
0 .1. NE NAL AE.,E:10-E)ATE 2000000
0 N't ACIATEYESAI I PO/1 AFHL it A PER )0A0, -"CMP OP A■ A 1000000
PRO-
X PO C, r
AUTOMOBILE LIABILITY
001/51NE SINGLE L EMIT $ 1000000
o.,
ANY AL,
0.“ -.)0NE5 AT 0S IN
SCI1E=0ULE I) ALET.DE
A X HIRE A CCS 0791403 01/13/10 01/13/11 EopiyNJR,
A X NUN LEANED AUTOS PLE
R TY fTAMAE;t
GARAGE LIABILITY
,LI•Te GNI Y AELc: DEN I 3
ANY A.,11 T EAN
F.A ACC. 3
;. E
AD TO DS, Y
EXCESS / UMBRELLA LIABILITY L AC, OC,
OCCDP CI AIMS MADE AGGRIC,A) 1
OLDEEC I ISLE
RETENTION
WORKERS COMPENSATION =
AND EMPLOYERS' LIABILITY
Y N
ANY' PROPN=ETCA:PAIIFNER:EXECL;TIVE, . AC- ACCEDE N' $
OEEECEP/MEMBER. EXCLOPED
INIandatocy in NHI ASI FAA MPLC't
• 1 cs-LY
Cr P.-EL:VISION:, Ey-IL 0' IsEA,01 OLE:,T LiM $
OMER
R ECEIVED
' DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES EXCLUSIONS ADDED 8Y ENDORSEMENT / SPECIAL PRCVISIONS
CITY OF OSHKOSH ITS OFFICERS, COUNCIL. MEMBERS, AGENTS, EMPLOYEES & N 2
/ ?Diu
AUTHORIZED VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED ON THE GENERAL
LIABILITY POLICY SHOWN, WHICH INCLUDES HIRED/NON-OWNED AUTO LIABILITY. T h C A' , 1L;Rk,,,
INSURED HAS NO OWNED AUTOS
CERTIFICATE HOLDER CANCELLATION
silouLc. ANY OE THE ABOVE DESCRIBED POLICIES DE CANCELLED BEFORE 1111 EXPIRATION!
DATE THEREOF, THE `5 SUING INSURER WILL ENDEAVOR TO MAIL 30 !!!.! DAYS WRITTEN
NCTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBUGA TICN OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
REPRESENTATIVES
CITY OF OSHKOSH
AUTHORIZED REPRESENTATIVE
215 CHURCH AVE Hugh J. Hughes
OSHKOSH WI 54901
ACORD 25 (2009/01) CO 1980-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
I C
J4A-P__7 -2010 12:12 Frow: To:4268847 Psae:P E
CERTIFICATE OF LIABILITY INSURANCE
American Family Insurance Company 0
American Family Mutual Insurance Company II selection box is not checked.
6000 American Pky Madison, Wisconsin 53783-0001
Insures Name and Address Agent's Name, Address and Phone Number (Agt./Dist.)
T.R. Karrel$ & Associates, S.C. 130b Main (920) 235.1776
1934 Algoma Blvd 1920 $ Washburn Street
Oshkosh. WI 54901-2104 0Shk0Sh, WI 54904-4253 (054/015)
This certificate Is Issued as a matter et information only and canters no rights upon use Certificate Holder.
This certificate does not amend, extend or alter the coverage afforded by the policies Hated below.
