HomeMy WebLinkAboutCAG2020-216 - Amendment - #2 - Green River Natural Resource Area South Stormwater Pump StationApprovalOriginator: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
AMENDMENT - 1 OF 2
AMENDMENT NO. 2
NAME OF CONSULTANT OR VENDOR: Jacobs Engineering Group Inc.
CONTRACT NAME & PROJECT NUMBER: Green River Natural Resource Area South
Stormwater Pump Station
ORIGINAL AGREEMENT DATE: December 16, 2019
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:
No change to the scope of work, however an amendment is
needed to extend the time of completion to December 31,
2021. The remaining budget will be utilized should questions
arise during the first year of the pump station's service.
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,
including applicable WSST
$65,500
Net Change by Previous Amendments
including applicable WSST
$41,800
Current Contract Amount
including all previous amendments
$107,300
Current Amendment Sum $0
Applicable WSST Tax on this
Amendment
$0
Revised Contract Sum $107,300
AMENDMENT - 2 OF 2
Original Time for Completion
(insert date)
Revised Time for Completion under
prior Amendments
(insert date)
QD
Add’l Days Required (±) for this
Amendment
calendar days
Revised Time for Completion
(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:
By:
(signature)
Print Name:
Its
(title)
DATE:
CITY OF KENT:
By:
(signature)
Print Name:
Its
(title)
DATE:
ATTEST:
___________________________
Kent City Clerk
APPROVED AS TO FORM:
(applicable if Mayor’s signature required)
Kent Law Department
Jacobs - GRNRA South PS 4 Amd 2/Lincoln
David L. Allison
Manager of Projects
December 29, 2020
Environmental Engineering Manager
12/29/2020
Michael P. Mactutis
COVERAGES
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER: se61ss81 REVISION NUMBER
DATE (MM/DD/YYYY}
o6 /26 /2020
RMATION 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
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFO
RTIFICATE
sTHI RTIFICACE OFTE N Us CERAN ESDO NOT CONSTITUTE coA BNTRACT ETWEEN TH ISSUIE GN N Us AUTHO RIZEDRER(S),
ORTIVE UPROD AND ETH Ec HCER,o ER.LD
thetf hocertificate lderT:ts na DAD ITIONAL SUN theRED,stmu ADDITIONALhave INSUREDpolicy(beor rsedendoprovisions
s BROU TIONGA WAIVEts thto termse nda ditiocon n theofsubjectD,certain licies anrepolcy'po ent.endorsem statemA onentrequimay
ts rtificatece ndoes coot nnfer theto holcertificate de n suchof
L
tf
th
1-2r.2-948-L306
.MAIL
,DDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
pRoDUcER LIC #0437153
Marsh Risk & Inaurance Servicee
CIRTg_Support@j acobs . com
533 W. Fif th St,reet.
I-212-948 -L306
Loe Ànge1ee, CÀ 90071 ¡NSURERA. ACE ÀMER INS CO 22667
INSURER B :
INSURER C
INSURER D :
INSURER E
INSURED
ilacobs Engineering Group Inc.
