HomeMy WebLinkAboutPW CNT 82-23/JDR Enterprises CONSTRUCTION CONTRACT
THIS AGREEMENT, made on the et, day of Novem ber , 1982
by and between the CITY OF OSHKOSH, party of the first part , hereinafter
referred to as the CITY, and J.D.R. Interprises
of 155 High Street, Oshkosh, WI 54901
party of the second part, hereinafter referred to as the CONTRACTOR,
WITNESSETH: That the City and the Contractor, for the
considerations 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. 82-23 for demolition of buildings at 18-20, 24 & 26
North Main Street, Oshkosh, Wisconsin,
pursuant to Resolution #6 adopted by the Oshkosh Common Council on November 22,
1982, •
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 General
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 $ 14,700.00 , adjusted by
any changes as provided in the General Conditions , 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 .
(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 General Conditions .
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
the negligent digging up of streets , alleys or public grounds or
which may result from the faulty , carelessness or neglect of said
Contractor , his agents , employees or workmen in the performance of
said work or caused by the violation of any City ordinance , and
shall refund to the City all sums which it may be obliged or adjudged
to pay on any such claims or demards within a reasonable time after
demand thereof .
ARTICLE V. 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 . General Conditions
2 . Advertisement for Bids
3. Instructions to Bidders
4 . Specifications , including any addenda
5 . Plans
6 . Contractor ' s Proposal
7 . This Instrument
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 .
TT IS HER.E3Y 1,LCLARED , If:MET: OUD A D AG...._, D that th word d
"Contractor" wherever used in this contract means the party of the
second part and its/his/ their legal representatives , successors and
assigns .
- 2 -
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 her hereunto set its, his or their hand and
seal the day and year first above written.
In the presence of: CONTRACTOR
J.D.R. Interprises (
fr By: -y,,,vJ 4/4'
1 -
...kik, / 4 . ji
peciy Tile
(Seal of Contractor
if a Corporation) By: ?
c. .ekiLANILi ,
Specify, Tit
ZLZ,0s�' /!CITY OF OSHKOSH
�i � C, I.� ffile6;----- ..ea )7u-c-/
, By.
I' WILLIAM D. FRUEH, City Manager
Air,/ _ G' By: /J/.U4.'�1 ,i 1�.,Y,
iCON-11P E C. MARKS, . - Clerk
I certify that provisions have been made to
pay the liability that will accrue to the
City of Oshkosh under the within contract. (Seal of City)
'`t' ak .,of
EDWARD A. NOKES, City Comptroller
Approveto fo m':1
TOM W. AHRENS, Asst. City Attorney
- 3 -
, t
::,27,75g,''''''!-F.7..!,F .,.*
1 11
-Q ELITY
UNITED STATES FIDEEI :, ,,```®(=�� :11`- UARANTY COMPANY
• ago , .
-
2-4 (A Stock Company)
LABOR AND MATERIAL PAYMENT BOND
°-_ :-=.-,-i Approved by The American Institute of Architects �
�
jj A. I.A.Document No.A-311 (February 1970 Edition) t,:::
KNOW ALL MEN BY THESE PRESENTS:
: BOND NUMBER
`a
That J•D.R. ENTERPRISES, 155 HIGH STREET, OSHKOSH, WI 54901
as Principal, L.
hereinafter called Principal, and UNITED STATES FIDELITY AND GUARANTY COMPANY, a corporation organized and existing under the laws
`ti of the State of Maryland, Baltimore, Maryland as Surety, hereinafter called Surety, are held and firmly bound unto CITY.OF
L.
OSHKOSH, WISCONSIN
as Obligee, hereinafter called Owner, for the use and benefit of claimants as hereinbelow defined, in the amount of Fourteen
thousand..seven..hundred..and..no/10.0 'Dollars($ 14,700.00 ),
for the payment whereof Principal and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and
C ? severally,firmly by these presents.
WHEREAS,Principal has as b y written agreement dated November 29 1982, entered into a contract with Owner for
Public Works Contract No. 82-23 for demolition of buildings at 18-20, 24 & 26
North M8 in Street (�s kosh sconsin
i in accordance with arawings and sppciTiicatiioons prepvarea oy
F'•, (Here insert full name, title and address)
which contract is by reference made a part 1
-- hereof,and is hereinafter referred to as the Contract.
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION is such that if the Principal shall promptly make payment to all
=•_ claimants as hereinafter defined, for all labor and material used or reasonably required for use in the performance of the Contract, then this
E obligation shall be void; otherwise it shall remain in full force and effect, subject, however, to the following conditions:
`' (1) A claimant is defined as one having a direct contract with the Principal or with a sub-contractor of the Principal for labor, material, t`='?
