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HomeMy WebLinkAboutFabick Cat Generator Maintenance Wastewater Treatment 2019 5N/ ' 4 ORIGINAL ciry ►3 o Oshkosh CONTRACTOR AGREEMENT: ANNUAL MAINTENANCE AGREEMENT—GENERATORS—WASTEWATER TREATMENT CITY OF OSHKOSH THIS AGREEMENT, made on the 15th day of APRIL, 2019, by and between the CITY OF OSHKOSH, party of the first part, hereinafter referred to as CITY, and FABICK CAT, PO BOX 19976, GREEN BAY WI 54307-9176 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. COMPONENT PARTS OF THE CON 1RACT 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. Proposal Solicitation 3. Contractor's Proposal 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. ARTICLE II. PROJECT MANAGER A. Assignment of Project Manager. The Contractor shall assign the following individual to manage the project described in this contract: (MATT MAYER, FABICK CAT, PRODUCT SUPPORT REPRESENTATIVE) 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. City Hall,215 Church Avenue P.O.Box 1 130 Oshkosh,WI 54903-1130 http://www.ci.oshkosh.wi.us ARTICLE III. CITY REPRESENTATIVE The City shall assign the following individual to manage the project described in this contract: (SHANE LEHR,WASTEWATER TREATMENT PLANT,WASTEWATER SUPERVISOR) ARTICLE IV. SCOPE OF WORK The Contractor shall provide the services described in the City's (INVITATION FOR BID OR REQUEST FOR QUOTATION) for the Project titled "PROJECT TITLE" dated MONTH, DATE, YEAR, and the contractor's bid form and materials attached as Exhibit A. If anything in the Bid Form conflicts with the Bid Specifications, the provisions in the Bid Specifications shall govern. The Contractor may provide additional products and/or services if such products/services are requested in writing by the Authorized Representative of the City. ARTICLE V. 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 VI. TIME OF COMPLETION The work to be performed under this contract shall be completed by no later than DECEMBER 31,2019 OR: The work to be performed under this contract shall be completed within XX days of the purchase order issued for this project. Any changes to this completion date must be agreed upon by both parties in writing. ARTICLE VII. PAYMENT A. The Contract Sum. The City shall pay to the Contractor for the performance of the contract the sum of$6,470.67 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 VIII. CONTRACTOR TO HOLD CITY HARMLESS The Contractor covenants and agrees to protect and hold the City of Oshkosh harmless against all actions, claims and demands of any kind or character whatsoever which may in any way be caused by or result from the intentional or negligent acts of the Contractor,his agents or assigns,his employees or his subcontractors related however remotely to the performance of this Contract or be caused or result from any violation of any law or administrative regulation, and shall indemnify or refund to the City all sums including court costs, attorney fees and punitive damages which the City may be obliged or ad- judged 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 IX. 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 X. 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. In the Presence of: CON TRACTOR/CONSULTANT By: ?0d4.0f- 54e,f - gee. (Seal of Contractor (Specify Title) if a Corporation.) By: 01.?/___Ca3,,44^- ev/v:t-to Gtv' i (Specify Title) CITY OF OSHKOSH "4-4) By: —/ l�1 — Mark A.Rohloff, City Manager ( fitness) And ( i ess) Pamela R. Ubrig, City Clerk APPROVED: I hereby certify that the necess- ary provisions have been made to pay the liability which will accrue under this contract. orney AVQ,ACN-) City Comptroller FABiCK CST Customer: Oshkosh Waste Water Utility Date: 4/9/2019 Address: 233 N.Campbell Rd. Quote: MJM19042-1 State/Zip: Oshkosh,WI 54L56 Quotation Valid Until: 519/2019 Attn: Shane Lehr SUBJECT: CUSTOMER SUPPORT AGREEMENT(CSA) Thank you for the opportunity to introduce Fabick Power Systems, Power Protection Plan(PPP). Fabick's Power Protection Pla i is a preventative maintenance and inspection program custom designed to help reduce generator operating costs, prolong component life and increase the overall reliability of your equipment. Total cost of all services (taxes not included): $6,470.67 This quote is for a 12 month maintenance agreement on the generator(s) discussed: Unit A: Caterpillar 600k\V Model: C18 Serial: STD00207 Broad Unit B: Waukesha 180ky V Model:P309362 Serial:92898 S Main Unit C: Caterpillar 400kW Model:C15 Serial: C5E03239 Bowen Unit D: Cummins 150kVy Model:GTA8.3G2 Serial: 46133418 2350 Bowen Unit G: Onan 60kW Model:GGHE-5001705 Serial: 1010285563 28th st Unit H: Onan 40kW Mo el:GGPB-1212363 Serial:1120394425 Lake Point Unit 1: Olympian 150kW Model: G15OLG6 Serial: GXG04377 Snell Unit J: Olympian 150kW Model G150 Mary Jewel Fabick Power Systems will perform the following: Level 1 -Inspection: A 58 point inspection/test checking the engine,generator,transfer switches,day tank, batteries,battery charger,engine block heaters,control panel,gauges and meters.On-site coolant test is performed.An oil sample is taken and sent to our lab for analysis,and reports with the results will be provided to you along with