C/O Global Risk lIanagement
1000 wil-shire B1vd., Suite 2100
Los Angeles, CÀ 90017 INSURER F :
CERTIFICATE MAY
TH ISù CERTIFYTO TTHA ETH POLIC OFES NSU CERAN L EST BELOWD HAVE EE N ISSUED THETO UREDINS NAMED ABOVE THEFOR PPOLICY RIODE
ND CATED,ANDINOTWITHST ANYNG REOU TERI\,4REMENT CONDITOR OFtoN coANY oNTRACT R OTHER MENTDOCU WITH PRES ECT WHICTO THH IS
YMA BE ùù ORUED RTAIPE THE URANCINS EN,AFFORDED B ETH LIPO CIES ESCRIBED HEREIN SUBJIS TOECT THALL TE E RMS
ùIEXCLU ANONS CONDD roNIT OFS UCHS POLtCI LES.SHOWNMITS YMA VEHA REBEEN CEDU BYD CLAIMSPAID
TYPÊ OF INSURANCE LIMITS
x EACH RRENCE $ 3,000,000
500,000
x
IVED EXP one $ 5,000
PERSONAL & ADV INJURY 3, 000, 000
GENERAL AGGREGATE 3,000,000
PRODUCTS - COMPiOP $ 3, 000, 000
COMMERCIAL GENERAL LIABILITY
x
CONTRÀCTUÀL IJIABILTTY
AGGREGATE LIN/lIT APPLIES PER:
x PRO.JECT I J
POLICY LOC
CLAIMS-MADE OCCUR
HDO G7r452694 07 /ot/20 07 /0J,/21,
$
$ 1,000,000
BODILY INJURY (Per person)$
BODILY INJURY (Per acc¡dent)$
$
À LIABILITY
SCHEDULED
AUTOS
NON.OWNED
AUTOS ONLY
ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONtY
rsÀ H25307306 07 /0r/20 07 /0
$
OCCURRENCE
UMBRELLA LIAB
EXCESS LIAB
OCCUR
AGGREGATE $
E.L. EACH ACCIDENT g 1,000,000
E.L. DISEASE. EA EM 1,000,000
À WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIEIORiPARTNERYEXECUTIVE
OFF I CER/¡,4 E¡i1 BER EXCLU DE D?N
Y/N
(Mandatory ¡n
If
NH)
under
N/A
wLR C57460303 sToP-cAP /oa/20 07 /07/2t
DISEASE - POLICY LII\,,IIT 1,000,000
A PROFESSIONÀIJ LIÀBIIJITY
trCLAIMS I{ÀDEil
EON c21655065 011 07 /ot/20 07 /0]-/2r PER CIJÀIM/PER ÀGG
ÀGGREGÀTE
DEFENSE INCLUDED
3, 000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Add¡tional Remarks Schedule, may be attâched ¡f more space ¡s rêquired)
MGRPRO.¡ECT ikEr IBrodah MGRCONTRÀCT KePaulíne II um RE Con ructiont o thef Greenphase Ri Naver ttura ResourceÀreatcaonatPumpectCONTRÀCTProjENDTEDÀL32012/0 NI'MBERPRO.JECT x7w3 0062 SECTOR cPubIi cí fo Kent LtyaaddedaddianLntionalfauredor1a1Iabiligener&foau l-íabi1t i aEty the ofrespectð the ainsured nnegligenc theoformancefinguredspercertotrvL¡te ec a derhoI conunder fortract oned workcapti gt andCoveragep certí ICaf.r:.mary
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TE
ACORD 25 (2016t031
Cert Renewal
CELLA
o 1988_2015 ACORD COR
The ACORD name and logo are reg¡stered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.
City of Kent
USA
Kent, WA 98032
220 Avenue South
AUTHORIZED REPRESENTATIVE
toal Eôol
PORATION. All rights reserved
Named lnsured Jacobs Engineering Group lnc.Endorsement Number
5
Policy Symbol
HDO
Policy Number
G71452694
Policy Per¡od
07 101 12020 ro 07 101 12021
Effective Date of Endorsement
lssued By (Name of lnsurance Company)
ACE American lnsurance Company
GoNSTRUCTTON PROJECT(S) GENERAL AGGREGATE LrMrT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING
COMMERC¡AL GENERAL LIABILITY COVERAGE FORM
A. Subject to and eroding the General Aggregate Limit shown in the Declarations, for all sums which the insured
beeomes legally obligated to pay as damages eaused by "oeeurrenees" under COVERAGE A (SECTION l), and for
all medical expenses caused by accidents under COVERAGE C (SECTION l), which can be attributed only to
ongoing operations at your construction projects away from premises owned by or rented to you (such ongoing
operations at such construction projects are hereinafter defined as "Your Projects"):
1. A separate Construction Project General Aggregate Limit applies to all of Your Projects, and that limit is equal to
the amount required under written contract, but in no event greater than the General Aggregate Limit shown in
the Declarations.
2. The Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under
COVERAGE A, except damages because of "bodily injury" or "property damage" included in the "products-
completed operations hazard", and for medical expenses under COVERAGE C, which damages and medical
expenses can be attributed only to Your Projects, regardless of the number of:
a. lnsureds;
b. Claims made or "suits" brought; or
c. Persons or organizations making claims or bringing "suits"
3. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses that can
be attributed to Your Projects shall reduce the Construction Project General Aggregate Limit and shall also
reduce and erode the General Aggregate Limit shown in the Declarations.