E_-a or both, used or reasonably required for use in the performance of the contract, labor and material being construed to include that
[, part of water, gas, power, light, heat, oil, gasoline, telephone service or rental of equipment directly applicable to the Contract. `'
(2) The above-named Surety al and
P y hereb y jointly and severally agree with the Owner that every claimant as herein defined, who l ;)
". has not been paid in full before the expiration of a period of ninety (90) days after the date on which the last of such claimant's -`i
is work or labor was done or performed, or materials were furnished by such claimant, may sue on this bond for the use of such ;
p, claimant, prosecute the suit to final judgment for such sum or sums as may be justly due claimant, and have execution thereon. The r I°?=
Owner shall not be liable for the payment of any costs or expenses of any such suit.
(3) No suit or action shall be commenced hereunder by any claimant,
::,:,•'.'' (a) Unless claimant, other than one having a direct contract with the Principal, shall have given written notice to any two of the
='='- following: The Principal, the Owner, or the Surety above named, within ninety(90) days after such claimant did or performed the --
last of the work or labor, or furnished the last of the materials for which said claim is made, stating with substantial accuracy n„
,,.. ,. the amount claimed and the name of the party to whom the materials were furnished, or for whom the work or labor was done or
E�� performed. Such notice shall be served by mailing the same by registered mail or certified mail, postage prepaid, in an envelope
addressed to the Principal, Owner or Surety, at any place where an office is regularly maintained for the transaction of business,
E; I or served in any manner in which legal process may be served in the state in which the aforesaid project is located'. , save that
such service need not be made by a public officer. `
(b) After the expiration of one (1) year following the date on which Principal ceased work on said Contract, it being understood,
`' I however, that if any limitation embodied in this bond is prohibited by any law controlling the construction hereof such limitation
_ shall be deemed to be amended so as to be equal to the minimum period of limitation permitted by such law. `=:=-
(c) Other than in a state court of competent jurisdiction in and for the county or other political subdivision of the state in which the r--=
L'..1 project, or any part thereof, is situated, or in the United States District Court for the district in which the project, or any part
F:- , thereof, is situated, and not elsewhere.
(4) The amount of this bond shall be reduced by and to the extent of any payment or payments made in good faith hereunder, inclusive
i;=` of the payment by Surety of mechanics' liens which may be filed of record against said improvement, whether or not claim for the
. 1 amount of such lien be presented under and against this bond.
Signed and sealed this 29 th day of November 19 82
By _ (Seal)(Witness) Principal
1'..::.:; )
:;;; "d�) UNI Dj Wald :ei: eai
/_/Z '/ -fact
• This bond is issued simultaneously with performance bond in favor of the Owner co ition o, the f d faithful performance of the Contract. :.
111
Contract 211-A (2-70)„:;;;;;;„,„7,:,:;:":„„,,,,'j.
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LI\IITIEDD STA-ITIES IFIIIDIEILII -104401/' ��; �e I�,IAIR,A\lf Y COMPANY
':a•' - rea(
A •18 9� '•' }s3
(A 'oc j o `any)
PERFORMANCE BOND
_.i Approved by The American Institute of Architects
A. I.A.Document No.A•311(February 1970 Edition)
r.-.: BOND NUMBER
KNOW ALL MEN BY THESE PRESENTS:
That J.D.R. ENTERPRISES, 155 HIGH STREET, OSHKOSH, WI 54901
as Principal,
hereinafter called Contractor, and UNITED STATES FIDELITY AND GUARANTY COMPANY, a corporation organized and existing under the laws
:-!'?..1 of the State of Maryland, Baltimore, Maryland, as Surety, hereinafter called Surety, are held and firmly bound unto CITY...QF
osimSFi,, Wi$ QQSIN
:::' as Obligee, hereinafter called Owner, in the amount of F011r.ee. .... ous and....s...ve n...bundred...an.d...noJ1.0..0---- -?
L:__;
,, 14,700,00
Dollars 4 ),
for the payment whereof Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and "1
":'.l severally, firmly by these presents.
WHEREAS„ Contractor has by written agreement dated ...lQY.embe.x...2.9 19..8.4 entered into a contract with Owner for _A
Public Works Contract No. 82-23 for demolition of buildings at 18-20, 24 d 26 ;;,�
'` North Main Street Oshkosh Wisconsin.
