HomeMy WebLinkAboutAgreement, HVAC improvements at Electric/Sign & Transit 2016 7[11 CONTRACTOR AGREEMENT.•
HVA PROVEMENTS. ELECTRIC/SIGN SHOP OFFICES
c�; r aV��' � ,'_��tl-- -'TRANSIT FACILITY CITY OF OSHKOSH
THiS AGREEMENT, made on the 3RD day of May, 2016, by and between the
CITY OF OSHKOSH, party of the first part, hereinafter referred to as CITY, and
AUGUST WINTER & SONS, INC., 2323 N. ROEMER ROAD, APPLETON, WI 54911,
hereinafter referred to as the CONTRACTOR,
WITNESSETH:
That the City and the Contractor, for the consideration hereinafter named, enter
into the following agreement. The Contractor'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 shall assign the following
individual to manage the project described in this contract:
(Tom Vander Heyden, Project Manager, August Winter & Sons Inc.)
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 If. CITY REPRESENTATIVE
The City shall assign the following individual to manage the project described in this
contract:
(,Jon Urben, General Services Manager)
ARTICLE Ill. SCOPE OF WORK
The Contractor shall provide the services described in their proposal attached as
Exhibit A. If anything in the Bid Form conflicts with the Bid Specifications, the
provisions in the Bid Specifications shall govern,
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The Contractor may provide additional products and/or services if such
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products/services are requested in writing by the Authorized Representative of the
City.
ARTICLE IV. CITY RESPONSIBLITIES
The City shall furnish, at the Contractor's request, such information as is needed
by the Contractor 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 work the City will
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 completed by no later
than June 30, 2016.
ARTICLE Ili. PAYMENT
A. The Contract Sum,
The City shall pay to the Contractor for the performance of the contract the sum of
$14,975.00, 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 shall submit itemized monthly
statements for services. The City shall pay the Contractor 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 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
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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 shall provide insurance for this project that includes the City of
Oshkosh as an additional insured. The contractor's certificate of insurance for this
project is attached as Exhibit B.
ARTICLE VI. TERMINATION
A. For Cause.
If the Contractor 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, In this event, the Contractor shall be entitled to
compensation for any satisfactory, usable work completed.
B. For Convenience,
The City may terminate this contract at any time by giving written notice to the
Contractor no later than 10 calendar days before the termination date. If the City
terminates under this paragraph, then the Contractor 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.
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In the Presence of: CONTRACTOR XONSULTANT
{Seal of,Contractor (Specify Title)
if a Corporation.)
By:
(Specify Title)
CITY OF OSHKOSH
BY:
' f Mark A. Rohloff, City Manager
( fitness)
And L�:L
(Witness) Pamela R. Ubrig, City Clerk
APPROVED: I hereby certify that the necess-
ary provisions have been made to
pay the liability which will accrue
/f under this contract.
City Atto ney
A(iA-D
✓'�
City Camp roller
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QUOTATION PROPOSAL
HVAC iMPROVEMENTS
ELECTRICISIGN SHOP OI=FICE$
CITY OF OSHKOSH
Paga 'I of 7
y
QUOTATION DEADLINE IS 70:00 AM, TUESDAY, APRIL 79, 2076
From;, August winter&Sons,Inc. (bidder's company name)
We, the undersigned, propose to furnish all labor, materials and installation per the
project specifications and drawings, Any area of the proposal page left blank may be
consideredras a non-responsive bid.
Base Quote:
Powrtego lhousand,,kliine Hundrg Seventy-Five Vollars $„ 14.9.7 tOa .__
(Base Quote Price— In Words)
Date Submitted: 4/19/2016
Name cf Com palty,lt August Winter&Sons,Inc.
Submitted by: (name and titlo). Tom'Vander Heyden -Project Manager
Email address: , Iheyden@augustwintejr,covi
n'L ..... •41,1•- .' -4� --- irr Ifi,Lq i'1. ..ri.r eu�.�
Address of Compafty;=2323 N._Roemer Road,Ap_pleton,-WJ 5,911
Phone:— {9z0)739-8681
Addendum Acknowledgement
We hereby acknowledge receipt of and have thoroughly examined the written
Addenda(s) issued prior to the bid date In association with this project. These Addenda
are numbered _ 1 through ,,,T,L., Incivalve. We further understand that
failure to fully list the nurribers of all published Addenda may cause the City to reject thls
bld. If no addenda were issued for this project simply enter"NIA" above.
