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HomeMy WebLinkAboutCAG2020-262 - Amendment - KPG, P.S. - 4th & Willis Roundabout - Construction Support Services - 04/27/2021ApprovalOriginator:Department: Date Sent:Date Required: Authorized to Sign: Director or Designee Mayor Date of Council Approval: Grant? Yes 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? Yes No* Business License Verification: Yes In-Process Exempt (KCC 5.01.045) If meets requirements per KCC 3.70.100, please complete “Vendor Purchase-Local Exceptions” form on Cityspace. Notice required prior to disclosure? Yes 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 Budget Account Number: Budget? Yes No Dir Asst: Sup/Mgr: Dir/Dep: rev. 200821 FOR CITY OF KENT OFFICIAL USE ONLY (Optional) * Memo to Mayor must be attached CAG2020-262 AMENDMENT - 1 OF 2 AMENDMENT NO. 3 NAME OF CONSULTANT OR VENDOR: KPG, P.S. CONTRACT NAME & PROJECT NUMBER: 4th and Willis Roundabout ORIGINAL AGREEMENT DATE: August 12, 2020 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: Provide additional construction support for the project. For a description, see the Consultant's Scope of Work which is attached as Exhibit A and incorporated by this reference. 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 $9,435 Net Change by Previous Amendments including applicable WSST $23,276 Current Contract Amount including all previous amendments $32,711 Current Amendment Sum $6,049 Applicable WSST Tax on this Amendment $0 Revised Contract Sum $38,760 Original Time for Completion (insert date) t2t3u2l Revised Time for Completion under prior Amendments (insert date) nla Add'l Days Required (+) for this Amendment o calendar days Revised Time for Completion (insert date) t2t3u2l 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. KPG - 4'h & willis Roundabout 2 Amd 3/Shields coNSULTANT/VENDOR: By Etizhbeth $tb*o* (signature) Print Na 69; Elizabeth Gibson, PLA I l'c Urban Des to n Manaoer (title) DATE:04t26t21 CITY OF KENT: By (signature) Print Name: Chad Bieren. P.E, I ic Dr rhlin Works Director 4/az/t r (titte) DATE ATTEST: Kent City Clerk APPROVED AS TO FORM: (appticable if Mayor's signature required) Kent Law Department AMENDMENT - 2OF 2 KPG lnterdisciplinary Design City of Kent Public Works 4th and Willis Roundabout Construction Support Supplement 3 - Additional Construction Support Scope of Work March 22,202L Proiect Descriptio n and Backsround The City of Kent is constructing a roundabout to replace the current intersection at 4th Avenue South and Willis Street. The City has requested that KPG ("Consultant") enter into a supplemental agreement for additional construction support for urban and landscape design for the roundabout construction. ASSUMPTIONS o See additionalassumptions listed for individualTasks PROVIDED BY KPG o Additional Construction Assistance support, response to RFI's RAM's and othersubmittals as provided by the City. o Additional Site Review visits (1 total) o See deliverables lists for individual Tasks. PROVIDED BY THE CITY The City will provide the following items: . Submittal reviews, comments and approvals . Meeting coordination TASK 5 - SUPPL ENT 3 ADDITIONAL CONSTRU CTION SUPPORT Task 5 Objective: Consultant shall provide additional construction administration support through completion of the roundabout construction, including the message board(s) signage and foundations, project site elements, landscaping and irrigation as required. Task 5 Work Elements: 5.1 ProjectManagement/Coordination 5.2 Construction administration support and site review visit (1), including reviewing and responding to RFI's, RAM's, shop drawings, and othersite construction questionsforthe message boards, other site elements as required, plant material and irrigation. Task 5 Deliverables: o Monthly progress report including invoices, emailed. r Meeting agendas and minutes, including summary of decisions made/needed resulting from design Page I L 4th and Willis Roundabout KPG Construction SuPPort EXHIBIT A K,PG lnterdisclPlinary Design coordination meeting and action items. a Task 5 Assumptions: o The Consultant will provide timely and immediate notification of any work items or project developments constituting a change to the written scope of work and fee budget estimate and sched ule. o The Consultant will attend meetings with City Staff for project coordination, either in person or teleconferencing as necessary. o The work of this task is estimated to be up to two (2) months in length. Other Services The City may require other services of the Consultant. These Services could include other work tasks not included in the scope of work. The scope of these services will be determined at the sole discretion of the City. At the time these services are required, the Consultant shall provide a detailed scope of work and estimate of costs. The Consultant shall not proceed with the work until the City has authorized the work and issued a notice to proceed. 4th and Willis Roundabout Construction Support Page | 2 KPG Erhlblt E Cllonlr CtyotKent Prolsct: 4th and WlllF Foundsbout Congtruclion Support Supplsmenl 3 - Addltional Conitructlon Suppotl XPG PROJECT NUMBER; 19029C KPG 5 781-00s,2 IAIPmlmt Manmement/C@rdinatlon c Stmoo2tA'CA Sillmd ,nd Sile Revlew 12 u 0 I 0 41 t 0,040.00142Task Tola Client#:"1487397 KPGPS ACORD^ CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS "RTIFICATE DOES NOT AFF|RMAT|VELY OR NEGATTVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ;OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ..ePRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: DATE (MM/DD/YYYY) 12t22t2020 IMPORTANT: lf the certilicate holder is an ADDITIONAL INSURED, the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. lf SUBROGATION lS WAIVED, subiect to the terms and conditions ol the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). Please