=1 in accordance with drawings and specifications prepared by
(Here insert full name, title and address) =-'t
, which contract is by reference made a part '1;:-3,
hereof, and is hereinafter referred to as the Contract. _:-
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION is such that, if Contractor shall promptly and faithfully perform
rl ""'t
said Contract, then this obligation shall be null and void;otherwise it shall remain in full force and effect. ;
=: The Surety hereby waives notice of any alteration or extension of time made by the Owner.
';,:, Whenever Contractor shall be, and declared by Owner to be in default under the Contract, the Owner having performed Owner's obligations R;z
thereunder, the Surety may promptly remedy the default, or shall promptly
(I) Complete the Contract in accordance with its terms and conditions,or
r` (2) Obtain a bid or bids for completing the Contract in accordance with its terms and conditions, and upon determination by Surety of the low-
.s:.':
g P Y Y .
+,,- est responsible bidder, or, if the Owner elects, upon determination by the Owner and the Surety jointly of the lowest responsible bidder, d-
arrange for a contract between such bidder and Owner, and make available as Work progresses (even though there should be a default or a
succession of defaults under the contract or contracts of completion arranged under this paragraph) sufficient funds to pay the cost of
completion less the balance of the contract price; but not exceeding, including other costs and damages for which the Surety may be liable =
hereunder, the amount set forth in the first paragraph hereof. The term "balance of the contract price," as used in this paragraph, shall
mean the total amount payable by Owner to Contractor under the Contract and any amendments thereto, less the amount properly paid by
Owner to Contractor.
`; Any suit under this bond must be instituted before the expiration of two (2) years from the date on which final payment under the
Contract falls due.
r,; rs3
`- . No right of action shall accrue on this bond to or for the use of any person or corporation other than the Owner named herein or
i;j the heirs,executors,administrators or successors of the Owner.
l.-:-< 29th November 82 ` 4
Signed and sealed this day of 19.... :,
In the presence of:
By (Seal)
:;i! ) (Witness) Principal
I.:"; " atieft 6 UNIT, STATE FI AND GUARANTY COMPANY �` ,j,u...„,,/ ,,,
, :„,
,,, (Witness) By Jeff J ••W• YL7t' " `1•C orrier in f Vi
Contract 21 1 (2.70)
• CERTIFIED COPY
GENERAL POWER OF ATTORNEY
Na. 92875
Know all Men by these Presents:
That UNITED STATES FIDELITY AND GUARANTY COMPANY, a corporation organized and existing under the laws of the
Mate of Maryland, and having its principal office at the City of Baltimore, in the State of Maryland, does hereby constitute and appoint
Jeffery J. Wirth
of the City of Neenah , State of Wisconsin
its true and lawful attorney in and for the State of Wisconsin
for the following purposes, to wit:
To sign its name as surety to, and to execute, seal and acknowledge any and all bonds, and to respectively do and perform any and
all acts and things set forth in the resolution of the Board of Directors of the said UNITED STATES FIDELITY AND GUARANTY
COMPANY, a certified copy of which is hereto annexed and made a part of this Power of Attorney; and the said UNITED STATES
FIIDELIT'i AND GUARANTY COMPANY, through us, its Board of Directors, hereby ratifies and confirms all and whatsoever the said
Jeffery J . Wirth
may lawfully do in the premises by virtue of these presents.
In Witness Whereof, the said UNITED STATES FIDELITY AND GUARANTY COMPANY has caused this instrument to be
sealed with its corporate seal, duly attested by the signatures of its Vice-President and Assistant Secretary, this 19th day of
March , A. D. 1982
UNITED STATES FIDELITY AND GUARANTY COMPANY.
(Signed) By Jeanne H. Eddy
Vice-President.
(SEAL)
(Signed) W. B. M. Hingeley
Assistant Secretary.
STATE OF MARYLAND, }
ss:
BALTIMORE CITY,
On this 19th day of March , A. D. 19 32, before me personally came
Jeanne H. Eddy , Vice-President of the UNITED STATES FIDELITY AND GUARANTY
COMPANY and W. B. M. Hingeley „Assistant Secretary of said Company, with both of
whom I am personally acquainted, who being by me severally duly sworn, said that they, the said Jeanne H. Eddy
and W. B . M. Hingeley were respectively the Vice-President and the Assistant Secretary of the said UNITED
STATES FIDELITY AND GUARANTY COMPANY, the corporation described in and which executed the foregoing Power of Attorney;
that they each knew the seal of said corporation; that the seal affixed to said Power of Attorney was such corporate seal, that it was
so fixed by order of the Board of Directors of said corporation, and that they signed their names thereto by like order as Vice-President
and Assistant Secretary. respectively, of the Company.
