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HomeMy WebLinkAboutPW13-148 - Original - Tierra Right of Way Services - Horseshoe Bend Levee Project Bartley Reestablishment - 05/15/2013 'tom Records Management. KENT Document WA5HINGTONJan CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerks Office. All portions are to be completed. If you have questions, please contact City Clerk's Office. Vendor Name: Tierra Right of Way Services, Ltd. Vendor Number: JD Edwards Number (� Contract Number: �(,J� 2 This is assigned by City Clerk's Office Project Name: Horseshoe Bend Levee Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment ® Contract ❑ Other: Contract Effective Date: 5/15/13 Termination Date: 5/31/13 Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: Ingrid Willms-Dixon Department: Engineering Detail: (i.e. address, location, parcel number, tax id, etc.): Provide services which includes reviewing claims, determining if additional documentation is needed, prepare a draft report of findings, and review draft letter to displaces for the Horseshoe Bend Levee - Bartley Re-establishment project. S Public\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08 e KENT W A 5 H$N G T C N PROFESSIONAL SERVICES AGREEMENT between the City of Kent and Tierra Right of Way Services, Ltd. THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation (hereinafter the "City"), and Tierra Right of Way Services, Ltd. organized under the laws of the State of Arizona, located and doing business at 1575 E. River Rd., Suite 201, Tucson, AZ 85718, Phone: (520) 319-2106/Fax: (520) 323-3326, Contact: Mack Dickerson (hereinafter the "Contractor"). I. DESCRIPTION OF WORK. Contractor shall perform the following services for the City: The Contractor shall provide services which includes reviewing claims, determining if additional documentation is needed, prepare a draft report of findings, and review draft letter to displacee for the Horseshoe Bend Levee Project Bartley Re-establishment. For a description, see the Contractor's April 15, 2013 Scope of Work which is attached as Exhibit A and incorported by this reference. Contractor further represents that the services furnished under this Agreement will be performed in accordance with generally accepted professional practices within the Puget Sound region in effect at the time those services are performed. II. TIME OF COMPLETION. The parties agree that work will begin on the tasks described in Section I above immediately upon the effective date of this Agreement, and Contractor shall complete the work by May 31, 2013. III. COMPENSATION. The City shall pay Contractor a total amount not to exceed Two Thousand, Four Hundred Dollars ($2,400.00) for the services described in this Agreement. The Contractor shall invoice the City monthly based on time and materials incurred during the preceding month. The hourly rates charged for Contractor's services shall be as delineated in the attached and incorporated Exhibit A. All hourly rates charged shall remain locked at the negotiated rates throughout the term of this Agreement. IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor- Employer Relationship will be created by this Agreement. By their execution of this Agreement, and in accordance with Ch. 51.08 RCW, the parties make the following representations: A. The Contractor has the ability to control and direct the performance and details of its work, the City being interested only in the results obtained under this Agreement. B. The Contractor maintains and pays for its own place of business from which Contractor's services under this Agreement will be performed. C. The Contractor has an established and independent business that is eligible for a business deduction for federal income tax purposes that existed before the City retained Contractor's services, or the Contractor is engaged in an independently established trade, occupation, profession, or business of the same nature as that involved under this Agreement. PROFESSIONAL SERVICES AGREEMENT - 1 (Under$10,000) D. The Contractor is responsible for filing as they become due all necessary tax documents with appropriate federal and state agencies, including the Internal Revenue