Proposed Subcontractor List
Electrical; 13y City Electricians
Mechanical; , . Ay ust Winter&Sons, Inc,
Insulator., August Winter&Sons, Inc, .
Other; .
Delivery and Install in 30-600 days after receipt of order
Payment terms Net 30 =
AUGUWIN-01 RAJAGOPALADE
CERTIFICATE OF LIABILITY INSURANCE DAT6121201
Y'''
s�2><2o1s
FNashville,
CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
OW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
ORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(los)must be endorsed. If SUBROGATION IS WAIVED,subject to
forms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to file
ificate holder In lieu of such endorsement(s).
ER CDNTACF
f Minnesota Inc. NAME: Willis Towers Watson Certificate Center
PRONE
Century Blvr) A/C No Exf•(877)945-7378 Ne: (868}467-2378
x 30N 37 Ao RIESS:Certificates@willls.comlle,TN 37230-5191INSURER'S)AFFORDING COVERAGE tJAiCwsuRERA;Phoenix Insurance Company 2562INsuRERR:Travelers Indemnity Company 25658
August Winter&Sons,Inc. INSURERC:Travelers Indemnity Company of America 26666
Attn. Sharon Bons
P 0 BOX 1896 INSURER D;
Appleton,WI 54912-1896 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. NOTVyiTHSTAND)NG 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 1S SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
[NSR B POLICYEFF POLICYEXP
LTR TYPAL GENERAL LIE INSD WVD POLICYNUMBER MMIDD MMIDD LIMITS
A X COMMERCIAL GENERAL LIABELfTY
EACH OCCURRENCE $ 2,000,000
CLAIMS-MADE a OCCUR X X DT-00-6934C377-PI-IX-16 10101/2015 10/01/2016 PREMISES Eaoceurrence $ 300,00X Contractual Llab. MED EXP(Any one Person) $ 10,000
PERSONAL&ADV INJURY $ 2,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 4,000,000
POLICYJE C LOC
PRODUCTS-COMP[OPAGO $ 4,000,000
OTHER:
$
AUTOMOBILE LIABILITY C0418INED SINGLE LIMIT
B X Eaacad $ 1,000,000
ANYAUTO X X DT-810-323D2093-IND-15 10/0112015 10/01/2016 BODILY INJURY(Perperson) s
ALL OWNED SCHEDULED
AUTOS AUTOS BODILYINJURY(Per acddenl) $
X HIREDAUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS Perse ddanl $
X UMBRELLA LIAB X $
OCCUR EACH OCCURRENCE $ 20,000,00
B EXCESS LIAR CLA M5:gADE X X DTSM-CUP-6934C377-IND-15 10/01/2015 10101/2016 AGGREGATE $ 20,000,000
DED X RETENTION$ 10,000 $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YtN X PER
ER
C ANPICRER1M IETORPARTNERAEEXCLUDEDECUTIVE NIA X DTD-TBH-US-6934C37-7-15 10101/2015 10/01/2016 E.L.EACH ACCIDENT $ 100,000
(Mandatory d fn and E.L.DISEASE-PA EMPLOYE
Ifyes,describeunder $ 100,00
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,00
A Workers Compensation DTN-UB-558OL00-2-15 10/0112015 10/01/2016 See Attached
DESCRIPTION OF OPERATIONS[LOCATIONS!VEHICLES (ACORD let,Additional Remarks Schedule,maybe attached If more space Is requlredi
Original Issue Date:05-2016.
Project:City of Oshkosh-HVAC Improvements Electric Sign Shop Offices.
City of Oshkosh,and its officers,council members,agents,employees and authorized volunteers shall be named as Additional Insureds under the
Commercial General Liability Policy(on a Primary and Non-Contributory basis),the Automobile Liability Policy and Excess Liability Policy for acts caused by
AWS In the performance of thefrwork to which the written signed contract requiring Insurance applies.Described Additional Insured(Contractors)
endorsement 4CGT815 attached(equivalent of CG 2010 07-04 and CG 2037 07-04).
SEE ATTACHED ACORD 101
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Oshkosh
Attn.City Clerk AUTHORIZED REPRESENTATIVE
215 Church Avenue
P 0 Box 1130 � f�
Oshkosh Wi54903-1130
O 1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:AUGUWIN-01 RAJAGOPALADE
LOC#: 1
ACORLY
�1 � ADDITIONAL REMARKS SCHEDULE Page 1 of 1
rAGENCYNAMED INSl1REe
of Minnesota,Inc. August Winter&Sons,Ino.