My commission expires the first day in July, A. D. 19 82
Margaret M. Hurst
(SEAL) (Signed)
Notary Public.
STATE OF MARYLAND 1
Sct.
BALTIMORE CITY,
j, Charles W. Mackey , J r. Clerk of the Superior Court of Baltimore City, which Court is a
Court of Record. and has a seal, do hereby certify that Margaret M. Hurst , Esquire, before
whom the annexed affidavits were made, and who has thereto subscribed his name, was at the time of so doing a Notary Public of the
State of Maryland, in and for the City of Baltimore, duly commissioned and sworn and authorized by law to administer oaths and take
acknowledgment. ■dr proof of deeds to be recorded therein. I further certify that I am acquainted with the handwriting of the said
Notary,and verily believe the signature to be his genuine signature.
In Testimony Whereof, I hereto set my hand and affix the seal of the Superior Court of Baltimore City, the same being a Court
of Record, this 19 t h day of March ,A. D. 19 82
(SEAL) (Signed) Charles W. Mackey z Jr.
FS 3 (12-81) Clerk of the Superior Court of Baltimore City.
COPY OF RESOLUTION
That Whereas,it is necessary for the effectual transaction of business that this Company appoint agents and attorneys with Dower
an States ether than Maryland, and in the Territories of the United States and in the Provinces
and authority to act for it and in its name in _
and territories■t Canada;
Therefore, he it Resolved, that this Company do, and it hereby does, authorize and President or either of its Vice•
d empower its
Presidents in conjunction with its Secretary or one of its Assistant Secretaries. under its corporate seal, to appoint any person or persons
as attorney or the t fidelity f persons or agent agents
positionst ofCpublic`ornprivatetl trust and
guarant guaranteeing execute
performances eofacontacts other contracts than
guaranteeing the tidelity .f o actions proceedings, or law
insurance policies and executing or guaranteeing bonds and undertakings, required or permitted in all actions or proc. g , by
allowed, and
:flcog in its name and as its attorney
pulationsr undertakings or anything in agents to execute f eitherdof the guarantee
h conditicns
s e r of
may by law.
bends, reco or other s,otherwise, by an, stipulations,
municipal or otherwise, or by any Statute of the United States or of any State or Territory of the United States or of the Provinces or
territories of Canada. or by the rules, regulations, orders, customs, practice or discretion of any board, body, organization. office or officer,
'oca!, municipal or otherwise, be allowed,fr any person permitted,to,bporaticnteibnd}�(IofficP taken.
iaterest murtieipalitycoFtother filed
associationdnd
for the security or ever. in any and or P
�, undertaking,or anything in the nature of either of the same.
of municipality
or any conditions which
organization n�hatsoever, in any and all capacities whatsoever, conditioned for the doing or not doing o anything
:na■ be provided for in any such bond, recognizance, obligation, stipulation, , :it . Secretary of the r_NIT .D ST a.TES FT!IET.ITY AND
i, Richard �-'�`-� of the original power of attorney given
GUARANTY COMPA t NY, do ereby certify that the foregoing is a full, true anti correct copy
by said Company to Jeffery J . Wirth
of Neenah , W i s c o n s i n , authorizing and empowering
him to sign bonds as therein set
forth, which power of attorney has never been revoked and is still in full force and effect.
And I do further certify that said Power of Attorney was pursuance atom of
anr in adopted at a meeting of
Jay of{ p
Beard of Direcbers of said Company, duly �,�.l.ed and
libr..enuher.1981, at which meeting a quorum of the Board of Directors was present, and that the foregoing is a true and correct copy of said
resolution,and the whole thereof as recorded in the minutes of said meeting.
In Testimony Whereof. I have her unto set my hand and the seal of the UNITED STATES FIDELITY AND GUARANTY
COMPANY on November 29, 1982,
(Date,
l /'
G..!i% Gv+ . , ..a, "`.
—/ Avs start Secretary.
■
i
NOTICE OF CANCELLATION OR NONRENEWAL
(Wisconsin)
KIND OF POLICY:
COMPREHENSIVE GENERAL LIABILITY
POLICY NO.:SMC 38 75 06/7 74 68 07
INSURANCE . WEST BEND MUTUAL INSURANCE COMPANY POLICY EFFECTIVE OR INCEPTION DATE:
COMPANY West Bend, WI FILED ' 11/22/82
CANCELLATION OR TERMINATION WILL TAKE EFFECT AT:
. 7/24/83 12: 01A.M.
