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C2019-622 - 9/24/2019 - Approved
00 52 23 AGREEMENT This Agreement, for the Project awarded on Tuesday,September 24, 2019, is between the City of Corpus Christi (Owner) and Environmental Solutions (US) Ltd dba Terrapure Environmental (Contractor). Owner and Contractor agree as follows: ARTICLE 1—WORK 1.01 Contractor shall complete all Work as specified or indicated in the Contract Documents. The Work is generally described as: ONS WTP Dredging of Lagoons 5 and 6 Project No. 19052A ARTICLE 2—DESIGNER AND OWNER'S AUTHORIZED REPRESENTATIVE 2.01 The Project has been designed by: LNV, Inc. 801 Navigation Blvd., Suite 300 Corpus Christi,Texas, 78408 2.02 The Owner's Authorized Representative for this Project is: Brett Van Hazel, PMP—Assistant Director of Construction City of Corpus Christi—Engineering Services 4917 Holly Road, Bldg#5 Corpus Christi,Texas 78413 ARTICLE 3—CONTRACT TIMES 3.01 Contract Times A. The Work is required to be substantially completed within 150 days after the date when the Contract Times commence to run as provided in the Notice to Proceed and is to be completed and ready for final payment in accordance with Paragraph 17.16 of the General Conditions within 180 days after the date when the Contract Times commence to run. B. Milestones,and the dates for completion of each,are as defined in SECTION 0135 00 SPECIAL PROCEDURES. Agreement 00 52 23- 1 ONS WTP Dredging of Lagoons 5 and 6 Project No. 19052A e 0/ 0 8 [\J ED FINAL CONSTRUCTION -GOPY- Co NTRACT DOCUMENTS FOR CONSTRUCTION OF Whitecap WWTP Odor Control and Bulkhead Rehabilitation PROJECT No, E10053 4 City of Corpus Christi T Q e omlampoa pppmp pa e......mo-emm egedti !* f ► ��f'. a�VVVVVVofJvOvfSaEv° a°°MmpRiMvvpJR e (A,f4 � k.i..aarrl mm..!l.l.mif*i oaA;° 89385 ° !,ff.JEFFREYC:CDYM'...i ``'d j 16 983 i iouAL p !'� LJA Engineering, Inc. X11 •'•mm!l�,C c T$pE F 138fi.rTBPLS 10104001 !, S'S+J� .A��,1G� 5350 SOUTH STAPLES STREET,SUITE 425 \s CORPUS CHRISTI,TEXAS 78411 + �� 04, nI p PHONE:361.991.8550 ���! !;MAIL:LJA5oumcc(Q7ila.com VVWW.LJA.COM Record Drawing Number STL 227 00 01 00 TABLE OF CONTENTS Division/ Title Section Division 00 Procurement and Contracting Requirements 00 00 00 Cover 00 01 00 Table of Contents(Rev.11-14-2018) 00 21 13 Invitation to Bid and Instructions to Bidders (Rev 10-11-2018) 00 30 00 Bid Acknowledgment Form (Rev 10-11-2018) 00 30 01 Bid Form (Rev 10-11-2018) 00 30 02 Compliance to State Law on Nonresident Bidders (Rev 10-11-2018) 00 30 05 Disclosure of Interest(Revo1-2016) 00 30 06 Non-Collusion Certification (Rev 10-11-2018) 00 45 16 Statement of Experience (Rev 10-11-2018) 00 52 23 Agreement(Rev 10-11-2018) 00 61 13 Performance Bond (Rev 10-11-2018) 00 61 16 Payment Bond (Rev 10-11-2018) 00 72 00 General Conditions (Rev 11-13-2018) 00 73 00 Supplementary Conditions(Rev 10-11-2018) Division 01 General Requirements 01 11 00 Summary of Work(Rev 10-11-2018) 01 23 10 Alternates and Allowances(Rev 10-11-2018) 01 29 01 Measurement and Basis for Payment(Rev 10-11-2018) 01 33 01 Submittal Register(Rev 10-11-2018) 01 35 00 Special Procedures (Rev 10-11-2018) 01 50 00 Temporary Facilities and Controls (Rev 10-11-2018) 01 57 00 Temporary Controls_(Rev 10-11-2018) Part S Standard Specifications Division 02 Site Work 021020 Site Clearing and Stripping (Rev 10-30-14) 021040 Site Grading(Rev 10-30-14) 021080 Removing Abandoned Structures (Rev 10-30-14) Table of Contents 000100- 1 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 11/2018 Division/ Title Section 022020 Excavation and Backfill for Utilities (Rev3-25-15) 022022 Trench Safety for Excavations (Rev 10-30-14) 022080 Embankment(Rev 10-30-14) 022100 Select Material (Rev 10-30-14) 025802 Temporary Traffic Controls During Construction (Rev 10-30-14) 026204 PVC Pipe—Pressure Pipe for Wastewater Force Mains, Irrigation Systems, and Water Trans Lines—ASTM D2241(Rev 10-30-14) 026206 Ductile Iron Pipe and Fittings (Rev 10-30-14) 027200 Control of Wastewater Flows (Temporary Bypass Pumping Systems) (Rev 10-30-14) 028020 Seeding(Rev 03-25-15) 028300 Fence Relocation (Rev 10-30-14) 028320 Chain Link Fence(Rev 10-30-14) 028340 Chain Link Security Fence(Rev 10-30-14) Division 03 Concrete 030020 Portland Cement Concrete(Rev 10-30-14) 032020 Reinforcing Steel (Rev 10-30-14) 037040 Epoxy Compounds (S-44) 038000 Concrete Structures(Rev3-25-15) TxDOT Items Item 169 Soil Retention Blankets Item 404 Driving Pile Part T Technical Specifications 016510-T Testing and Startup 022410-T