Service and the state Department of Revenue. E. The Contractor has registered its business and established an account with the state Department of Revenue and other state agencies as may be required by Contractor's business, and has obtained a Unified Business Identifier (UBI) number from the State of Washington. F. The Contractor maintains a set of books dedicated to the expenses and earnings of its business. V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party seven (7) calendar days written notice at its address set forth on the signature block of this Agreement. VI. DISCRIMINATION. In the hiring of employees for the performance of work under this Agreement or any subcontract, the Contractor, its subcontractors, or any person acting on behalf of the Contractor or subcontractor shall not discriminate against any person who is qualified and available to perform the work to which the employment relates as provided for by the City of Kent's Equal Employment Opportunity Policy. Contractor shall execute the attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement. VII. INDEMNIFICATION. Contractor shall defend, indemnify and hold the City, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits, including all legal costs and attorney fees, arising out of or in connection with the Contractor's performance of this Agreement, except for that portion of the injuries and damages caused by the City's negligence. The City's inspection or acceptance of any of Contractor's work when completed shall not be grounds to avoid any of these covenants of indemnification. The provisions of this section shall survive the expiration or termination of this Agreement. In the event Contractor refuses tender of defense in any suit or any claim, if that tender was made pursuant to this indemnification clause, and if that refusal is subsequently determined by a court having jurisdiction (or other agreed tribunal) to have been a wrongful refusal on the Contractor's part, then Contractor shall pay all the City's costs for defense, including all reasonable expert witness fees and reasonable attorneys' fees, plus the City's legal costs and fees incurred because there was a wrongful refusal on the Contractor's part. VIII. INSURANCE. The Contractor shall procure and maintain for the duration of the Agreement, insurance of the types and in the amounts described in Exhibit B attached and incorporated by this reference. XII. CONTRACTOR'S WORK AND RISK. The Contractor agrees to comply with all federal, state, and municipal laws, rules, and regulations that are now effective or in the future become applicable to Contractor's business, equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance of those services. All work shall be done at Contractor's own risk, and Contractor shall be responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. XIII. MISCELLANEOUS PROVISIONS. A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its contractors and consultants to use recycled and recyclable products whenever practicable. A price preference may be available for any designated recycled product B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the covenants and agreements contained in this Agreement, or to exercise any option conferred by this PROFESSIONAL SERVICES AGREEMENT - 2 (Under$10,000) Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and effect. C. Resolution of Disputes and Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute, difference or claim arising from the parties' performance of this Agreement, the exclusive means of resolving that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in writing to an alternative dispute resolution process. In any claim or lawsuit for damages arising from the parties' performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred in defending or bringing such claim or lawsuit, including all appeals, in addition to any other recovery or award provided by law; provided, however, nothing in this paragraph shall be construed to limit the City's right to indemnification under Section VII of this Agreement D. Written Notice. All communications regarding this Agreement shall be sent to the parties at the addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written