(DATE) (HOUR—STANDARD TIMEI
NAME AND . R. Vii ayaraghaven & V J pit)oTlsLr gg�uC%ion DATE OF MAILING: 7/12/83 nbr '
ADDRESS . Corp. ISSUED THROUGH AGENCY OR OFFICE AT:
OF INSURED. 155 High Street CITY CLERK Babbitt-Sholund Insurance Agency
Oshkosh, WI 54901 OSHKOSH, WIS. Neenah, WI 48 044
and See Attached:
(Applicable item marked I)
CANCEL- You are hereby notified in accordance with the terms and conditions of the above mentioned policy, and in accordance with Wisconsin law, that your
LATION ❑insurance will cease at and from the hour and date mentioned above. _
For information concerning Premium Adjustment, if any, and Replacement Insurance, please refer to the "Premium Adjustment" and "Important Notices"
Sections below.
You are hereby notified in accordance with the terms and conditions of the above mentioned policy, and in accordance with Wisconsin law, that your
insurance will cease at and from the hour and date mentioned above due to nonpayment of premium.
Please refer to the "Premium Adjustment" Section below. Pro-rata
You are hereby notified in accordance with the terms and conditions of the above mentioned policy, and in accordance with Wisconsin law, that your •
insurance will cease at and from the hour and date mentioned above.
Wisconsin law provides that upon written request to.this Company this Company will furnish you in writing the facts on which the cancellation is based.
Such information will be mailed to you within 5 working days after receipt of your request.
For information concerning Premium Adjustment, if any, and Replacement Insurance, please refer to the "Premium Adjustment" and "Important Notices"
Sections below.
•
Premium Premium adjustment will be made as soon as practicable after can- ❑ Enclosed is $_ , being amount of return premium at
Adjustment: cellation becomes effective. pro rata rate for the unexpired term of this policy.
❑ A bill for the premium earned to the time of cancellation will be ❑ The excess of paid premium, if any, above the pro rata premium for
forwarded in due course. the expired time, (if not tendered) will be refunded upon demand.
❑ As the premium due has not been received by this Company for this ❑ Please return the policy to us with remittance of $
insurance, there is none to be returned. being the amount of earned premium for.time it has been in force
at date of cancellation.
NON- You are hereby notified in accordance with Wisconsin law that the above mentioned policy will expire effective at and from the hour and date mentioned
RENEWAL ❑above and the policy will NOT be renewed.
Wisconsin law provides that upon written request ton-this Company this Company will furnish you in writing the facts on which the nonrenewal is based.
Such information will be mailed to you within 5 working days after receipt of your request.
For information concerning Replacement Insurance, please refer to the "Important Notices" Section below.
❑Your policy is not being renewed as the Agency which issued the above mentioned policy no longer represents this Company. Under Wisconsin law,
however, you have the right to have your policy renewed by this Company for an additional period of time equivalent to the expiring term, not exceed-
ing one year, either by contacting us directly or through another agent licensed to represent us, provided the risk to be covered by the renewed policy
meets our current underwriting standards applicable to similar risks.
IMPORTANT Replacement Insurance Information: You have been notified herewith that this Company does not desire to carry your insurance any longer. If you wish
NOTICES to replace your policy you should make an effort to obtain insurance through another insurance company, however, if you are unable to procure replacement
coverage from another company you may be eligible for coverage under one of the following Plans.
Wisconsin Automobile Insurance Plan: If this notice pertains to the cancellation or nonrenewal of automobile insurance, you may be eligible for auto-
mobile bodily injury and property damage liability and/or automobile physical damage insurance under the Wisconsin Automobile Insurance Plan,
Jackson Building, 732 North Jackson Street, Milwaukee, Wisconsin 53202. .
Wisconsin Insurance Plan: If this notice pertains to the cancellation or nonrenewal of a policy providing basically fire and extended coverage ar
homeowners or crime insurance, you possibly may obtain fire and extended coverage or homeowners or crime insurance through the Wisconsin
Insurance Plan. You may make application to the Plan at 615 East Michigan Street, Milwaukee, Wisconsin 53202 (on and after July 1, 1983, the •
address is 744 North 4th Street, Milwaukee, Wisconsin 53203). •
Rejected Risk Plan: If this notice pertains to tle cancellation or nonrenewal of worker's compensation insurance, and you are in good faith entitled
to insurance under the Wisconsin Worker's Compensation Law, you may make application to the Wisconsin Compensation Rating Bureau for insurance
through the Rejected Risk Plan, Jackson Building, 732 North Jackson Street, Milwaukee, Wisconsin 53202.