Stormwater Pollution Prevention 028020-T Seeding (S-14) 032100-T Concrete Reinforcement 037050-T Flowable Fill 132520-T Biological Odor Control System 313519-T Erosion Control Turf Reinforcement Matting 314116-T Metal Sheet Pile SS 4586-T Dynamic Monitoring and Analysis of Driven Piling Table of Contents 000100- 2 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 11/2018 Division/ Section Title Electrical Specifications prepared by Bath Engineering—Joe B. Martinez, PE 26 01 26 Electrical Testing 26 05 00 Common Work Results for Electrical 26 05 19 Low-Voltage Electrical Power Conductors and Cables 26 05 19.01 Wire Connections and Devices 26 05 26 Grounding and Bonding for Electrical Systems 260533 Raceways and Boxes for Electrical Systems 26 05 43 Underground Ducts and Raceways for Electrical Systems 26 05 53 Identification for Electrical Systems Whitecap WWTP Concrete Cap Bulkhead Assessment prepared by UA Engineering, Appendix Inc.—November 2018 END OF SECTION Table of Contents 000100-3 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 11/2018 00 21 13 INVITATION TO BID AND INSTRUCTIONS TO BIDDERS ARTICLE 1—DEFINED TERMS 1.01 Terms used in this Invitation to Bid and Instructions to Bidders have the meanings indicated in the General Conditions and Supplementary Conditions. ARTICLE 2—GENERAL NOTICE 2.01 The City of Corpus Christi, Texas (Owner) is requesting Bids for the construction of the following Project: Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 This Project includes installation of a new odor control system (Base Bid Part 1)and rehabilitation of an existing bulkhead (Base Bid Part 2). Bidders may submit bids on either Base Bid Part 1, Base Bid Part 2, or both. The City may potentially award Part 1 and Part 2 to two different bidders. Bids for Base Bid Part 1 and Base Bid Part 2 will be evaluated separately for the Award. An Additive Alternate 1 is included with Base Bid Part 2 for steel sheet piling instead of vinyl. 2.02 The Engineer's Opinion of Probable Construction Cost for the Project is$400,000 for Base Bid Part 1 and $1,850,000 for Base Bid Part 2. The Project is to be substantially complete and ready for operation within 40 days for Base Bid Part 1 and 180 days for Base Bid Part 2. The Project is to be complete and eligible for Final Payment 30 days after the date for Substantial Completion. 'No additional time will be allotted for any Additive Alternate'. 2.03 Advertisement and bidding information for the Project can be found at the following website: www.CivCastUSA.com 2.04 Contract Documents may be downloaded or viewed free of charge at this website. This website will be updated periodically with Addenda, lists of interested parties, reports,or other information relevant to submitting a Bid for the Project. ARTICLE 3— DELIVERY AND OPENING OF BIDS 3.01 Bids must be received no later than 2:00 PM on Wednesday, August 28, 2019 to be accepted. Bids received after this time will not be accepted. It is the sole responsibility of the Bidder to deliver the Bid, electronic or hard copy, by the specified deadline. 3.02 Complete and submit the Bid Form,the Bid Bond and the Bid Acknowledgement Form along with all required documents identified in the Bid Acknowledgement Form. 3.03 Electronic Bids may be submitted to the CivCast website at www.civcastusa.com. Bid Security as detailed in Article 8 of this Section must be submitted in accordance with paragraph 3.04. Invitation to Bid and Instructions to Bidders 002113- 1 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 3.04 If submitting a hard copy bid or bid security, please address envelopes or packages: City of Corpus Christi City Secretary's Office City Hall Building, 1" Floor 1201 Leopard Street Corpus Christi, Texas 78401 Attention: City Secretary Bid—Whitecap WWTP Odor Control and Bulkhead Rehabilitation Project No. E10053 Attention: City Secretary All envelopes and packages (including FEDEX envelopes) must clearly identify, on the OUTSIDE of the package, the project name and number and that bid documents are enclosed. 3.05 Bids will be publicly opened and read aloud at the date and time shown in paragraph 3.01, at the following location: City of Corpus Christi City Hall Building, 3rd Floor Engineering SmartBoard Conference Room 1201 Leopard Street Corpus Christi, Texas 78401 3.06 The Owner will read aloud the names of the Bidders and the apparent Bid amounts shown on the Bid Summary for all Bids received in time to be considered. ARTICLE 4—PRE-BID CONFERENCE 4.01 A non-mandatory pre-bid conference for the Project will be held on Tuesday, August 6, 2019 at 10:30 AM at the following location: City Hall Building, 3rd Floor Engineering SmartBoard Conference Room 1201 Leopard Street Corpus Christi,Texas 78401 ARTICLE 5—COPIES OF CONTRACT DOCUMENTS 5.01 Obtain a complete set of the Contract Documents as indicated in SECTION 00 52 23 AGREEMENT. 