4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Expense continue to apply.
However, such limits will be subject to the Construction Project General Aggregate Limit, as well as the General
Aggregate Limit shown in the Declarations.
B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under
COVERAGE A (SECTION I ), and for all medical expenses caused by accidents under COVERAGE C (SECTION I ),
which cannot be attributed only to Your Projects:
Any payments made under COVERAGE A for damages or under GOVERAGE C for medical expenses shall
reduce the amount available under the General Aggregate Limit or the Products-Completed Operations
Aggregate Limit, whichever is applicable; and
2. Such payments shall not reduce the Construction Project General Aggregate Limit.
C. When coverage for liability arising out of the "products-completed operations hazard" is provided, any payments for
damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard" will
reduce the Products-Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the
Construction Project General Aggregate Limit.
MS-22357 (07117) @chubb. 2010. Atl rishts resorved. Page 1 of 2
GoNSTRUCT|ON PROJECT(S) GENERAL AGGREGATE LtMtT
D. lf any one or more of Your Projects has been abandoned, delayed, or abandoned and then restarted, or if the
authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still
be deemed to be the same construction project.
E. The provisions of Limits Of lnsurance (SECTION lll) not othen¡vise modified by this endorsement shall continue to
apply as stipulated.
MS-22357 (07t17)@Chubb.2016. All rights reserved.Page 2 of 2
Named lnsured JaCobS Engineering GrOUp lnC,Endorsement Number
270
Policy Symbol
HDO
Policy Effective Date of
G71452694 07 101 12020 ro 07 lO1 12021
ACE American lnsurance Company
ADDITIONAL INSURED . AUTOMATIC STATUS
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
COMMERC¡AL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name of Person or Organization: Any person or organization for whom any Named lnsured is required by written
contract or agreement entered into prior to the loss to provide insurance, where such written contract or agreement does
not expressly identify a particular lnsurance Service Organization Form to be applied to their additional insured status.
Who ls An lnsured (Section ll) includes as an additional insured the person or organization shown in the Schedule, but the
insurance shall not exceed the scope of coverage and/or limits of this policy. Notwithstanding the foregoing sentence, in
no event shall the insurance provided such additional insured exceed the scope of the coverage and/or limits required by
said contract or agreement; and, if such additional insured's scope of coverage is not expressly stated in such contract or
agreement, then such coverage is limited to the additional insured's vicarious liability to the extent directly caused by the
Named lnsured's negligence during the Named lnsureds ongoing operations. This insurance shall be primary insurance to
the extent required by said contract or agreement, and any other insurance or self-insurance maintained by such person
or organization shall be noncontributory with the insurance provided hereunder to the extent specified in said contract
agreement,
Where the contract or agreement provides that the additional insured's scope of coverage is for the Named lnsured's
indemnity obligations under such contract or agreement, then such coverage shall be limited to the extent such indemnity
obligations are enforceable under applicable law.
Notwithstanding the foregoing sentence, in no event shall the insurance provided such additional insured exceed the
scope of coverage required by said contract or agreement.
Notwithstanding anything to the contrary, the coverage provided an additional insured under this endorsement shall be
limited to the minimum coverage limits required to be provided by the Named lnsured under the written contract or
agreement,
MS-32057 (07/19)@Chubb. 2016. All rights reserved.Page 1 of 1
Namod lnsured Jacobs Engineering Group lnc.hndorssment Number
165
Policy Symbol
ISA
Policy Number
H25307306
Pol¡cy Period
07 101 12020 ro 07 tol t2021
Etfec{ive Date of Endorsemenl
lssusd tsy (Name of lnsurance company)
ACE American lnsurance Company
ADDITIONAL INSURED. DESIGNATED PERSONS OR ORGANIZATIONS
THIS ENDORSEMENT CHANGES THE POL¡CY. PLEASE READ IT CAREFULLY.
