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Home My WebLink AboutCAG2020-286 - Change Order - #2 - Industrial Coatings Unlimited - 640 Water Tank Exterior Cleaning - 09/11/2020ApprovalOriginator:Department: Date Sent:Date Required: Authorized to Sign: o Director or Designee o Mayor Date of Council Approval: Budget Account Number: Budget? o Yes o No Grant? o Yes o No Type:Review/Signatures/RoutingDate Received by City Attorney:Comments: Date Routed to the Mayor’s Office: Date Routed to the City Clerk’s Office:Agreement InformationVendor Name:Category: Vendor Number:Sub-Category: Project Name: Project Details: Agreement Amount: Start Date: Basis for Selection of Contractor: Termination Date: Local Business? o Yes o No* *If meets requirements per KCC 3.70.100, please complete “Vendor Purchase-Local Exceptions” form on Cityspace. Notice required prior to disclosure? o Yes o No Contract Number: Agreement Routing Form For Approvals, Signatures and Records Management This form combines & replaces the Request for Mayor’s Signature and Contract Cover Sheet forms. (Print on pink or cherry colored paper) Visit Documents.KentWA.gov to obtain copies of all agreementsadccW22373_1_20 CHANGE ORDER - 1 OF 3 CHANGE ORDER NO. 2 NAME OF CONTRACTOR: Industrial Coatings Unlimited (“Contractor”) CONTRACT NAME & PROJECT NUMBER: 640 Water Tank Exterior Cleaning ORIGINAL CONTRACT DATE: September 11, 2020 This Change Order amends the above-referenced contract; all other provisions of the contract that are not inconsistent with this Change Order shall remain in effect. For valuable consideration and by mutual consent of the parties, the project contract 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: Correct the error in the amount and sales tax reflected in Change Order No. 1 as reflected in Exhibit A which is attached and incorporated by this reference. The correct amount is as follows: Current Change Order: $4,000 Sales Tax $400 Revised Contract Amount: $17,600 2. The contract amount and time for performance provisions of Section II “Time of Completion,” and Section III, “Compensation,” are hereby modified as follows: Original Contract Sum, (including applicable alternates and WSST) $13,200 Net Change by Previous Change Orders (incl. applicable WSST) $0 Current Contract Amount (incl. Previous Change Orders) $13,200 Current Change Order $4,000 Applicable WSST Tax on this Change Order $400 Revised Contract Sum $17,600 Original Time for Completion (insert date) 12t3U20 Revised Time for Completion under prior Change Orders (insert date) N/A Days Required (+) for this Change Order 0 calendar days Revised Time for Completion (insert date) t2t3lt20 Pursuant to the above-referenced contract, Contractor agrees to waive any protest it may have regarding this Change Order and acknowledges and accepts that this Change Order constitutes final settlement of all claims of any kind or nature arising from or connected with any work either covered or affected by this Change Order, including, without limitation, claims related to contract time, contract acceleration, onsite or home office overhead, or lost profits. This Change Order, unless otherwise provided, does not relieve the Contractor from strict compliance with the guarantee and warranty provisions of the original contract, particularly those pertaining to substantial completion date, All acts consistent with the authority of the Agreement, previous Change Orders (if any), and this Change Order, prior to the effective date of this Change Order, are hereby ratified and affirmed, and the terms of the Agreement, previous Change Orders (if any), and this Change Order 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 contract modification, which is binding on the parties of this contract. 