5.02 Use complete sets of Contract Documents in preparing Bids; Bidder assumes sole responsibility for errors or misinterpretations resulting from the use of incomplete sets of Contract Documents. 5.03 OPT makes copies of Contract Documents available for the sole purpose of obtaining Bids for completion of the Project and does not confer a license or grant permission or authorization for any other use. Invitation to Bid and Instructions to Bidders 002113- 2 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 ARTICLE 6—EXAMINATION OF CONTRACT DOCUMENTS 6.01 Before submitting a Bid: A. Examine and carefully study the Contract Documents, including any Addenda and related supplemental data. B. Become familiar with all federal, state, and local Laws and Regulations that may affect cost, progress, or the completion of Work. C. Carefully study and correlate the information available to the Bidder with the Contract Documents, Addenda, and the related supplemental data. D. Notify the OAR of all conflicts, errors, ambiguities, or discrepancies that the Bidder discovers in the Contract Documents, Addenda, and the related supplemental data. E. Determine that the Contract Documents, Addenda, and the related supplemental data are generally sufficient to indicate and convey understanding of all terms and conditions for completion of Work. 6.02 The submission of a Bid will constitute an incontrovertible representation by the Bidder that the Bidder has complied with every requirement of this Article 5, that without exception the Bid is premised upon completion of Work required by the Contract Documents, Addenda, and the related supplemental data,that the Bidder has given the OAR written notice of all conflicts,errors, ambiguities, and discrepancies that the Bidder has discovered in the Contract Documents, Addenda, and the related supplemental data and the written resolutions provided by the OAR are acceptable to the Bidder, and that the Contract Documents, Addenda, and the related supplemental data are generally sufficient to indicate and convey understanding of all terms and conditions for completion of Work. ARTICLE 7—INTERPRETATIONS AND ALTERNATE BIDS 7.01 Submit all questions about the meaning or intent of the Contract Documents, Addenda, and the related supplemental data using the Owner's Bidding Website at www.civcastusa.com. Responses to questions submitted will be posted on the website by the Owner for the benefit of all Bidders. Questions must be submitted by 5:00 p.m. 7 days prior to the date of the bid opening in order for responses to be posted. Inquiries made after this period may not be addressed. 7.02 Submit any offer of alternate terms and conditions,or,offer of Work not in strict compliance with the Contract Documents to the OAR no later than 14 days prior to the date for opening of Bids. OAR and Designer will issue Addenda as appropriate if any of the proposed changes to the Contract Documents are accepted. A Bid submitted with clarifications or taking exceptions to the Contract Documents, except as modified by Addenda, may be considered non-responsive. 7.03 Addenda may be issued to clarify, correct, or change the Contract Documents, Addenda or the related supplemental data as deemed advisable by the Owner or Designer. Modifications to the Contract Documents prior to the award of contract can only be made by Addenda. Only answers in Addenda authorized by the Owner will be binding. Oral and other interpretations or clarifications will be without legal effect. Invitation to Bid and Instructions to Bidders 002113-3 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 ARTICLE 8—BID SECURITY 8.01 Bidders must submit an acceptable Bid Security with their Bid as a guarantee that the Bidder will enter into a contract for the Project with the Owner within 10 days of Notice of Award of the Contract. The security must be payable to the City of Corpus Christi, Texas in the amount of 5 percent (5%) of the greatest amount bid. 8.02 Bid Security may be in the form of a Bid Bond or a cashier's check, certified check, money order, or bank draft from a chartered financial institution authorized to operate in the State of Texas. Bidders submitting bids electronically through the CivCast System at www.CivCastUSA.com shall scan and upload a copy of the Bid Security as an attachment to their bid. The original Bid Bond, cashier's check,certified check, money order or bank draft must be enclosed in a sealed envelope, plainly identified on the outside as containing bid documents,the bidder's name and thejob name and number and delivered as required in Article 3 of this Section. 