a copy of the inspection report.You will be provided with recommendations of any corrective measures necessary,either immediately if repair is urgent,or in a quote form shortly after completion of inspection. Level 2-Service: This incorporates all of the components of a Level 1 Inspection in addition to replacement of the engine oil,oil,Ilfuel&coolant filters as applicable.A coolant sample is taken and sent in to Caterpillar for a level 2 analy is.All old fluids and filters removed for this service will be taken back to our facility to be disposed of prop rly, leaving your generator area environmentally clean. Services Performed: Units: (1)Level 1 Inspection with oil sarrtple (7)Level 2 Services and Inspections with oil and coolant samples A-I (1)Change Check Valves on Fuel System A $734.26 F.4BICK. CAT- Customer: Oshkosh Wast- Water Utility Date: 4/9/2019 Address: 233 N.Campbe I Rd. Quote: MJM19042-1 State/Zip Oshkosh,WI 5 956 Quotation Valid Until: 5/9/2019 ATTN: Shane Lehr SUBJECT: CUSTOMER SUPPORT AGREEMENT(CSA) Thank you again for the oppoqunity to supply a quote to you on our Power Protection Program . If you have any questions please do not hesitate to call.We welcome the opportunity to address any questions or concerns yoill may have. Upon acceptance of this agreement please sign, date, and return a copy to me. Company: Oshkosh Waste Water Utility Acceptance Date: Signed By: (Authorized Signature) Purchase Order No: Respectfully Submitted, - Matt Mayer Fabick Power Systems Product Support Representative Commercial Engines Office- (920)498-8000 Ext. 6079 Fax- (920)499-0890 Cell- (920)370-8348 E-Mail - matthew.mayer(a)fabickcat.com After Hours Emergency Service 1-800-646-8802 Web Site-www.fabickcat.com • ATE ACRCP CERTIFICATE OF LIABILITY INSURANCE D05/01/2019DmYY) O • 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 have ADDITIONAL INSURED provisions or 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 PHON: Marsh USA Inc. FAX PHONE One Towne Square,Suite 1100 (A/C.No.Extl: (A/C,No): Southfield,MI 48076 EMAIL Attn:DetroitGroupCaptive.CertRequest@marsh.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN102670506-STND-JFTCO-19-20 01 INSURER A:National Union Fire Ins Co Pittsburgh PA 19445 INSURED INSURER B:Insurance Company State Of Pennsylvania 19429 JFTCO,Inc. aka Fabick Cat,Fabick Rents and Fabick Power Systems INSURER C: 11200 W Silver Spring Rd INSURER D: Milwaukee,WI 53225 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CHI-008963313-27 REVISION NUMBER: 4 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 ADOL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD(YYYY) (MM/DD(YYYY) A X COMMERCIAL GENERAL LIABILITY GL5180090 03/01/2019 03/01/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREMISESG(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 25,000 PERSONAL S ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ $ OTHER: COMBINED SINGLE LIMIT A AUTOMOBILE LIABILITY CA2961522 03/01/2019 03/01/2020 (Ea accident) $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS x HIRED x NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WC080756215 03/01/2019 03/01/2020 x PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N Does not apply to Monopolistic 1,000,000 ANYPROPRIETORWARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? I i N f A and [ND, OH,WA, 1,000,000 (Mandatory in NH) States �, E.L.DISEASE-EA EMPLOYEE $ If yes,describe under Puerto Rico,or the Virgin Islands 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS(LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Oshkosh is/are included as additional insured for general liability and auto liability as required by written contract or written agreement,per policy terms and conditions. CERTIFICATE HOLDER CANCELLATION City of Oshkosh SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 215 Church Avenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 1130 ACCORDANCE WITH THE POLICY PROVISIONS. Oshkosh,WI 54903 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. John C Hurley ---e---s:— I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT This endorsement, effective 12:01 A.M. 03/01/2019 forms a part of Policy No.CA 296- 15-22 issued to JOHN FAB I CK TRACTOR COMPANY by NATIONAL UNION FIRE INSURANCE COMPANY OF P I TTSBURGH, PA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - WHERE REQUIRED UNDER CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE ADDITIONAL INSURED: ANY PERSON OR ORGANIZATION FOR WHOM YOU ARE CONTRACTUALLY BOUND TO PROVIDE ADDITIONAL INSURED STATUS BUT ONLY TO THE EXTENT OF SUCH PERSON OR ORGANIZATIONS LIABILITY ARISING OUT OF THE USE OF A COVERED "AUTO" . I. SECTION II - COVERED AUTOS LIABILITY COVERAGE, A. Coverage, 1. - Who Is Insured, is amended to add: d. Any person or organization, shown in the schedule above, to whom you become obligated to include as an additional insured under this policy, as a result of any contract or agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy, but only with respect to liability arising out of use of a covered "auto". However, the insurance provided will not exceed the lesser of: (1) The coverage and/or limits of this policy, or (2) The coverage and/or limits required by