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2007-162
ORDINANCE NO. OO ' ~ ,~L AN ORDINANCE ACCEPTING COMPETITIVE BIDS AND AWARDING A PUBLIC WORKS CONTRACT FOR THE CONSTRUCTION OF CELLS 3A AND 3B AT THE CITY OF DENTON LANDFILL; PROVIDING FOR THE EXPENDITURE OF FUNDS THEREFOR; AND PROVIDING AN EFFECTIVE DATE (BID 3809-LANDFILL CELL 3A/3B AWARDED TO L.D. KEMP EXCAVATING, INC. IN THE AMOUNT OF $3,533,741. WHEREAS, the City has solicited, received and tabulated competitive bids for the construction of public works or improvements in accordance with the procedures of State law and - City ordinances; and WHEREAS, the City Manager or a designated employee has received and recommended that the herein described bids are the lowest responsible bids for the construction of the public works or improvements described in the bid invitation, bid proposals and plans and specifications therein; NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS: SECTION 1. The following competitive bids for the construction of public works or improvements, as described in the "Bid Invitations", "Bid Proposals" or plans and specifications on file in the Office of the City's Purchasing Agent filed according to the bid number assigned hereto, are hereby accepted and approved as being the lowest responsible bids: BID NUMBER CONTRACTOR AMOUNT 3809 L.D. Kemp Excavating, lnc. $3,533,741 SECTION 2. The acceptance and approval ofthe above competitive bids shall not constitute a contract between the City and the person submitting the bid for construction of such public works or improvements herein accepted and approved, until such person shall comply with all requirements specified in the Notice to Bidders including the timely execution of a written contract and furnishing of performance and payment bonds, and insurance certificate after notification of the award of the bid. SECTION 3. The City Manager is hereby authorized to execute all necessary written contracts for the performance of the construction of the public works or improvements in accordance with the bids accepted and approved herein, provided that such contracts are made in accordance with the Notice to Bidders and Bid Proposals, and documents relating thereto specifying the terms, conditions, plans and specifications, standards, quantities and specified sums contained therein. SECTION 4. Upon acceptance and approval ofthe above competitive bids and the execution of contracts for the public works and improvements as authorized herein, the City Council hereby authorizes the expenditure of funds in the mamier and in the amount as specified in such approved bids and authorized contracts executed pursuaritthereto. SECTION 5. This ordinance shall become effective immediately upon its passage and approval. PASSED AND APPROVED this the ~ day of , 2007. C PERRY cNEILL, MAYOR ATTEST: JENNIFER WALTERS, CITY SECRETARY a BY: APPROVED AS TO LEGAL FORM: EDWIN M. SNYDER, CITY ATTORNEY BY: e~~~ 3-ORD-Bj~ 809 1': CONTRACT AGREEMENT STATE OF TEXAS § COUNTY OF DENTON § THIS AGREEMENT, made and entered into this 7 day of August A.D, 2007, by and between City of Denton of the County of Denton and State of Texas, acting through George C. Campbell thereunto duly authorized so to do, hereinafter termed "OWNER," and LD Kemp Excavating Inc. Fort Worth, TX 76148 of the City of Fort Worth, County of Tarrant and State of Texas ,hereinafter termed "CONTRACTOR." WITNESSETH: That for and in consideration of the payments and agreements hereinafter mentioned, to be made and performed by O WNER, and under the conditions expressed in the bonds attached hereto, CONTRACTOR hereby agrees with OWNER to commence and .complete performance of the work specified below: Bid 3809-Landfill Ce113A/3B Construction in the amount of $3,533,741 and all extra work in connection therewith, under the terms as stated in the General Conditions of the agreement; and at his (or their) own proper cost and expense to furnish all materials, supplies, machinery, equipment, tools, superintendence, labor, insurance, and other accessories and services necessary to complete the work specified above, in accordance with the conditions and prices stated in the Proposal and the Performance and Payment Bonds, attached hereto, and in accordance with all the General Conditions of the Agreement, the Special Conditions, the Notice to Bidders (Advertisement for Bids), and Instructions to Bidders, as referenced herein and on file in the office of the Purchasing Agent, and in accordance with all local, state and federal laws; and plans, which includes all maps, plats, blueprints, and other drawings and printed or written explanatory matter thereof, and the Specifications therefore, as prepared by: City of Denton all of which are referenced herein and made a part hereof and collectively evidence and constitute the entire contract. s CA-1 Independent Status It is mutually understood and agreed by and between City and Contractor that Contractor is an independent contractor and shall not be deemed to be or considered an employee of the City of Denton, Texas, for the purposes of income tax, withholding, social security taxes, vacation or sick leave benefits, worker's compensation, or any other City employee benefit. City shall not have supervision and control of Contractor or any employee of Contractor, and it is expressly understood that Contractor shall perform the services hereunder according to the attached specifications at the general direction of the City Manager of the City of Denton, Texas, or his designee under this agreement. Indemnification Contractor covenants and agrees to and does hereby indemnify, hold harmless and defend, at its own expense, Owner, its officers, servants and employees, from and against any and all claims or suits for property loss or damage and/or personal injury, including death, to any and all persons, of whatsoever kind or character, whether real or asserted, azising out of the Work and services to be performed hereunder by Contractor, its officers, agents, employees, subcontractors, licensees or invitees, whether or not caused, in whole or in part, by the alleged negligence of the