COVERAGES
The is so cerm, 'nal poecea of insumme WEI Delos. nova txran rg.uad to PP 'MI .1.rreCI named &Ow., 11 .' 1 of. Pact' pen 1 0 O.:Emitted oaten:10;769i awl naglite 'he'll. tem or ccodlio.ri oi w' comae or 0th9r
document e.r.h reaped to titur-ti War Erratical. may bar resuset or may pensIn, the insurance 2ticarrOd or 4 .4 pole as EleithOlid War Et fogad to all the lamtili exCtioarns, VI Cc:nab:Al Er radl poly's,
-----eQLKIP61E
TYPE OF INSURANCE POLICY NUMBER EFCECTIV6 EXPIRATION OMITS F LIABILITY
Tr) (M. IN
Homeowners/ Booty iryng and P 04
Mobilehomeowners Liability Each Occumency $ .....000
Boatovmers1.4bility 1,, In;, EP< Prcormy
_ Eton Octor'4o4 S ,000 I
— ,
Doc* 'Play ao0 Pioonay
Personal Umbrella Liability Dorreo,
f...xn 0a.am".4. 5 .000'
—___.. _........_
Faro Lary & Pelona! Liirali.is
Farm/Ranch Liability , $ .000
EAC CtErcza
Par Employers LiWly
Each OC $ ..040
i Woriters Compensation end F.AlhaCtly --.—■— • * • ** •-**• **•
Employers liability t Earn Accident $ 100 .000
48-X90054-90-00 6.'27/2009 6/27/2010
Dittana Each Emplafee 5 100 , 000
L...ase
•Oic Lour $ 500 .
_
General liability Gamirr .11,22250„ $ ,000
C;) Commercial General eroaucis - COnateracl OPrrairrOrla A S ,000
Llabi MY (occurrence) $
Perscna■ mil rtiChitita* I AhlOY 000
0
Each 0E,,raratior S :t
0 Dwane to P,emi see Reoced oz. You $
ejecpcs Ibraanir LAr., One f $
Ea......10c I t $ .000
Businessowners Liebiiify
Aerega■ott $ ,000
l-7-0 Catrre lamo 5 .000
Liquor Liability $ ,000
.7 1
—
Automobile Uability Bally Ir ory , Earn Parson S ,000
■
0 Any Auto ,
0 All Owned Autos Beady iis oly - Foci) Aoceen1 $ 000
- -
0 Scheduled Autos $
Plevery Oamage .000
- 0 1.1 ired Auk> --
O Nonosvned Autos
I El a‘,01,i lour,. r..:1 Proven', Damage Cc'T'Axrto' $ .000
EaCCS5 Liability
(: Cornmerciai Blanket Excess Ear.: 0, 5 ,COO
1 to
Other (Miscellaneous Covereoes)
1
oescreirTioN oF 0PERArOh4 i LOCATIONS / EPO I RESTRICTIONS 1 SPEC int rreras t no ea.-m.11 r• pat Worm 4, motio Om.. •
Womb t t• comml . mokrwent Wyk! ••6 WO
1tevexh.C.41 Ow nen 4:I9• • !gag la tie
OLCWV103 WO tea a i10.0 A DORY raisin
CERTIFICATE HOLDER% NAME AND ADOFIESS , ,_ .' ' CANCEt-LAT1ON .
---------- any of ate above desCritted poticies be cancelled before the
• City of Oshkosh expiration date thereof, the company will endeavor to mai ( (Jays)
Ado Jon Urban/ Director of General Services written notice to the Certificate holder named but failure lo mad such
notice shall impose no obligation or iiebility of any kind upon the
commny, its agents or representatives 10 days unless dirminnt
RECE . numr.r of days shown
/ YE() 933 This certifies Covelage on the date 01 issue only The above
described policies at subject to cancellation in conformity with their
terms and by the laws ,I the state f iSSU.?
, .140U 2 -,
11 i 2010 I....Tr. 61..1kID FLITI-10q7.E.C1NEPP
_.__.
1 /2 I '2010 I: i . :? / r- / /4
-_
..__S '
_
"------._________.... .Slyck No 06668 Rev 7/02
1.1-201 rd S/00
-------___,
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DOIYYYY
TV 1/27/2010
PRODUCER Phone: 847-517-E Iax, S47 f-,CY9Cfl THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Willis of Illinois,
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
425 N Martingale Rd., ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
it 1100
Schaumburg IL 60173
INSURERS AFFORDING COVERAGE NAIC #
INSURED 1NsussaA Seazley insurance Company, :Inc
T.R. Karreis & Associates, S.C.