NUMBER Attn: Sharon Bons
AGE1 P 0 Box 1696
Appleton,WI$4912-1896
RNAIC CODEAGE 1 ISEE P 1 EFFEcrive Dare:SEE PAGE 1
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER, ACORD 2s FORM TITLE: Certificate of Liabflfty insurance
Description of Operations/LocationsNehicies:
Waiver of Subrogation In favor of the additional insureds applies to the Comm'[General Liability,Automobile Liability,Umbrella
Liability,and Workers Compensation policies to the extent required by written signed contract.
30 day notice of cancellation to the certificate holder per attached form.
ACORD 101 (2008101) 02008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ADDITIONAL COVERAGE SCHEDULE
COVERAGE LIMITS
POLICY TYPE: Workers Compensation and Employers Liability WC—Per Statute
CARRIER: Phoenix Insurance Company E.L. Each Accident: $100,000
POLICY TERM: 10/1/2016--10/1/2016 E.L. Disease- policy limit: $500,000
POLICY NUMBER: DTN-UB-5580L00-2.15 E.L. Disease Each Employee: $100,000
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POLICY NUMBER: DT-CO-6934C377-PH7{- COMMERCIAL GENERAL LIABILITYGENERAL PURPOSE ENDORSEMENT
THIS MMORMWENT CEM098 THE POLICY, PLEASE READ IT CAREFULLY
DESCRIBED ADDITIONAL INSURED
(CONTRACTORS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1, WHO IS AN INSURED - (Section II) is amended to include any person or
organization that you agree in a "written contract requiring insurance■ to
include as an additional insured on this Coverage Part, but only if
the "written contract requiring insurance";
a) Specifically requires you to provide additional insured coverage to
that person or organization for the sole negligence or independent acts
or omissions of that person or organization; or
b) Specifically requires you to provide additional insured coverage to
that person or organization by the use of:
.i. The Additional Insured,- owners, Lessees or Contractors - (Form B)
endorsement C¢ 2010 11 85; or
ii, The Additional Insured - Owners, Lessees or Contractors - Scheduled
Person Or Organization endorsement CG 2010 10 01 and the Additional
Insured - Owners, Lessees or Contractors - Completed Operations
endorsement Co 20 37 10 01.
However, the person or organization is only an additional insured:
a) With respect to liability for "bodily injuryn, "property damagell
or "personal injury", and
b) If the injury or damage axises out of "your work" to which the "written
contract requiring insurancell applies.
2. The insurance provided to the additional insured by this endorsement is
limited as follows;
a) In the event that the Limits of Insurance of this Coverage Part shown
in the Declarations exceed the limits of liability required by
the "written contract requiring Insurance", the insurance provided to
the additional insured shall be limited to the limits of liability
required by that "written contract requiring insurance". This
endorsement shall not increase the limits of insurance described in
Section III - Limits of Insurance,
b) The insurance provided to the additional insured does not apply
to "bodily injury°, "property damage" or ■personal injury" arising out
of the rendering of, or failure to render, any professional
architectural, engineering or surveying services, including:
CG T8 15
Page 1 j
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COMMERCIAL GENERAL LIABILITY 1'
POLICY NUMBER: nT-c0-6934C377-PHX GENERAL PURPOSE ENDORSEMENT
i. The preparing, approving, or failing to prepare or approve, maps,
shop drawings, opinions, reports, surveys, field orders or change
orders, or the preparing, approving, or failing to prepare or
approve, drawings and specifications; and
ii. Supervisory, inspection, architectural or engineering activities.
c) The insurance provided to the additional insured does not apply to
"bodily injury" or "property damage" caused by "your work" and included
in the "products-completed operations hazard" unless the "written
contract requiring insurance" specifically requires you to provide such
coverage for that additional insured, and then the insurance provided to
the additional insured applies only to such "bodily injury" or "property
damage" that occurs before the end of the period of time for which the
"written contract requiring insurance" requires you to provide such
coverage or the end of the policy period, whichever is earlier.
3. The insurance provided to the additional insured by this endorsement is
excess over any valid and collectible other insurance, whether primary,
excess, contingent or on any other basis, that is available to the
additional insured for a loss we cover under this endorsement. However,
if the "written contract requiring insurance" specifically requires that
this insurance apply on a primary basis or a primary and non-contributory
basis, this insurance is primary to other insurance available to the
additional insured which covers that person or organization as a named
insured for such loss, and we will not share with that other insurance.