officers, servants, employees, of the Owner. Contractor likewise covenants and agrees to, and does hereby, indemnify and hold harmless Owner during the performance of any of the terms and conditions of this Contract, whether arising out of in whole or in part, any and all alleged acts or omissions of officers, servants, or employees of Owner. The provisions of this paragraph aze solely for the benefit of the pazties hereto and not intended to create or grant any rights, contractual or otherwise, to any other person or entity. Choice of Law and Venue This agreement shall be governed by the law of the State of Texas and venue for its construction and enforcement shall lie in the courts of Denton County, Texas. The CONTRACTOR hereby agrees to commence work on or after the date established for the start of work as set forth in written notice to commence work and complete all work within the time stated in the Proposal, subject to such extensions of time as aze provided by the General and Special Conditions. The OWNER agrees to pay the CONTRACTOR in current funds the price or prices shown in the Proposal, which forms a part of this contract, such payments to be subject to the General and Special Conditions of the Contract. CA-2 IN WITNESS WHEREOF, the parties of these presents have executed this agreement in the year and day fast above written. ATTEST: P,/ClLGCL~A//)1 ~ /,~Ad~ City of Denton OWNER BY: ~ ~~ G._ (SEAL) ATTEST: ANN ~TTG c.J h iT"c. L , 7 K c ~~ EX C.A t)~nla ?n( L' . CONTRACTOR .T 4 i7~~N !-I ~ ~ Fr'i~Le)nr1Th . ~X %~/~~ MAILING ADDRESS Ply- ~2P1- ~/~70 PHONE NUMBER ~ - / 332. FAX NUMB APPROVED AS TO FORM: ,- ~~~ ~ ~ ITY ATTORN Y BY: PRIll~7ED NAME ~~ ~~~ CA-3 PERFORMANCE BOND STATE OF TEXAS § ~~~- YlG1 ~~. ~, `~k~ ~I ~~ COUNTY OF DENTON § KNOW ALL MEN BY THESE PRESENTS: That L.D. Kemp Excavating, Inc./ who address is 5409 Denton H .Fort Worth Texas 76148 hereinafter called Principal, and Il -- ~ ~ l ~ - (~(~ i1 a corporation organized and existing under the laws of the State of ; r 1 fl In n~ ,and fully authorized to transact business in the State of Texas, as Surety, aze held and firmly bound unto the City of Denton, a municipal corporation organized and existing under the laws of the State of Texas, hereinafter called Owner, in the penal / sum of Three Million Five Hundred Thirty Three Thousand Seven Hundred Forty One and 0/100 DOLLARS ($3,533,74h)~plus ten percent of the stated penal sum as an additional sum of money representing additional court expenses, attorneys' fees, and liquidated damages arising out of or connected with the below identified Contract, in lawful money of the United States, to be paid in Denton County, Texas, for the payment of which sum well and truly to be made, we hereby bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents. This Bond shall automatically be increased by the amount of any Change Order or Supplemental Agreement, which increases the Contract price, but in no event shall a Change Order or Supplemental Agreement, which reduces the Contract price, decrease the penal sum of this Bond. THE OBLIGATION TO PAY SAME is conditioned as follows: Whereas, the Principal entered into a certain Contract, identified by Ordinance N~ber 2007-162, with the City of Denton, the Owner, dated the 7 day of Aueust A.D. 2007 ~dcopy of which is hereto attached and made apart hereof, for Bid 3809 Landfill Cell 3A/3B Construction. / NOW, THEREFORE, if the Principal shall well, truly and faithfully perform and fulfill all of the undertakings, covenants, terms, conditions and agreements of said Contract in accordance with the Plans, Specifications and Contract Documents during the original term thereof and any extension thereof which may be granted by the Owner, with or without notice to the Surety, and during the life of any guazanty or warranty required under this Contract, and shall also well and truly perform and fulfill all the undertakings, covenants, terms, conditions and agreements of any and all duly authorized modifications of said Contract that may hereafter be made, notice of which modifications to the Surety being hereby waived; and, if the Principal shall repair and/or replace all defects due to faulty materials and workmanship that appear within a period of two (2) years from the date of final completion and final acceptance of the Work by the Owner; and, if the Principal shall fully indemnify and save harmless the Owner from all costs and damages which Owner may suffer by reason of failure to so perform herein and shall fully reimburse and repay Owner all outlay and expense which the Owner may incur in making good any default or deficiency, then this obligation shall be void; otherwise, it shall remain in full force and effect. PB-1 PROVIDED FURTHER, that if any legal action be filed upon this Bond, exclusive venue shall lie in Denton County, State of Texas. AND PROVIDED FURTHER, that the said Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract, or to the Work to be performed thereunder, or to the Plans, Specifications, Drawings, etc., accompanying the same, shall in anywise affect its obligation on this Bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the Contract, or to the Work to be performed thereunder, or to the Plans, Specifications, Drawings, etc. This Bond is given pursuant to the provisions of Chapter 2253 of the Texas Government Code, as amended, and any other applicable statutes of the State of Texas. The undersigned and designated agent is hereby designated by the Surety herein as the Resident Agent in Denton County to whom any requisite notices may be delivered and on whom service of process may be had in matters arising out of such suretyship, as provided by Article 7.19- 1 of the Insurance Code, V ernon's Annotated Civil Statutes of the State of Texas. IN WITNESS WHEREO. F, this instr ent is execute in 4 copies, each one of which shall be deemed an original, this the day of ~~' /. ATTEST: BY: pNNe~~ [.