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Home My WebLink AboutPW13-002 - Amendment - #2 - A & M Consulting - Utility Coordination for SR 516 to S 231st Way Levee Project - 01/29/2013 e Owds Manag6re KENT Document WASHINGTGN �u 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: A & M Consulting Vendor Number: JD Edwards Number i Contract Number: This is assigned by City Clerk's Office Project Name: SR 516 to S. 231'` Way Levee Description: ❑ Interlocal Agreement ❑ Change Order ® Amendment ❑ Contract ❑ Other: Contract Effective Date: 12/10/14 Termination Date: 12/31/15 Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: Toby Hallock Department: Engineering Contract Amount: Approval Authority: (CIRCLE ONE) ( Department Director Mayor City Council Detail: (i.e. address, location, parcel number, tax id, etc.): Extend the time of completion to December 31, 2015. i As of: 08/27/14 KENT AMENDMENT NO. NAME OF CONSULTANT OR VENDOR: A & M Consulting CONTRACT NAME & PROJECT NUMBER: SR 516 to S. 231st Way Levee ORIGINAL AGREEMENT DATE: January 29, 2013 This Amendment is made between the City and the above-referenced Consultant or Vendor and amends the original Agreement and all prior Amendments. All other provisions of the original Agreement or prior Amendments not inconsistent with this Amendment shall remain in full force and effect. For valuable consideration and by mutual consent of the parties, Consultant or Vendor's work is modified as follows: 1. Section I of the Agreement, entitled "Description of Work," is hereby modified to add additional work or revise existing work as follows: In addition to work required under the original Agreement and any prior Amendments, the Consultant or Vendor shall: The scope of work remains the same, however an amendment is needed to extend the time of completion to December 31, 2015 because the project is still under design. 2. The contract amount and time for performance provisions of Section II "Time of Completion," and Section III, "Compensation," are modified as follows: Original Contract Sum, $5,280.00 including applicable WSST Net Change by Previous Amendments $0 including applicable WSST Current Contract Amount $5,280.00 including all previous amendments Current Amendment Sum $0 Applicable WSST Tax on this $0 Amendment Revised Contract Sum $5,280.00 AMENDMENT - 1 OF 2 Original Time for Completion 12/31/13 (insert date) Revised Time for Completion under 12/31/14 prior Amendments (insert date) Add'I Days Required (f) for this 365 calendar days Amendment Revised Time for Completion 12/31/15 (insert date) The Consultant or Vendor accepts all requirements of this Amendment by signing below, by its signature waives any protest or claim it may have regarding this Amendment, and acknowledges and accepts that this Amendment constitutes full payment and final settlement of all claims of any kind or nature arising from or connected with any work either covered or affected by this Amendment, including, without limitation, claims related to contract time, contract acceleration, onsite or home office overhead, or lost profits. This Amendment, unless otherwise provided, does not relieve the Consultant or Vendor from strict compliance with the guarantee and warranty provisions of the original Agreement. All acts consistent with the authority of the Agreement, previous Amendments (if any), and this Amendment, prior to the effective date of this Amendment, are hereby ratified and affirmed, and the terms of the Agreement, previous Amendments (if any), and this Amendment shall be deemed to have applied. The parties whose names appear below swear under penalty of perjury that they are authorized to enter into this Amendment, which is binding on the parties of this contract. IN WITNESS, the parties below have executed this Amendment, which will become effective on the last date written below. CONSULTANT/VENDOR: CITY OF1KENT: l /l K(signature) Print Name: A , rf` r;/ _ ` `` Print Name: Timothy J. LaPorte, P.E. Its r� = �t '�� Its Public Works Director (title) r DATE ` J ' -�` � � ' �^ DATE: r i APPROVED AS TO FORM: (applicable if Mayor's signature required) i i Kent Law Department I I i A&M Consulting-SR 516 to 231st Amp 2/Munllo AMENDMENT - 2 OF 2 —"--1 ® - JRK DATB(MMlDD1YYYY) CERTIFICATE OF LIABILITY INSURANCE ROOT F0f17fz014 THIS