TH¡S ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
BUSINESS AUTO COVERAGE FORM
Additional lnsured(s): Any person or organization whom you have agreed to include as an additional insured under a
written contract, provided such contract was executed prior to the date of loss.-Project and/or Contract: All projects and/or
contracts where you perform work for such additional insured pursuant to any such written contract.
A. For a covered 'auto," Who ls lnsured is amended to include as an "insured,' the persons or organizations named in
this endorsement, However, these persons or organizations are an "insured" only for "bodily injury" or "propeny
damage" resulting from acts or omissions of:
1. You.
2, Any of your "employees'or agents,
3. Any person operating a covered "auto" w¡th permission from you, any of your "employees" or agents.
B' The persons or organizations named in this endorsement are not liable for payment of your premium,
C' W¡th respect to the insurance afforded to these additional insureds, the following applies:
lf coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf ofthe additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of lnsurance shown in the Declarations;
whichever is less.
lf such additional insured's scope of coverage is not expressly stated in a contract or agreement, then suchcoverage is limited to the additional insured's vicarious liability to the extent direcfly caùsed by the Named
lnsured's negligence during the Named lnsureds ongoing operations. This insurance shall be primary insuranceto the extent required.by said contract or agreement, and any other insurance or self-insurancä mainiained bysuch person or organization shall be noncontributory with thé insurance provided hereunder to the extentspecified in said contract agreement.
Where the contract or agreement provides that the additional insured's scope of coverage is for the namedinsured's indemnity obligations under such contract or agreement, then suih coverage ınall ¡e limited to theextent such indemnity obligations are enforceable under applicable law.
MS-60621 (07/18) @chubb. 201ô. Arr rishts reserved. page 1 of 1
Named lnsured JacObs Engineering Group lnc.Endorsement Number
15
Policy Symbol
HDO
P0licy Number
G71452694
Pol¡cy Period
07 101 12020 ro 07 101 12021
Effective Date of Endorsement
lssued By (Name of lnsurance Company)
ACE American lnsurance Company
4
NOTICE TO OTHERS ENDORSEMENT - SCHEDULE - EMAIL ONLY
lnsert the policy number. The remainder of the Information is to be completod only when this endorsement is issued subsequent to the preparation of the policy.
THIS ENDORSEMENT CHANGES THE POLIGY. PLEASE READ IT CAREFULLY.
A. lf we cancel the Policy prior to its expiration date by notice to you or the first Named lnsured for any reason other than
nonpayment of promium, we will ondeavor, as 6ot out bolow, to eond writton noticc of canccllation, vio such cloctronic
notification as we determine, to the persons or organizations listed in the schedule that you or your representative
provide or have provided to us (the "Schedule"). You or your representative must provide us with the e-mail address
of such persons or organizations, and we will utilize such e-mail address that you or your representative provided to
us on such Schedule.
B. The Schedule must be initially provided to us within 15 days after:
i. The beginning of the Policy period, if this endorsement is effective as of such date; or
¡i. This endorsement has been added to the Policy, if this endorsement is effective after the Policy period
commences.
C. The Schedule must be in an electronic format that is acceptable to us; and must be accurate.
D. Our delivery of the notification as described in Paragraph A. of this endorsement will be based on the most recent
Schedule in our records as of the date the notice of cancellation is mailed or delivered to the flrst Named lnsured.
E. We will endeavor to send such notice to the e-mail address corresponding to each person or organization indicated in
the Schedule at least 30 days prior to the cancellation date applicable to the Policy.
F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or
organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal
obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of
cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any
kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any
cancellation of the Policy.
G. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any
incorrect information that you or your representative provide to us. lf you or your representative does not provide us
with a Schedule, we have no responsibility for taking any action under this endorsement. ln addition, if neither you
nor your representative provides us with e-mail address information with respect to a particular person or
organization, then we shall have no responsibility for taking action with regard to such person or entity under this
endorsement.
H. We may arrange with your representative to send such notice in the event of any such cancellation.
l. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule.
