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HomeMy WebLinkAboutAnnualObstructionLicenseApplicationPacket I:\Engineering\ROW Permits\ROW Bond & License Checklist_1-8-19.docx Page 1 of 1 Right-of-Way License and Bond Submittal Checklist Review City’s License Applications and City’s Bond Forms. Match License and Bond to scope of intended work. Complete License Application and have signed by authorized personnel. Review Bond Form for correct license end date. All licenses will terminate on December 31st of the same year the bond was issued. City Staff will enter bond issuance date. All bonds shall cover an additional two (2) year maintenance period beyond the license’s expiration date. Bond Form to be signed correctly by authorized personnel. Acquire proof of insurance documentation showing all required insurance coverages, including endorsements showing required additional insured’s. Provide payment for License. Checks should be identified as payment of License Application Fee. Submit signed ORIGINAL Bond and License Forms and insurance documentation to Department of Public Works-Engineering Division. I:\Engineering\ROW Permits\Annual ROW Obstruction Bond & License_1-8-19.doc FEE: $20.00 ANNUAL RIGHT-OF-WAY OBSTRUCTION LICENSE Application is made for a license to maintain street/sidewalk obstruction: NAME: E-MAIL: ADDRESS: __ __ _______ I (We) further agree to provide the City of Oshkosh with a surety bond issued by a company licensed in the State of Wisconsin in the amount of Five Thousand Dollars ($5,000.00). I (we) further agree to secure a Commercial General Liability Policy with limits of: (a) $500,000 each occurrence (b) $500,000 personal liability and advertising injury (c) $500,000 general aggregate (d) $500,000 products – completed operations aggregate and shall name the City of Oshkosh, its officers, council members, agents, employees, and authorized volunteers as an additional insured thereon. Proof of said coverage in the form of an insurance certificate shall be submitted to the City of Oshkosh prior to issuance of any permit for street or sidewalk obstruction. Each individual project/address at which an obstruction will be placed requires a separate permit which may be obtained from the City of Oshkosh Department of Public Works-Engineering Division. DATE ISSUED: ___________________________ EXPIRATION: ___________________________ BOND TERM: ___________________________ INSURANCE TERM: ___________________________ DATE: _________________ _________________________________________ Applicant’s Signature _________________________________________ Telephone Number Type of organization: ___ individual ___ partnership ___ corporation State of Incorporation __________ I:\Engineering\ROW Permits\Annual ROW Obstruction Bond & License_1-8-19.doc ANNUAL RIGHT-OF-WAY OBSTRUCTION BOND PRINCIPAL(S) (Legal name(s) and business address(es)) Surety(ies) (Name(s) and business address(es)) Penal Sum of Bond: $5,000.00 OBLIGATION: We, the Principal(s) and Surety(ies), are firmly bound to the City of Oshkosh in the above penal sum. For payment of the penal sum, we bind ourselves, our heirs, executors, administrators, and successors, jointly and severally. CONDITIONS: The Principal contemplates placing an obstruction within right-of-way area(s) within the City of Oshkosh from time to time during the calendar year shown below. The Principal desires that all of those projects be covered by a single bond rather than a separate bond for each contract. The Principal shall faithfully perform all work done in the City of Oshkosh with proper care and skill; obey all laws of the State of Wisconsin and ordinances of the City of Oshkosh in connection with such work performed and with the employment of labor; properly replace and restore any street, sidewalk, terrace, or other public right-of-way, vacated right-of-way, or City easement areas in accordance with the current edition of the Standard Specifications for City of Oshkosh, Wisconsin; and pay to the City of Oshkosh any amounts due for services or materials furnished in connection therewith within one (1) month of invoice. The Principal shall for a period beginning on the date of issuance of this bond through a two (2) year period from the expiration date of the annual license save, defend, and hold harmless the City of Oshkosh from and against any and all claims, damages, costs, and expenses of any kind or character arising out of or resulting, however remotely, from the work performed by the Principal under the attached license, including but not limited to, all accidents and damages caused by any failure to erect and maintain sufficient barriers or lights at the place where licensee has placed obstruction or performed work, or by failure to guard against injury to persons passing upon the street or sidewalk, or by failure to