CERTIFICATEIS 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 policylk s)must be endorsed. If SUBROGATIONIS 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 E: AJ GALLAGHER & CO INS BRKRS CA/PHS PWOU ,Eux (866) 467-8730 FAX (877} 905-U457 255202 P: (866) 467-8730 F: (877) 905-0457 ;R'E$R: PO BOX 33015 INSURUNS)APORDING COVERAGE Ni SAN ANTONIO TX 78265 INSURER A: Hartford Casualty Ins Co 29424 INSURED INSURER 8: '.. INSURER C: ARNOLD T0.'4AC DBA A & M CONSULTING INSURERD: 18119 NE 30TH ST INSURER E: REDMOND WA 98052 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 TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. YIPOLICYEFF POLICYEXP )I OR TYPE On INSURANCE ADDL.fURR POLICY.ND'MAER A/M/OD LIMITS /Y ' COMMERCIAL GENERAL LIABILnY EACH OCCURRENCE s2, 000, 000 CLAIMS-MADE OCCUR DAMAGE.(E.ae ED s306 OOO DAMAGES(Eaaccurzence} / A X General Liab X 72 SBM IlK5025 11/01/2014 11/01/2015 MED EXP(My One person) $10, 000 PERSONAL&ADV INJURY s2, 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE s4, 000, 000 POLICY PRO �LOC PRODUCTS-COMPIOPAGG $4, 000, 000 OTHER: JECT COMBINEDLE LIMIT s2, 000,000 AUTOMOBILE LIABILITY (Ea eccidrrd)tleni) ANY AUTO BODILY INJURY(Per person) $ H ALL OWNED SCHEDULED' 72 SBM UK5025 11/01/2014 11/01/2015 BODILY INJURY(Per acckhonp $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Peracli S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LINESCLAIMS-MADE AGGREGATE $ IVORXERSCOAIPEA'SATION PER OTH- AN➢Ed119,0I'INIV LIABILITY STATUTE ER ANY PROPRIETOIUPARTNERfEXECUTIVE YIN E.L.EACH ACCIDENT OFFICERIMEMBER EXCLUDED? ❑ N/A ( andatory In NH)M E.L.DISEASE-EA EMPLOYEE $ If Yes,dBSaibe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below '.. A EMP STOP GAP 72 SBM UK5025 11/01/2014 11/01/2015 $1,000,000/1,000,000/1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Those usual to the Insured's Operations. Certificate Holder is an AdditionalL.. Insured per the Business Liability Coverage Form SS0008 attached to this policy. CERTIFICATE HOLDER CANCELLATION III SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE The City of Kent DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Public Works Engineering AUTHORIZED REPRESENTATIVE 222 4TH AVE S KENT, WA 98032 01988.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD IMPORTANT NOTICE TO POLICYHOLDERS To help your insurance keep pace with increasing costs, we have increased your amount of Insurance . . . giving you r better protection in case of either a partial, or total loss to your property. If you feel the new amount is not the proper one, please contact your agent or broker. a a N O lfl N CN N O O f�l i �C I O n � i 25 This Spectrum Policy consists of the Declarations, Coverage Forms, Common Policy Conditions and any 50 other Forms and Endorsements issued to be a part of the Policy. This insurance is provided by the stock UK insurance company of The Hartford Insurance Group shown below. SBM INSURER: HARTFORD CASUALTY INSURANCE COMPANY ONE HARTFORD PLAZA, HARTFORD, CT 06155 ' COMPANY CODE: 3 T Policy Number: 52 SBMUK5025 DX THE HARTFORD SPECTRUM POLICY DECLARATIONS ORIGINAL m Named Insured and Mailing Address: ARNOLD TOMAC DBA A & M a (No., Street, Town, State, Zip Code) CONSULTING 18119 N.E. 30TH STREET REDMOND WA 98052 m Policy Period: From 11/01/12 To 11/01/13 1 YEAR Ln 12:01 a.m., Standard time at your mailing address shown above. Exception: 12 noon in New Hampshire. N Name of Agent/Broker: AJ GALLAGHER RSK MGMT SVCS INC/PHS Code: 612490 N N Previous Policy Number: 52 SBM UK5025 0 0 m Named Insured is: INDIVIDUAL � I Audit Period: NON-AUDITABLE Type of Property Coverage: NONE Insurance Provided: in return for the payment of the premium and subject to all of the terms of this policy,we agree with you to provide insurance as stated in this policy. TOTAL ANNUAL PREMIUM IS: $425 MP IN RECOGNITION OF THE MULTIPLE COVERAGES INSURED WITH THE HARTFORD, YOUR POLICY PREMIUM INCLUDES AN ACCOUNT CREDIT. Countersigned by 09/17/12 Authorized Representative Date Form SS 00 02 12 06 Page 001 (CONTINUED ON NEXT PAGE) 1 1 tnI /1 z SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 52 SBM UK5025 Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premises as designated by Number below. Location: 001 Building: 001 18119 N.E. 30TH STREET REDMOND WA 98052 Description of