3. The Contractor will adjust the amount of its performance bond (if any) for this project to be consistent with the revised contract sum shown in section 2, above, IN WITNESS, the parties below have executed this Agreement, which will become effective on the last date written below. CONTRACTOR: By @.'tt€ (signature) Print Name: MattNorth Its Field Manaper DATE ftitle) t2-l-20' CITY OF KENT: By Print Name: David A. Brock. P,E. DATE:6 CHANGE ORDER - 2OF 3 CHANGE ORDER - 3 OF 3 ATTEST: ___________________________ Kent City Clerk APPROVED AS TO FORM: (applicable if Mayor’s signature required) Kent Law Department Industrial Coatings - 640 Exterior Cleaning CO2/Reed KENT PUBLIC WORKS Chad Bieren, P.E,, Director OPERATIONS DIVISION Dave Brock, P,8., Deputy Director/Operations Manager Phone: 253-856-5600 Fax: 253-856-6600 WÂsBrÉGroN Mailing Address: 220 Fourth Avenue South Kent, WA 98032-5895 Location Address: 5821 South 240th 64O Water Tank Exterior Cleaning Industrial Coatings Unlimited pressure washed the exterior of the 640 tank and during the cleaníng and inspection of the exter¡or paint condition they noticed approximately 30 spots that needed touch up. we approved thepaint touch up. The original contract for the cleaning with tax was $13,200.00 and the change order amount with tax ¡s 94,400.00 The total of the contract plus the change order is 917,600.00. Thanks, Jim P : C)perations\For'rtrs\Adnti n\PWOpsM ento [:'o l.ur EXHIBIT A ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 9/1/2020 (907) 348-1105 (907) 782-4429 10851 Industrial Coatings Unlimited, LLC PO Box 112629 Anchorage, AK 99511-2629 38733 A 1,000,000 X EF4ML06460-201 9/1/2020 9/1/2021 100,000 Contractors Pollutio 10,000 1,000,000 2,000,000 2,000,000 Pollution 1,000,000 1,000,000B X 20IAS11251 9/1/2020 9/1/2021 4,000,000A X EF4CU01499-201 9/1/2020 9/1/2021 4,000,000 0 A EF4ML06460-201 9/1/2020 9/1/2021 1,000,000 1,000,000 1,000,000 RE: Job #20095; Project# GOODS & SERVICES AGREEMENT "This is evidence of insurance procured and developed under the Alaska Surplus Lines Law AS21.34 It is not covered by the Alaska Insurance Guaranty Association Act, AS21.80." Worldwide Facilities, LLC - License #9718 Carrier A PROJECT: Tank Washing Project @ Martin Sortun Elementary School SCOPE OF WORK: Pressure wash the exterior of (1) 127’ high X 75’ diameter water tank. SEE ATTACHED ACORD 101 City of Kent Engineering Administration & Public Works Dept 220 4th Ave S Kent, WA 98032 INDUCOA-05 SPOPE Hub International Northwest LLC 480 W. Tudor Road Suite 100 Anchorage, AK 99503 Sharon Pope sharon.pope@hubinternational.com Everest Indemnity Insurance Company Alaska National Insurance Company X X X X XX X X X X X X FORM NUMBER: EFFECTIVE DATE: The ACORD name and logo are registered marks of ACORD ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE FORM TITLE: Page of THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, ACORD 101 (2008/01) AGENCY CUSTOMER ID: LOC #: AGENCY NAMED INSURED POLICY NUMBER CARRIER NAIC CODE © 2008 ACORD CORPORATION. All rights reserved. Hub International Northwest LLC INDUCOA-05 SEE PAGE 1 1 SEE PAGE 1 ACORD 25 Certificate of Liability Insurance 1 SEE P 1 Industrial Coatings Unlimited, LLC PO Box 112629 Anchorage, AK 99511-2629 SEE PAGE 1 SPOPE 1 Description of Operations/Locations/Vehicles: The City of Kent is Additional Insured on the General Liability, Auto Liability, and Excess Liability policies, where required by written contract or written agreement, subject to the policies' terms, conditions and exclusions. The General Liability policy shall be primary and non-contributory with any other insurance in force for or which may be purchased by the Certificate Holder, where required by written contract or written agreement, subject to the policy’s terms, conditions and exclusions. Cancellation as per Alaska Statute AS 21.36.220 Advance Notice Required for Premium or Coverage Changes as