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HomeMy WebLinkAboutPW CNT 13-06/AL DIX CONCRETE CITY OF OSHKOSH LEGAL DEPARTMENT 215 CHURCH AVENUE, P.O. BOX 1130, OSHKOSH, WI 54903-1130 PHONE: (920)236-5115 FAX(920)236-5106 LETTER OF TRANSMITTAL To: AL DIX CONCRETE INC Date: May 2, 2013 500 Draper Street Project: Concrete Sidewalk Kaukauna, WI 54130 From: Carol Marchant, Adm. Assistant Re: Contract 13-06 Attn: Please find: ® Attached ❑ Under Separate Cover ❑ Copy of Letter ® Contracts ❑ Amendment ❑ Report ❑ Agenda ❑ Meeting Notes ❑ Photos ❑ Mylars ❑ Change Order ❑ Plans ❑ Specifications ❑ Estimates ❑ Diskette ❑ Zip Disk ❑ Other Quantity Description 1 Signed Construction Contract— City Contract 13-06 These are being transmitted as indicated below: ❑ For Approval ® For Your Use ❑ As Requested ❑ For Review&Comment Remarks: Signed: ea/a4, qnah-e-ketA, Carol Marchant cc: City Clerk (original) Public Works, Engineering (original) City Attorney (copy) CONSTRUCTION CONTRACT THIS AGREEMENT, made on the 27th day of March, 2013, by and between the CITY OF OSHKOSH, party of the first part, hereinafter referred to as CITY, and AL DIX CONCRETE, INC., 500 Draper Street, Kaukauna, WI 54130-, party of the second part, hereinafter referred to as the CONTRACTOR, WITNESSETH: That the CITY and the CONTRACTOR, for the consideration hereinafter named, agree as follows: ARTICLE I. SCOPE OF WORK The CONTRACTOR hereby agrees to furnish all of the materials and all of the equipment and labor necessary, and to perform all of the work shown on the plans and described in the specifications for the project entitled or described as follows: Public Works Contract No. 13-06 for the Concrete Sidewalk, for the Public Works Department, pursuant to Resolution 13- 130 adopted by the Common Council of the City of Oshkosh on the 26th day of March, 2013, all in accordance and in strict compliance with the CONTRACTOR's Proposal and the other Contract Documents referred to in ARTICLE V of this Contract. ARTICLE II. TIME OF COMPLETION The work to be performed under this contract shall be commenced and the work completed within the time limits specified in the Special Conditions and/or CONTRACTOR's proposal. ARTICLE III. PAYMENT (a) The Contract Sum. The CITY shall pay to the CONTRACTOR for the performance of the Contract the sum of $323,478.50, adjusted by any changes as provided in the Specifications, or any changes hereafter mutually agreed upon in writing by the parties hereto, provided, however, in the event the Proposal and Contract Documents are on a "Unit Price" basis, the above mentioned figure is an estimated figure, and the CITY shall, in such cases, pay to the CONTRACTOR for the performance of the Contract the amounts determined for the total number of each of the units of work as set forth in the CONTRACTOR's proposal; the number of units therein contained is approximate only, and the final payment shall be made for the actual number of units that are incorporated in or made necessary by the work covered by the Contract. 1 (b) Progress Payments. In the event the time necessary to complete this Contract is such that progress payments are required, they shall be made according to the provisions set forth in the Specifications. ARTICLE IV. CONTRACTOR TO HOLD CITY HARMLESS The CONTRACTOR covenants and agrees to protect and hold the CITY 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 Insurance required by the City of Oshkosh as specified in the CITY's specifications, including addenda, or plans, or instructions, or advertisements, shall be primary coverage and that any insurance or self insurance maintained by the City of Oshkosh, its officers, council members, agents, employees or authorized volunteers will not contribute to a loss. All insurance shall be based upon the occurrence of an event, and not based on claims made. All insurance shall be in full force prior to commencing work and remain in force until the entire job is completed and the length of time that is specified, if any, in this Contract, the Specifications, whichever is longer. ARTICLE VI. COMPONENT PARTS OF THE CONTRACT This Contract consists of the following component parts, all of which are as fully a part of this contract as if herein set out verbatim, or if not attached, as if hereto attached: 1. This Instrument 2. The City's Approved Plans 3. Specifications, including any addenda 4. City of Oshkosh Standard Specifications 5. Instructions to Bidders 6. Advertisement for Bids 7. Contractor's Proposal The Contract Documents are complementary;what is required by one is as binding as if required by all. Before undertaking each part of the work, the CONTRACTOR shall carefully study and compare the Contract Documents and check and verify all pertinent figures and measurements required therein. CONTRACTOR shall promptly report in writing to the Engineer any conflict, error, ambiguity or discrepancy which CONTRACTOR may discover and shall obtain written clarification from the Engineer before proceeding with any work affected thereby. 