J. This endorsement does not apply in the event that you cancel the Policy.
ALL-32685 (01/11)Page 1 of 2
All other terms and conditions of the Policy remain unchanged
Authorized Representative
)
ALL-32685 (01/1 1)Page 2 of 2
Named lnsured Jacobs Engineering Group lnc.Endorsement Number
3
Policy Symbol
ISA
Policy Number
H25307306
Policy Period
07 101 12020 ro 07 101 12021
Effective Date of Endorsement
lssuêd By (Name of lnsurance Company)
ACE American lnsurance Company
NOTICE TO OTHERS ENDORSEMENT - SCHEDULE - EMAIL ONLY
lnsert the pol¡cy number, The remainder of the information is to be completed only when this endorsement is ¡ssued subsequent to the preparãtion of thê policy.
THIS ENDORSEMENT CHANGES THE POL¡CY. PLEASE READ IT CAREFULLY.
A. lf we cancel the Policy prior to its expiration date by notice to you or the first Named lnsured for any reason other than
nonpayment of premium, we will ondoavor, a6 sot out below, to send written notico of cancellation, via such electronic
notification as we determine, to the persons or organizations listed in the schedule that you or your representative
provide or have provided to us (the "Schedule"). You or your representative must provide us with the e-mail address
of such persons or organizations, and we will utilize such e-mail address that you or your representative provided to
us on such Schedule.
B. The Schedule must be initially provided to us within 15 days after:
i. The beginning of the Policy period, if this endorsement is effective as of such date; or
ii. This endorsement has been added to the Policy, if this endorsement is effective after the Policy period
commences.
C. The Schedule must be in an electronic format that is acceptable to us; and must be accurate.
D. Our delivery of the notiflcation as described in Paragraph A. of this endorsement will be based on the most recent
Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named lnsured.
E. We will endeavor to send such notice to the e-mail address corresponding to each person or organization indicated in
the Schedule at least 30 days prior to the cancellation date applicable to the Policy.
F. The notice referenced in this endorsement is intended only to lre a courtesy notification to the person(s) or
organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal
obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of
cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any
kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any
cancellation of the Policy.
G, We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any
incorrect information that you or your representative provide to us. lf you or your representative does not provide us
with a Schedule, we have no responsibility for taking any action under this endorsement. ln addition, if neither you
nor your representative provides us with e-mail address information with respect to a particular person or
organization, then we shall have no responsibility for taking action with regard to such person or entity under this
endorsement.
H. We may arrange with your representative to send such notice in the event of any such cancellation.
l. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule.
J. This endorsement does not apply in the event that you cancel the Policy.
ALL-32685 (01/11)Page 1 of 2
I
All other terms and conditions of the Policy remain unchanged
Authorized Representative
ALL-32685 (01t11)Page 2 of 2
Endorsement NumberNamed lnsuredJACOBS ENGINEERING GROUP INC.
1000 wrLsHrRE BOULEVARD, SUrTE 1000
LOS ANGELES CA 90017 Policy Number
Symbol:lü,R Number: C67460303
Poliry Period
07-0L-2020 TO 07-01-2021 Effective Date of Endorsement
o7-oL-2020
lssued 8v lName of lnsurânce Comoanv)
ACE AMERICÀN INSURAI{CE COMP.A¡ÍY
lnsen tne OOIICV number. The remâ¡nder of the information ¡s to be cômôletêd on
Workers' Gompensation and Empl Poli
NOTICE TO OTHERS ENDORSEMENT - SCHEDULE - EMAIL ONLY
A. lf we cancel this Policy prior to its expiration date by notice to you or the first Named insured for any reason other than
nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic
notification as we determine, to the persons or organizations listed in the schedule that you or your representative
provide or have provided to us (the "Sehedule"). You or vor-r!' !'eoresentative must nrovide us with the e-mai! address-__ _-r'
of such persons or organizations, and we will utilize such e-mail address that you or your representative provided to
us on such Schedule.
B. The Schedule must be initially provided to us within 15 days after:
i, The beginning of the Policy period, if this endorsement is effective as of such date; or
ii. This endorsement has been added to the Policy, if this endorsement is effective after the Policy period
commences.
^
TL- ô-L-J..t-
-..-¡
L^ :- -- -t--Â---l. t--^-L a-Lt- ¡-v, r ilË !)uilcuurc ilruÞt uc Ir ail ErcuuUiltu ruilil¿tr, Utal ts auueplaute [u u5, ailu iltusr, tJc auuutarc.