per Alaska Statute AS 21.36.240 EF4ML06460 - 201 ECG 24 588 12 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY ONGOING AND/OR COMPLETE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART MOTOR VEHICLES POLLUTION LIABILITY COVERAGE PART D Paragraph 4., Other Insurance of Conditions (Section IV) is amended by the addition of the following: If other liability insurance similar to this insurance listing as a Named Insured a person or organization that is: a. An owner of real or personal property on which you are performing operations; or b. A contractor on whose behalf you are performing operations, and this policy names those persons or organizations as additional insureds for those operations, then this insur- ance 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 and/or completed operations performed for that person or organization under a written contract which requires that this insurance be primary. However, this does not apply if the written contract was not executed prior to the date that your operations for that person or organization com- menced. ECG 24 588 12 15 Copyright Everest Reinsurance Company, 2015 Page 1 of 1 ❑ Includes copyrighted material of Insurance Services Office, Inc., with its permission. ANIC CA 1150 10 13 Page 1 of 4 BUSINESS AUTO COVERAGE ENHANCEMENT ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM Various provisions in this endorsement restrict coverage. Read the entire policy carefully to determine rights, duties, and what is and is not covered. Throughout this policy, the words “you” and “your” refer to the Named Insured shown in the Declarations. The words “we”, “us”, and “our” refer to the company providing this insurance. Other words and phrases that appear in quotation marks have special meaning. Refer to SECTION V – DEFINITIONS in the Business Auto Coverage Form. The coverages provided by this endorsement apply per “accident” and, unless otherwise specified, are subject to all of the terms, conditions, exclusions and deductible provisions of the policy, to which it is attached. SECTION II – COVERED AUTO LIABILITY COVERAGE, Paragraph A.1. Who Is An Insured is amended to include: d. Any “employee” of yours while operating an “auto” hired or rented under a contract or agreement in an “employee’s” name, with your permission, while performing duties related to the conduct of your business. e. Any person or organization for whom you have agreed in writing to provide insurance such as is afforded by this Coverage Form, but only with respect to liability arising out of the ownership, maintenance or use of “autos" covered by this policy. If such person or organization has other insurance then this insurance is primary to and we will not seek contribution from the other insurance. SECTION IV – Business Auto Conditions, Paragraph A. 5. – Transfer of Rights of Recovery Against Others To Us is amended to include: 5. Transfer of Rights of Recovery Against Others to Us This condition does not apply to any person(s) or organization(s) to the extent that subrogation against that person or organization is waived prior to the “accident” or the “loss” under a contract with that person or organization. SECTION II – COVERED AUTO LIABILITY COVERAGE, Paragraph A.2.a. (2) – Supplementary Payments is replaced by the following: (2) Up to $10,000 for cost of bail bonds (including bonds for related traffic law violations) required because of an “accident” we cover. We do not have to furnish these bonds. SECTION II – COVERED AUTO LIABILITY COVERAGE, Paragraph A.2.a. (4) – Supplementary Payments is replaced by the following: (4) All reasonable expenses incurred by the “insured” at our request, including actual loss of earnings up to $500 a day because of time off from work. ANIC CA 1150 10 13 Page 2 of 4 SECTION II – COVERED AUTO LIABILITY COVERAGE, Paragraph A.2.c. – Voluntary