But the insurance provided to the additional insured by this endorsement
still is excess over any valid and collectable other insurance, whether
primary, excess, contingent or on any other basis, that is available to
the additional insured when that person or organization is an additional
insured under such other insurance.
4. As a condition of coverage provided to the additional insured by this
endorsement:
a) The additional insured must give us written notice as soon as
practicable of an "occurrence" or an offense which may. result in a
claim. To the extent possible, such notice should include:
I. How, when and where the "occurrence" or offense took place;
ii. The names and addresses of any injured persons and witnesses; and
iii. The nature and location of any injury or damage arising out of
the "occurrenceK or offense.
b) If a claim is made or "suit" is brought against the additional insured,
the additional insured must:
I. Immediately record the specifics of the claim or "suit" and the
date received; and
ii. Notify us as soon as practicable.
CG T815 Page 2
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POLICY NUMBER: DT-Co-59340377-P8X- COMMERCIAL GENERAL LIABILITY
GENERAL PURPOSE ENDORSEMENT
The additional insured must see to it that we receive written notice of
the claim or "suit" as soon as practicable.
c) The additional insured must immediately send us copies of all legal
papers received in connection with the claim or "suit', cooperate with
us in the investigation or settlement of the claim or defense against
the "suit", and othemise comply with all policy conditions,
d) The additional insured must tender the defense and indemnity of any
claim or "suit" to any provider of other insurance which would cover the
additional insured for a loss we cover under this endorsement. However,
this condition does not affect whether the insurance provided to the
additional insured by this endorsement is primary to other insurance
available to the additional insured which covers that person or
organization as a named insured as described in paragraph 3. above.
5. The following definition is added to SECTION V. - DEFINITIONS: {
"Written contract requiring insurance" means that part of any written
contract or agreement under which you are required to include a person or
organization as an additional insured on this Coverage Part, provided that
the "bodily injury" and "property damaged occurs and the "personal injury"
is caused by an offense committed..-
a. After the execution of the contract or agreement by you,
b. While that part of the contract or agreement is in effect; and
c. Before the end of the policy period.
CG T8 15 Page 3
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POLICY NUMBER:DT-CO-69340377-PHX•
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
DESIGNATED ENTITY- NOTICE OF
CANCELLATION/NONRENEWAL PROVIDED BY US
This endorsement modifies insurance provided under the following: �
ALL COVERAGE PARTS INCLUDED IN THIS POLICY
i
SCHE[7ULE
CANCELLATION: Number of days Notice of Cancellation: 31)
NONRENEWAL: Number of bays Notice of Nonrenewal:
PERSON OR
ORGANIZATION:
ANY PERSON OR ORGANIZATION TO WHOM YOU HAVE AGREED X21 A WRITTEN
CONTRACT THAT NOTICM OF CANCELLATION OR MATERIAL LIMITATIONS Or THIS
POLICY WILL BE GIVEN, $IIT ONLY IFt:
S.. YOU SEND IIS A WRITTEN REQUEST TO PROVIDE SUCa IzoTrCL, INCLUDING
THX NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFXRR THF;
FIRST NAMED INSURED RECEIVES NOTICE FRom IIS OF TaR CANCELTIO x1 OR
14ATERIAL LIKITATION OF THIS POLICY: AND
2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE
BEGINNI21Ox Oi+ THE APPLICABLE WMU MER OF DAYS SHOWN IN THIS SCHEDULE.
ADDRESS:
THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN SUCH WRITTEN
REQUEST FROM YOU TO US.
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PROVISIONS:
A. If we cancel this policy for any statutorily permit_ S. If we decide to not renew this policy for any statu-
ted reason other than nonpayment of premium, torily permitted reason, and a number of days €R
and a number of days is shown for cancellation in shown for nonrenewal in the schedule above, we
the schedule above,we will mail notice of cancel- will mail notice of the nonrenevral to the person or
latlon to the person or organization shown In the organization shown in the schedule above. We
schedule above. We will mall such notice to the wil€mai€ such notice to the address shown In the
address shown in the schedule above at least the schedule above at least the number of days
number of days shown for cancellation In the shown for nonrenevial In the schedule above be-
schedule above before the effective date of can- fore the expiration date,
cei€ation.