Wisconsin Heath Care Liability Insurance Plan: If this notice pertains to the cancellation or nonrenewal of health care liability insurance, you may
be eligible for health care liability insurance under the Wisconsin Health Care Liability Insurance Plan, 2000 Westwood Drive, Wausau, Wisconsin
54401.
❑ Appeal to Automobile Insurance Plan Governing Committee: As your policy was one obtained through the Wisconsin Automobile Insurance Plan, you are
hereby advised, regarding the above notification of cancellation, that you have the right of appeal to the Governing Committee of the Plan, Jackson
Building, 732 North Jackson Street, Milwaukee, Wisconsin 53202.
•
❑ Consumer Report: In compliance with the Fair Credit Reporting Act (Public Law 91-508), you are hereby informed that the action taken above is being
taken wholly or partly because of information contained in a consumer report from the following consumer reporting agency:
(NAME)
(ADDRESS) arhod. X
•
GU 6639g(Ed.4-83) UNIFORM PRINTING a SUPPLY DIV. INSURED'$ COPY
Authorized Representative
1
•C _ _.
NOTICE OF CANCELLATION OR NONRENEWAL
(Wisconsin)
KIND OF POLICY:
WORKER'S COMPENSATION
POLICY NO.: SMC 38 75 06/5 77 19 97
INSURANCE . WEST BEND MUTUAL INSURANCE COMPANY POLICY EFFECTIVE OR INCEPTION DATE:
COMPANY West Bend, WI +I I E D 11/22/82
�` j CANCELLATION OR TERMINATION WILL TAKE EFFECT AT:
8/13/83 12:01A.M.
J lq�l� (DATE) (HOUR-STANDARD TIME)
NAMEAND . R. Vijayaraghaviun & -.T OnS rlul(Ctio . DATE OF MAILING: 7/12/83 nbr
ADDRESS Corp. ISSUED THROUGH AGENCY OR OFFICE AT:
OF INSURED . 155 High Street CITY CLERK Babbitt-Sholund Insurance Agency
Oshkosh, WI 54901 osHKOSH. WIS. Neenah, WI 48 044
And .See Attached:
(Applicable item marked El
CANCEL- You are hereby notified in accordance with the terms,and conditions of the above mentioned policy, and in accordance with Wisconsin law, that your
LATION ❑insurance will cease at and from the hour and date mentioned above.
For information concerning Premium Adjustment, if any, and Replacement Insurance, please refer to the "Premium Adjustment" and "Important Notices"
Sections below.
You are hereby notified in accordance with the terms and conditions of the above mentioned policy, and in accordance with Wisconsin law, that your
insurance will cease at and from the hour and date mentioned above due to nonpayment of premium.
Please refer to the "Premium Adjustment" Section below. Pro-rata
You are hereby notified in accordance with the terms and conditions of the above mentioned policy, and in accordance with Wisconsin law, that your •
❑insurance will cease at and from the hour and date mentioned above.
Wisconsin law provides that upon written request to this Company this Company will furnish you in writing the facts on which the cancellation is based.
Such information will be mailed to you within 5 wo>jicing days after receipt of your request.
For information concerning Premium Adjustment, if any, and Replacement Insurance, please refer to the "Premium Adjustment" and "Important Notices"
Sections below.
Premium Premium adjustment will be made as soon as practicable after can- ❑ Enclosed is $ , being amount of return premium at
Adjustment: cellation becomes effective. pro rata rate for the unexpired term of this policy.
❑ A bill for the premium earned to the time of cancellation will be ❑ The excess of paid premium, if any, above the pro rata premium for'
forwarded in due course. the expired time, (if not tendered) will be refunded upon demand.
❑ As the premium due has not been received by this Company for this ❑ Please return the policy to us with remittance of $
insurance, there is none to be returned. being the amount of earned premium for time it has been in force
at date of cancellation.
NON- You are hereby notified in accordance with Wisconsin law that the above mentioned policy will expire effective at and from the hour and date mentioned
RENEWAL ❑above and the policy will NOT be renewed.
Wisconsin law provides that upon written request to"this Company this Company will furnish you in writing the facts on which the nonrenewal is based.
Such information will be mailed to you within 5 working days after receipt of your request.
For information concerning Replacement Insurance, please refer to the "Important Notices" Section below.