Property Damage is added as follows: c. Voluntary Property Damage At your written request, we may make a voluntary payment for Property Damage caused by an “insured”, but without liability to a third party, up to $25,000. We will not make a Voluntary Property Damage payment to anyone who is an “insured” under this policy. SECTION III – PHYSICAL DAMAGE COVERAGE, Paragraph A.2. – Towing is replaced by the following: Towing We will pay up to $500 for towing and labor costs incurred each time a covered “auto” that is a: a. Private passenger; b. Truck; c. Pick-up truck; d. Panel ; or e. Van type vehicle under 20,000 lbs. of Gross Vehicle Weight is disabled. However, the labor must be performed at place of disablement. SECTION III – PHYSICAL DAMAGE COVERAGE, Paragraph A.3. – Glass Breakage – Hitting a Bird or Animal – Falling Objects or Missiles is replaced by the following: Glass Breakage – Hitting a Bird or Animal – Falling Objects or Missiles If you carry Comprehensive Coverage for the damaged covered “auto”, we will pay the following under Comprehensive Coverage: a. Glass Breakage; b. “Loss” caused by hitting a bird or animal; and c. “Loss” caused by falling objects or missiles. However, you have the option of having glass breakage caused by a covered “auto’s” collision or overturn considered a “loss” under Collision Coverage. Glass Repair – Waiver of Deductible No deductible applies to glass breakage, if the glass is repaired rather than replaced. SECTION III – PHYSICAL DAMAGE COVERAGE, Paragraph A.4.a. – Transportation Expenses is replaced by the following: a. Transportation Expenses We will pay up to $200 per day to a maximum of $1,500 for temporary transportation expense incurred by you because of the total theft of a covered “auto” that is a: (1) Private passenger; (2) Truck; (3) Pick-up truck; (4) Panel; or (5) Van type vehicle under 20,000 lbs. of Gross Vehicle Weight. We will pay only for those covered “autos” for which you carry either Comprehensive or Specified Causes of Loss Coverage. We will pay for temporary transportation expenses incurred during the period beginning 48 hours after the theft and ending, regardless of the policy’s expiration, when the covered “auto” is returned to use or we pay for its “loss”. ANIC CA 1150 10 13 Page 3 of 4 SECTION III – PHYSICAL DAMAGE COVERAGE, Paragraph A.4.b. – Loss of Use Expenses is replaced by the following: b. Loss of Use Expenses – Hired, Rented, or Borrowed Automobiles We will pay expenses for which an “insured” becomes legally responsible to pay for loss of use of a vehicle hired, rented or borrowed without a driver under a written rental contract or agreement. We will pay for loss of use expenses, if caused by: (1) Other than Collision, only if the Declarations indicate that Comprehensive Coverage is provided for the vehicle withdrawn from service. (2) Specified Causes of Loss only if the Declarations indicate that Specified Causes of Loss Coverage is provided for the vehicle withdrawn from service. (3) Collision only if the Declarations indicate that Collision Coverage is provided for the vehicle withdrawn from service. However, the most we will pay for any expenses for loss of use is $200 per day, to a maximum of $1,500. SECTION III – PHYSICAL DAMAGE COVERAGE, Paragraph A.4.c. – Non-Transportation Loss of Use Expenses is added as follows: c. Non-Transportation Loss of Use Expenses We will pay up to $2,000 for non- transportation expense incurred by you, because of “loss” to a covered “auto”, if caused by: (1) Other than Collision, only if the Declarations indicate that Comprehensive Coverage is provided for the “auto” withdrawn from service; (2) Specified Causes of Loss only if the Declarations indicate that Specified Causes of Loss Coverage is provided for the “auto” withdrawn from service; or (3) Collision only if the