said contract or agreement. f,! AUTHORIZED REPRESENTATIVE 87950 (9/14) Includes copyrighted information of Insurance Services Office, Inc., Page 1 of 1 with its permission. ENDORSEMENT # This endorsement, effective 12:01 A.M. 03/01/2019 forms a part of Policy No.CA 296- 15-22 issued to JOHN FAB I CK TRACTOR COMPANY By NATIONAL UNION FIRE INSURANCE COMPANY OF P I TTSBURGH, PA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITED ADVICE OF CANCELLATION PROVIDED VIA E-MAIL TO ENTITIES OTHER THAN THE FIRST NAMED INSURED This policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non-payment of premium, and 1. the cancellation effective date is prior to this policy's expiration date; 2. the First Named Insured is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the "Certificate Holder(s)") and has provided to the Insurer, either directly or through its broker of record, the email address of a contact at each such entity; and 3. the Insurer received this information after the First Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that is acceptable to the Insurer, the Insurer will provide advice of cancellation (the "Advice") via e-mail to each such Certificate Holders within 30 days after the First Named Insured provides such information to the Insurer; provided, however, that if a specific number of days is not stated above, then the Advice will be provided to such Certificate Holder(s) as soon as reasonably practicable after the First Named Insured provides such information to the Insurer. Proof of the Insurer emailing the Advice, using the information provided by the First Named Insured, will serve as proof that theinsurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided under this policy or the cancellation of this policy or the effective date thereof,nor shall this endorsement invest any rights in any entity not insured under this policy. The following Definitions apply to this endorsement: 1. First Named Insured means the Named Insured shown on the Declarations Page of this policy. 2. Insurer means the insurance company shown in the header on the Declarations page of this policy. All other terms, conditions and exclusions shall remain the same. Authorized Representative 107414 (03/11) Page 1 POLICY NUMBER: GL 518-00-90 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations ANY PERSON OR ORGANIZATION WHOM YOU PER THE WRITTEN CONTRACT OR AGREEMENT. BECOME OBLIGATED TO INCLUDE AS AN ADDITIONAL INSURED AS A RESULT OF ANY WRITTEN CONTRACT OR AGREEMENT YOU HAVE ENTERED INTO. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to that which you are required by the contract include as an additional insured the person(s) or or agreement to provide for such additional organization(s) shown in the Schedule, but only insured. with respect to liability for "bodily injury", B. With respect to the insurance afforded to these "property damage" or "personal and advertising additional insureds, the following additional injury" caused, in whole or in part, by: exclusions apply: 1. Your acts or omissions; or This insurance does not apply to "bodily injury" 2. The acts or omissions of those acting on or "property damage" occurring after: your behalf; 1. All work, including materials, parts or in the performance of your ongoing operations equipment furnished in connection with such for the additional insured(s) at the location(s) work, on the project (other than service, designated above. maintenance or repairs) to be performed by or on behalf of the additional insured(s) at However: the location of the covered operations has 1. The insurance afforded to such additional been completed; or insured only applies to the extent permitted 2. That portion of "your work" out of which by law; and the injury or damage arises has been put to 2. If coverage provided to the additional its intended use by any person or insured is required by a contract or organization other than another contractor or agreement, the insurance afforded to such subcontractor engaged in performing additional insured will not be broader than operations for a principal as a part of the same project. CG 20 10 04 13 ) Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III - Limits Of Insurance: whichever is less. If coverage provided to the additional insured is required by a contract or agreement, the most This endorsement shall not increase the we will pay on behalf of the additional insured applicable Limits of Insurance shown in the is the amount of insurance: Declarations. 1. Required by the contract or agreement; or Page 2 of 2 Insurance Services Office, Inc., 2012 CG 20 10 0413 POLICY NUMBER: GL 518-00-90 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Operations Or Organization(s) ANY PERSON OR ORGANIZATION WHOM PER THE WRITTEN CONTRACT OR YOU BECOME OBLIGATED TO INCLUDE AS AGREEMENT. AN ADDITIONAL INSURED AS A RESULT OF ANY WRITTEN CONTRACT OR AGREEMENT YOU HAVE ENTERED INTO. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to which you are required by the contract or include as an additional insured the person(s) or agreement to provide for such additional organization(s) shown in the Schedule, but only insured. with respect to liability for "bodily injury" or B. With respect to the insurance afforded to these "property damage" caused, in whole or in part, additional insureds, the following is added to by "your work" at the location designated and Section III - Limits Of Insurance: described in the Schedule of this endorsement If coverage provided to the additional insured is performed for that additional insured and required by a contract or agreement, the most included in the "products-completed operations we will pay on behalf of the additional insured hazard". is the amount of insurance: However: 1. Required by the contract or agreement; or 1. The insurance afforded to such additional 2. Available under the applicable Limits of Insu- insured only applies to the extent permitted rance shown in the Declarations; by law; and whichever is less. 2. If coverage provided to the additional insured is required by a contract or agree- This endorsement shall not increase the appli- ment, the insurance afforded to such addi- Limits of Insurance shown in the Decla- tional insured will not be broader than that rations. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 ❑ ENDORSEMENT # This endorsement, effective 12:01 A.M. 03/01/2019 forms a part of Policy No.GL 518-00-90 issued to JOHN FABICK TRACTOR COMPANY By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITED ADVICE OF CANCELLATION PROVIDED VIA E-MAIL TO ENTITIES OTHER THAN THE FIRST NAMED INSURED This policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non-payment of premium, and 1. the cancellation effective date is prior to this policy's expiration date; 2. the First Named Insured is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the "Certificate Holder(s)") and has provided to the Insurer, either directly or through its broker of record, the email address of a contact at each such entity; and 3. the Insurer received this information after the First Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that is acceptable to the Insurer, the Insurer will provide advice of cancellation (the "Advice") via e-mail to each such Certificate Holders within 30 days after the First Named Insured provides such information to the Insurer; provided, however, that if a specific number of days is not stated above, then the Advice will be provided to such Certificate Holder(s) as soon as reasonably practicable after the First Named Insured provides such information to thelnsurer. Proof of the Insurer emailing the Advice, using the information provided by the First Named Insured, will serve as proof that the Insurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided under this policy or the cancellation of this policy or the effective date thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following Definitions apply to this endorsement: 1. First Named Insured means the Named Insured shown on the Declarations Page of this policy. 2. Insurer means the insurance company shown in the header on the Declarations page of this policy. All other terms, conditions and exclusions shall remain the same. Authorized Representative 107414 (03/11) Page 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following"attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy), This endorsement, effective 12:01 AM 03/01/2019 forms a part of Policy No. WC 080-75-6215 Issued to John Fabick Tractor Company By Insurance Co. of the State of Penn LIMITED ADVICE OF CANCELLATION PROVIDED VIA E-MAIL TO ENTITIES OTHER THAN THE NAMED INSURED (WORKERS' COMPENSATION ONLY) This policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non-payment of premium, and 1. the cancellation effective date is prior to this policy's expiration date; 2. the Named Insured or, if applicable, any other employers named in Item 1 of the Information Page is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the "Certificate Holder(s)") and the Named Insured has provided to the Insurer, either directly or through its broker of record, the email address of a contact at each such entity; and 3. the Insurer received this information after the Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that is acceptable to the Insurer, the Insurer will provide advice of cancellation (the "Advice") via e-mail to each such Certificate Holders within 30 days after the Named Insured provides such information to the Insurer; provided, however, that if a specific number of days is not stated above, then the Advice will be provided to such Certificate Holder(s) as soon as reasonably practicable after the Named Insured provides such information to the Insurer. Proof of the Insurer emailing the Advice, using the information provided by the First Named Insured, will serve as proof that the Insurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided under this policy or the cancellation of this policy or the effective date thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following definitions apply to this endorsement: 1. Named Insured means the insured first named employer in Item 1 of the Information Page of this policy. 2. Insurer means the insurance company shown in the header on the Information Page of this policy. All other terms, conditions and exclusions shall remain the same. AUTHORIZED REPRESENTATIVE WC 99 00 56 (Ed. 04/11)