notice hereunder shall become effective three (3) business days after the date of mailing by registered or certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may be hereafter specified in writing. E. Assignment. Any assignment of this Agreement by either party without the written consent of the non-assigning party shall be void. F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement shall be binding unless in writing and signed by a duly authorized representative of the City and Contractor. G. Entire Agreement. The written provisions and terms of this Agreement, together with any Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the City, and such statements shall not be effective or be construed as entering into or forming a part of or altering in any manner this Agreement Should any language in any of the exhibits to this Agreement conflict with any language contained in this Agreement, the terms of this Agreement shall prevail. IN WITNESS, the parties below execute this Agreement, which shall become effective on the last date entered below. CONTRACTOR: CITY OOFF�KENT:,/ 4 By: tI2By:�////����% ( igeature) (signature) Print N me: tr ieAzgyre^ Print Name: Mark Howlett Its: f,,eC 0. + Its: Design Engineering Manager (title) DATE: r- 10 13 DATE: NOTICES TO BE SENT TO: NOTICES TO BE SENT TO: CONTRACTOR: CITY OF KENT: Mack Dickerson Timothy J. LaPorte, P.E. Tierra Right of Way Services, Ltd. City of Kent 1575 E. River Rd., Suite 201 220 Fourth Avenue South Tucson, AZ 85718 Kent, WA 98032 (520) 319-2106 (telephone) (253) 856-5500 (telephone) (520) 323-3326 (facsimile) (253) 856-6500 (facsimile) PROFESSIONAL SERVICES AGREEMENT - 3 (Under$10,000) DECLARATION CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. As such all contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with the regulations of the City's equal employment opportunity policies. The following questions specifically identify the requirements the City deems necessary for any contractor, subcontractor or supplier on this specific Agreement to adhere to. An affirmative response is required on all of the following questions for this Agreement to be valid and binding. If any contractor, subcontractor or supplier willfully misrepresents themselves with regard to the directives outlines, it will be considered a breach of contract and it will be at the City's sole determination regarding suspension or termination for all or part of the Agreement; The questions are as follows: 1. I have read the attached City of Kent administrative policy number 1.2. 2. During the time of this Agreement I will not discriminate in employment on the basis of sex, race, color, national origin, age, or the presence of all sensory, mental or physical disability. 3. During the time of this Agreement the prime contractor will provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 4. During the time of the Agreement I, the prime contractor, will actively consider hiring and promotion of women and minorities. 5. Before acceptance of this Agreement, an adherence statement will be signed by me, the Prime Contractor, that the Prime Contractor complied with the requirements as set forth above. By signing below, I agree to fulfill the five requirements referenced above. Dated this /Q day of 20/.? . For: i�rraJl�d� Lf� Title: Ica rrGjl�� Date: EEO COMPLIANCE DOCUMENTS - 1 i CITY OF KENT ADMINISTRATIVE POLICY NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998 SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996 CONTRACTORS APPROVED BY Jim White, Mayor POLICY: Equal employment opportunity requirements for the City of Kent will conform to federal and state laws. All contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity within their organization and, if holding Agreements with the City amounting to $10,000 or more within any given year, must take the following affirmative steps: 1. Provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 2. Actively consider for promotion and advancement available minorities and women. Any contractor, subcontractor, consultant or supplier who willfully disregards the City's nondiscrimination and equal opportunity requirements shall be considered in breach of contract and subject to suspension or termination for all or part of the Agreement. Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works Departments to assume the following duties for their respective departments. 1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are familiar with the regulations and the City's equal employment opportunity policy. 2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines. EEO COMPLIANCE DOCUMENTS - 2 CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the Agreement. I, the undersigned, a duly represented agent of 1:,r#-A (Z4Y&l Company, hereby acknowledge and declare that the before-mentionec company was the prime contractor for the Agreement known as 11er" X.1XIgee -,?Ar?eed that was entered Into on lS�2 the k 6l U12 (date), between the firm I represent and the City of Kent. I declare that I compiled fully with all of the requirements and obligations as outlined In the City of Kent Administrative Policy 1,2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned Agreement. Dated this . 20 day of M&V , 20u. By: For; [ i_R/ /w Title: 'd Rusistj _ Date: EEO COMPLIANCE DOCUMENTS - 3 CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the Agreement. / I, the undersigned, a duly represented agent of', lP ✓% 17��21 W611 Gl I Company, hereby acknowledge and declare that the before-mentioned company was the prime contractor for the Agreement known as �,; �a� 3f iJ l uo E - &' �/ that was entered into on the (date) between the firm I represent and the City of Kent. I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned Agreement. Dated this Z`74" day of 2013 By: For: 1 ie> rz. ( 1 Title: + �r�.i r bt Date: `13 EEO COMPLIANCE DOCUMENTS - 3 EXHIBIT A 4LLm ei April 15,2013 Ms. Ingrid Wilms-Dixon,Project Analyst City of Kent,Design Engineering&Public Works 220 Fourth Avenue South Kent,WA 98032 i Re: Horseshoe Bend Levee Project Project 09 3005 3 Bartley Re-establishment Dear Ms.Wilms-Dixon: Per our previous phone conversations,Tierra proposes the following scope of work and budget for the above referenced project: I Scope of Work Receive the City of Kent("the City") relocation file,review claims for reimbursement under moving and re-establishment made by the displaces to determine whether each claim is allowed under the Uniform Act and WSDOT LAG, determine additional documentation that might be needed to support the displacee's claim and draft a report of findings. The deliverable to the City will be a report of findings for each claim Michael Gallagher will perform these services on behalf of Tierra Right of Way Services,Ltd ("Tierra"). The report will be delivered back to the City along with the relocation file upon completion and within 5 business days. Review draft letter to displacee to be prepared by the City of Kent,provide edits and comments Budget, 2 hours for Project Kickoff Meeting between the City and Tierra. 12 hours to review file contents and draft report. 2 hours for meeting between the City and Tierra to review report findings. 4 hours to complete review of draft letter to displacee and provide edits and comments. 20 hours total budgeted, total cost$2,400,00. Should you have any questions,please feel free to contact me. Sincerely, f '�6l�cle 't"�ccrscn,iois I-- Mack Dickerson, SR/WA,RW-RAC, GRI Vice President,Right of Way Operations i Randye K. Ferrick, President & Broker 2611 N.E. 12S11, Street, Suite 202 • Scathe, Washington 40125 • 206.363 ISS6 • Fax: 204.363.0106 flight of Way • CnitLI al Resources > Environmental Planning Federal, State, and local Permitting • G15/CAD Mapping www.tierra-i ow.con EXHIBIT B INSURANCE REQUIREMENTS FOR CONSULTANT SERVICES AGREEMENTS Insurance The Consultant shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which may arise from or in connection with the performance of the work hereunder by the Consultant, their agents, representatives, employees or subcontractors. A. Minimum Scope of Insurance Consultant shall obtain insurance of the types described below: 1. Automobile Liability insurance covering all owned, non-owned, Fired and leased vehicles. Coverage shall be written on Insurance Services Office (ISO) form CA 00 01 or a substitute form providing equivalent liability coverage. If necessary, the policy shall be endorsed to provide contractual liability coverage. 