Declarations indicate that Collision Coverage is provided for the “auto” withdrawn from service. SECTION III – PHYSICAL DAMAGE COVERAGE, Paragraph A.4.d. – Airbag Coverage is added as follows: d. Airbag Coverage We will pay for the cost to repair, replace, or reset an airbag that inflates for any reason other than as a result of a collision, if the Declarations indicate that the covered “auto” has Comprehensive Coverage or Specified Causes of Loss Coverage. SECTION III – PHYSICAL DAMAGE COVERAGE, Paragraph A.4.e. – Rental Reimbursement Coverage is added as follows: e. Rental Reimbursement Coverage We will pay up to $75 per day for rental reimbursement expenses incurred by you for the rental of an “auto” because of “loss” to a covered “auto” that is a: (1) Private Passenger; (2) Truck; (3) Pick-up truck; (4) Panel; or (5) Van type vehicle under 20,000 lbs. of Gross Vehicle Weight. Payment applies in addition to the otherwise applicable amount of each coverage you have on a covered “auto”. No deductibles apply to this coverage. This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy. Endorsement Effective Policy No. Insured Endorsement No. Countersigned By © Insurance Services Office, Inc., 2009 ANIC CA 1150 10 13 Page 4 of 4 (1) We will pay only for those expenses incurred during the policy period beginning 24 hours after the “loss” and ending, regardless of the policy’s expiration, with the lesser of the following number of days: (a) The number of days reasonably required to repair or replace the covered “auto”. (b) 30 days. (2) This coverage does not apply while there are spare or reserve “autos” available to you for your operations. (3) The Rental Reimbursement Coverage described above does not apply to a covered “auto” that is described or designated as a covered “auto” on Rental Reimbursement Coverage Form CA 99 23. SECTION IV – BUSINESS AUTO CONDITIONS – Paragraph B.2. – Concealment, Misrepresentation Or Fraud is amended by adding Unintentional Failure to Disclose Hazards at the end of Paragraph B.2. as follows: Unintentional Failure to Disclose Hazards If you unintentionally fail to disclose any hazards existing at the inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non-renewal. SECTION IV – BUSINESS AUTO CONDITIONS – Paragraph B.5.b. – Other Insurance is replaced by the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered “autos” you own: (1) Any covered “auto” you lease, hire, rent, or borrow; and (2) Any covered “auto”” hired or rented by your “employee” under a contract in that individual “employee’s” name, with your permission, while performing duties related to the conduct of your business. However, any “auto” that is leased, hired, rented or borrowed with a driver is not a covered “auto”. SECTION V – DEFINITIONS – Paragraph C. – “Bodily injury” is replaced by the following: C. “Bodily injury” means bodily injury, sickness or disease sustained by a person including death or mental anguish resulting from any of these. Mental anguish means any type of mental or emotional illness or disease 725 S.Figueroa Street,19th Floor,Los Angeles,CA 90017 office 213-236-4500 |fax 213-244-9655 WA License #116180 1 CC-R v5.8.19 08/27/2020 C O N F I R M A T I O N O F C O V E R A G E #7708791-01 INSURED:Industrial Coatings Unlimited LLC PO Box 112629 Anchorage,AK 99511 AGENT:Hub International Northwest LLC 480 W.Tudor Road Anchorage,AK 99503 Confirmation of Coverage is effective for 90 days from the effective date unless cancelled or replaced by the Policy. Policy is Effective from 09/01/2020 to 09/01/2021. This is to certify that,in accordance with your instructions,we have procured insurance as hereinafter specified: CARRIER:Everest Indemnity Insurance Co (Non-Admitted)POLICY NO:EF4ML06460201 Renewal of:EF1ML00022191 Coverage:Commercial General Liability Coverage Part –Occurrence Form