2 In the event that any provision in any of the above component parts of this Contract conflicts with any provision in any other of the component parts, the provision in the component part first enumerated above shall govern over any other component part which follows it numerically except as may be otherwise specifically stated. IT IS HEREBY DECLARED, UNDERSTOOD AND AGREED that the word "CONTRACTOR" wherever used in this Contract means the party of the second part and its/his/their legal representatives, successors, and assigns. IN WITNESS WHEREOF, the City of Oshkosh, Wisconsin, has caused this contract to be sealed with its corporate seal and to be subscribed to by its City Manager and City Clerk and countersigned by the Comptroller of said City, and the party of the second part hereunto set its, his or their hand and seal the day and year first above written. In th en of: CONTRACTOR AL DIX CONCRETE, INC.AA/ v OJL B y: tv,. G'V� d (Seal of Contractor (Specify Title) if a Corporation.) By: (Specify Title) CITY OF OSHKOSH ., t, By: � 11'11 � � �.� ;� - Mark A. Rohloff, City Manager (Witness) ___ -____ ` ' '� And: ! L_�� (Witness) Pamela R. Ubrig, City jerk APPROVED: I hereby certify that the necessary provisions have been made to pay the liability which will accrue under . G -� this contract ttorney City Comptr61l0 3 .-"ID*Auto-Owners° insurattee BOND RIDER (ALL PURPOSE) To be attached to and form part of Bond No.66155572 Executed the 1st Day of April, 2013 In The Penal Sum of($323,479..) By Al Dix Concrete Inc As Principal and The Auto-Owners Insurance Company As Surety, In Favor of City of Oshkosh As Obligee. The above mentioned bond covers the aforesaid Principal as Reconstruction Sidewalk Project The aforesaid Principal and Surety hereby agree that: 1. Bond is amended Bond wording is added: Maintenance Bond coverage for 2 years after completion of the job. 2. The attached bond shall be subject to all its agreements, limitations and conditions except as herein expressly modified. 3. This rider shall become effective as of the beginning of the 1st day of April, 2013. Auto-Owners Insurance Company By: _n u_. 1 r — J.. . ,t . IP Stefanie S Schwandt,Attorney-in-fact Date Signed and Sealed:April 9,2013 2959(7-10) DACE AND ATTACH TO ORIGINAL BOND AUTO-OWNERS INSURANCE COMPANY LANSING,MICHIGAN POWER OF ATTORNEY NO. 66155572 KNOW ALL MEN BY THESE PRESENTS: That the AUTO-OWNERS INSURANCE COMPANY AT LANSING, MICHIGAN,a Michigan Corporation,having its principal office at Lansing,County of Eaton,State of Michigan,adopted the following Resolution by the directors of the Company on January 27,1971,to wit: "RESOLVED,That the President or any Vice President or Secretary or Assistant Secretary of the Company shall have the 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. Signatures of officers and seal of Company imprinted on such powers of attorney by facsimile shall have same force and effect as if manually affixed. Said officers may at any time remove and revoke the authority of any such appointee." Does hereby constitute and appoint Stefanie S Schwa ndt its true and lawful attorney(s)-in-fact,to execute,seal and deliver for and on its behalf as surety,any and all bonds and undertakings,recognizances, contracts of indemnity and other writings obligatory in the nature thereof,and the execution of such instrument(s)shall be as binding upon the AUTO- OWNERS INSURANCE COMPANY AT LANSING,MICHIGAN as fully and amply,to all intents and purposes,as if the same had been duly executed and acknowledged by its regularly elected officers at its principal office. IN WITNESS WHEREOF,the AUTO-OWNERS INSURANCE COMPANY AT LANSING, MICHIGAN,has caused this to be signed by its authorized offi r this 2nd ay of November . 2012 . Arai 1/ jl.