2. Commercial General Liability insurance shall be written on ISO occurrence form CG 00 01 and shall cover liability arising from premises, operations, independent contractors, products-completed operations, personal injury and advertising injury, and liability assumed under an insured contract. The City shall be named as an insured under the Consultant's Commercial General Liability insurance policy with respect to the work performed for the City using ISO additional insured endorsement CG 20 10 11 85 or a substitute endorsement providing equivalent coverage. 3. Workers' Compensation coverage as required by the Industrial Insurance laws of the State of Washington. 4. Professional Liability insurance appropriate to the Consultant's profession. B. Minimum Amounts of Insurance Consultant shall maintain the following insurance limits: 1. Automobile Liability insurance with a minimum combined single limit for bodily injury and property damage of $1,000,000 per accident. 2. Commercial General Liability insurance shall be written with limits no less than $1,000,000 each occurrence, $2,000,000 general aggregate and a $1,000,000 products-completed operations aggregate limit. 1 EXHIBIT B (Continued) 3. Professional Liability insurance shall be written with limits no less than $1,000,000 per claim and $1,000,000 policy aggregate limit. C. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following provisions for Automobile Liability and Commercial General Liability insurance: 1. The Consultant's insurance coverage shall be primary insurance as respect the City. Any Insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the Consultant's insurance and shall not contribute with it. 2. The Consultant's insurance shall be endorsed to state that coverage shall not be cancelled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. 3. The City of Kent shall be named as an additional insured on all policies (except Professional Liability) as respects work performed by or on behalf of the Consultant and a copy of the endorsement naming the City as additional insured shall be attached to the Certificate of Insurance. The City reserves the right to receive a certified copy of all required insurance policies. The Consultant's Commercial General Liability insurance shall also contain a clause stating that coverage shall apply separately to each insured against whom claim is made or suit is brought, except with respects to the limits of the insurer's liability. D. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M. Best rating of not less than A:VII. E. Verification of Coverage Consultant shall furnish the City with original certificates and a copy of the amendatory endorsements, including but not necessarily limited to the additional insured endorsement, evidencing the insurance requirements of the Contractor before commencement of the work. F. Subcontractors Consultant shall include all subcontractors as insureds under its policies or shall furnish separate certificates and endorsements for each subcontractor. All coverages for subcontractors shall be subject to all of the same insurance requirements as stated herein for the Consultant. OP ID:JC CERTIFICATE OF LIABILITY INSURANCE �ATE`M1PD011YYY' 09110112 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE cERTIPCATE NOLOEa THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PULICIE� � BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE 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 endorsements) PRODUCER 602-264-6533 CONTACT Stuckey Ins&Assoc Agencies NAME PHONE I FAX 5343 N 16th Street,Suite 110 602-279-9336 A/c No E,d IF NO). Phoenix,AZ 85016 E-MAIL Larry Stuckey CPCU CLU ADDRESS PRODUCER CUSTOMER ID#TIERR4 INSURE S)AFFORDING COVERAGE NAIC# INSURED Tierra Right of Way INSURERA Phoenix Insurance Company 25623 1575 E River Rd.