8.03 Bid Bond Requirements: 1. A Bid Bond must guarantee, without qualification or condition, that the Owner will be paid a sum equal to 5 percent (5%)of the greatest amount bid if, within 10 calendar days of Notice of Award of the Contract, the Bidder/Principal: a. fails to enter into a contract for the Project with the Owner; or b. fails to provide the required Performance and Payment Bonds. 2. A Bid Bond may not limit the sum payable to the Owner to be the difference between the Bidder/Principal's bid and the next highest bidder. 3. The Bid Bond must reference the Project by name as identified in Article 2. 4. Bidders may provide their surety's standard bid bond form if revised to meet these Bid Bond Requirements. 8.04 Failure to provide an acceptable Bid Security will constitute a non-responsive Bid which will not be considered. 8.05 Failure to provide the required Performance and Payment Bonds will result in forfeiture of the Bid Security to the City as liquidated damages. 8.06 Owner may annul the Notice of Award and the Bid Security of the Bidder will be forfeited if the apparent Selected Bidder fails to execute and deliver the Agreement or Amendments to the Agreement. The Bid Security of other Bidders whom the Owner believes to have a reasonable chance of receiving the award may be retained by the Owner until the earlier of 7 days after the Effective Date of the Contract or 90 days after the date Bids are opened. 8.07 Bid Securities are to remain in effect until the Contract is executed. The Bid Securities of all but the three lowest responsible Bidders will be returned within 14 days of the opening of Bids. Bid Securities become void and will be released by the Owner when the Contract is awarded, or all Bids are rejected. Invitation to Bid and Instructions to Bidders 002113-4 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 ARTICLE 9—PREPARATION OF BID 9.01 The Bid Form is included with the Contract Documents and has been made available at the Owner's Bidding Website. Complete all blanks on the Bid Form by typing or printing in ink. Indicate Bid prices for each Bid item or alternate shown in accordance with SECTION 01 29 01 MEASUREMENT AND BASIS FOR PAYMENT. 9.02 Execute the Bid Acknowledgement Form as indicated in the document and include evidence of authority to sign. 9.03 Acknowledge receipt of all Addenda by filling in the number and date of each Addendum. Provide a signature as indicated to verify that the Addenda were received. A Bid that does not acknowledge the receipt of all Addenda may be considered non-responsive. 9.04 Provide the name, address, email, and telephone number of the individual to be contacted for any communications regarding the Bid in the Bid Acknowledgement Form. 9.05 Provide evidence of the Bidder's authority and qualification to do business in the State of Texas or covenant to obtain such qualification prior to award of the Contract. ARTICLE 10—CONFIDENTIALITY OF BID INFORMATION 10.01 In accordance with Texas Government Code 552.110, trade secrets and confidential information in Bids are not open for public inspection. Bids will be opened in a manner that avoids disclosure of confidential information to competing Bidders and keeps the Bids from the public during considerations. All Bids are open for public inspection after the Contract is awarded, but trade secrets and confidential information in Bids are not typically open for public inspection. The Owner will protect this information to the extent allowed by Laws and Regulations. Clearly indicate which specific documents are considered to be trade secrets or confidential information by stamping or watermarking all such documents with the word "confidential" prominently on each page or sheet or on the cover of bound documents. Place "confidential" stamps or watermarks so that they do not obscure any of the required information on the document, either in the original or in a way that would obscure any of the required information in a photocopy of the document. Photocopies of "confidential" documents