��I e'!s/ �i'1 Ken th R.Schroeder,Senior Vice President STATE OF MICHIGAN COUNTY OF EATON 1SS. On this 2nd day of November , 2012,before me personally carne Kenneth R.Schroeder,to me known,who being duly sworn,did depose and say that they are Kenneth R.Schroeder,Senior Vice President of AUTO-OWNERS INSURANCE COMPANY the corporation described in and which executed the above instrument,that they know the seal of said corporation,that the seal affixed to said instrument is such Corporate Seal,and that they received said instrument on behalf of the corporation by authority of their office pursuant to a Resolution the Board off Directors ofsid corporation. My commission expires January 01,2014 , (/M-OC. '7Le"-cs.2f Amanda Lamp,Notary Public STATE OF MICHIGAN I COUNTY OF EATON ss. I,the undersigned Senior Vice President, Secretary and General Counsel of AUTO-OWNERS INSURANCE COMPANY,do hereby certify that the authority to issue apower of attorney as outlined in the above board of directors resolution remains in full force and effect as written and has not been revoked and the resolution as set forth are now in force. Signed and sealed at Lansing,Michigan. Dated this 9th day of April ,20 13 William F.Woodbury,Senior Vice President Secretary and General r.,unsel 2940(11-12) �a� Bond Number 66155572 ....lute-Owners Insurance Life Home Car Business 14'M HefM'q�4• PAYMENT OR LABOR AND MATERIAL BOND KNOW ALL BY THESE PRESENTS, that we, AL DIX CONCRETE INC. of W4437 SCHMIDT RD KAUKAUNA, WI 54130 (hereinafter called the Principal), as Principal, and AUTO-OWNERS INSURANCE COMPANY a corporation organized and existing under the laws of the State of Michigan and duly authorized to transact business in the State of WISCONSIN, (hereinafter called the Surety), are held and firmly bound unto CITY OF OSHKOSH, 215 CHURCH AVE, OSHKOSH WI 54901 (hereinafter called the Obligee), in the full and just sum of Three Hundred Twenty-Three Thousand Four Hundred Seventy-Nine and xx/ 100 Dollars ($323,479.00) lawful money of the United States of America, to be paid to the said Obligee to which payment well and truly be made, we bind ourselves, our heirs, executors, administrators, successors and assigns,jointly and severally,firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH, that WHEREAS, the Principal has entered into a contract with the said Obligee, dated the 1st day of April, 2013 for RECONSTRUCTION SIDEWALK PROJECT which contract is herein referred to and made a part of as fully and to the same extent as if the same were entirely written herein and WHEREAS, it was one of the conditions of the award of the said Obligee, pursuant to which said contract was entered into, that these presents should be executed. AND THE SAID SURETY, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the contract or to the work to be performed thereunder or the specifications accompanying the same shall in anywise affect its obligations on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the contract or to the work or to the specifications. NOW, THEREFORE, if the above Principal shall in all accordance with applicable Statutes, promptly have made payment to all persons supplying labor and material in the prosecution of the work provided for in said contract that may hereinafter be made, notice of which modifications to Surety being waived, then this obligation to be void; otherwise to remain in full force and effect. Signed and sealed this 20th day of March, 2013 A-715A IAA . ■9--------- Witness AL DIX ONCRETE INC. Principal Title AUTO-OWNERS INSURANCE COM erfeN. / • . , . cifi,m_.0. ilom. ..re,‘......_____.__ ..1!.., ...... / Amanda Lamp Witness Jim House Attorney-in-Fact Print Date:03/20/2013 Print Time: 9:12:34 am • Bond Number 66155572 ✓luto-Owners Insurance Life Home Gar Business PERFORMANCE BOND KNOW ALL BY THESE PRESENTS, that we, AL DIX CONCRETE INC. of W4437 SCHMIDT RD KAUKAUNA, WI 54130 (hereinafter called the Principal), as Principal, and AUTO-OWNERS INSURANCE COMPANY a corporation organized and existing under the laws of the State of Michigan and duly authorized to transact business in the State of WISCONSIN, (hereinafter called the Surety), are held and firmly bound unto CITY OF OSHKOSH, 215 CHURCH AVE, OSHKOSH WI 54901 (hereinafter called the Obligee), in the full and just sum of Three Hundred Twenty-Three Thousand Four Hundred Seventy-Nine and xx/ 100 Dollars ($323,479.00) lawful money of the United States of America, to be paid to the said Obligee to which payment well and truly be made, we bind ourselves, our heirs, executors, administrators, successors and