See Below 610-362-8530lS8.NrEo. enr, 206 441 -6300 uest@usi.comSeattle. NAIC #INSURER(S) AFFORDING COVERAGE 25666tNsuRER A: Travelers lndemnity Co of America PRODUCER USI lnsurance Services NW PR 601 Union Street, Suite 1000 Seattle, wA 98101 31 194tNsuREB B, Travelers Casualty & Surety Co. of Amer 32603tNsuRER c : Berkley lnsurance Company 2561 5tNsuRER D. Chaner Oak Fire lnsurance Company INSURER E : INSURER F KPG, P.S. tka KPG, Inc. 3131 Elliott Avenue, Suite 400 Seattle, WA 98121 INSURED THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEENISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR 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, INSRITR TYPE OF INSURANCE SUBFWVN POLICY NUMBER POLIUY EFF(MM/DDTYYYY)POLICY EXPIMMiDD/VYYYI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS.MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY OTHER: PRO.JEcr | | Loc x x x X 6809M6778552147 )1t0112021 01t01t2022 EACH OCCURRENCE $1.000.000 DAMAGE TO RENTEDPRtrMlSFS /F, 6rn"rron.ol s1.000.000 MED EXP (Anv one oerson)s5.000 PERSONAL & ADV INJURY s 1.000.000 GENERAL AGGREGATE s2.000.000 PRODUCTS - COMP/OP AGG s2.000.000 I LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON-OWNED AUTOS ONLYXx X X BA3R5763862147G ,1t01t2021 01t01t2022 s1,000,000 BODILY INJURY (Per person)$ BODILY INJURY (Per accident)$ $ $ A X UMBRELLA LIAB EXCESS LIAB x OCCUR CLAIMS-IVIADE X X cuP9M6824352147 (Follow Form) )1to1t2021 01t01t2022 EACH OCCURRENCE s5.000.000 AGGREGATE s5.000-000 DFf}X nrrfl'rrror'r nl0,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNEF/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandalory in NH) ll yes, describe under DESCRIPTION OF OPERATIONS below N N/A x u85R4996122047G (lncl. WA Stop Gap) tot20t2020 10t20t2021 x PER OTH.tra E.L. EACH ACCIDENT s1.000.000 E.L. DISEASE - EA EMPLOYEE s1.000.000 E.L. DISEASE - POLICY LIMIT s1.000.000 c Professional Liability lncl. Pollution X AEC904155903 ,1t01t2021 01t01t2022 $3,000,000 per claim $5,000,000 annl aggr. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: KPG PN 19029C- Willis Roundabout Construction Assistance. The General Liability and Automobile Liability policies include an automatic Additional lnsured endorsement thal provides Additional lnsured status to the Certificate Holder, only when there is a written contract that requires such status, and only with regard to work performed on behall ol the named insured. The General Liability and Automobile Liability policies contain a special endorsement with Primary and Noncontributory wording, when required by written contract. (See Attached Descriptions) City of Kent Attn: Nancy Yoshitake 220 Fourth Avenue South Kent, WA 98032-0000 I SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEHED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPBESENTATIVE Q"*a. /2r/*^- @ 198&2015 ACORD CORPORATION. All rights reserved. ACORD 25 (20161031 1 ol 2 The ACORD name and logo are registered marks of ACORD #s30701464/M30699619 S9KZP DESCRIPTIONS (Gontinued lrom Page 1) The General Liability, Automobile Liability and Professional Liability policies include an endorsement'-\iding that 30 days notice of cancellation will be given to the Certificate Holder by the lnsurance ier- Umbrella Liability follows form. The General Liability includes per project aggregate limits. SAGITTA 25.3 (2016/03) 2 ot2 #s30701464tM30699619 GENERAL PURPOSE ENDORSEMENT OFFICE PAC POLICY NUMBEFI: 6809M6778552147 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY- eGD351 This endorsement modifies insurance provided under the following: ADDITIONAL INSURED - OWNEBS, LESSEES OH CONTRACTORS - SCHEDULED PEFISON OFI ORGANIZATION THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GHNHFIAL LIABILITY COVERAGH PART SCHEDULE NAMES OF ADDTfiONAL INSURED PER$ON(Si OR ORGANIZATION(S): Any person or organization that you agree in a written contract to include as an additional insured on this Coverage Part, provided that such written contract was signed by you before,and is in effect when, the "bodily injury" Or "property damage" oCCUTs Or the "personal injury" orr "advertising injUry" offense is committed. LOCATION OF COVERED OPERATION$: Any project to which a written conract with the Additional lnsured Person{s} or Organization{s} in the Schedule applies- (|NFORMATTON REQUTRED TO COMPLETE THtS SCHEDULE, rF NOT SHOWN ABOVE, WILL BE sHolvN rN THF DECLARATTONS.) A. SECTION II - WHO IS AN INSURED IS AMEND=D TO INCLUDE AS AN ADDITIONAL tNsuRED THE PEF|SON($)On OHGANTZATTON(S) SHOWN lN THE SCHEDULE, 3UT ONLYWITH RESPFCT TO LIASILITY FOR "BODILV INJURY", "FFIOPFRTY DAMAGEU,PERSONAL INJURY OR "ADVERTISING INJURY* CAUSTD, IN WHOLE OR IN PAFIT, BY: 1. YOUR ACTS OR OMISSIONS; OFI 2. THE ACTS OR OMIBSIONS OF THOSE ACTING ON YOUR BEHALF; IN THE PERFOHMANCE OF YOUR ONGOING OPERATION$ FOH THE ADDITICINALINSURED{$) AT THE LOCATTON(S) DESTGNATED ABOVE. B. WITH RESFECT TO THE INSURANCE AFFORDHD TO THTSH ADDITIONAL INSURED, THE FOLLOWING ADDITIONAL EXCLUSIONS APPLY: This insurance does not apply to "bodily injury" or "property damage" occurring, or "personal injury" or "advefiising injury" arising out of an offense committed, after: 1. ALL WORK, INCLUDING MATERIALS, PARTS OR EQUIPMENT FURNISHED INCONNECTION WITH SUCII WORK, ON THE PROJECT {OTHER THAN SERVICE, MAINTENANCEOH REPAIRS) TO BE PERFORMED By OR ON BEHALF OF THE ADDTTTONAL TNSUnED{S}ATTHE LOCATION OF THE COVERED OPERATIONS HAS BEEN COMPLETED; OR 2. THAT PORTION OF "YOUR WORK'OUT OFWIIICH THE INJURY OR DAMAGE ARISESHAS cGT8A10121 Page z of 2 GENERAL PUHPOSE ENDORSEMENT OPFICE PAC POLICY NUMBEH: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CGD36L This endorsement modifies insurance provided under the following: BEEN PUT TO ITS INTENDED USE BY ANY PERSON OR ORGANIZATION OTHER THANANOTHER CONTRACTOR OR SUBCONTRACTOR ENGAGED IN PERFORMING OPERATIONS FOR APRINCIPAL AS A PART OFTHE SAME