D, Our delivery of the notifìcation as described in Paragraph A. of this endorsement will be based on the most recent
Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named lnsured.
E. We will endeavor to send such notice to the e-mail address corresponding to each person or organization indicated in
the Schedule at least 30 days prior to the cancellation date applicable to the Policy.
F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or
organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal
obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of
cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any
kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any
cancellation of the Policy.
G, We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any
incorrect information that you or your representative provide to us. lf you or your representative does not provide us
with a Schedule, we have no responsibility for taking any action under this endorsement. ln addition, if neither you
nor your representative provides us with e-mail address information with respect to a particular person or
organization, then we shall have no responsibility for taking action with regard to such person or entity under this
endorsement.
H. We may arrange with your representative to send such notice in the event of any such cancellation.
L You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule.
J. This endorsement does not apply in the event that you cancel the Policy.
All other terms and conditions of this Policy remain unchanged.
wc 99 03 68 (01/11)Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
NOTICE TO OTHERS ENDORSEMENT - SCHEDULE
A. lf We cancel or non-renew the Policy prior to its expiration date by notice to You for any reason other
than nonpayment of premium, We will endeavor, as set out below, to send written notice of
cancellation or non-renewal via such electronic or other form of notification as We determine, to thepersons or organizations listed in the schedule that You or Your representative provide or have
provided to Us (the Schedule). You or Your representative must provide Us with both the physical
and e-mail address of such persons or organizations, and We will utilize such e-mail address and/or
physical address that You or Your representative provided to Us on such Schedule.
B, The Schedule must be initially provided to Us within 30 days after:
i. The beginning of the Policy Period, if this endorsement is effective as of such date; or
i¡' This endorsement has been added to the Policy, if this endorsement is effective after the policy
Period commences.
C. The Schedule must be in a format that is acceptable to Us and must be accurate.
D' Our delivery of the notifìcation as described in Paragraph A of this endorsement will be based on themost recent Schedule in Our records as of the date the notice of cancellation or non-renewal is
mailed or delivered to You.
E. We will endeavor to send or deliver such notice to the e-mail address or physical address
corresponding to each person or organization indicated in the Schedule at least 30 days prior to the
cancellation or non-renewal date applicable to the policy.
F. The notice referenced in this endorsement is intended only to be a courtesy notification to theperson(s) or organization(s) named in the Schedule in the event of a pendinþ cancellation or non-renewal of coverage. We have no legal obligation of any kind to any such person(s) ororganization(s). Our failure to provide advance notifìcation of cancellation ór non-renewal io'theperson(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kindupon Us, Our agents or representatives, will not extend any Policy cancéllation or non-ienewal dateand will not negate any cancellation or non-renewal of the policy.
G. We are not responsible for verifying any information provided to Us in any Schedule, nor are Weresponsible for any incorrect information that You or Your representative
-provide
to Us. lf you orYour representative does not provide Us with a Schedule, We have no responsibility for taking anyaction under this endorsement. ln addition, if neither You nor Your representative provides Us withe-mail address and/or physical address information with respect to a particular person ororganization, then We shall have no responsibility for taking actiôn with regard to such person orentity under this endorsement.
H. With respect to this endorsement Our, Us or We means the stock insurance company listed in theDeclarations, and You or Your means the insured person or entity listed in ltem '1
'of
t'he Declarationspage.
All other terms and conditions of this policy remain unchanged
JOHN J, LUPICA, President
Named lnsured
Jacobs Engineering Group lnc.Endorsement Number
29
Policy Symbol
EON
Policy Number
G21655065 ofi
Policy Per¡od
07 101 12020 to 07 101 12021 0710112020
lssued By (Name of lnsurance Company)
ACE American Insurance Company
MS-36362 (04i19)
Auth orized
SUPPLEMENT TO CERTIFICATE OF INSURANCE DAT2I
06 / 26 /2020
NAME OF INSURED: .facobs Engineering croup rr¡c.
TI¡E APPLICABIJE CONTRÀCT. *
(r 0/00)