assigns,jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH, that WHEREAS, the Principal has entered into a contract with the said Obligee, dated the 1st day of April, 2013 for RECONSTRUCTION SIDEWALK PROJECT which contract is herein referred to and made a part of as fully and to the same extent as if the same were entirely written herein and WHEREAS, it was one of the conditions of the award of the said Obligee, pursuant to which said contract was entered into, that these presents should be executed. AND THE SAID SURETY, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the contract or to the work to be performed thereunder or the specifications accompanying the same shall in anywise affect its obligations on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the contract or to the work or to the specifications. NOW, THEREFORE, if the above Principal shall in all respects comply with the terms and conditions of said contract, and their obligation thereunder, including the specifications therein referred to and made a part thereof, and such alteration as may be made in such specifications, as herein or therein provided for, then this obligation to be void, or otherwise to be and remain in full force, effect and virtue. Signed and sealed this 20th day of March, 2013 Witness AL DIX CONCRETE INC. Principal Title AUTO-OWNERS INSURANCE COM' Y.H. „5:70m• Amanda Lamp Witness Jim House Attorney-in-Fact Print Date:03/20/2013 Print Time: 9:12:35 am • .Q� Bond Number 66155572 v?uto-Ou�ssers Insurance Life home Car Business MAINTENANCE BOND KNOW ALL BY THESE PRESENTS, that we, AL DIX CONCRETE INC. of W4437 SCHMIDT RD KAUKAUNA, WI 54130 (hereinafter called the Principal), as Principal, and AUTO-OWNERS INSURANCE COMPANY a corporation organized and existing under the laws of the State of Michigan and duly authorized to transact business in the State of WISCONSIN, (hereinafter called the Surety), are held and firmly bound unto CITY OF OSHKOSH, 215 CHURCH AVE, OSHKOSH WI 54901 (hereinafter called the Obligee), in the full and just sum of Three Hundred Twenty-Three Thousand Four Hundred Seventy-Nine and xx/ 100 Dollars ($323,479.00) lawful money of the United States of America, to be paid to the said Obligee to which payment well and truly be made, we bind ourselves, our heirs, executors, administrators, successors and assigns,jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH, that WHEREAS, the Principal has entered into a contract with the said Obligee, dated the 1st day of April, 2013 for RECONSTRUCTION SIDEWALK PROJECT which contract is herein referred to and made a part of as fully and to the same extent as if the same were entirely written herein and WHEREAS, said contract has been completed, and was approved on the 1st day of April, 2013. NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if the Principal shall guarantee that the work will be free of any defective materials or workmanship which become apparent during the period of twelve months following completion of the contract, then this obligation shall be void, otherwise to remain in full force and effect, provided, however, any additional warranty or guarantee, whether expressed or implied, is extended by the Principal or Manufacturer only, and the Surety assumes no liability for such a guarantee. Signed and sealed this 20th day of March, 2013 ALAAAALLA Witness AL DIX CONCRETE INC. Principal itle AUTO-OWNERS INSURANCE COM Y. . 4 i 4)(.17v.Th 9919. kSat Vjg Amanda Lamp Witness Jim House Attorney-in-Fact Print Date:03/20/2013 Print Time: 9:12:36 am Q Bond Number 66155572 ..?u -=-Owners Innerance Lila Home Car Business 774A6A66.,'gyk• ACKNOWLEDGEMENT BY SURETY STATE OF MICHIGAN County of Eaton On this 20th day of March, 2013, before me personally appeared Jim House, known to me to be the Attorney-in-Fact of AUTO-OWNERS INSURANCE COMPANY, the corporation that executed the within instrument, and acknowledged to me that such corporation executed the same. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal, at my office in the aforesaid County, the day and year in this certificate first above written. NOTARY PUBLIC', COUNTY OF EATON NY ComIflUlon Ewirw•. JANOARY1 2014 Amanda Lamp j N,AC1iq N1M mn1y W;'=^ 9rF.................