~Jh :7-~ .SECRETARY AT~1 BY: PRINCIPAL ~.p.1 ~ v BY. P SIDENT Cr TA FTV The Resident Agent of the Surety in Denton County, Texas far delivery of notice and service of the process is: NAME: STREET ADDRESS: T (NOTE: Date of Performance Bond must be date of Contract. If Resident Agent is not a corporation, give a person's name.) PB-2 ~L ~i4`o~ MID-CONTINENT CASUALTY COMPANY PAYMENT BOND STATE OF TEXAS COUNTY OF DENTON ~r~l Geo.', rKi~ -bob KNOW ALL MEN BY THESE PRESENTS: That L.D. Kemn Excavating Inc./whose add ss is 5407 Denton H Fort Worth Texas 76148 hereinafter called Principal, and ~ i dC~« corporation organized and existing under the laws of the State of ' ~( ~(A lnfSW~Q~ ~ , an~~d fully authorized to transact business in the State of Texas, as Surety, aze held and firmly bound unto the City of Denton, a municipal corporation organized and existing under the laws of the State of Texas, hereinafter called Owner, and unto all persons, firms, and corporations who may furnish materials for, or perform labor upon, the building or improvements hereinafter referred to, in the penal suer t of Three Million Five Hundred Thirtv Three Thousand Seven Hundred Forty One and 0/100~DOLLARS ($3,533,741~m lawful money of the United States, to be paid in Denton, County, Texas, for the payment of which sum well and truly to be made, we hereby bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents. This Bond shall automatically be increased by the amount of any Change Order or Supplemental Agreement which increases the Contract price, but in no event shall a Change Order or Supplemental Agreement which reduces the Contract price decrease the penal sum of this Bond. THE OBLIGATION TO PAY SAME is conditioned as follows: Whereas, the Principal entered into a certain Contract, identified by Ordinance Number 2007-162, with the City of Denton, the Owner, dated the 7 day of Au ust A.D. 2007 , a copy of which is hereto attached and made a part hereof, for Bid 3809 Landfill Ce113A/3B Construction. NOW, THEREFORE, if the Principal shall well, truly and faithfully perform its duties and make prompt payment to all persons, firms, subcontractors, corporations and claimants supplying labor and/or material in the prosecution of the Work provided for in said Contract and any and all duly authorized modifications of said Contract that may hereafter be made, notice of which modifications to the Surety being hereby expressly waived, then this obligation shall be void; otherwise it shall remain in full force and effect. PROVIDED FURTHER, that if any legal action be filed on this Bond, exclusive venue shall lie in Denton County, Texas. AND PROVIDED FURTHER, that the said Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract, or to the Work to be performed thereunder, or to the Plans, Specifications, Drawings, etc., accompanying the same, shall in anywise affect its obligation on this Bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the Contract, or to the Work to be performed thereunder, or to the Plans, Specifications, Drawings, etc. PB-3 This Bond is given pursuant to the provisions of Chapter 2253 of the Texas Government Code, as amended, and any other applicable statutes of the State of Texas. The undersigned and designated agent is hereby designated by the Surety herein as the Resident Agent in Denton County to whom any requisite notices may be delivered and on whom service of process may be had in matters azising out of such surety, as provided by Article 7.19-1 of the Insurance Code, Vemon's Annotated Civil Statutes of the State of Texas. IN WITNESS WHEREOF this instru ent is executed in pies, each one of which shall be deemed an original, this the day of ~~~~~, ~_. ATTEST: SECRETARY ATTEST: BY: PRINCIPAL ~. ~. ~~ ~L ~~, ~~ ~ BY PRESIDENT CTTRPTV The Resident Agent of the Surety in Denton County, Texas for delivery of notice and service of the process is: NAME: ~h~l Y y'Ck~YI ~~ f 11~- ~S- STREET ADDRESS: ~t S, C~fo~~ 6S~ (NOTE: Date of Payment Bond must be date of Contract. If Resident Agent is not a corporation, give a person's name.) PB-4 ~~f 5 MID-CON'. Know all -Men by the;e presents: Tha[ the MID,C principal office inthe city-oCTulsa, Oklahoma, pii~su on March 13th, 1947, to-wit: and revoke[he power,and authonty::given hnn. None CITY OF DENTON INSURANCE REQUIREMENTS FOR CONTRACTORS Bidder's attention is directed to the insurance requirements below. It is highly recommended that bidders confer with their respective insurance carriers or brokers to determine in advance of Bid submission the availability of insurance certificates and endorsements as prescribed and provided herein. If an apparent [ow bidder fails to comply strictly with the insurance requirements, that bidder may be disqualifted from award of the contract. Upon bid award, all insurance requirements shall become contractual obligations, which the successful bidder shall have a duty to maintain throughout the course of this contract. STANDARD PROVISIONS: Without limiting any of the other obligations or liabilities of the Contractor, the Contractor shall provide and maintain until the contracted work has been completed and accepted by the Ciry of Denton, Owner, the minimum insurance coverage as indicated hereinafter. A.s soon as practicable after notifcation of bid award, Contractor shall file with the Purchasing Department satisfactory certificates of insurance, containing the bid number and title of the project. Contractor may, upon written request to the Purchasing Department, ask for clarification of any insurance requirements at any time; however, Contractors are strongly advised to make such requests prior to bid opening, since the insurance requirements may not be modified or waived after bid opening unless a written exception has been submitted with the bid. Contractor shall not commence any work or deliver any material until he or she receives notification that the contract ltas been accepted, approved, and signed by the City of Denton. All insurance policies proposed or obtained in satisfaction of these requirements shall comply with the following general specifications, and shall be maintained in compliance with these general specifications throughout the duration of the Contract, or longer, if so noted: Each policy shall be issued by a company authorized to do business in the State of Texas with an A.M. Best