PROJECT. cG D361 0305 Gopyright 2OO5 The St. Paul Travelers Companies, lnc- All rights resenred- lncludes copyrighted rnaterial of lnsurance Services Office, lnc. with its permission. cG T8 01 A1 21 Page 2 of 2 FQLICY: 8A3R57038621 47 G COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The fellowing is added to Paragraph c. in A.1., Who ls An lnsured. of SECTION ll * COVERED AUTOS LIABILITY COVERAGE in the BUSINESS AUTO COVERAGE FORM and Paragraph e. in A.1., Who ls An lnsured, sf SECTION ll * COVERED AUTOS LIABILITY COVERAGE iN thE MOTOR CARRIER COVERAGE FORM, whichever Coverage Form is part of your policy: This includes any person or organization who you are required under a written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "propert5r damage" occurs and that is in effect during the policy period, to name as an additionalinsured for Covered Autos Liability Coverage, but only for damages to which this insurance applies and only to the extent of that person's or organization's liability for the conduct of another "insured'i. @ 2O16 The Travelers lndemnity Company. All rights reserved . lncludes copyright€d malo{al oi lnsuranca Ssrvices Oftice, !nc" with ils pormission" cAT4 37 A216 Page 1 of 1 POLICY: 6809M67785521 47 COMMERCIAT GENFRAL LIABILIry COMMERCIAL GENERAL LIABILITY COVERAGE FORM Various provisions in this policy restrict coverage. Read the entire poliry carefully to determine rights, duties and what is and is not covered. Throughout this policy the words "you'' and "your" refer to the Named lnsured shown in the Declarations, and any oths person or organization qualifying as a Named lnsured under this policy. The words nwe", "ss" and "our" refer to the company providing this insurance. The word "insured" means any person or organization quafifying as such under Section ll - \{ho ls An lnsured. Other words and phrases that appear in quolation marks have special meaning. Refer to Section V - Definitions. SECTION I - COVERAGES COVERAGE A - BODILY INJURY AND PROPERTY DAMAGE LIABILITY 1. lnsuring Agreement a. We will pay those sums that the insured becomes legally obligated to pay as damages because of 'bodib injury" or "property damage" to which this insurance applies. We will have the right and duty to defend the insured against any osuit" seeking those damages. However, we will have no duty to defend the insured against any "suif' seeking damages for "bodily injury" or "property damage" to which this insurance does not apply. We may, at our discretion, investigate any "occurrence" and settle any claim or "suit" that rnay result. But: {1) The amount we will pay for damages is limited as described in Section lll - Limits Of Insurance; and {2) Our right and duty lo defend end when we have used up the applicable limit of insurance in the payment of judgments or settlements under Coverages A or B or medical expenses under Coverage C. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Supplementary Payments. b. This insurance applies to "bodify injury" and "property damage" only if: (1) The "bodily injury" or "property damage" is caused by an "occurrence" that takes place in the "coverage tenitofy": {2} The "bodily injury" or "properly damage" occurs during the poliry period; and (3) Prior to the policy period, no insured listed under Paragraph 1. of Section ll - Who ls An lnsured and no "employee" authorized by you 1o give or receive notice of an "occurrence" or claim knew that the "bodily injury/" or "property damage" had sccurred, in whole or in par.t. lf such a listed insured or authorized "employee" knew, prior to the policy period, lhat the "bodily injury" or "property damage" occuned. then any continuation, change or resumption of such "bodily injury" or "proper\r damage" during or after the policy period will be deemed to have been known prior to the poliry period. c. "Bodily injury" or "property damage" rvhich occurs during the policy period and was not, prior to the policy period. known to have occurred by any insured listed under Paragraph 1. of Section ll - Who ls An lnsured or any "employee" authorized by you to give or receive notice of an "occurrence" or claim, includes any conlinuation, change or resumption of that "bodily injury" or "property damage" after the end of the policy period. d. "Bodity injury" or "property damage" will be deemed to have been known to have occurred at the earliest time when any insured listed under Paragraph 1. of Section ll * Who ls An lnsured or any "employee" authorized by you to give or receive notice of an "occurrence" or claim: (1) Reports all, or any part, of the "bodily injury" or "property damage" to us ot any other insurer; (2) Receives a written or verbal demand or claim for damages because of the "bodily injury" or "property damage"; or (3) Becomes aware by any other means that "bodily inju4y'' or "property damage' has occurred or has begun to occur. g 2017 The Travelers lndemnity Gompany, All righls reserved. lndudes copyrighted rnaterial of lnsurane Services Offre, lnc. with its permission. cG T1 00 02 19 Page 1 of21 venture or limited liability company that is not shown as a Named lnsured in the Declarations. This paragraph does not apply to any such partnership, joint venture or limiied liability company that otherwise qualifies as an insured under Section ll - Who ls An lnsured. SECTION III - LIMITS OF INSURANCE t. The Limits of lnsurance shown in the Declaralions and the rules below fix the most we will pay regardless of the number of: a. lnsureds: b. Claims made or nsuits" brought: or c. Persons or organizations making claims or bringing "suits". 2, The General Aggregate Limit is the most we will pay fsr the sum of: a. Medical expenses underCoverage C; b. Damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products<ompleted operations hazard,,: and c. Damages under Coverage B. 3, The Products-Compleled Operations Aggregate Limit is the most we will pay under Coverage A for damages because of "bodily injury" and "property damage" included in the "products-completed operations hazard". 