#201 INSURER a Travelers Prop Cas of America 25674 Tucson,AZ 85718-5831 INSURER Travelers Indemnity Company 25658 INSURER D Travelers Indemnity Co of CT 25682 INSURER E XL Specialty Ins Co 37885 INSURER F COVERAGES CERTIFICATE NUMBER, REVISION NUMBER, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED 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 TD ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IN TYPE OFINSURANCE DDL U R POLICY EFF POLICY EXP IN SR VU 01 POLICY NUMBER MM/DD/YYYY IMMJDDn YYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A X COMMERCIALGENERALLIABILITY X 6804832L470 07/10/12 07/10/13 PREMISES Ea cllmr rice $ 300,000 CLAIMS-MADE oOCCUR MED EXP(Any one person) $ 10,000 X I Contractual Liab PERSONAL B ADV INJURY S 1,000,000 X XCU coverage NO DEDUCTIBLE GENERAL AGGREGATE $ 2,D00,00 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/DPAGG $ 2,000,000 POLICY X PIECT RD- F LOC $ AUTOMOBILE LIABILITY X COMBINED SINGLE LIMIT $ 1,000,� (Ea acwenD B X ANY AUTO BA63991_303 07/10/12 07/10/13 BODILY I NJURY(Per parson) $ ALL OWNED AUTOS NO DEDUCTIBLE BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNEDAUTOS $ I$ UMBPELLA LIA3 X OCCUR EACH OCCURRENCE S 5,00D,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 C CUP7180Y034 07/10/12 07110113 DEDUCTIBLE S rX RETENTION $ 10000 $ WORKERS COMPENSATION X I VVC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER D ANY PROPRIETOR/PARTNER/EXECUTIVEYIN NIA U89213Y784 07/10/12 07/10113 EL EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUGEDo (Mandatory in rH) EL DISEASE-EA EMPLOYE $ 1,000,000 If yes describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 E Professional Liab DPR9700652 07/10/12 i 07110/13 IPer Claim 2,000,000 Includes NETWORK SECURITY LIAB. Aggregate 2,0D0,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Professional Liability -Claims Made-Retro Date 5111/98 City of Kent is Included as additional insured as per written contract as respects to general and auto liability on a primary and non contributory basis CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Kent THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 400 West Gowe ACCORDANCE WITH THE POLICY PROVISIONS Kent,WA 98032 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION All rights reserved ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD TRAVELERSJ� POLICYNUMBER: BA-6399L303-12-GRP EFFECTIVE DATE: 07-10-12 ISSUE DATE: 07-03-12 LISTING OF FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS THIS LISTING SHOWS THE NUMBER OF FORMS, SCHEDULES AND ENDORSEMENTS BY LINE OF BUSINESS. IL TO 02 11 89 COMMON POLICY DECLARATIONS IL T8 01 10 93 FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS IL TO 01 01 07 COMMON POLICY CONDITIONS COMMERCIAL AUTOMOBILE CA TO 01 02 07 BUSINESS AUTO COV PART ITEMS 1, 2 CA TO 02 11 06 BUSINESS AUTO COV PART DEC- ITEM 3 CA TO 03 03 10 BUS AUTO COV PART DECLARATIONS-4&5 CA TO 30 11 06 BUSINESS AUTO/TRUCK COV PART-SUPPL SCHD CA TO 31 03 10 TABLE OF CONTENTS-BUSINESS AUTO COV FORM CA 00 01 03 10 BUSINESS AUTO COVERAGE FORM CA T4 59 03 10 614KNDNENT OF EMPLOYEE DEFINITION CA 01 39 12 Ol NEW MEXICO CHANGES CA 01 75 07 04 ARIZONA CHANGES CA 04 23 07 04 ARIZONA-FULL GLASS COVERAGE CA 20 48 02 99 DESIGNATED INSURED CA 21 39 07 09 ARIZONA UM COVERAGE CA 21 40 07 09 ARIZONA UIM COVE�GE CA 31 29 05 08 NEW MEXICO UNINSURED MOTORIST COVERAGE CA 99 03 03 05 AUTO MED PAY COVERAGE CA 99 10 03 10 DRIVE OTHER CAR COV-BROAD COV NAMED INSD CA T3 40 08 08 BLANKET WAIVER OF SUBROGATION � .�� CA T4 37 08 08 BLANKET ADDITIONAL INSURED S CA 02 50 02 99 NEW MEXICO CANCELLATION CHANGES {i CA T3 04 01 87 AMENDED TITLE-AUTO COVERAGE PARTS INTERLINE ENDORSEMENTS IL 00 21 09 08 NUCLEAR ENERGY tlAB EXCL END-BROAD FORM F 4 I r f t IL T8 01 10 93 PAGE: 1 OF 1 , f i i POLICY NUMBER: 680-4832L470-PHX-12 EFFECTIVE DATE; 07-10-12 ISSUE DATE: 07-03-12 1 I LISTING OF FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS THIS LISTING SHOWS THE NUMBER OF FORNA, SCHEDULES AND ENDORSEMENTS BY LINE OF BUSINESS. ; * IL TO 25 08 01 RENEWAL CERTIFICATE * MP TO O1 02 05 BUSINESSOWNERS COVERAGE PART DECS j * IL TS 01 01 01 FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS IL T3 15 09 07 COMMON POLICY CONDITIONS * IL TO 20 02 05 ADDITIONAL LOCATIONS 1 BUSINESSOWNERS * CP 12 18 06 95 LOSS PAYABLE PROVISIONS * MP T1 30 02 05 TBL OF CONT-BUSINESSOWNERS COV-DELUXE MP Tl 02 02 05 BUSINESSOWNERS PROPERTY COV-SPEC FORM MP T1 05 02 05 AMENDATORY PROVISIONS-OFFICES MP PO 