Company rating of at least A. Any deductibles or self-insured retentions shall be declared in the bid proposal. If requested by the City, the insurer shall reduce or eliminate such deductibles or self-insured retentions with respect to the CiTy, its officials, agents, employees and volunteers; or, the contractor shall procure a bond guaranteeing payment of losses and related investigations, claim administration and defense expenses. • Liability policies shall be endorsed to provide the following: •• Name as additional insured the City of Denton, its Officials, Agents, Employees and volunteers. •• That such insurance is primary to any other insurance available to the additional insured with respect to claims covered under the policy and that this insurance applies separately to each insured against whom claim is made or suit is brought. The inclusion of more than one insured shall not operate to increase the insurer's limit of liability. • All policies shall be endorsed to read: "SAID POLICY SHALL NOT BE CANCELLED, NONRENEWED OR MATERIALLY CIIANGE WITHOUT 30 DAYS ADVANCED WRITTEN NOTICE BEING GIVEN TO THE OWNER (CITY) EXCEPT WHEN THE POLICY IS BEING CANCELLED FOR NONPAYMENT OF PREMIUM IN WHICH CASE IO DAYSADVANCE WRITTEN NOTICE IS REQUIRED': • Should any of the required insurance be provided under aclaims-made form, Contractor shall maintain such coverage continuously throughout the term of this contract and, without lapse, for a period of three yeazs beyond the contract expiration, such that occurrences arising during the contract term which give rise to claims made after expiration of the contract shall be covered. Should any of the required insurance be provided under a form of coverage that includes a general annual aggregate limit providing for claims investigation or legal defense costs to be included in the general annual aggregate limit, the Contractor shall either double the occurrence limits or obtain Owners and Contractors Protective Liability Insurance. Should any required insurance lapse during the contract term, requests for payments originating after such lapse shall not be processed until the City receives satisfactory evidence of reinstated coverage as required by this contract, effective as of the lapse date. If insurance is not reinstated, City may, at its sole option, terminate this agreement effective on the date of the lapse. SPECIFIC ADDITIONAL INSURANCE REQUIREMENTS: All insurance policies proposed or obtained in satisfaction of this Contract shall additionally comply with the following marked specifications, and shall be maintained in compliance with these additional specifications throughout the duration of the Contract, or longer, if so noted: [X] A. General Liability Insurance: General Liability insurance with combined single limits of not less than $ 1,000,000 shall be provided and maintained by the Contractor. The policy shall be written on an occurrence basis either in a single policy or in a combination of underlying and umbrella or excess policies. If the Commercial General Liability form (ISO Form CG 0001 current edition) is used: • Coverage A shall include premises, operations, products, and completed operations, independent contractors, contractual liability covering this contract and broad form property damage coverage. • Coverage B shall include personal injury. • Coverage C, medical payments, is not required. If the Comprehensive General Liability form (ISO Form GL 0002 Current Edition and ISO Form GL 0404) is used, it shall include at least: • Bodily injury and Property Damage Liability for premises, operations, products and completed operations, independent contractors and property damage resulting from explosion, collapse or underground (XCU) exposures. • Broad form contractual liability (preferably by endorsement) covering this contract, personal injury liability and broad form property damage liability. [X] Automobile Liability Insurance: Contractor shall provide Commercial Automobile Liability insurance with Combined Single Limits (CSL) of not less than $500,000 either in a single policy or in a combination of basic and umbrella or excess policies. The policy will include bodily injury and property damage liability arising out of the operation, maintenance and use of all automobiles and mobile equipment used in conjunction with this contract. Satisfaction of the above requirement shall be in the form of a policy endorsement for: • any auto, or • all owned, hired and non-owned autos. [X] Workers Compensation Insurance Contractor shall purchase and maintain Worker's Compensation insurance which, in addition to meeting the minimum statutory requirements for issuance of such insurance, has Employer's Liability limits of at least $100,000 for each accident, $100,000 per each employee, and a $500,000 policy limit for occupational disease. The City need not be named as an "Additional Insured" but the insurer shall agree to waive all rights of subrogation against the City, its officials, agents, employees and volunteers for any work performed for the City by the Named Insured. For building or construction projects, the Contractor shall comply with the provisions of Attachment 1 in accordance with §406.096 of the Texas Labor Code and rule 28TAC 110.110 of the Texas Worker's Compensation Commission (TWCC). [ ] Owncr's and Contractor's Protective Liability Insurance The Contractor shall obtain, pay for and maintain at all times during the prosecution of the work under this contract, an Owner's and Contractor's Protective Liability insurance policy naming the City as insured for property damage and bodily injury which may azise in the prosecution of the work or Contractor's operations under this contract. Coverage shall be on an"occurrence" basis, and the policy shall be issued by the same insurance company that car ies the Contractor's liability insurance. Policy limits will be at least combined bodily injury and property damage per occurrence with a aggregate. [ ] Fire Damage Legal Liability Insurance Coverage is required if Broad form General Liability is not provided or is unavailable to the contractor or if a contractor leases or