4, Subject to Paragraph 2. above, the Personal And Advertising lnjury Limit is the msst we will pay under Coverage B for the sum of all damages because of all "personal injury" and "advertising injury" sustained by any one person or organization. 5, Subject to Faragraph 2. or 3. above, whichever applies, the Each Occurrence Limit is the most we will pay for the sum of: a. Damages underCoverage A: and b, Medical expenses under Coverage C; because of all "bodily injury" and "property damage" arising out of any one "occurrgnce". For the purposes of determining the applicable Each Occurrence Limit, all related acts or omissions committed in providing or failing to provide tirst aid or "Good Samaritan services" to any one person will be deemed to be one "occurrence". 6. Subject to Paragraph 5. above. the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of "premises damage" to any one premises. The Damage To Premises Rented To You Limit willbe: COMMERCIAT GENERAL TIABILITY a. The amount shown for the Damage To Premises Rented To You Limit in the Declarations of this Coverage Part; or b. $300,000 if no amount is shown for the Damage To Premises Rented To You Limit in the Declarations of this Coverage Part. 7. Subject io Paragraph 5. above, the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by any one person. The Lirnits of lnsurance of this Coverage Part apply separately to each consecutive annual period and tc any remaining period of less than 12 rnonths, starting with the beginning of the policy period shown in the Declarations, unless the policy period is extended after issuance for an additianal period of less than 12 months. ln that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of lnsurance. SECTICIN IV. COMMERE|AL GENERAL LIABILITY CONDITIONS I. Sankruptcy Bankruptcy cr insolvency of the insured or of the insured's estate will not relieve us of our obligations under this Coverage Pari. 2. Duties ln The Event Of Occurrence, Offense, Claim Or Suit a. You must see to it that we are notified as soon as practicable of an "occurrence" or an offense which may result in a claim. To the extent possible, notice should include: {1} How, when and where the "occurrence" or offense tcok place; t2) The names and addresses of any injured persons and witnesses; and {3) The naiure and location of any injury or damage arising out of the "occurence" or ofiense. b. lf a claim is made or "suit" is brought against any insured. you must: {1} lmmediately record the specifics of the claim or "suii" and the date received; and t2) NotE us as soon as practicable. You must see to it that we receive written notice of the claim or "suif' as soon as practicable. c. You and any olher involved insured must: {1) lmmediately send us copies of any demands, notices, summonses or legal papers received in eonnection with the claim or "suitf'; O 2017 The Travelers lodemnity Company, All righls reserved. lncludes copyrighted material of lnsurance Services Office, tnc. whh its petmission. cG T1 00 02 t9 Page 13 of 21 COMMERCIAL GENERAL LIABILIry (2) Authorize us to obtain records and other inforrnation; (3) Cooperate with us in the investigation or settlement of ihe claim or defense against lhe "suit"; and (4) Assist us, upon our request, in the enforcement of any right against any person or organization which may be liable to the insured because of injury or damage to which this insurance may also apply. d, No insured will, except at that insured's own cost. voluntarily make a payment, asEume any obligation, or incur any expense, other than for first aid, without our consent. e. The following provisions apply to Paragraph a. above, but only for purposes of the insurance provided under this Coverage Part tc you or any insured listed in Par:agraph 1. or 2. of Section ll - Who ls An lnsured: (1) Notice to us of such "occufrence" or offense must be given as soon as practicable only after the noccurrence" or offense is known ta you (if you are an individual). any of your partners or members who is an individual (if you are a partnership or joint venture), any of your managers who is an individual (if you are a limited liability company), any of your "execrtive officers" or directors {if you are an organizaiion other than a partnership, joint venture, or limited liability company), any of your trustees who is an individual (if you are a trust) or any "employee" authorized by you to give notice of an "occurrence" or offense. (2) lf you are a pa*nership, joinl venture, limited liability company or trust, and none of your partners, ioint venture members, manager$ or trustees are individuals, notice to us of such "occurreilce" cr offense must be given as soon as practicable only after the ooccurrence" or offense is known by: (al Any individualwho is; (i) A paftner or member of any partnership or joint venture; (ii) A manager of any limited liability comPany; (iii) An executive officer or directsr of any other organization; or (ivf A trustee of any trust; that is your partner, joint venture member, manager ortrustee; or {b) Any ernployee authorized by such partnership, joint venture, limited liability company, trust or other organization to give notice of an "occurrence" or offense. {3} Notice to us of such "occurrence" or offense will be deemed to be given as soon as practicable if it is given in good faith as soon as practicable to your workers' compensation insurer. This applies only if you subseguently give notice to us of the "occurrence" or offgnsg as soon as practicable after any of the persons degcribed in Paragraph e.