Business: REAL ESTATE APPRAISER Deductible: NO COVERAGE BUILDING AND BUSINESS PERSONAL PROPERTY LIMITS OF INSURANCE BUILDING NO COVERAGE BUSINESS PERSONAL PROPERTY REPLACEMENT COST NO COVERAGE PERSONAL PROPERTY OF OTHERS REPLACEMENT COST NO COVERAGE MONEY AND SECURITIES INSIDE THE PREMISES NO COVERAGE OUTSIDE THE PREMISES NO COVERAGE Form SS 00 02 12 06 Page 002 (CONTINUED ON NEXT PAGE) Process Date: 09/17/12 Policy Expiration Date: 11/01/13 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 52 SBM UK5025 BUSINESS LIABILITY LIMITS OF INSURANCE LIABILITY AND MEDICAL EXPENSES $1,000,000 MEDICAL EXPENSES -ANY ONE PERSON $ 10,000 PERSONAL AND ADVERTISING INJURY $1, 000, 000 DAMAGES TO PREMISES RENTED TO YOU $ 300,000 in ANYONE PREMISES o AGGREGATE LIMITS PRODUCTS-COMPLETED OPERATIONS $2, 000,000 0 GENERAL AGGREGATE $2,000, 000 Ln a EMPLOYMENT PRACTICES LIABILITY m COVERAGE: FORM SS 09 01 N N EACH CLAIM LIMIT $ 5,000 0 0 rn DEDUCTIBLE -EACH CLAIM LIMIT 44 NOT APPLICABLE AGGREGATE LIMIT $ 5,000 RETROACTIVE DATE: 11012005 This Employment Practices Liability Coverage contains claims made coverage. Except as may be otherwise provided herein, specified coverages of this insurance are limited generally to liability for injuries for which claims are first made against the insured while the insurance is in force. Please read and review the insurance carefully and discuss the coverage with your Hartford Agent or Broker. The Limits of Insurance stated in this Declarations will be reduced, and may be completely exhausted, by the payment of"defense expense" and, in such event, The Company will not be obligated to pay any further"defense expense" or sums which the insured is or may become legally obligated to pay as "damages". BUSINESS LIABILITY OPTIONAL COVERAGES HIRED/NON-OWNED AUTO LIABILITY $1,000, 000 FORM: SS 01 70 i Form SS 00 02 12 06 Pane 003 (CONTINUED ON NEXT PAGE) SPECTRUM POLICY DECLARATIONS (Continued) POLICYNUMBER: 52 SBM UK5025 BUSINESS LIABILITY OPTIONAL COVERAGES LIMITS OF INSURANCE (Continued) EMPLOYERS LIABILITY AND STOP GAP BODILY INJURY BY ACCIDENT EACH ACCIDENT $1,000,000 BODILY INJURY BY DISEASE EACH EMPLOYEE $1,000, 000 BODILY INJURY BY DISEASE POLICY LIMIT $1,000, 000 APPLICABLE TO LOCATIONS IN THE FOLLOWING STATE W : WASHINGTON WAIVER OF SUBROGATION: - FORM SS 12 15 LOCATION: 001 BUILDING: 001 NAME: IF ANY Form SS 00 02 12 06 Page 004 (CONTINUED ON NEXT PAGE) Process Date: 09/17/12 Policv Exniration Date: 11/01113 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 52 SBM UK5025 ADDITIONAL INSUREDS: THE FOLLOWING ARE ADDITIONAL INSUREDS FOR BUSINESS LIABILITY COVERAGE IN THIS POLICY. LOCATION 001 BUILDING 001 TYPE MANAGER LESSOR 0 NAME SEE FORM IH 12 00 r 0 m ri uoi I, r� O N hD N u'J CV 0 O .-1 m it Form SS 00 02 12 06 Paae 005 (CONTINUED ON NEXT PAGE) SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 52 SBM UK5025 Form Numbers of Forms and Endorsements that apply: SS 00 01 04 93 SS 00 05 12 06 SS 00 08 04 05 SS 00 45 12 06 SS 01 28 10 08 SS 01 70 09 09 SS 41 02 04 05 SS 41 62 06 11 SS 41 63 06 11 SS 05 03 03 00 SS 05 47 09 01 SS 09 01 10 08 SS 09 25 10 08 SS 09 42 07 99 SS 10 04 09 98 SS 12 15 03 00 SS 50 19 03 12 IH 99 40 04 09 IH 99 41 04 09 SS 83 76 03 12 IH 12 00 11 85 ADDITIONAL INSURED - MANAGER/LESSOR Form SS 00 02 12 06 Page 006 PrnrPcQ flats• 09/17/12 Pnliry Fvniratinn Plata• 11 /01 /14 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 52 SBM UK5025 SUPPLEMENTAL DECLARATIONS: A service fee of $ 0006.00 is charged for each installment when your premium is paid in installments. The service fee is $ 0006.00 per withdrawal when you select an electronic fund transfer payment plan. The service fee will be added to the premium amount shown on your premium billing statement. 0 0 N O N N 0 0 .