rents a portion of a City building. Limits of not less than each occurrence aze required. [ ] Professional Liability Insurance Professional liability insurance with limits not less than per claim with respect to negligent acts, errors or omissions in connection with professional services is required under this Agreement. [ ] Builders' Risk Insurance Builders' Risk Insurance, on an All-Risk form for 100% of the completed value shall be provided. Such policy shall include as "Named Insured" the City of Denton and all subcontractors as their interests may appeaz. [ ] Commercial Crime Provides coverage for the theft or disappearance of cash or checks, robbery inside/outside the premises, burglary of the premises, and employee fidelity. The employee fidelity portion of this coverage should be written on a "blanket" basis to cover all employees, including new hires. This type insurance should be required if the contractor has access to City funds. Limits of not less than each occurrence are required. [) Additional Insurance Other insurance may be required on an individual basis for extra hazardous contracts and specific service agreements. If such additional insurance is required for a specific contract, that requirement will be described in the "Specific Conditions" of the contract specifications. ATTACHMENT 1 [X] Worker's Compensation Coverage for Building or Construction Projects for Governmental Entities A. Definitions: Certificate of coverage ("certificate")-A copy of a certificate of insurance, a certificate of authority to self-insure issued by the commission, or a coverage agreement (TWCC- 81, TWCC-82, TWCC-83, or TWCC-84), showing statutory workers' compensation insurance coverage for the person's or entity's employees providing services on a project, for the duration of the project. Duration of the project -includes the time from the beginning of the work on the project until the contractor's/person's work on the project has been completed and accepted by the govemmental entity. Persons providing services on the project ("subcontractor" in §406.096) -includes all persons or entities performing all or part of the services the contractor has undertaken to perform on the project, regardless of whether that person contracted directly with the contractor and regazdless of whether that person has employees. This includes, without limitation, independent contractors, subcontractors, ]easing companies, motor carriers, owner-operators, employees of any such entity, or employees of any entity which furnishes persons to provide services on the project. "Services" include, without limitation, providing, hauling, or delivering equipment or materials, or providing labor, transportation, or other service related to a project. "Services" does not include activities unrelated to the project, such as food beverage vendors, office supply deliveries, and delivery of portable toilets. B. The contractor shall provide coverage, based on proper reporting of classification codes and payroll amounts and filing of any overage agreements, which meets the statutory requirements of Texas Labor Code, Section 401.011(44) for all employees of the Contractor providing services on the project, for the duration of the project. C. The Contractor must provide a certificate of coverage to the governmental entity prior to being awazded the contract. D. If the coverage period shown on the contractor's current certificate of coverage ends during the duration of the project, the contractor must, prior to the end of the coverage period, file a new certificate of coverage with the governmental entiTy showing that coverage has been extended. E. The contractor shall obtain from each person providing services on a project, and provide to the governmental entity: (1) a certificate of coverage, prior to that person beginning work on the project, so the governmental entity will have on file certificates of coverage showing coverage for all persons providing services on the project; and (2) no later than seven days after receipt by the contractor, a new certificate of coverage showing extension of coverage, if the coverage period shown on the current certificate of coverage ends during the duration of the project. F. The contractor shall retain all required certificates of coverage for the duration of the project and for one yeaz thereafter. G. The contractor shall notify the governmental entity in writing by certified mail or personal delivery, within 10 days after the contractor knew or should have known, of any change that materially affects the provision of coverage of any person providing services on the project. H. The contractor shall post on each project site a notice, in the text, form and manner prescribed by the Texas Workers' Compensation Commission, informing all persons providing services on the project that they are required to be covered, and stating how a person may verify coverage and report lack of coverage. I. The contractor shall contractually require each person with whom it contracts to provide services on a project, to: (1) provide coverage, based on proper reporting of classification codes and payroll amounts and filing of any coverage agreements, which meets the statutory requirements of Texas Labor Code, Section 401.011(44) for all of its employees providing services on the project, for the duration of the project; (2) provide to the contractor, prior to that person beginning work on the project, a certificate of coverage showing that coverage is being provided for all employees of the person providing services on the project, for the duration of the project; (3) provide the contractor, prior to the end of the coverage period, a new certificate of coverage showing extension of coverage, if the coverage period shown on the current certificate of coverage ends during the duration of the project; (4) obtain from each other person with whom it contracts, and provide to the contractor: (a) a certificate of coverage, prior to the other person beginning work on the project; and 0 (b) anew certificate of coverage showing extension of coverage, prior to the end of the coverage period, if the coverage