{1) or {2} above discovers that the "occurrence" or offense may result in sums to which ihe insurance provided under this Coverage Part may apply- However. if this policy includes an endorsement that provides limited coverage for "bodily injury" or "properiy damage" or pollution costs arising out of a discharge, release or escape of "pollutants" which contains a reguirement that the discharge, release or escape of "pollutants* must be reported to us within a specific number of days after its abrupi commencement. this Paragraph e. dues not affect thai requirement. 3. Legal Action Against Us No person or organization has a right under this Coverage Part: a. To join us as a party or otherurise bring us into a "suit" asking for damages from an insured: or b, To sue us on this Coverage Part unless all of its terms have been fully complied with. A person or organization may sue us to recover on an agreed settlement or on a final judgment against an insured; but we will not be liable for damages that are not payable under the terms of this Coverage Part or that are in excess of the appllcable limit of insurance. An agreed settlement means a settlement and release of liability signed by us. the insured" and ihe claimant or the claimant's legal representative. @ 2017 The Travglers Indemnity Gornparry. All righls reserved. lndudes copyrighted material of lnsurane Services Offce, lnc. with its permission. Page 14 of21 cG T1 00 02 19 4. Other lnsurance lf valid and collectible other insurance is available to the insured for a loss we cover under Coverages A or. B of this Coverage Part, our obligations are limited as described in Paragraphs a. and b. below. As used anywhere in this Coverage Part, other insurance means insurance, or the funding of losses, that is provided by, through or on behalf of: (i) Another insurance company; (ii) Us or any of our affiliated insurance companies, except when the Non cumulation of Each Occurrence Limit provision of Paragraph 5. of Sestion lll - Limits Of lnsurance or the Non cumulation of Personal and Advertising lnjury Limit provision ol Paragraph 4. of Section lll -Limits of lnsurance appties because the Amendment Non Cumulation Of Each Occurrence Limit Of Liability And Non Curnulation Of Personal And Advertising lnjury Limit endorsement is included in this policy; (iii) Any risk retention group; or (ivlAny self-ihsurance method or program. in which case the insured will be deemed to be the provider of other insurance. Other insurance does not include umbrella insurance. or excess insurance, that was bought specifically to apply in excess sf the Limits of lnsurance shown in the Declarations of this Coverage Part. As used anlnrvhere in this Coverage Part, other insurer means a provider of other insurance. As used in Paragraph c" below, insurer means a provider of insurance. a. Primary lnsurance This insurance is primary except when Paragraph b. below applies- lf this insurance is primary, our obligations are noi affected unless any of the other insurance is also primary. Then, we will share with all lhat other insurance by the method described in Paragraph c. below, except when Paragraph d. below applies. b. Excess lnsurance (1) This insurance is excess over: ta) Any of the other insurance, whether primary, excess, contingent or on any other basis: {i} That is Fire, Extended Coverage, Builder's Risk, lnstallation Risk or similar coverage for "your workf': @ 2017 The Travelers lndemnily Company, AU righls lndudes copyrighted matedal of lnsuranoe Services Office, lnc. COMMFRCIAL GENERAL LIABILITY (ii) That is insurance for "premises damage"; {iii) lf the loss arises out of the maintenance or use of aircraft, "autos" or raatercraft to the extent not subject to any exclusion in this Coverage Part that applies to aircraft, "autos" or walercraft; (iv) That is insurance available to a premises owner, manager oI lessor that qualifies as an insured under Paragraph 4. of Section ll - Wha ls An lnsured. except when Paragmph d. below applies; or (v) That is insurance available to an equipment lessor that qualifies as an insured under Paragraph 5. of Sestion ll - Who ls An lnsured, except when Paragraph d. below applies. (b) Any of the other insurance, whether primary, excess, contingent or on any olher basis, thai is available to the insured when the insured is an additional insured, or is any other insured that does not qualify as a named insured, under such other insurance. (21 When this insurance is excess, we will have no duty under Coverages A or B to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". 1f no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. (3) When this insurance is excess over other insurance, we wilJ pay only our share of the amount of the loss, if any, that exceeds the sum of: (a) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (b) The total of all deductible and self- insured amounts under all that other insurance" (4) We will share the remaining loss, if any, with any other insurance that is not described in this Excess lnsurance provision and was not bought specifically to apply in excess of the LimiG of lnsurance shown in the Declarations of this Coverage Part. reserved. wilh ils permission. cG T1 00 02 19 Page 15 of21 COM MERCIAL GENHRAL LIABILITY c. Meihod Of Sharing lf all of the other insurance permits contribution by equal shares, we willfollow this method alsa. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. lf any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is b*sed on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers, d. Primary And Non Contributory lnsurance lf Required By Wrltten Cor*fac,t lf you specifically agree in a written contract or agreemen: that the insurance afforded to an insured under this Coverage Part must apply on a primary basis, or a primary and non- contributory basis, this insurance is primary to other insurance that is available to such insured which covers such insured as a named insured, and we will not share with that other insurance, provided that: tl) The "bodily injury' or "property damage" for which coverage is sought cccurs; and {2} The "personal and advertising injury" for which coverage is sought is caused by an offense that is committed: subsequent to the signing of that contract or agreement by you. 5. Premium Audit a. We will compute all prerniums for this Coverage Fart in accordance with our rules and rates. b. Prernium shown in this Coverage Part as advance premium is a deposit premium only. At the close of each audit period we wiil compute the earned premium for that period and send notice to the first Named lnsured. The due date for audit and retrospective premiums is the date shown as the due date on the bill. lf the sum of the advance and audit premiums paid for the policy period is greater than the eamed premium, we will return the excess to the first Named lnsured. c. The first Named lnsured must keep records ofthe information we need for premium computation, and send us copies at such times as we may request. 6. Representations By accepting this poliry, you agree: a, The statements in the Declarations are accurate and complete; b. Those statements are based upon representations you made to us; and c. We have issued this policy in reliance upon your representations. The unintentional omission of, or unintentional enor in, any information provided by you which we relied upon in issuing this policy will not prejudice your rights under this insurance- However, this provision does not affect our right to collect additional prernium or to exercise our rights of cancellation or nonrenewal in accordance with applicable insurance laws or regulations. 7. Separation Of lnsureds Except with respect to the Lirnits of lnsurance, and any rights or duties specifically assigned in this Coverage Part to the first Named lnsured, this insurance applies: a. As if each Named Insured were ihe only Named lnsured; and b. Separately to each insured against whom claim is made or "suit" is brought. 3. Transfer Of Rights Of Recovery Against Others To Us lf the insured has rights :o recover all or part of any payment we have made under this Coverage Part, those rights are tran$ferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce thern. 9. When We Do Not Renew lf we decide not to renew this Coverage Paft, we will mail or deliver to the first Named lnsured shown in the Declarations written notice of the nonrenewal not less than 30 days before the expiration date. lf notice is mailed, proof of mailing will be sufficient proof of notice. SECTION V - DEFINITIONS 1. "Advertisement" means a notice that is broadcast or published io the general public or specific market segments about your goods, products or services for the purpose of attracling customers or supporters. For the purposes of this definition: a. Notices that are published include material placed on the lnternet or on similar electronic means of communication; and b, Regarding websites, only that part of a website that is about your goods, producG or services for the purposes of attracting customers or supporters is considered an advertisement. @ 2017 The Travelers lndemnily Company' All tighls reserved. lnc{udes copyrighted material of lnsurance Services Offe, lnc. with ils permission. Page 16 of21 cG T1 00 02 19 POLICY: 8A3R57638621 47 G COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED * PRIMARY AND NON.CONTRIB UTORY WITH OTHER INSURANCE This endorsement modifies insurance provided under the following BUSINESS AUTO COVERAGF FORM PROVISIONS 1. The following is added to Paragraph A,'!.c., Who ls An lnsured, of SECTION ll * COVERED AUTOS LIABILITY COVERAGE; This includes any person or organization who you are required under a written contract or agreement between you and that person or organizatisn, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to name as an additional insured for Covered Autos Liability Coverage, but only for damages to which this insurance applies and only to the extent of that person's or organization's liability for the conduct of another "insured". 2. The following is added to Paragraph B,5., Other lnsurance of SECTION lV - BUSINESS AUTO CONDITIONS; Regardless of the provisions of paragmph a. and paragraph d. of lhis part 5. other lnsurance, this insurance is primary 1o and non-contributoty with applicable other insurance under which an additional insured person or organization is the first named insured when the written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, requires this insurance to be primary and non*contributory. @ 2016 The Travelers lndemnity Company. All rights reserved. lncludes copyrrghted material of lnsurance Services Otfice, lnc. with its pemission. cA T4 74 02 t6 Page 1 of 1 POLICY NUMBER: 6Eo -eM6??s ss -zL- 47 THIS ENDORSEMENT CI{ANGES THE POLICY. PLEASE READ IT CAREFULLY. TOTAL AGGREGATE LIMIT OTHER THAN PROJECTS AND DESIGNATED PROJECT AND LOCATION AGGREGATE LIMIT$ This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE. LIMITS OF INSURANCE AND DESIGNATED PROJECTS AND LOCATIONS LIMITS OF INSURANCE TotalAggregatelimit $ 8,000,000 (Other Than Projects and Products-Completed Operations) Designated Location Aggregate Limit $ 2,000, 000 (Other Than Products-Completed Operations) Designated ProjectAggregate Limit $ 2' 000.000 (Other Than Products-Completed Operations) GeneralAggregateLimit $ 2'000,000 {Other Than Products-Completed Operations} Designated Projects: Each "project" for whLch you have agreed. in a rrritten donbract which iE j.n effect during this policy period, bo provide a separate General Aggregate Linit, provlded that the contract Le sigrred by you before the I'bodily injury" or tproperty danager occurE. Designated Locaticns;All locatloas 1lsted j-n ltem 3. of ehe Comon FolJ.cy Daclaratj.o*s or in any lvlasEer Fac AceouDe E''qroEure Endcrsement lncluded ia thle policy. PROVTSTONS 1. The General Aggregate Limit (Other Than Products€ompleted Operations) shown in the Declarations is replaced by the Limits of lnsurance shown in the Schedule - Lim'rts Of lnsurance And Designaled Projects And Locations. 