01 09 07 ARCHITECTS,ENGINEERS & SURVEYORS END * MP T3 07 03 97 PROTECTIVE SAFEGUARDS-SPRINK&RESTAURANT MP T3 25 01 08 TERRORISM RISK INS ACT OF 2002 NOTICE * MP T3 29 02 05 ERISA COVERAGE MP T3 50 11 06 EQUIP BREAKDOWN SERV INTERRUPTION LIM MP T3 56 02 08 AMENDATORY PROVISIONS-GREEN BLD * MP T1 55 02 05 AMEND EMPLOYES DISHONESTY LIMIT CP T9 58 02 11 ARIZONA CHANGES CP O1 32 06 04 ARIZONA CHANGES CP 01 60 12 98 WASHINGTON CHANGES - DOMESTIC ABUSE * CP 12 20 06 07 LOSS PAYABLE PROVISIONS-WASHINGTON MP T4 31 12 09 WA CHANGES i COMMERCIAL GENERAL LIABILITY CG D3 15 11 03 BLANKET DESIG LOCATIONS) GENL AGGR LMT CG TO 34 11 03 TABLE OF CONTENTS CG 00 01 10 01 COMMERCIAL GENERAL LIABILITY COV FORM CG D2 55 11 03 AMENDMENT OF COVERAGE - POLLUTION CG D3 09 11 03 AMEND ENDT-PRODUCTS-COMPLETED OPR HAZARD I � XG D3 81 09 07 ADDT INSURED ARCHITECT,ENGINEER,SURVEYOR x CG D3 82 09 07 ADDL INSURED-ARCHITECT,ENGINEER,SURVEYOR * CG D4 71 02 09 AMEND COVERAGE B - PERS & ADV INGURY f CG 21 70 01 08 CAP ON LOSSES-CERTIFIED ACTS-TERRORISM l CG DO 37 04 05 OTHER INSURANCE-ADDITIONAL INSUREDS } * CG D2 03 12 97 AMEND-NON CUMULATION OF EACH OCC f CG D3 79 09 07 ARCHITECT,ENGINEER,SURVEYOR XTEND ENDORS * CG D4 13 04 08 AMENDMENT OF COVERAGE-COOLING-POLLUTION CG D2 88 11 03 EMPLOYMENT-RELA'PED PRACTICES EXCLUSION * CG D3 26 10 11 EXCLUSION - UNSOLICITED COMMUNICATION CC- D3 56 01 05 MOBILE EQUIP/EXCL VEHICLES SUB TO MV LAW � * CG D3 80 10 11 EXCL-ENGIN ARCHITECT OR SURVEY PROF LIAB * TEXT IN THIS FORM HAS CHANGED, OR THE FORM WAS NOT ON POLICY BEFORE. IL T8 0101 01 PAGE: I OF 2 i , � POLICY NUMBER: CUP-7180YO34-12-47 EFFECTN,E DATE: 07/10/2012 ISSUE DATE: 07/03/2012 LISTING OF FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS THIS LISTING SHOWS THE NUMBER OF FORMS, SCHEDULES AND ENDORSEMENTS BY LINE OF BUSINESS ; 1 CO TO 14 04 96 POLICY DECLARATIONS COMMERCIAL EXCESS LIABILITY UMBRELLA IL T8 01 Ol 01 FORMS ENDORSEMENTS AND SCHEDULE NUMBERS 3 UMBRELLA / EXCESS It1 CG DO 23 04 96 SCHEDULE OF UNDERLYING INSURANCE UM 00 Ol 11 03 COMMERCIAL EXCESS LIABILITY UMBRELLA INSURANCE I '>UM 03 45 02 DO AUTO LIABILITY - FOLLOWING FOR14 UM 03 81 01 06 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM -?UM 03 92 ll 03 EMPLOYERS LIABILITY - FOLLOWING FORM UM 04 45 05 06 AMENDMENT OF WHO IS AN INSURED UM 04 77 07 08 AMENDMENT OF DUTIES IN THE EVENT OF OCCURRENCE OR OFFENSE CLAIM UM 04 68 D7 OS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS UM OS 11 02 09 AMENDMENT OF COVERAGE H - PERSONAL INJURY AND ADVERTISING INJURY LIABILITY UM 00 94 08 86 AMENDMENT OF COVERAGE - NAMED INSURED UM O1 52 11 03 EMPLOYEE BENEFITS LIABILITY UM 03 37 01 99 REASONABLE FORCE - BODILY INJURY OR PROPERTY DAMAGE UM 00 76 01 86 NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENTBROAD FORM UM 01 66 08 91 EXCLUSION - LEAD INCLUDING PRODUCTS - COMPLETED OPERATIONS HAZARD UM 01 91 01 02 WAR EXCLUSION UM 01 96 07 96 EXCLUSION - ASBESTOS UM 04 15 10 11 EXCLUSION - UNSOLICITED COMMUNICATIONS UM 04 49 09 07 EXCLUSION - ARCHITECTS ENGINEERS OR SURVEYORS PROFESSIONAL LIABILITY UM 05 30 03 09 EXCLUSION - DISCRIMINATION UM 06 09 10 11 EXCLUSION - VIOLATION OF CONSUMER FINANCIAL PROTECTION j LAWS UM 01 08 11 03 AZ MANDATORY �ENTaORSEMENT INTERLINE ENDORSEMENTS IL T3 68 05 10 FEDERAL TERRORISM RISK INSURANCE ACT DISCLOSURE (4 f e I I S 1 , IL T8 01 01 01 PAGE: 1 of 1 }I t COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following- COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following Is added to WHO IS AN INSURED ;I'NSURANCE (Section 111) for this Coverage (Section II): Part. Any person or organization that you agree in a B. The following is added to Paragraph a. of 4. "contract or agreement requiring insurance"to in- Other Insurance in COMMERCIAL GENERAL clude as an additional insured on this Coverage LIABILITY CONDITIONS (Section IV): Part, but only with respect to liability for"bodily in- However, if you specifically agree in a "contract or jury", "property damage" or "personal injury" agreement requiring insurance"that the insurance caused, in whole or in part, by your acts or omis- provided to an additional Insured under this Cov- sions or the acts or omissions of those acting on erage Part must apply