-1 rn i i Form SS 00 45 12 06 Process Date: 09/17/12 Policv Expiration Date: 11/01/13 N Ln i f7 �a-I c-I � 0 N 0 Lnr i N Lf) N 0 0 t-{ f�l �C COMMON POLICY CONDITIONS r,. ce nn ng v> na QUICK REFERENCE - SPECTRUM POLICY DECLARATIONS and COMMON POLICY CONDITIONS I. DECLARATIONS Named Insured and Mailing Address Policy Period Description and Business Location Coverages and Limits of Insurance II. COMMON POLICY CONDITIONS Beginning on Page A. Cancellation 1 B. Changes 1 C. Concealment, Misrepresentation Or Fraud 2 D. Examination Of Your Books And Records 2 E. Inspections And Surveys 2 F. Insurance Under Two Or More Coverages 2 G. Liberalization 2 H. Other Insurance-Property Coverage 2 I. Premiums 2 J. Transfer Of Rights Of Recovery Against Others To Us 2 K. Transfer Of Your Rights And Duties Under This Policy 3 L. Premium Audit 3 Fnrm SS nn 01; 12 n6 COMMON POLICY CONDITIONS All coverages of this policy are subject to the following conditions. A. Cancellation (5) Failure to: 1. The first Named Insured shown in the (a) Furnish necessary heat, water, Declarations may cancel this policy by mailing sewer service or electricity for 30 or delivering to us advance written notice of consecutive days or more, except cancellation. during a period of seasonal 0 2. We may cancel this policy by mailing or unoccupancy; or delivering to the first Named Insured written (b) Pay property taxes that are owing notice of cancellation at least: and have been outstanding for a. 5 days before the effective date of more than one year following the o t1, cancellation if any one of the following date due, except that this N conditions exists at any building that is provision will not apply where you LO Covered Property in this policy; are in a bona fide dispute with the taxing authority regarding payment N (1) The building has been vacant or of such taxes. unoccupied 60 or more consecutive days.This does not apply to: b. 10 days before the effective date of cancellation if we cancel for nonpayment (a) Seasonal unoccupancy; or of premium. (b) Buildings in the course of c. 30 days before the effective date of construction; renovation or cancellation if we cancel for any other addition. reason. Buildings with 65% or more of the rental 3. We will mail or deliver our notice to the first j units or floor area vacant or unoccupied Named Insured's last mailing address known are considered unoccupied under this to us. provision. 4. Notice of cancellation will state the effective (2) After damage by a Covered Cause of date of cancellation. The policy period will end Loss, permanent repairs to the on that date. building: 5. If this policy is canceled, we will send the first (a) Have not started; and Named Insured any premium refund due. (b) Have not been contracted for, Such refund will be pro rata. The cancellation within 30 days of initial payment of will be effective even if we have not made or loss. offered a refund. (3) The building has: 6. If notice is mailed, proof of mailing will be sufficient proof of notice. (a) An outstanding order to vacate; 7. If the first Named Insured,cancels this policy, _ (b) An outstanding demolition order; we will retain -no less than $100 of the or premium. (c) Been declared unsafe by B. Changes governmental authority. This policy contains all the agreements between you (4) Fixed and salvageable items have and us concerning the insurance afforded. The first been or are being removed from the Named Insured shown in the Declarations is building and are not being replaced, authorized to make changes in the terms of this policy This does not apply to such removal with our consent. This policy's terms can be that is necessary or incidental to any amended or waived only by endorsement issued renovation or remodeling. by us and made a part of this policy. i I Pnrm RR nn n5 19 na pans i of I COMMON POLICY CONDITIONS C. Concealment, Misrepresentation Or Fraud I. Premiums This policy is void in any case of fraud by you as it 1. The first Named Insured shown in the relates to this policy at any time. It is also void if you Declarations: or any other insured, at any time, intentionally conceal a. Is responsible for the payment of all or misrepresent a material fact concerning: premiums; and 1. This policy; b. Will be the payee for any return premiums 2. The Covered Property; we pay. 3. Your interest in the Covered Property; or 2. The premium shown in the Declarations was 4. A claim under this policy. computed based on rates in effect at the time D. Examination Of Your Books And Records the policy was issued. If applicable, on each renewal, continuation or anniversary of the We may examine and audit your books and effective date of this policy, we will compute records as they relate to the policy at any time the premium in accordance with our rates and during the policy period and up to three years rules then in effect. afterward. 