promptly remove all tools, implements, refuse, and unused materials from said right-of- way. The Principal shall indemnify and refund to the City of Oshkosh all sums which it may become obligated to pay, including damages, punitive damages, attorney fees, and court costs, within thirty (30) days of written demand for payment; however, the penal sum of this bond shall not exceed $5,000. It is understood and agreed by the Principal(s) and Surety(ies) that this bond supplements, but does not take the place of, any liability insurance required to be carried by said Principal(s) herein by the City of Oshkosh policies or ordinances. TERM OF BOND: This bond shall cover work performed from ____________________ (Date of Issuance) to December 31, 20_____ (the annual license period). This bond shall cover claims made for work performed during this annual license period and for an additional two (2) year maintenance period beyond the expiration of this annual license period. The principal agrees to correct all maintenance issues brought to the attention of the Principal(s) upon receiving notice from the City of Oshkosh within the two (2) year maintenance period. SIGNATURES/SEALS: For the Principal: For the Surety: Signature Signature Name Name Title Title Address Any person signing in a representative capacity (e.g., an attorney-in-fact) must furnish evidence of authority if that representative is not a member of the firm or partnership or an officer of the corporation involved. Type of organization: ___ Individual ___ Partnership ___ Corporation State of Incorporation ______________ 12/20/18 V - 1 CITY OF OSHKOSH INSURANCE REQUIREMENTS V. RIGHT-OF-WAY OBSTRUCTION / RIGHT-OF-WAY ANNUAL EXCAVATION / RIGHT-OF-WAY SINGLE SITE EXCAVATION / WORK IN RIGHT-OF-WAY LICENSES INSURANCE REQUIREMENTS The Contractor shall not commence work on contract until proof of insurance required has been provided to the applicable City department before the contract or purchase order is considered for approval by the City. It is hereby agreed and understood that the insurance required by the City of Oshkosh is primary coverage and that any insurance or self insurance maintained by the City of Oshkosh, its officers, council members, agents, employees or authorized volunteers will not contribute to a loss. All insurance shall be in full force prior to commencing work and remain in force until the entire job is completed and the length of time that is specified, if any, in the contract or listed below whichever is longer. 1. GENERAL LIABILITY COVERAGE A. Commercial General Liability (1) $500,000 each occurrence limit (2) $500,000 personal liability and advertising injury (3) $500,000 general aggregate (4) $500,000 products – completed operations aggregate B. Claims made form of coverage is not acceptable. C. Insurance must include: (1) Premises and Operations Liability (2) Contractual Liability (3) Personal Injury (4) Explosion, collapse and underground coverage (5) Products/Completed Operations for 2 years after acceptance of completed work (6) The general aggregate must apply separately to this project/location 2. BUSINESS AUTOMOBILE COVERAGE– If this exposure shall exist: A. $500,000 Combined Single Limit for Bodily Injury and Property Damage each accident. B. Must cover liability for Symbol #1 -“Any Auto” – including Owned, Non-Owned and Hired Automobile Liability. 3. WORKERS COMPENSATION AND EMPLOYERS LIABILITY – “If”required by Wisconsin State Statute or any Workers Compensation Statutes of a different state. A. Must carry coverage for Statutory Workers Compensation and an Employers Liability limit of: (1) $100,000 Each Accident (2) $500,000 Disease Policy Limit (3) $100,000 Disease – Each Employee 12/20/18 V - 2 4. BUILDER’S RISK / INSTALLATION FLOATER / CONTRACTOR’S EQUIPMENT OR PROPERTY The contractor is responsible for loss and coverage for these exposures. City of Oshkosh will not assume responsibility for loss, including loss of use, for damage to property, materials, tools, equipment, and items of a similar nature which are being either used in the work being performed by the contractor or its subcontractors or are to be built, installed, or erected by the contractor or its subcontractors. 5. ADDITIONAL PROVISIONS A. Acceptability of Insurers - Insurance is to be placed with insurers who have an A.M. Best rating of no less than A- and a Financial Size Category of no less than Class VI, and who are authorized as an admitted insurance company in the state of Wisconsin. B. Additional Insured Requirements – The following must be named as additional insureds on all Liability Policies for liability arising out of project work -City of Oshkosh, and its officers, council members, agents, employees and authorized volunteers. On the Commercial General Liability Policy, the additional insured coverage must be ISO form CG 20 10 07 04 or its equivalent and also include Products – Completed Operations ISO form CG 20 37 07 04 or its equivalent for a minimum of 2 years after acceptance of work. This does not apply to Workers Compensation Policies. C. Certificates of Insurance acceptable to the City of Oshkosh shall be submitted prior to commencement of the work to the applicable City department. These certificates shall contain a provision that coverage afforded under the policies will not be canceled or non renewed until at least 30 days’ prior written notice has been given to the City Clerk – City of Oshkosh. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE (A/C. No. Ext): FAX (A/C. No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:ABC Insurance Company NAIC # INSURED INSURER B:XYZ Insurance Company NAIC # INSURER C:LMN Insurance Company NAIC # INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER IOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE AMY 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYY) POLICY EXP (MM/DD/YYY)LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurrence)$ 50,000 A CLAIMS-MADE OCCUR MED EXP (Any one person)$ 5,000 ISO FORM CG 20 37 OR EQUIVALENT PERSONAL & ADV INJURY $ 500,000 GENERAL AGGREGATE $ 500,000 GEN’L AGGREGATE LIMIT APPLIES PER:PRODUCTS – COMP/OP AGG $ 500,000 POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident)$ 500,000 ANY AUTO BODILY INJURY (Per person)$ B ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident)$ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE (Per accident)$ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $$ C WORKERS COMPENSATION AND EMPLOYERS’ LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICE/MEMBER EXCLUDED?Y / N (Mandatory in NH)N If yes, describe under DESCRIPTION OF OPERATIONS below WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE – EA EMPLOYEE $ 100,000 E.L. DISEASE – POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Additional Insureds per attached endorsements. Certificates of Insurance acceptable to the City of Oshkosh shall be submitted prior to commencement of the work to the applicable City department. These certificates shall contain a provision that coverage afforded under the policies will not be canceled or non renewed until at least 30 days’ prior written notice has been given to the City Clerk – City of Oshkosh. CERTIFICATE HOLDER CANCELLATION City of Oshkosh, Attn: City Clerk 215 Church Avenue PO Box 1130 Oshkosh, WI 54903-1130 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE, THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Insurer(s) must have a minimum A.M. Best rating of A- and a Financial Performance Rating of VI or better. Policy effective and expiration date. Policy effective and expiration date. Policy effective and expiration date. General Liability Policy Number Auto Liability Policy Number Workers Compensation Policy Number Insurance Agent’s contact information. Insurance Agency contact information, including street address and PO Box if applicable. Insured’s contact information, including name, address and phone number. Insurance Standard V SAMPLE CERTIFICATE Please indicate somewhere on this certificate, the contract or project # this certificate is for. POLICY NUMBER:COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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 As required by contract Any and all job sites 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for “bodily injury”, “property damage” or “personal and advertising injury” caused, in whole or in part, by: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the additional insured(s) at the location(s) design- nated above. B.With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to “bodily injury” or “property damage” occurring after: 1.All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.That portion of “your work” out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 Insurance Standard V SAMPLE CERTIFICATE Please indicate somewhere on this certificate, the contract or project # this certificate is for. Policy # POLICY NUMBER:COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 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 SCHEDULE Name Of Additional Insured Person(s) Or Organization(s):Location And Description Of Completed Operations As required by contract Any and all job sites Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for “bodily injury”, “property dam- age” caused, in whole or in part, by “your work” at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the “products-completed operations hazard”. CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 Policy # Insurance Standard V SAMPLE CERTIFICATE Please indicate somewhere on this certificate, the contract or project # this certificate is for.