� <' Notary Public in the State of Michigan °F County of Eaton AMANDA LAMP NOTARY PUBLIC-STATE OF MICHIGAN COUNTY OF EATON My Commission Expires January 1st,2014 Acting in the County of Eaton Print Date:03/20/2013 Print Time: 9:12:37 am DATE AND ATTACH TO ORIGINAL BOND AUTO-OWNERS INSURANCE COMPANY LANSING,MICHIGAN POWER OF ATTORNEY NO.66155572 KNOW ALL MEN BY THESE PRESENTS:That the AUTO-OWNERS INSURANCE COMPANY AT LANSING,MICHIGAN,a Michigan Corporation,having its principal office at Lansing,County of Eaton,State of Michigan,adopted the following Resolution by the directors of the Company on January 27,1971,to wit: "RESOLVED, That the President or any Vice President or Secretary or Assistant Secretary of the Company shall have the 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. Signatures of officers and seal of Company imprinted on such powers of attorney by facsimile shall have same force and effect as if manually affixed.Said officers may at any time remove and revoke the authority of any such appointee." Does hereby constitute and appoint Jim House its true and lawful attorney(s)-in-fact,to execute,seal and deliver for and on its behalf as surety,any and all bonds and undertakings,recognizances,contracts of indemnity and other writings obligatory in the nature thereof,and the execution of such instrument(s)shall be as binding upon the AUTO-OWNERS INSURANCE COMPANY AT LANSING, MICHIGAN as fully and amply, to all intents and purposes,as if the same had been duly executed and acknowledged by its regularly elected officers at its principal office. IN WITNESS WHEREOF,the AUTO-OWNERS INSURANCE COMPANY AT LANSING, MICHIGAN, has caused this to be signed by its authorized officer this 2nd day of November,2012 A r t,r , • Kenneth R.Schroeder Senior Vice President STATE OF MICHIGANlss. COUNTY OF EATON MICHIGAN} """` 1• ptADA 'NOTARY..............fiu vs. PUBLIC J� On this 2nd day of November,2012,before me personally came Kenneth R.Schroeder, to me known,who being duly sworn,did L :COUNTY OF EATON•. V depose and say that they are Kenneth R.Schroeder, Senior Vice President of AUTO-OWNERS INSURANCE COMPANY,the corporation F NY`s '""E�°• P ; JANUARY 1,2014 described in and which executed the above instrument,that they know the seal of said corporation,that the seal affixed to said instrument is <N,. such Corporate Seal,and that they received said instrument on behalf of the corporation by authority of their office pursuant to a Resolution `r9`•.. vim' of the Board of Directors of said corporation. alP of.M.c�= January 1st 2014 // c42,7-ktit-QM My commision expires ' Amanda Lamp Notary Public STATE OF MICHIGANss. COUNTY OF EATON f I,the undersigned First Vice President,Secretary and General Counsel of AUTO-OWNERS INSURANCE COMPANY,do hereby certify that the authority to issue a power of attorney as outlined in the above board of directors resolution remains in full force and effect as written and has not been revoked and the resolution as set forth are now in force. Signed and sealed at Lansing,Michigan.Dated this 20th day of March 2013 r��NgWaVq"", ijr••MM�•}•• ,<3 ; ALDIX-1 OP ID: AP AA,,C°RE CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/20/13 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 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 endorsement(s). PRODUCER CONTACT 920-766-1791 NAME: Al Dix Abel Insurance&Assoc,LTD PHONE 766-4344 FAX 920-766-9677 One Bank Avenue,Suite A (A/C,No.Ext): (NC,No): Kaukauna,WI 54130 E-MAIL Mark W.Abel ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Secura Insurance 22543 INSURED Al Dix Concrete, Inc. INSURER B: W4437 Schmidt Rd. Kaukauna,WI 54130 INSURER C INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY I EACH OCCURRENCE $ 2,000,000 A COMMERCIAL GENERAL LIABILITY X 20TC003045471 &3187965 03/01/13 03/01/14 DAMAGE TO RENTED 250,000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 X Business Owners PERSONAL&ADV INJURY 1$ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 X POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ A X ANY AUTO 20A003045473 03/01/13 03/01/14 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY (Per $ AUTOS AUTOS ( accident) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A ' EXCESS LIAB CLAIMS-MADE 2000003149012 03/01/13 03/01/14 AGGREGATE $ fDED X RETENTION$ 10000 $ WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY X TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 20WC003160483 03/01/13 03/01/14 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory in NH) . E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) "See policy(ies)and endorsements for actual descriptions and provisions." CERTIFICATE HOLDER CANCELLATION