2. The following replaces Paragraph 1. of SECTION III- LIMITS OF INSURANCE: COMMERCIAT GENERAL LIABILIry ISSUE DATE:L2/L4/2020 1. The Limits of lnsurance shown in the Declarations or the schedule - Limits of lnsurance And Designated Projects And Locations, whichever apply, and the rules below fix the most we will pay regardless of the number of: a. lnsureds: b. Claims made or "suitsn brought; o 2017 The Travelers lndemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office, lnc. wilh its permlssion- cG D4 69 02 19 Page 1 of3 COM MERCIAL GENERAL LIABILITY c, Persons or organizations making claims or bringing "suits"; or d. "Projects" or "locations'. 3. The following replaces Paragraph 2. of SECTION III- LIMITS OF INSURANCE: 2. a. The Total Aggregate Limit shown in the Schedule - Limits 0f lnsurance And Designated Projects And Locations is the most we will pay for the sum of all amounts under the Designated Location Aggregate Limit and all amounts underthe General Aggregate Limit. This includes: {1) Damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard"; {2) Damages underCoverage Bl and (3) Medical expenses under Coverage C. b. The Designated Project Aggregate Limit shown in the Schedule - Umits Of lnsurance And Designated Projects And Locations applies and is further subject to all of the following provisions: {1) The Designated Project Aggregate Limit is the most we will pay for the sum of: (a) Damages under Coverage A because of "bodily injury" and "property damage" caused by "occurrences"; and {b} Medical expenses under Coverage C for "bodily injury" caused by accidents; that can be attributed only to operations at a single "projecl". (2) The Designated Project Aggregate Limit applies separately to each "project". {3} The Designated Project Aggregate Limit does not apply to damages because of "bodily injury" or "property damage" included in the "products- completed operations hazard". lnstead, the Products-Completed Operations Aggregate Limit described in Paragraph 3. below applies to such damages. {4) The Designated Project Aggregate Limit does not apply to damages under Coverage B, lnstead, ihe General Aggregate Limit described in Paragraph 2.d. below applies to such damages. (5) Any payments made for damages or medical expenses to which the Designaled Project Aggregate Limit applies will reduce the Designated Project Aggregate Limit for the applicable "project". Such payments will not reduce the Total Aggregate Limit, the General Aggregate Limit described in Paragraph 2.d. below, the Designated Project Aggregate Limit for any other "project" or the Designated Location Aggregate Limit. c. Subiect to the Total Aggregate Limit described in Paragraph 2.a. above, the Designated Location Aggregate Limit shown in the Schedule - Limits Of lnsurance And Designated Projects And Locations applies and is further subject io all of the following provisions: {1) The Designated Location Aggregate Limit is the most we will pay for the sum ol: (a) Damages under Coverage A because of "bodily injury" and "properly damage" caused by "occurrences": and {b) Medical expenses under CoveraEe C for "bodily injury" caused by accidents; that can be attributed Gnly to operations at a single "location". (2) The Designated Location Aggregate Limit applies separately to each "location". (3) The Designated Location Aggregate Limit does not apply to damages because of "bodily injury" or "property damage* included in the "producls- completed operations hazard". lnstead, the Products-Completed Operations Aggregate Limit described in Paragraph 3, below applies to such damages. (4) The Designated Location Aggregate Limit does not apply to damages under Coverage E. lnstead, the General Aggregate Limit described in @ 2617 The Travelers lndemnity Company. All rights reserved- lncludes copyrighted material ol lnsurancg Services Office. lnc. with ils permission Page 2 of 3 cG D4 69 02 19 Paragraph 2.d. below applies to such damages. (5) Any payments made for damages or medical expenses to which the Designated Location Aggregate Limit applies will reduce: {a) The Total Aggregate Limit; and {b} The Designated Location Aggregate Limit for the applicable "location". Such payments will not reduce the General Aggregate Limit described in Paragraph 2,d. below, the Designated Project Aggregate Limitor the Designated Location Aggregate Limit far any other "locatign", d. Subject to the Total Aggregate Limit described in Paragraph 2,a. above, the General Aggregate Limit shown in the Schedule * Limits Of lnsurance And Designated Projects And Locations applies and is further subject ts all of the following provisions: (1) The General Aggregate Limit is the mosl we will pay for the sum of: (a) Bamages under Coverage A because of "bodily injury" and "property damage" caused by "occurrences", and medical expenses under Coverage C for "bodily injury" caused by accidenls, that cannot be attribded only to operations at a single "project" or a single "location''; and (b) Damages under Coverage B. {2) The General Aggregate Limit does not apply to damages for "bodily injury" or "property damage" includedin the "products<ompleted sper- ations hazard". lnstead, the Products-Completed Operations Aggregate Limit described in Paragraph 3. below applies to such damages. (3) Any payments made for damages or medical expenses to which the COMMIRCIAL GHNERAL LIABILIry General Aggregate Limit applies will reduce: ta) The Total Aggregate Limit; and (b) The GeneralAggregate Limit. Such payments will not reduce the Designated Project Aggregate Limh for any "project" or the Designated Location Aggregate Limit for any nlocation", 4. The following replaces Paragraph 3. af SECT|ON III- LIMITS QF INSURANCE: 3. The Products-Completed Operations Aggre- gate Limit shown in the Declarations is the most we will pay under Coverage A for damages because of "bodily injury" or "property damage" included in the "products- completed operations hazardl. Any payments made for such damages will not reduce the Total Aggregate Limil, the General Aggregate Limit, the Designated Project Aggregate Limil for any "projectu or the Designated Location Aggregate Limit for any "location". 