, NSuRER8
1934 Algoma 'Blvd
NSURERC
hk0Sh i 54901
.SUER D
NSURERE
COVERAGES
TIRE POLISIES OF INSURANCE BEI,OW HAVE. LEEN :SEE 70 THE INSURED NAMED ABOVE FCR THE POOICY PERICD INDICAEN
aSTWITHSTANCING ANY REQUIREMENC, TEEM CONDaTION CF ANY SONTEAuT OR OPHEE CCOU.MENT WITH RESPECT TC• WHICH THIS
CESTIFICATE MAY BE ISSUED, 3E KAY PERTAiN, THE SNSURANCE AFFORDED BY THE PCaT ESORIBED HEREIN TS EZDESECT TO A. TEE
TERMY, EXCL,USIONS AND COMPITIONS Cr SJCE SPRICIES. AO:SSE:SATE LAHLTS SHOWN MAY HAVE BEEN RED;ICED HY PAID C_AIMS,
INSR ADO'C POUCYEFFECTWE POUCYEXPIRAT1ON
„Liaintik TYPEOFMSURANC POUCYNUMBER Of AU " A*. umas
GENERALUAWLffY EACH OCCURRENCE
DkmAGE10RENTM
CRC GP.IERAt ,ABI,rrY PRE M ■ SE S tE wcur
LLAMS MADE OCCUR MED E XP &t V05,0 5
RSONA, & A[ 15,litRY 5
AGGREGATE 5
3EN1AGG4EGATEUMTAPP,,ESPE5 < CMPOPAGG 5
PO RW CY T ,OC
AUTOMOBILEUA&LITY
COMBINf'D E L■Mr" s
ANY AUTO
ALL OWNED AJ1OS
BOD:LY NJURY
sCHEOULED 5JT ;h5f SOP)
D ASA OS
*411Rs'
.1,,,(t.lellt)
NON OWNED AUTOS
o50 RI"? DAM AGE
• Pe Af.,,,scenti
GARAGE LIABILITY AUTO 05,,Y - EA ACCIDENT 5
AB`, ALISO EA ACC $
OTHER THAN
AUTOONSY
AGG $
EXCESSAMBRELLAUABILaY rACHUCCURRENCF,
oCCuR cawmSmwS AGGRFDATE
DE01J1 8LE 5
RETEN"iON 5 5
A0.STAr.l OTH
WORKERS COMPENSATION AND icHTAITS BR
EMPLOYERS1AAMLITY
Ea EACHACCOENT
AN
(_'±vICERiMEMBEREXCLLOED, ITSEASE-FAEMP_OYEE,I
ve$ oescl the
D smdisf
&PEAL, P50015055 bebw E OiSEASE ROL r.CY L,M;S 5
A OTHER V15:1N7090201 12/24/20'29 12/24;2010
1,1ab',1:ty .
RE MED
T-HcroAs,- KAR,9,,E;spt-,,s.c
DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES ! EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
NnT1.-ayner,t,
JAN 2 ?o
CERTIFICATE HOLDER CANCELLATION
1
'5 J.. ANY OF TEE ABOVE DESCF:DE PCaTiSUE2 RI SANCELOED
SEFOE :HD EXPILATION A THERECI :HE INER
CI y ENLEASOP ;'Y MAIL, YAYS SEDSTEN
2010 Urten, 9:r92905r of sent SERYIPPTATE HY:,PER NYE:. YC HE LEES, PTY' o.. 's. ac, ST
Se /' v i ces a.,:so., HvaSIHR NO OBLISA::CN E,,TAYS—ITY A:°:Y :‹aNS, YOCN
2.1.!. Church Ave7ue THE INS,UREP ITS ASEN OP SHORESENSATD
sic kcsh WI' 5901
AUTHORIZED RE PR ESENTATIVE
"\---.
ACORD 25(2001/08) OACORD CORPORATION 1988