❑Your policy is not being renewed as the Agency which issued the above mentioned policy no longer represents this Company. Under Wisconsin law,
however, you have the right to have your policy rentiwed by this Company for an additional period of time equivalent to the expiring term, not exceed-
ing one year, either by contacting us directly or through another agent licensed to represent us, provided the risk to be covered by the renewed policy
meets our current underwriting standards applicable to similar risks.
IMPORTANT Replacement Insurance Information: You have been notified herewith that this Company does not desire to carry your insurance any longer. If you wish
NOTICES to replace your policy you should make an effort to obtain insurance through another insurance company, however, if you are unable to procure replacement
coverage from another company you may be eligible for coverage under one of the following Plans.
Wisconsin Automobile Insurance Plan: If this notice pertains to the cancellation or nonrenewal of automobile insurance, you may be eligible for auto-
mobile bodily injury and property damage liability and/or automobile physical damage insurance under the Wisconsin Automobile Insurance Plan,
Jackson Building, 732 North Jackson Street, Milwaukee, Wisconsin 53202.
Wisconsin Insurance Plan: If this notice pertains to the cancellation or nonrenewal of a policy providing basically fire and extended coverage of •
homeowners or crime insurance, you possibly may obtain fire and extended coverage or homeowners or crime insurance through the Wisconsin
Insurance Plan. You may make application to the Plan at 615 East Michigan Street, Milwaukee, Wisconsin 53202 (on and after July 1, 1983, the
address is 744 North 4th Street, Milwaukee, Wisconsin 53203).
Rejected Risk Plan: If this notice pertains to the cancellation or nonrenewal of worker's compensation insurance, and you are in good faith entitled
to insurance under the Wisconsin Worker's Compensation Law, you may make application to the Wisconsin Compensation Rating Bureau for insurance
through the Rejected Risk Plan, Jackson Building, 732 North Jackson Street, Milwaukee, Wisconsin 53202.
Wisconsin Heath Care Liability Insurance Plan: If this notice pertains to the cancellation or nonrenewal of health care liability insurance, you may
be eligible for health care liability insurance under the Wisconsin Health Care Liability Insurance Plan, 2000 Westwood Drive, Wausau, Wisconsin
54401.
❑ Appeal to Automobile Insurance Plan Governing Committee: As your policy was one obtained through the Wisconsin Automobile Insurance Plan, you are
hereby advised, regarding the above notification of cancellation, that you have the right of appeal to the Governing Committee of the Plan, Jackson
Building, 732 North Jackson Street, Milwaukee, Wisconsin 53202.
❑
•
Consumer Report: In compliance with the Fair Credit Reporting Act (Public Law 91-508), you are hereby informed that the action taken above is being
taken wholly or partly because of information contained in a consumer report from the following consumer reporting agency:
(NAME)
(ADDRESS)
GU 6639g(Ed.4-83) UNIFORM PRINTING a SUPPLY DIY. INSURED'S COPY ______
Authorized Representative
T T
NOTICE OF CANCELLATION OR NONRENEWAL
(Wisconsin)
KIND OF POLICY:
UMBRELLA
POLICY NO.SIIC 38 75 06/7 75 86 15
INSURANCE . WEST BEND MUTUAL .INSURANCE COMP; 1 POLICY EFFECTIVE OR INCEPTION DATE: •
COMPANY West Bend, WI 11/22/82
?; IL CANCELLATION OR TERMINATION WILL TAKE EFFECT AT:
7/24/83 12: 01A.M.
(DATE) (HOUR-STANDARD TIME)
NAME AND U! i- i 1 I DATE OF MAILING: 7/12/83 nbr ••
R. Vijayaraghavan & V J nnstruction
ADDRESS . COrp. ISSUED THROUGH AGENCY OR OFFICE AT:
OF INSURED. 155 High Street CITY CLERK Babbitt-Sholund Insurance Agency
Oshkosh, WI 54901 OSHKOSH, WIS. Bab
•
and See Attached:
(Applicable item marked (II) ,
CANCEL- You are hereby notified in accordance with the terms..and conditions of the above mentioned policy, and in accordance with Wisconsin law, that your
LATION ❑insurance will cease at and from the hour and date mentioned above. —
For information concerning Premium Adjustment, if any, and Replacement Insurance, please refer to the "Premium Adjustment" and "Important Notices"
Sections below.
You are hereby notified in accordance with the terms and conditions of the above mentioned policy, and in accordance with Wisconsin law, that your
insurance will cease at and from the hour and date mentioned'above due to nonpayment of premium.