IL T4 00 12 09 0 2009 7ha Travelers Indemnity company Page 9 of 1
POLICY NUMBER:DT-810-323D2093-TIE,
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
DESIGNATED ENTITY NOTICE OF '
CANCELLATIGNINONRENEWAL PROVIDED BY US
This endorsement modifies insurance provided under he following:
ALL COVERAGE PARTS INCLUDED IN THIS POLICY
SCH- ---EDIJLE
CANCELLATION: Number of bays Notice of Cancellation: 30
NONRENEWAL: Number of Days Notice of Nonrenewal:
PERSON OR
ORGANIZATION:
°ANY PERSON OR ORGANIZATION TO tVHO)4 YOU
HAVI4 AGREED IN A WRITTEN CONTRACT THAT
NOTICE OF CANCELLATXON OR MATF,RIAL
LINITATIONs Oy THIS POLICY WXLL lig
GIVEN, BUT ONLY IFr:
3.. YOU SEND US A WRITTEN REQUEST TO
PROV'X:DE SUCH NOTICE, INCLUDING THE NAME
AND ADDRBSS OF SUCfi PERSON OR
ORGANXZATXON, AFTER TSE FIRST NAMED
IN'SUREt) REC191VES NOTICE FROM US OF TRg
CANCELLATION OR MATERIAL LIMITATION OF
THIS POLICY, AND 2. WE kECBTVE SUCH
WRITTEN REQUEST AT LEAST 14 DAY'S BEFORJE
THE DEGYNNING OF THE APPLICABL8 NDMrsER
OF DAYS BROWN IN THIS SCHEJ)ULE.
ADDRESS:
THM ADD$ESS FOR T)iAT 13RRSON OR
ORGANIZATION INCLUDED IN SUCH WRITTEN
REQUEST FROM YOU To us."
PROVISIONS.
A. If we cancel his policy for any statutorily permit- B. If vie decide to not renew this policy for any statu-
ted reason other than nonpayment of premium, torily permitted reason, and a number of days Is
and a number of days is shown for cancellation in shown for nonrenewal in the schedule above,we
the schedule above, we will mail notice of cancel-
will mail notice of the nonrenewal to the person or
Iafiori to the person or urganixatlon shown in the
above. We
schedule above. We will mail such notice to the will mail such notice anization shown lta he addressn theeshown in he
address shown in the schedule above at least the schedule above at least he number of days
number of days shown for cancellation in the shown for nonrenewal In the schedule above be-
schedule above before the effective date of can- fore the expiration date.
cellation,
IL T4 00 12 09 X2009 The Travelers Indemnity Company
Page f of i
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AMk
TRAVELERS J WORKERS COMPENSATION
ONg xOAER SQUARE AND
IraRTRORi3, CT 0€193 EMPLOYERS LIA131LITY POLICY
ENE)0RSEMENT WC 93 OS 11 (A)
NOTICE OF CAN ELLATION
Except for non-payment of premium:by you,We agree that n cancellation or limitation of#his policy shall become
elfec6ve until the number of day's written notice specified In em 2 of the Schedule has been mailed to you and to
the person or organization designated in item 1 of the Sched de at the address indicated.
SCHEDU E
1. !Name. ANY PERSON OR ORGANIZATION TO WHOM U HAVE AC
RERD IN A WRITTEN
CONTRACT THAT NOTICE Or CANCELLATIO OR MATERIAL LIMITATIONS
OF THIS POLICY WILL BE GIVSi , BUT, ON Y Ill:
1. YOU SEND US A WRITTEN REQUEST TO ROVIDE SUCH NOTICE,
INCLUDING THE NAM13AND ADDREPS OF. SU PERSON OR ORGANIZATION,
AFTER THE FIRST NAMED INSURED RECEZ 8 NOTICE PROM Us OF TH,S
CANCELLATION 012 MATERIAL LIMITATION F THIS P07,TCy1 AND
2. WS RECI3IV>3 SUCH x'1RETTEN REQUEST A LEAST 14 DAYS 1313I.0RE THE
i3EQ1NNXXG OF THE: APPLIC"LV EMBER 0 DAYS SaOWN IN THIS
SCHEDULE.
i
Address: THE ADDRESS FOP, THAT P13RSO OR OR G 17-AT-TON INCLUDED IN SUCH
WRITTEN REQUEST FROM YOU TO US.
2. Number of Days Written Notice: 30 Additional[Says
This endorsement changes the policy to tivh
stated. lch It Is attached nd is effective on the date Issued unless otherwise
(The information below is required only when hem
ant endor
the policy.) Qent is issued subsequent to preparation of
Endorsement Effective Policy No
Insured Endorsement No,
Insurance Company Prernlum$
countersign d by
ST ASSIGN;
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