period shown on the current certificate of coverage ends during the duration of the project; (5) retain all required certificates of coverage on file for the duration of the project and for one yeaz thereafter; (6) notify the governmental entity in writing by certified mail or personal delivery, within 10 days after the person knew or should have known, of any change that materially affects the provision of coverage of any person providing services on the project; and (7) contractually require each person with whom it contracts, to perform as required by paragraphs (1) - (7), with the certificates of coverage to be provided to the person for whom they are providing services. J. By signing this contract or providing or causing to be provided a certificate of coverage, the contractor is representing to the govemmental entity that all employees of the contractor who will provide services on the project will be covered by workers' compensation coverage for the duration of the project, that the coverage will be based on proper reporting of classification codes and payroll amounts, and that all coverage agreements will be filed with the appropriate insurance carrier or, in the case of a self- insured, with the commission's Division of Self-Insurance Regulation. Providing false or misleading information may subject the contractor to administrative penalties, criminal penalties, civil penalties, or other civil actions. K. The contractor's failure to comply with any of these provisions is a breach of contract by the contractor which entitles the governmental entity to declaze the contract void if the contractor does not remedy the breach within ten days after receipt of notice of breach from the governmental entity. BID No. 3809 PROPOSAL TO THE CITY OF DENTON, TEXAS FOR THE CONSTRUCTION OF LANDFILL CELL 3A/3B CONSTRUCTION IN DENTON,TEXAS The undersigned, as bidder, declazes that the only person or parties interested in this proposal as principals are those named herein, that this proposal is made without collusion with any other person, firm, or corporation; that he has carefully examined the form of contract, Notice to Bidders, specifications and the plans therein referred to, and has carefully examined the locations, conditions, and classes of materials of the proposed work and agrees that he will provide all the necessary labor, machinery, tools, apparatus, and other items incidental to construction, and will do all the work and finnish all the materials called for in the contract and specifications in the manner prescribed herein and according to the requirements of the City as therein set forth. It is understood that the following quantities of work to be done at unit prices aze approximate only, and aze intended principally to serve as a guide in evaluating bids. It is agreed that the quantities of work to be done at unit prices and material to be furnished may be increased or diminished as may be considered necessary, in the opinion of the City, to complete the work fully as planned and contemplated, and that all quantities of work whether increased or decreased aze to be performed at the unit prices set forth below except as provided for in the specifications. The contractor shall provide the numeric unit price and the unit price in words for each quantity. Unit price in words governs over the numeric price given. It is further agreed that lump sum prices may be increased to cover additional work ordered by the City, but not shown on the plans or required by the specifications, in accordance with the provisions to the General Conditions. Similazly, they may be decreased to cover deletion of work so ordered. It is understood and agreed that the work is to be completed in frill within the number of workdays shown on the bid tabulation sheet. Accompanying this proposal is a certified or cashier's check or Bid Bond, payable to the Owner, in the amount of five percent of the total bid. PAGE P -1 OF BID #3809 LI] 1Z~1M~~ ILXG,4/p•~~+JL~TNt It is understood that the bid security accompanying this proposal shall be returned to the bidder, unless in case of the acceptance of the proposal, the bidder shall fail to execute a contract and file a perfommance bond and a payment bond within fifteen days after its acceptance, in which case the bid security shall become the property of the Owner, and shall be considered as a payment for damages due to delay and other inconveniences suffered by the Owner on account of such failure of the bidder. Owner reserves the right to reject any and all bids. Owner may investigate the prior performance of bidder on other contracts, either public or private, in evaluating bid proposals. Should bidder alter, change, or qualify any specification of the bid, Owner may automatically disqualify bidder. The undersigned hereby proposes and agrees to perform all work of whatever nature required, in strict accordance with the plans and specifications, for the following sum or prices, to wit: For Technical Specifications, please see the attached specification and Contract Documents for: "Cell 3A/3B Landfill Construction- Scale Pit, Area Paving, Building Construction, and South Pond Improvements" as included in Appendix A. PAGE P - 2 OF BID #38~ 9 L 1~ Iii ~/v,,,P ~5r,c.,9,>>9•f-, ~7L~~N ~ Bid 3809 Proposal Form Landfill Construction -Cell 3A13B Item No. Estimated Quantity Unit Description Unit Price Total 1 1 L.S. Mobilization .~ d Unit Price in WordsC% ~~yy~~~~ NPJ y ~ V e ~'(.~~KJ'''~~ $ 2 425,000 C.Y. ral Excavation, Hauling and Stockpiling ne G e ~~ }} ll ~~ 77--~~ Unit Price in Words~e UJ(J(/LrV"A/ ~ /v~ ~7P. $/ •Sy ~~ 3 12,500 C.Y. uth Pond Excavate So ~I~ / Unil Price in Words ~ ~ (~~ ./ ~ v~ $ 4 40,500 Y. C Install Compacted Clay Liner in Ce113A/36 i O ^ Unit Price in Words / GV 0 ~Iah~ ~ Nr' $ ~~ l / T 5 ~ 1,250 C.Y. Miscellaneous Soil Fill Unit Price in Words ~~~ baLL~}}/ $~ ~ ZJ'D~ 6 59,000 S.Y. Supply and Install Textured (Both Sides) Geomemb2ne in Cell 3A/38 (PLUS mplete R oll for OWNER's use) Additional C o P ro vi de 1 ll yy ~~ ~~ // ,, // ^y! I o Unit Price in Words j"DL(zV ~.OWA-/I.t'~ ~!' ~6~ ~ c`y' $ / '~ C'`z '~-~/ 7 60,900 S.Y. Tri-Planar Geocem osite in Cell 3A13B Supply and Install Double-sid ed s , Unit Price in Words ~Ci ~~R.MS ~ ~~9 ~ @ $O ~ 8 40,500 C.Y. Install Protective Cover in Cell 3AI3B _ Unit Price in Words ~JU ~LLIG.a,.t ~ ~/tv-~ Y $ Z ~ S>i ~ 9 1 L.S. Supply and Install Leac Collection and Pumping System in Ce113A/3B Unit Price in Words d/1G ~ bud~nJA7 ~ ~--~ $4Xo~a 9bbD 10 1 L.S. Supply and Install undwater Underdrain System at Cell 3A/3B II `/ ~ t ,~, ~1 y~~~~! Unit Price in Words .cvJG 7 v ~l ~ U!