Contractors Pollution Liability Coverage Part –Occurrence Form (Excluding Mold) Limits:Commercial General Liability Coverage Part –Occurrence Form General Aggregate:$2,000,000 Products/Completed Operations Aggregate:$2,000,000 Personal and Advertising Injury:$1,000,000 Each Occurrence:$1,000,000 Damages to Premises Rented By You:$100,000 Medical Expense:$10,000 Defense Costs:Outside Limits Contractors Pollution Liability Coverage Part –Occurrence Form (Excluding Mold) Aggregate Limit:$2,000,000 Each Pollution Condition Limit:$1,000,000 Defense Costs:In Addition to Limits Stop Gap Liability Coverage Part Bodily Injury By Accident:$1,000,000 Bodily Injury by Disease:$1,000,000 Bodily Injury by Disease:$1,000,000 Policy Aggregate Limit $2,000,000 Deductible:Commercial General Liability Coverage Part –Occurrence Form Deductible Amount:$5,000 Deductible Applies To:B.I.and P.D. Contractors Pollution Liability Coverage Part –Occurrence Form (Excluding Mold) Each Pollution Condition Deductible:$5,000 Deductible Applies To:Damages and Claim Expenses 725 S.Figueroa Street,19th Floor,Los Angeles,CA 90017 office 213-236-4500 |fax 213-244-9655 WA License #116180 2 CC-R v5.8.19 Stop Gap Liability Coverage Part Deductible Each Accident:$1,000 Deductible Each Employee:$1,000 Deductible Applies To:Damages Terms / Exclusions: Industrial Coatings Unlimited LLC Mailing Address:PO Box 112629,Anchorage,Alaska 99511 Policy Period:9/1/20-9/1/21 TRIA Coverage Rejected Common Forms EDEC 324 06 08 Common Policy Declarations EDEC 114 03 99 Schedule of Forms and Endorsements EIL 00 503 07 02 Common Policy Conditions EIL 00 502 03 07 Policy Signature EIL 00 507 10 12 Policy Aggregate Limit Provision EIL 00 553 04 09 Minimum Premium Endorsement EIL 00 21 05 04 Nuclear Energy Liability Exclusion Endorsement EIL 02 531 02 16 Washington Changes -Cancellation EIL 00 554 05 16 Notice of Cancellation By Us To Third Party Endorsement EIL 00 576 03 12 No Premium Audit ECG 03 365 03 20 Communicable Disease Exclusion Commercial General Liability Coverage Part -Occurrence Form EDEC 146 05 00 CGL Declarations Page CG 00 01 12 07 Commercial General Liability Coverage Form (Occurrence) CG 03 00 01 96 Deductible Endorsement CG 21 07 05 14 Exclusion -Access Or Disclosure Of Confidential Or Personal Information And Data-Related Liability -Limited Bodily Injury Exception Not Included CG 21 47 12 07 Employment Related Practices Exclusion CG 22 33 07 98 Exclusion -Testing Or Consulting Errors and Omissions CG 21 49 09 99 Total Pollution Exclusion Endorsement ECG 21 501 06 08 Known,Continuous or Progressive Injury or Damage Exclusion ECG 21 536 07 01 Organic Pathogen,Mold or Fungus Exclusion CG 21 564 06 08 Exclusion –Any Professional Services ECG 21 699 07 09 Exclusion -Asbestos And Silica ECG 25 546 09 15 Limitation -No Stacking Of Occurrence Limits Of Insurance CG 04 35 12 07 Employee Benefits Liability Coverage CG 20 10 07 04 Additional Insured -Owners,Lessees,Contractors -Scheduled Person or Organization CG 20 37 07 04 Additional Insured -Owners,Lessees,Contractors -Completed Operations ECG 20 557 06 08 Additional Insured -Lessor Of Leased Equipment ECG 22 532 11 11 Consolidated Insurance Program And Designated Project Exclusion (With 725 S.Figueroa Street,19th Floor,Los Angeles,CA 90017 office 213-236-4500 |fax 213-244-9655 WA License #116180 3 CC-R v5.8.19 Coverage for Designated Operations) ECG 22 535 08 09 Cross Liability Exclusion ECG 24 506 06 15 Waiver of Transfer Of Rights Of Recovery Against Others To Us ECG 25 536 07 11 Amendment –Per Project(s)General Aggregate Limit With Cap ECG 24 588 12 15 Primary And Noncontributory Provision -Your Ongoing And/Or Completed Operations EIL 00 555 10 09 Coverage -Punitive Damages,Fines And Penalties EIL 00 581 04 12 Waiver Of Deductible -Mediation CG 20 11 04 13 Additional Insured -Managers Or