3. With our consent, you may continue this policy E. Inspections And Surveys in force by paying a continuation premium for We have the right but are not obligated to: each successive one-year period. The 1. Make inspections and surveys at anytime: premium must be: a. Paid to us prior to the anniversary date;and 2. Give you reports on the conditions we find; and 3. Recommend changes. b. Determined in accordance with Paragraph 2. above. Any inspections, surveys, reports or Our forms then in effect will apply. If you do recommendations relate only to insurability and the not pay the continuation premium, this policy premiums to be charged. We do not make safety will expire on the first anniversary date that we inspections. We do not undertake to perform the duty have not received the premium. of any person or organization to provide for the health or safety of any person. And we do not represent or 4. Changes in exposures or changes in your warrant that conditions: business operation, acquisition or use of 1. Are safe or healthful; or locations that are not shown in the Declarations may occur during the policy period, If so,we may 2. Comply with laws, regulations, codes or require an additional premium. That premium will standards. be determined in accordance with our rates and This condition applies not only to us, but also to rules then in effect. any rating, advisory, rate service or similar J. Transfer Of Rights Of Recovery Against Others organization which makes insurance inspections, To Us surveys, reports or recommendations. Applicable to Property Coverage: F. Insurance Under Two Or More Coverages If any person or organization to or for whom we If two or more of this policy's coverages apply to make payment under this policy has rights to the same loss or damage, we will not pay more recover damages from another, those rights are than the actual amount of the loss or damage. transferred to us to the extent of our payment. G. Liberalization That person or organization must do everything If we adopt any revsion that would broaden the necessary to secure our rights and must do c nothing after loss to impair them. But you may overage under this policy without additional premium within 45 days pdorto or during the policy waive your rights against another party in writing: period, the broadened coverage will immediately 1. Prior to a loss to your Covered Property. apply to this policy. 2. After a loss to your Covered Property only if, at H. Other Insurance -Property Coverage time of loss,that party is one of the following: If there is other insurance covering the same loss a. Someone insured by this insurance; or damage, we will pay only for the amount of b. A business firm: covered loss or damage in excess of the amount (1) Owned or controlled by you; or due from that other insurance, whether you can collect on it or not. But we will not pay more than (2) That owns or controls you; or the applicable Limit of Insurance. Panp 7 of A Farm SS 00 05 12 06 COMMON POLICY CONDITIONS c. Yourtenant. L. Premium Audit You may also accept the usual bills of lading or a. We will compute all premiums for this policy in shipping receipts limiting the liability of carriers. accordance with our rules and rates. This will not restrict your insurance, b. The premium amount shown in the K. Transfer Of Your Rights And Duties Under This Declarations is a deposit premium only. At the Policy close of each audit period we will compute the Your rights and duties under this policy may not be earned premium for that period. Any transferred without our written consent except in additional premium found due as a result to the case of death of an individual Named Insured. the the audit are due and payable ble notice the first Named Insured. If the deposit If you die, your rights and duties will be transferred premium paid for the policy term is greater to your legal representative but only while acting than the earned premium, we will return the h within the scope of duties as your legal excess to the first Named Insured. representative. Until your legal representative is c. The first Named Insured must maintain all appointed, anyone having proper temporary records related to the coverage provided by a custody of your property will have your rights and this policy and necessary to finalize the o duties but only with respect to that property. premium audit, and send us copies of the N same upon our request. 