on a primary basis, or a your behalf: primary and non-contributory basis, this insurance a. In the performance of your ongoing opera- is primary to other insurance that is available to tions, such additional insured which-covers such addi- b. In connection with premises owned by or tional insured as a named insured, and we will not rented to you, or share with the other Insurance, provided that. c, In connection with "your work" and included (1) The "bodily injury" or "property damage" for within the "products-completed operations which coverage is sought occurs; and hazard" (2) The "personal injury" for which coverage is m- Such person or organization does not qualify as sought arises out of an offense committed; an additional insured for "bodily injury", "property after you have entered into that "contract or m damage" or "personal injury" for which that per- agreement requiring insurance" But this insur- son or organization has assumed liability in a con- ance still is excess over valid and collectible other tract or agreement insurance, whether primary, excess, contingent or The Insurance provided to such additional insured on any other basis, that is available to the insured is limited as follows when the insured is an additional insured under d. This insurance does not apply on any basis to any other insurance `= any person or organization for which cover- C. The following is added to Paragraph 8. Transfer age as an additional insured specifically is Of Rights Of Recovery Against Others To Us added by another endorsement to this Cover- in COMMERCIAL GENERAL LIABILITY CON- age Part DITIONS (Section IV): e. This insurance does not apply to the render- We waive any rights of recovery we may have ing of or failure to render any "professional against any person or organization because of services". payments we make for "bodily injury", "property f. The limits of insurance afforded to the add!- damage' or "personal injury" arising out of "your fional insured shall be the limits which you woik" performed by you, or on your behalf, under agreed in that "contract or agreement requir- a "contract or agreement requiring insurance"with ing insurance" to provide for that additional that person or organization We waive these insured, or the limits shown in the Declara- rights only where you have agreed to do so as tions for this Coverage Part, whichever are part of the "contract or agreement requiring insur- less This endorsement does not increase the ante"'wifh" such person or organization entered limits of insurance stated in the LIMITS OF into by you before, and in effect when, the "bodily CG D3 81 09 07 ©2007 The Travelers Companies,Inc Page 1 of 2 includes the copyrighted material of Insurance Services Office,Inc,with its permission ooieae - ----- - - -- - ----- COMMERCIAL GENERAL LIABILITY F injury" or "property damage" occurs, or the "per- erage Part, provided that the "bodily injury" and sonal Injury"offense is committed "property damage" occurs, and the "personal in- ©. The following definition is added to DEFINITIONS jury" Is caused by an offense committed. (section V): a. After you have entered into that contract or "Contract or agreement requiring insurance" agreement; means that pail of any contract or agreement un- b. While that part of the contract or agreement is der which you-are required to include a person or in effect; and organization as an additional insured on this Cov- c. Before the end of the policy period. i I II i , Page 2 of 2 ©2007 The Travelers Companies,Inc CG D3 81 09 07 Includes the copyrighted material of Insurance services office,Inc,with its permission 1 � ' v CA T4 37 08 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. The following is added to the Section 11—Liability Coverage, Paragraph A.I.Who Is An Insured Provision Any person or organization that you are required to include as additional insured on the Coverage Form in a written contract or agreement that is signed and executed by you before the "bodily injury"or"property damage"occurs and that is in effect during the policy period is an "insured"for Liability Coverage but only for damages to which this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section 11 I i