Please refer to the "Premium Adjustment" Section below. Pro-rata
You are hereby notified in accordance with the terms and conditions of the above mentioned policy, and in accordance with Wisconsin law, that your .
insurance will cease at and from the hour and date mentioned above.
Wisconsin law provides that upon written request to this Company this Company will furnish you in writing the facts on which the cancellation is based.
Such information will be mailed to you within 5 working days after receipt of your request.
For information concerning Premium Adjustment, if any, and Replacement Insurance, please refer to the "Premium Adjustment" and "Important Notices"
Sections below.
Premium Premium adjustment will be made as soon as practicable after can- ❑ Enclosed is $ , being amount of return premium at
Adjustment: cellation becomes effective. pro rata rate for the unexpired term of this policy.
❑ A bill for the premium earned to the time of cancellation will be ❑ The excess of paid premium, if any, above the pro rata premium for
forwarded in due course. the expired time, (if not tendered) will be refunded upon demand.
❑ As the premium due has not been received by this Company for this ❑ Please return the policy to us with remittance of $
insurance, there is none to be returned. being the amount of earned premium for time it has been in force
at date of cancellation.
NON- You are hereby notified in accordance with Wisconsin law that the above mentioned policy will expire effective at and from the hour and date mentioned
RENEWAL II above and the policy will NOT be renewed.
Wisconsin law provides that upon written request to this Company this Company will furnish you in writing the facts on which the nonrenewal is based.
Such information will be mailed to you within 5 working days after receipt of your request.
For information concerning Replacement Insurance, please refer to the "Important Notices" Section below.
❑Your policy is not being renewed as the Agency which issued the above mentioned policy no longer represents this Company. Under Wisconsin law,
however, you have the right to have your policy renbived by this Company for an additional period of time equivalent to the expiring term, not exceed-
ing one year, either by contacting us directly or through another agent licensed to represent us, provided the risk to be covered by the renewed policy
meets our current underwriting standards applicable to similar risks.
IMPORTANT Replacement Insurance Information: You have been notified herewith that this Company does not desire to carry your insurance any longer. If you wish
NOTICES to replace your policy you should make an effort to obtain insurance through another insurance company, however, if you are unable to procure replacement
coverage from another company you may be eligible for coverage under one of the following Plans.
Wisconsin Automobile Insurance Plan: If this notice pertains to the cancellation or nonrenewal of automobile insurance, you may be eligible for auto-
mobile bodily injury and property damage liability and/or automobile physical damage insurance under the Wisconsin Automobile Insurance Plan,.
Jackson Building, 732 North Jackson Street, Milwaukee, Wisconsin 53202.
Wisconsin Insurance Plan: If this notice pertains to the cancellation or nonrenewal of a policy providing basically fire insurance or crime or glass
insurance, you possibly may obtain FIRE AND ADDITIONAL PERILS insurance or CRIME OR GLASS insurance through the Wisconsin Insurance Plan.
You may make application to the Plan at 615 East Michigan Street, Milwaukee, Wisconsin 53202.
Rejected Risk Plan: If this notice pertains to the cancellation or nonrenewal of worker's compensation insurance, and you are in good faith entitled :
to insurance under the Wisconsin Worker's Compensation Law, you may make application to the Wisconsin Compensation Rating Bureau for insurance
through the Rejected Risk Plan, Jackson Buildinrpi 732 North Jackson Street, Milwaukee, Wisconsin 53202.
Wisconsin Heath Care Liability Insurance Plan: If this notice pertains to the cancellation or nonrenewal of health care liability insurance, you may
be eligible for health care liability insurance under the Wisconsin Health Care Liability Insurance Plan, 2000 Westwood Drive, Wausau, Wisconsin
54401.
❑ Appeal to Automobile Insurance Plan Governing Committee: As your policy was one obtained through the Wisconsin Automobile Insurance Plan, you are
hereby advised, regarding the above notification of cancellation, that you have the right of appeal to the Governing Committee of the Plan, Jackson
Building, 732 North Jackson Street, Milwaukee, Wisconsin 53202.
❑ Consumer Report: In compliance with the Fair Credit Reporting Act (Public Law 91-508), you are hereby informed that the action taken above is being
taken wholly or partly because of information contained in a consumer report from the following consumer reporting agency:
(NAME)
(ADDRESS> / ) i t
A-'
•
GU 6639f(Ed. 9-79) UNIFORM PRINTING &SUPPLY DIV. ' INSURED'S COPY -
Authorized Representative (lY
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