0 N rn N 0 Our President and Secretary have signed this policy. Where required by law,the Declarations page has also been countersigned by our duly authorized representative. Terence Shields,Secretary Andri A Napoli,Resident i THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM This endorsement modifies insurance provided under the following: � I BUSINESS LIABILITY COVERAGE FORM o OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM SPECIAL PROPERTY COVERAGE FORM STANDARD PROPERTY COVERAGE FORM a UMBRELLA LIABILTY PROVISIONS 0 N 0 A. Disclosure Of Federal Share Of Terrorism 3. The act is a violent act or an act that is Losses dangerous to human life, property or CN i.n infrastructure and is committed by an individual N The United States Department of the Treasury will o . reimburse insurers for 85% of that portion of insured or individuals acting as part of an effort to losses attributable to"certified acts of terrorism"that coerce the civilian population of the United * exceeds the applicable insurer deductible. States or to influence the policy or affect the However, if aggregate industry insured losses under conduct of the United States Government by the federal Terrorism Risk Insurance Act, as coercion. amended ("TRIA") exceed $100 billion in a Program If aggregate industry insured losses attributable to Year (January 1 through December 31), the "certified acts of terrorism" under TRIA exceed $100 Treasury shall not make any payment for any billion in a Program Year (January 1 through portion of the amount of such losses that exceeds December 31), and we have met, or will meet, our '- $100 billion. The United States government has not insurer deductible under TRIA, we shall not be liable charged any premium for their participation in for the payment of any portion of the amount of such covering terrorism losses. losses that exceed $100 billion. In such case, your = coverage for terrorism losses may be reduced on a B. Cap On Insurer Liability for Terrorism Losses pro-rats basis in accordance with procedures A "certified act of terrorism" means an act that is established by the Treasury, based on its estimates certified by the Secretary of the Tr`'easury, in of aggregate industry losses and our estimate that _ concurrence with the Secretary of State and the we will exceed our insurer deductible. In Attorney General of the United States to be an act accordance with the Treasury's procedures, of terrorism under TRIA. The criteria contained in amounts paid for losses may be subject to further TRIA for a "certified act of terrorism" include the adjustments based on differences between actual following: losses and estimates. 1. The act results in insured losses in excess of$5 C. Application Of Exclusions Million in the aggregate, attributable to all types The terms and limitations of any terrorism exclusion, of insurance subject to TRIG; and the inapplicability or omission of a terrorism 2. The act results in damage within the United exclusion, or the inclusion of terrorism coverage, do States, or outside the United States in the case not serve to create coverage for any loss which of certain air carriers or vessels or the premises would otherwise be excluded under this Coverage of an United States mission; and Form or Policy, such as losses excluded by the Nuclear Hazard Exclusion or the War And Military Action Exclusion. i Form SS 50 19 03 12 Page 1 of 1 Cc) 2012. The Hartford POLICY NUMBER: 52 SBM UK5025 Aa THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGER/LESSOR I � THE CITY OF KENT r PUBLIC WORKS ENGINEERING 0 222 FOURTH AVE. SO. KENT WA 98032 M c-I ri 0 N O Lt7 N N N O C? m x I i I Form IH 12 00 11 85 T SEQ.NO. 002 Printed in U.S.A. Page 001 I Process Date: 0 9/17/12 Expiration Date: 11 t 01113 THE HARTFORD Named Insured: ARNOLD TOMAC DBA A & M Policy Number: 52 SBM UK5025 Effective Date: 11/01/12 Expiration Date: 11/01/13 r� a Company Name: AJ GALLAGHER RSK MGMT SVCS INC/PHS 0 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. N TRADE OR ECONOMIC SANCTIONS ENDORSEMENT � I N N o This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit us from providing insurance, including, but not limited to,the payment of