/GI~PYV.! ~1~ &~J~V 11 1 L.S. Supply Retaining Wall tedals Delivered to Site (No Installation) s, 2,88 Blo , 2,000 Pins. (See Spec ectio 02834 1 ,7 64 Ca p ~ ~ / 1 n Unit Price in Words ~ 7 !~ f'~~ ~ ~~ 12 1 ents L.S. Construct South P d Improvem UnR Price in Word J ~,~~~J f ~Il~ 7 ~w~ ~ ~~^'°`.'i ~r'd~ ~~~ 13 nd 60X60' (nominal buildings in labs Fo O'x 4 0' a g 1 L.S. Construct Build S ~p / ~ ,, ~ ~ f~ Unit Price in Word~~/IJP~ /HIV ~fR~^'/ ~~ ~ T ~~~~~ r/ ~~~/b~ 3609 Proposal Fortn Addendum 2.x15 Page 1 mob] I~1=rv~.~ rix.~a~a~.n~GJ~n~~ Bid 3809 Proposal Form Landfill Construction -Cell 3A136 Item No. Estimated QuanEty Unit Description Unit Price Total L S S upply and Install Memb2ne Covered Buildings (60'x40' & 60'x60') and all 14 1 a ccessories ,~ J G~~p Unit Price in Word~.,~IJG T/ t/~ ~ $ ~'~5'~~ 16 1 Install Truck Sc System and all accessories d L.S. Supply an /, a Unit Price in Words/(' !//~ bLr~~~ '~' Construct Reinforced Concrete Truck Scale pits, and Reinforced Concrete 16 1 L.S. Acres oadway .~L, ' ~~ 6 1.l7~t7 nN ~ wD ~ m p ~ ~ t Price in ors U 17 3200 LF cing Silt F e n / } ~ ~ ~ ` aG~ ~~ ~ ` $` Y' T ~~~v i ~ / J / Unit Price in Words 18 1 LS Tempos rosion Control) ~ ~ 7 ~ ~" ~J,J r /~ `~S / Unit Price in Words 19 ,120 LF 1-1f2"Water Service Line Unit Price in Words 1`{ ~~ L ~ ~/ 20 1 EA 1-112" Domestic Water rvice & Meter Box u~~ ~ ~ ~ .aQ ~~Uvr / SD J Unit Price in Word ` ~ 21 160 LF ewer Pipe 4" SDR-3 5 ~q'~ ] ` Unit Price in Words ~ ~ Y /~ L v~ a/~ !~~D 22 2 EA 4"Cleanouts D~~ `, ~ Y ~~D/ ~~J Unit Price in Words / 23 80 LF 24" Class III RCP nn ~ d W ~Jv~ / $ s or ~ Unit Price in J dwall ea d H 24 B EA 24" SI d En ~~ LL ~~ // ,,/ ~~~ ~ ~Nx..r LID Unit Price in Word ~/ 25 2 EA Y- t l/~ ya ~~ ~ Unit Price in Words ~~~ ~~~~ V~"""`~ ~ s $~~ 26 ~ 180 ~ LF (Trench Drain I _ I _ J (Unit Price in Words Z L6!/7 ~/ /- 1 1~~ C !l L LJ~.ts I$ ~ ~~~ 3809 Proposal Form Atldendum 2.z15 Page 2 LD I~NhG) ~LA.7 a,c~~AJL~TNc. Bid 3809 Proposal Form Landfill Construction -Cell 3A136 Item No. Estimated Unit Description Unit Price Total Quantity Finish grading of Road Base and Installtion of 12-Inch HMAC Pavement. 27 1 LS (Base Course and Wearing nurse) / ~p Unit Price in WordsJ/+Ua / V / b ~~ ~~ i ~7 3809 Proposal Fonn Addentlum .xls Page 3 L D KCunl~ ~x.t.,~Av~.a1)~JZ BID SU1vIMARY In the event of the awazd of a contract to the undersigned, the undersigned will famish a performance bond and a payment bond for the full amount of the contract, to secure proper compliance with the terms and provisions of the contract, to insure and guarantee the work until final completion and acceptance, and to guarantee payment for all lawful claims for labor performed and materials furnished in the fulfillment of the contract. It is understood that the work proposed to be done shall be accepted, when fully completed and finished in accordance with the plans and specifications, to the satisfaction of the Engineer. The undersigned certifies that the bid prices contained in this proposal have been cazefully checked and are submitted as correct and final. Unit and lump sum prices as shown for each item listed in this proposal, shall control over extensions. The undersigned agrees this bid becomes the property of the City of Denton after the official opening. The undersigned affums that they are duly authorized to execute this contract. Vendor hereby assigns to purchaser any and all claims for overchazges associated with this contract which arise under the antitrust laws of the United States, 15 USCA Section 1 et seq., and which arise under the antitrust laws of the State of Texas, Tex. Bus. & Com. Code, Section 15.01, et seq. PAGE P - 3 OF BID #3$09 L n 1L~w~ D ~X.c.n/ , nJLJ ANC Tl1TAT bD ThC T.T TI IlIT)TO. Receipt is hereby acknowledged of the following addenda to the plans and specifications: AddendumNo. 1 dated Si.ai ,e.. 2g~ ~ Received /V~" Addendum No. 2 dated D'7 Received Addendum No. 3 dated '-" v Received Addendum No. 4 dated Received Addendum No. 5 dated Received L Seal & Authorization (~~7 (If a Corporation) ~f ~ - Z [~~ ~ T i Telephone PAGE P - 4 OF BID #3809 /~~ Stre t d/dr~e"ss~ J fit ~ .lJ~~ ~F~ l ~~ City and State ACORD ~ CERTI~[CATE OF LIABILI (4NCE °ATE,MM/°°"" TY INSUR ' , -- , 08 14 07 _ ~ PRODUCER ~ ~~~ OF INFORMATION 'THIS CERTIFICATE IS ISSUED ASA MATTER MIKE BRI SLOE INSURANCE (817-428-2295) ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR mbi4@mindspring. com (FAX 428-5834) ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P O BOX 162747 COMPANIES AFFORDING COVERAGE FORT WORTH, TEXAS 76161 coMPANv A EVEREST INDEMNITY INSURACE COMPANY INSURED / COMPANY L. D.KEMP EXCAVATING, INC./ B TEXAS MUTUAL INSURANCE COMPANY ~ 5409 DENTON HIGHWAY ~ ^ COMPANY FORT WORTH, TX 76148 ` 6or C PRAETORIAN SPECIALTY INSURACE CO. A` ~ 1 COMPANY D COVERAGES 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 MAV 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. CO LTR TypE OFINSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DOMQ POLICY E%PIRATION DATE (MM/DD/YY) LIMITS GEN ERAL LIABILI G ERALAGGREGATE $ 2 O O O O O O / A X COMMERCIALGENERAL LIABILITY 4 0004280-071 O8/11/O7 OB/11/OS PRODUCTS-COMP/OPAGG $ 2 OOO OOO CLAIMS MADE a OCCUR PERSONAL 8 AOV INJURY $ 1 O O O O O O OWNER'S 8 CONTRACTOR'S PROT EACH OCCURRENCE $ 1 0 0 0 O O O / FIRE DAMAGE (Any one Tire) $ 1 O O O O O X CONTRACTUAL MED EXP (Any one person) $ 5 O O O (' AUT OMOBILE LIABILI ANY AUTO PSITX0002155~ O7/22/O7 07/22/08 MBINEOSINGLELIMIT 5 1 OOO,OOO `~ ALL OW NEO AUTOS BODILY INJURY P r n $ X SCHEDULED AUTO@ e erso ( P ) ~ X HIRED AUTOS S BODILY INJURY P id t $ X NON-OWNED AUTO er acc en ) ( PROPERTY DAMAGE $ GAR AGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY. EACH ACCIDENT $ AGGREGATE 5 EXC ESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM / / / / AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AN ORV LIMIUS ER ' B EMPLOYERS'LIABILITY TSF-20070405 O4/OS/O7 O4/OS/O8 EL EACH ACCIDENT $ 1 OOO OOO ~' THE PROPRIETOFU X INCL EL DISEASE-POLICY LIMIT 5 1 OOO OO ~ r~ PARTNERS/EXECUTIVE OFFICERS ARE EXCL EL DISEASE- EA EMPLOYEE S 1 O O O O O O ~ OTHER / / / / DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLES/SPECIAL ITEMS REBID 3809 LANDFILL CELL 3A/3B CONSTRUCTION/ **THE CITY OF DENTON,ITS OFFICALS,AGENTS.EMPLOYEES AND VOLUNTEERS ARE NAMED AS AD INSUR ~ BLANKET WAIVER OF SUBROGATION ALSO APPLIES CERTIFICATE HOLDER CANCELtATlOt3 _ SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE / EXPIRATI Oy~13ATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL CITY OF DENTON / ~_~DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 9O 1 B TEXAS STREET BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY DENTON, TX 76201 OF ANY UPON THE CO NY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED EN IVE I ........ .................. ...... _.._. ACOFID 25.5 (tl99) ... ............... .. ...... © CORp GORP4RATICIIJ 1988 POLICY BANNER PAGE POLICY NUMBER: 4000004280-071 INSURED: L.D. Kemp Excavating, Inc. POLICY FORMS ARE COMPLETE RuE 27 07 02:20p Mike Briscoe 817-428-5834 THIS ENDORSEMENT CHANGES THE POLICY. PLCASE READ IT CAREFULLY. POLICY CHANGES Policy Change Numbers POLICY NUMBER aooooon2eo-o~i NAMED INSURED ?•.n r[nmr z:xr•.w.aring, Tnc. POLICY CHANGES COMPANY EFFECTIVE nn/7 a/2n07 Everest Indemnity lnsuranrn Company AUTI IORIZCD RCf rC:,CNTATIVE NECC COVERAGE PARTS AFFECTED Commcrciol Cenerel Liobility p.2 CHANGES IN CONSIDERATION OF THE ADDITIONAL PREMIUM OF 3500.00, WHICH IS FULLY EARNED AT ATTACHMENT, IT IS I ICRCDY UNDCRCTOOD AND AGRCCD ThIAT IN THE EVENT THAT £AID POLICY.SHALL NOT BE CANCELLED, NONRENEWED OR MATERIALLY CHANGE WITHOUT 30 DAYS ADVANf_:ED WRITTEN NOTIf_.E BEING C;IVFN T(1 THFj OWNER (CITY OF DENTON. 901 B TEXAS STREET. DENTON. TX 76201) EXCEPT WHEN THE POLICY IS BEING CANCELLED FOR NONPAYMENT OF PREMIUM IN WHICH CASE 70 DAYS ADVANCE WRITTEN NOTICE IS REQUIRED. ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. ~y ~j,,~ __ ~ ~ CFG~[~L~drL°ys- Authorizetl Representative Si9n3tUre rmy 8/^3/0'1 IL 12 01 71 DS Copyright Insurance Services Office, Inc., 1907 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: 4000004280-071 COMMERCIAL GENERAL LIABILITY CG 20 10 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED`DOWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ~~. ORGANIZATION ~~ This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: City of Denton, it's Officals, Agents, Employees and Volunteers 901 B Texas Street Denton, TX 76201 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II -Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment 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 insureds) at the site 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 intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 10 01 ©ISO Properties, Inc., 2000 Page 1 of 1 fiu~ 27 07 02:20p Mike Briseoe 817-428-5834 p.l MCTCE BRTSCOE INSURANCE P O ROX 162747 PUR'1' WO.RT1-l,T$XAS 76161 Pl-IONL (817-428-2295) FAQ (817-428-5834) Em ai I :m bi4(a~mindsprin~. com Dule~/ ~-7 /2007 COIV4PANY: A"f'fENTi FAh NUMBER: ~! 7"0 - 3 ~F 7- ~ ~ S~NUM.I3ER OF PACES: SENDER :MIKE. RRiSCOT', (INCT:C11)>~.R C'nVRR SHF.F.T n RT:FFRENCE: ~~ COMMERCIAL GENERAL LIABILITY ECG 24 515 OS 00 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY PROVISION - YOU~~ OPERATIONS FOR NAMED PERSON This endorsement modifes insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Paragraph 4., Other Insurance of Conditions (Section IV) is amended by the addition of the following: If insurance similar to this insurance is held by a person or organization named below, this insurance is primary to that other insurance, and that other insurance shall not contribute to amounts payable under this insurance, for liability arising out of your ongoing operations performed for that person or organization under a written contrail. However, this does not apply if you did not receive a specific written request from the person or organization named below: a. That this insurance be primary; or b. If that request was not received by you prior to the date that your operations for that person or organization commenced. SCHEDULE Name of Person or Organization: City of Denton, it's Officals, Agents, Employees and Volunteers 901 B Texas Street Denton, TX 76201 But Solely in respect to operations performed by or on behalf of the Named Insured at: Project Location: 1527 S. Mayhill, Denton, TX 76208 Project Number: BID3809 But only at the specifc written request by that person or organization to you, and if: 1. That request is made prior to the date your operations for that person or organization commenced; and 2. A certifcate of insurance evidencing that request is on file with, or received by, us prior to sixty days after the end of the policy period for this insurance. ECG 24 515 OS 00 Copyright, Everest Reinsurance Company 2000 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. used with its permission Copyright, Insurance Services Office, Inc., 1997 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number 2 POLICY NUMBER POLICY CHANGES COMPANY EFFECTIVE 4000004280-071 oe/14/o7 Everest Indemnity Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE L.D. Kemp Excavating, Inc. NECC COVERAGE PARTS AFFECTED Commercial General Liability CHANGES IN CONSIDERATION OF THE ADDITIONAL PREMIUM OF $250.00, WHICH IS FULLY EARNED AT ATTACHMENT, IT IS HEREBY UNDERSTOOD AND AGREED THAT IN THE EVENT OF CANCELLATION, WE AGREE TO MAIL PRIOR WRITTEN NOTICE OF CANCELLATION TO: SCHEDULE 1. Name: City of Denton 2. Address: 901 B Texas Street Denton, TX 76201 3. Number of days advanced notice: 30 Days (10 days for Non-Payment of Premium) ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. ~~ ~ ~~~ Authorized Representative Signature 8/14/07 is IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983