Lessors Of Premises CG 26 88 01 15 Alaska Exclusion Of Certified Acts Of Terrorism CG 20 12 04 13 Additional Insured –State Or Governmental Agency Or Subdivision Or Political Subdivision –Permits Or Authorization CG 20 18 04 13 Additional Insured –Mortgagee,Assignee Or Receiver CG 20 32 04 13 Additional Insured-Engineers,Architects or Surveyors Not Engaged by The Named Insured ECG 03 365 03 20 Communicable Disease Exclusion Contractors Pollution Liability Coverage Part -Occurrence Form (Excluding Mold) EDEC 144 05 00 Contractors Pollution Liability Declarations Page ECG 00 515 06 08 Contractors Pollution Liability Coverage Form -Occurrence Form ECG 21 759 05 14 Exclusion -Access Or Disclosure Of Confidential Or Personal Information And Data-Related Liability ECG 25 546 09 15 Limitation -No Stacking Of Occurrence Limits Of Insurance ECG 00 560 10 10 Emergency Response Expense Coverage ECG 00 561 10 10 Temporary Storage Coverage For Asbestos ECG 04 534 05 00 Claims Expenses Additional Limit Endorsement ECG 04 612 11 08 Loading Or Unloading Coverage Endorsement ECG 04 670 09 11Non-Owned Disposal Site Coverage -Off Site Only ECG 04 683 02 12 Transportation Pollution Liability Coverage (By Or On Behalf Of Named Insured) ECG 20 532 04 12 Additional Insured –Designated Person Or Organization –Ongoing And Completed Operations ECG 22 537 08 09 Cross Liability Exclusion ECG 24 506 06 15 Waiver Of Transfer of Rights Of Recovery Against Others To Us ECG 24 588 12 15 Primary And Noncontributory Provision -Your Ongoing And/Or Completed Operations EIL 00 555 10 09 Coverage -Punitive Damages,Fines And Penalties EIL 00 581 04 12 Waiver Of Deductible -Mediation EIL 21 514 04 12 Consolidated Insurance Program And Designated Project Exclusion (With Coverage For Designated Operations) CG 26 88 01 15 Alaska Exclusion Of Certified Acts Of Terrorism ECG 03 365 03 20 Communicable Disease Exclusion Stop Gap Liability Coverage Part EDEC 104 04 99 Stop Gap Coverage Part Declarations ECG 00 501 06 08 Stop Gap Coverage Part 725 S.Figueroa Street,19th Floor,Los Angeles,CA 90017 office 213-236-4500 |fax 213-244-9655 WA License #116180 4 CC-R v5.8.19 CG 26 88 01 15 Alaska Exclusion Of Certified Acts Of Terrorism ECG 03 365 03 20 Communicable Disease Exclusion 1AS REQUIRED BY THE TERRORISM RISK INSURANCE ACT OF 2015, THE ATTACHED POLICYHOLDER DISCLOSURE NOTICE MUST BE FORWARDED WITH THE BINDER. PLEASE SEE THE ATTACHED IMPORTANT NOTICE FOR ADDITIONAL INFORMATION. Thank you for your order on the above captioned account. This Binding Confirmation is subject to all the terms and conditions of the policy being issued. In the event of cancellation or expiration of this insurance, we are required to hold the insured, his agent or representative responsible for earned premiums in all cases for a time in force, subject to the minimum earned premium, at pro-rate or short-rate (whichever is applicable) of the policy premium charged. ***Please REVIEW this binder for accuracy and notify us immediately if there are any discrepancies or errors. STANDARD TERMS AND CONDITIONS Flat cancellations are not permitted. Minimum earned premium at inception for this policy 25% Premium is due 25 days from the effective date. Confirmation of Coverage is valid for 30 days from the date of this letter. The terms and conditions of this proposal may differ materially from those requested in your submission. We will, upon request, provide sample policy forms for your review prior to binding. Policyholder agrees to accept an electronic policy and other related documents issued by Everest; policyholder may request a written policy. "This Contract is registered and delivered as a surplus line coverage under the insurance code of the state of 725 S.Figueroa Street,19th Floor,Los Angeles,CA 90017 office 213-236-4500 |fax 213-244-9655 WA License #116180 5 CC-R v5.8.19 