CITYOCH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Oshkosh THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 1130 215 Church Avenue AUTHORIZED REPRESENTATIVE Oshkosh,WI 54903 Mark W.Abel i ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BUSINESSOWNERS BP 04 51 01 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - WITH ADDITIONAL INSURED REQUIREMENT IN CONSTRUCTION CONTRACT This endorsement modifies insurance provided under the following: BUSINESSOWNERS POLICY The following is added to Paragraph C. Who Is An Insured in the Businessowners Liability Coverage Form: 4. Any person or organization for whom you are performing operations is also an insured, if you and such person or organization have agreed in writing in a contract or agreement that such per- son or organization be included as an additional insured on your policy. Such person or organiza- tion is an additional insured only with respect to li- ability arising out of your ongoing operations per- formed for that insured. A person's or organization's status as an insured under this paragraph ends when your operations for that in- sured are completed or the contractor's agree- ment is terminated. BP 04 51 01 97 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ❑ gulletin to Insurers Regarding Misleading Property and Casualty Certificates of Insurance Page 1 of 1 = Wisconsin Office of the r , Commissioner of Insurance Laws/Rules/Bulletins>Bulletins to Insurers Date: August 27, 2012 To: All Property and Casualty Insurers and Agents From: Theodore K. Nickel, Commissioner of Insurance Subject: Misleading Property and Casualty Certificates of Insurance "Certificates of insurance" are typically used to provide proof of liability insurance and to summarize the terms of the policy for a third party instead of providing a complete copy of the policy. This bulletin is to clarify the use of certificates of insurance by intermediaries and insurers within the state of Wisconsin. This bulletin supersedes the Office of the Commissioner of Insurance (OCI) bulletin issued on May 5, 2008. Section 631.20, Wis. Stat., generally requires insurers to file insurance policy forms with OCI prior to using the forms in Wisconsin. Section 628.34 (1), Wis. Stat., provides that "No person who is or should be licensed ... may make or cause to be made any communication relating to an insurance contract ... which contains false or misleading information, including information misleading because of incompleteness ... . No intermediary may provide a misleading certificate of insurance." Certificates of insurance which clearly and accurately state the insurance coverage provided to an insured or third party are not forms subject to filing with OCI under s. 631.20, Wis. Stat., because these certificates do not affirmatively or negatively amend, extend or alter coverage or terms of the policy. They simply summarize the coverage and terms of the policy. Where an insurer or an agent acting on behalf of the insurer uses a certificate of insurance or other evidence of coverage which goes beyond an accurate summary of the policy, the insurer or agent may be misrepresenting the policy language as issued by the insurer and filed with OCI. Language included in the certificate that amends or extends coverage or terms of the policy, such as stating that coverage is in force when it is not or stating that a notice of policy cancellation will be given when it will not, is a misrepresentation. An insurer or agent issuing these certificates would be in violation of s. 628.34 (1), Wis. Stat., and may be subject to administrative penalties including possible license suspension or revocation. To ensure that consumers as well as those requesting certificates of insurance are aware that the certificate does not expand or restrict coverage, an insurer or agent should include on the certificate a statement such as: "This certificate of insurance neither affirmatively nor negatively amends, extends, or alters the coverage afforded by the policies described herein." A similar statement is included on the preprinted certificate of insurance forms provided by both ACORD and ISO. OCI encourages insurers to notify their agents of this bulletin. If you have any questions regarding the information contained in this bulletin, you may contact Ronnie Demergian at ronnie.demergianwisconsin.gov or 608-266- 7077. Last Updated: August 27, 2012 http://oci.wi.gov/bulletin/0812pccertins.htm 9/11/2012