5. The following is added to the DEFINITIONS Section: "Location" means any designated location shown in the Schedule - Limits Of lnsurance And Designated Projecis and Locations that is owned by or rented to you, For the purposes of determining the applicable aggregate limit of insurance, each "location" that includes a premises involving :he same or connecting lots, or premises whose connection is interupted only by a street, roadway or waterway, or by a right-of- way of a railroad, will be considered a single "location", "Projecf' means any designated project shown in the Schedule Limits Of lnsurance And Designated Projects And Locations that is away from premises owned by or rented to you and at which you are performing operations pursuant to a contract or agreemeni. For the purposes of detennining the applicable aggregate limit of insurance, each "project" that includes a premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway or waterway, or by a right-of- way of a railroad, will be considered a single "project". O 20.|? The Travelers lndemnity Company- All rights reserved. lncludes copyrighted material ol lnsurance Services Office, lnc. wiih its permission' cG D4 69 0Z 19 Page 3 of 3 POLICY NUMBER: 580'9u577855 -21-4?ISSUE DATE: ,2/\412a2a THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DES1GNATED PERSON OR ORGANIZATION - NOTICE OF CANCELLATION ON NONRENEWAL PROVIDED BY US This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCfiLLATION: Number of Days Notice: WHEN WE DO NOT RENEW {Nonrenewal}: Numbar of Days Notice: FERSON OR ORGANIZATION: A$T PERSON OR ORGAI{TUATTO}I ?O }ffTOM YOU EAVE EGREED IN A WRITTEN CONTRI'CT THAT }IOTTCE OF C"AIICEIJIJATION OR NONREI.IEW&T' OF TIiIS POIICY WII,L BE GIVE$, BUA 6NLY IF: 1. YOU SEND US A. WRIITEN REQI'EST TO PROVIDE SUCA NOTICET INCLUDINC TIIE lrAr'{E AND ADDRESS Or SUCH pERSOW Og ORGANIZA?ION, E,FTER IgE FIRST NA!ilED TNSURED RECEIVSS NOTICE FROH 1'S OF AHE CANCELITA3IOT.! OR NOIiRENEHAJ, OF Tl{Ig FOLICY; Al{D 2. wE RECETVE gltcE WRrsrEN REQUEST AT LE.AST 14 DAYS BEFORE TI{E BFGINNING OF ?HE APFT,IC-I3LE NII]IBER OF DAYS SSOilN IN TI{IS SCHSDUI,E. ADDRESS: THE ADDRESS I'OR "IIA? PERSON OR OEGA}IIZ. ATION INCI,TIDED IN SUCE WRIT?E}I REQI'ESA FROM YOU TO U,S. 30 30 B. lf we do not renew this policy for any legally permitted reason other than nonpayment of premium, and a aumber of days is shown for When We Do Not Renew (Nonrenewal) in the Schedule above, we wilt mail notice of nonrenewal to tie person or organization shown in such Schedule. We will mail such notice to the address shown in the Schedule above at least the number of days shown for When We Do Not Renew (Nonrenewal) in such Schedule before the effective date of nonrenewal. PROVISTONS A. lf we cancel this policy for any legally permitted reason other than nonpayment oi premium, and a number of days is shown for Cancellation in the Schedule above, we will mail notice of cancellation to the person or organization shown in such Schedule. We will mail such notice to the address shown in the Schedule above at least the number of days shown for Cancellation in such Schedule before the effective date of cancellation. tL T4 00 05 19 o 2019 The Travelers lndemnity Company. All rights reserved.Page 1 of 1 COIIMERCIAL AUIIO POI.ICY ENDORSST,TSNT CATS 04 l}I 21 pol.rcr Drur4BER BA-3R5?6386-2147-G ** TSIS ENDORSE}.TEI{I CSAilGSS TITE POIICY. PIE,ISE READ II CAREJ.UI,',Y. ** NOIICE OF CANCEI,I,ATTON II I5 AGREED ISAT TflIS ENDORSB.IENT CHAI{GES THE POIICI. PITFASE REAS IT CARETULIY. DESIGNArED ENTITY * XOTICS OF CAIICEI,T.AIION PROVIDED BY U8 rUIg ENDORSET|TENT UODXI'IES INSI'A.ENCE PBOVIDED UNDER TIIS f,OII,O}IING: AI.I' CO\IE&trGE ?NRT8 INCIJUDED IN EITIS POIICY scgsDsr,E CATICELLAIIION: NUUBEII Ol' DttYS NOfICg Of CILITCELLAIION: 30 PSRSON OR ORIIilNIZAIION: T$Y PERSON OR ORGANTSITION TO I{SOI.' YOU }TA\TE AGREED IN A I'RITTEN.CO}ITR,ACT TSAT NOTXCE OF CINCSLI.ATION OF 1SIS por,rcY t{rtr, BE GilIEN, 3uT OIILY rF: 1. YOU SgllD SS A ERTTTEN RE9UEST rO PROVTDE SUCH NOTICE, INCLUDING TgS $AItlE AIID ADDRESS OF SUCH FERSOII OR ORGA}IIZATION, AF'TER $iS TIRST NEMED INS1'8ED SNOWN IN TIIE DECI.ARtr1IIONS nECSrVES NOTICS r.Roff US AE THU CANCELLArION OF TIIIS FOITICY; 3!lD 2" IIE RECEIVE SUCS TIRITIEN REQUEST AT &EAST 1/T DAYS BEFORE NIE SEGNWI$G OF THE APPLICASI,E NUMBER OI. DAYS SHOTIN II{ rsrs scssDurE. ADDRESS: IIIE ASDRESS FOR TBAS PSRSON OR ORGA}IIZATION INCT.T'DED IN SUCH IIRITTEN AEQIJEST FBO[tl XOU ?0 US. FROYISIQN$:A. IF ICS CI!ICfrI. 1SIS POIICY T'OR A}IY STATUf,ORII,Y PNRMTTTED aaasoN 0THER rsaN NolrPAvuElrr or Fnslrruu sE tifi.L llAIIr NOTICA OF CSIICEIIATION TO fgE PERSON OR ORGJANTZATTON SBOII}I III TEE SCEEDAI.E ABOVE. T{E I{I!L MAIL SUCTT IIOIICE TO THS ADDRESS SSONN IN AHE SCHED{'I,S AEWE AT LE,ASI TTIE NUMBER OT DAYS SHOWN FOR CAI{CELLtrTION IX THE SCnEDUI'E ABC\IE BEFORE THE EI'FSCTII/g DATE OS CAI{CELLATXON.B. II' I{E DSCXDE TO NOT NEbIBII TSIS POLICY FOR AI.IX sTAruroRrl.y FsBrdrTrED REesoN, exa A IIITXBER OF DAYS rs sHoItN ron !{oNRl$lEt{A.t r$ trgs scsuDutE aBoItE, }lE I{Ix.I MI,IL NOTICE OF trIIE NONRENEITAI. TO THE PERSON OR ORGA}IIZAEIOX SBOITN IN THE SCSEDT'LE ABOVE. WE }III.L }IAIL SgCg NryIICE TO TgE ADDRESS SSOHN TN THE SCHEDSIS eBo\tE AT LEASI TI{E N!}{aER OF DAYS SHOI{N AOR NONRENEI{A! IN TEE SCHEDULE ABOVE ASEORE TIIE EXPIR,ATION DATS. EFFECTIVE DATE O1'01/2021 PAGE OOO1 Ex3raarxoN DATE 0110{/2022