Washington,Title 48 RCW.It is not protected by any Washington state guaranty association law." Worldwide Facilities LLC -116180 Please review the above carefully;terms and/or conditions may differ from those requested in your submission.In addition to the above mentioned exclusions,the policy contains other standard exclusions;specimen policies are available upon request.Terms herein are summarized for use by a licensed broker and should not be submitted in this format to the applicant.Please call with any questions. This Confirmation of Coverage is subject to all terms and conditions of the policy to be issued.The Confirmation of Coverage shall be terminated and voided by delivery of a policy to either the Insured,his agent or representative.The coverage will remain in effect for the term indicated unless cancelled by the Insured,Worldwide Facilities,LLC or the Company,via written notice. This Confirmation of Coverage is a privileged document and shall not be released or assigned in whole or in part to any other person or entity without the written consent of Worldwide Facilities,LLC,endorsed here on. ANIC CA 069 10 13 Page 1 of 9 BUSINESS AUTO DECLARATIONS Item One - Insured: Item Two - Schedule of Coverages and Covered Autos This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those “autos” shown as covered “autos.” “Autos” are shown as covered “autos” for a particular coverage by the entry of one or more of the symbols from the Covered Autos section of the Business Auto Coverage Form next to the name of the coverage. Coverages Covered Autos Limit Premium Covered Autos Liability Personal Injury Protection (or Equivalent No-fault Coverage) Separately stated in each Personal Injury Protection Endorsement minus deductible Added Personal Injury Protection (or Equivalent Added No-fault Coverage) Separately stated in each added Personal Injury Protection Endorsement Property Protection Insurance (Michigan Only) Separately stated in the Property Protection Insurance Endorsement minus deductible for each accident Auto Medical Payments Each Insured Medical Expense and Income Loss Benefits (Virginia Only) Separately stated in the Medical Expense and Income Loss Benefits Endorsement Uninsured Motorists Separately stated in each Uninsured Motorists Endorsement Underinsured Motorists (When Not Included in Uninsured Motorists Coverage) Separately stated in each Underinsured Motorists Endorsement (When Not Included in Uninsured Motorists Coverage) 9 99 9 @ > > ANIC CA 069 10 13 Page 2 of 9 BUSINESS AUTO DECLARATIONS Item Two - Schedule of Coverages and Covered Autos (Continued) Coverages Covered Autos Limit Premium Physical Damage Comprehensive Coverage Actual cash value or cost of repair, whichever is less, minus deductible for each covered auto, but no deductible applies to loss caused by fire or lightning See ITEM FOUR for hired or borrowed autos. Physical Damage Specified Causes of Loss Coverage Actual cash value or cost of repair, whichever is less, minus deductible for each covered auto for loss caused by mischief or vandalism See ITEM FOUR for hired or borrowed autos. Physical Damage Collision Coverage Actual cash value or cost of repair, whichever is less, minus deductible for each covered auto See ITEM FOUR for hired or borrowed autos. Physical Damage Towing and Labor for each disablement of a private passenger auto Premium for Endorsements Estimated Total Premium* *This policy may be subject to final audit. Item Three - For Owned Auto Coverage, Refer to the Schedule of Covered Autos You Own @. @. 9 99 9 (% 9 99 9 + - 8/ 8 +* !&17& +7 / * + - ' # 7& +% 0 &'5 ?"+-@ # 5 8 0 , ' ' 0 0 # 5 =' & = + 0 ! * 1 5 5 # ; 5 8+@ - @ 7& * * 15 0 0 , ' ; 5 0- 0 ;& ! 1 5 0 0 , ' 75=$&+ 0 =$&8 =41 A5 #-- 0 , ' =$&/0 0 & & 7 =$&5 =$40- 0 , ' ' 7 0 0 , ' !&1 -%. +& =1 * 1=$&= 2# 86 .. ! + &!+ .@ !5 &1 !+ .-@