claims. _ I All other terms and conditions remain unchanged. I Form IH 99 41 04 09 Page 1 of 1 POLICY NUMBER: 52 SBM UK5025 THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT. DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT 0 m SCHEDULE 0 cv 0 un Terrorism Premium(Certified Acts): �n N $ $5.00 o j o � d � m A. Disclosure Of Premium C. Cap On Insurer Liability for Terrorism Losses In accordance with the federal Terrorism Risk If aggregate industry insured losses attributable to Insurance Act, as amended ("TRIA"), we are "certified acts of terrorism" under TRIA exceed $100 required to provide you with a notice disclosing the billion in a Program Year (January 1 through o portion of your premium, if any, attributable to December 31) and we have met, or will meet, our coverage for certified acts of terrorism under TRIA, insurer deductible under TRIA, we shall not be liable The portion of your premium attributable to such for the payment of any portion of the amount of such coverage is shown in the Schedule of this losses that exceed $100 billion. In such case, your endorsement. coverage for terrorism losses may be reduced on a B. Disclosure Of Federal Share Of Terrorism pro-rata basis in accordance with procedures Losses established by the Treasury, based on its estimates The United States Department of the Treasury will of aggregate industry losses and our estimate that '— we will exceed our insurer deductible, in accordance reimburse insurers for 85% of that portion of insured with the Treasury's procedures, amounts paid for losses attributable to "certified acts of terrorism" losses may be subject to further adjustments based under TRIA that exceeds the applicable insurer on differences between actual losses and estimates. deductible. D. All other terms and conditions remain the same. However, if aggregate industry insured losses under TRIA exceed $100 billion in a Program Year (January 1 through December 31), the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. The United States government has not charged any premium for their participation in covering terrorism losses. Form SS 83 76 03 12 Page 1 of 1 n, OnI0 Th. i-I�rffnrrl I,. Policy Number: 52 SSM UK5025 IMPORTANT NOTICE TO POLICYHOLDERS DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT Lo SCHEDULE ri rf 0 N Terrorism Premium (Certified Acts): Lo $ $5.00 N 02 N 0 0 .-i m �e A. Disclosure Of Premium C. Cap On Insurer Liability for Terrorism Losses In accordance with the federal Terrorism Risk If aggregate industry insured losses attributable to Insurance Act, as amended ("TRIA"), we are "certified acts of terrorism" under TRIA exceed $100 required to provide you with a notice disclosing the billion in a Program Year (January 1 through portion of your premium, if any, attributable to December 31), and we have met, or will meet, our coverage for certified acts of terrorism under TRIA. insurer deductible under TRIA, we shall not be liable The portion of your premium attributable to such for the payment of any portion of the amount of such coverage is shown in the Schedule of this losses that exceed $100 billion. In such case, your endorsement. coverage for terrorism losses may be reduced on a B. Disclosure Of Federal Share Of Terrorism pro-rata basis in accordance with procedures Losses established by the Treasury, based on its estimates of aggregate industry losses and our estimate that The United States Department of the Treasury will we will exceed our insurer deductible. In accordance reimburse insurers for 85°lo of that portion of insured with the Treasury's procedures, amounts aid for losses attributable to "certified acts of terrorism" rys p under TRIA that exceeds the applicable insurer losses may be subject to further adjustments based — on differences between actual losses and estimates. deductible. D. All other terms and conditions remain the same. However, if aggregate industry insured losses under TRIA exceed $100 billion in a Program Year (January 1 through December 31), the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. The United States government has not charged any premium for their participation in covering terrorism losses. Form SS 83 80 03 12 Page 1 of 1 O 2012, The Hartford flnrinriag rnnvrinhfari matarinl of the Ingnranra Aaniirps Offica Inc with itg nermigginn 1