will be made only for the convenience of the selection committee and will be destroyed after the Effective Date of the Contract. Original confidential documents will be returned to the Bidder after the Effective Date of the Contract if the Bidder indicates that the information is to be returned with the Bid, and arrangements for its return are provided by the Bidder. ARTICLE 11—MODIFICATION OR WITHDRAWAL OF BID 11.01 A Bid may be withdrawn by a Bidder, provided an authorized individual of the Bidder submits a written request to withdraw the Bid prior to the time set for opening the Bids. 11.02 A Bidder may withdraw its Bid within 24 hours after Bids are opened if the Bidder files a signed written notice with the Owner and promptly, but no later than 3 days, thereafter demonstrates to the reasonable satisfaction of the Owner that there was a material and substantial mistake in the preparation of its Bid. The Bid Security will be returned if it is clearly demonstrated to the Owner that there was a material and substantial mistake in its Bid. Invitation to Bid and Instructions to Bidders 002113-5 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 A Bidder that requests to withdraw its Bid under these conditions may be disqualified from responding to a reissued invitation to Bid for the Work to be furnished under these Contract Documents. ARTICLE 12—BIDS REMAIN SUBJECT TO ACCEPTANCE 12.01 All Bids will remain subject to acceptance for 90 days, but the Owner may, at its sole discretion, release any Bid and return the Bid Security prior to the end of this period. ARTICLE 13—STATEMENT OF EXPERIENCE 13.01 Bidders must submit the information required in SECTION 00 45 16 STATEMENT OF EXPERIENCE with the date Bid to demonstrate that the Bidder meets the minimum requirements to complete the Work. ARTICLE 14—EVALUATION OF BIDS 14.01 The Owner will consider the amount bid, the Bidder's responsibilities, the Bidder's safety record, the Bidder's indebtedness to Owner, the Bidder's capacity to perform the work and/or whether the Bidder has met the minimum specific project experience requirements. 14.02 Owner may conduct such investigations as it deems necessary to establish the responsibility of the Bidder and any Subcontractors, individuals, or entities proposed to furnish parts of the Work in accordance with the Contract Documents. 14.03 Submission of a Bid indicates the Bidder's acceptance of the evaluation technique and methodology as well as the Bidder's recognition that some subjective judgments must be made by the Owner during the evaluation. Each Bidder agrees to waive any claim it has or may have against the OPT and their respective employees, arising out of or in connection with the administration, evaluation, or recommendation of any Bid. ARTICLE 15—AWARD OF CONTRACT 15.01 The Bidder selected for award of the Contract will be the lowest responsible Bidder that submits a responsive bid. Owner will,at its discretion,award the contract to the lowest responsible bidder for the base bid, plus any combination of Add or Deduct Alternates. 15.02 Owner reserves the right to reject any and all Bids, including without limitation, non-conforming, non-responsive or conditional Bids. The Owner reserves the right to adopt the most advantageous interpretation of the Bids submitted in the case of ambiguity or lack of clearness in stating Bid prices and/or waive any or all formalities. 15.03 More than one Bid for the same Work from an individual or entity under the same or different names will not be considered. Reasonable grounds for believing that any Bidder has an interest in more than one Bid for the Work shall be cause for disqualification of that Bidder and the rejection of all Bids in which that Bidder has an interest. Invitation to Bid and Instructions to Bidders 002113-6 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 ARTICLE 16—MINORITY/ MBE/DBE PARTICIPATION POLICY 16.01 Selected Contractor is required to comply with the Owner's Minority/ MBE / DBE Participation Policy as indicated in SECTION 00 72 00 GENERAL CONDITIONS. 16.02 Minority participation goal for this Project has been established to be 45%. 16.03 Minority Business Enterprise participation goal for this Project has been established to be 15%. ARTICLE 17—BONDS AND INSURANCE 17.01 Article 6 of the General Conditions and Article 6 of the Supplementary Conditions set forth the Owner's requirements as to bonds and insurance. When the Selected Bidder delivers the executed Agreement to the Owner, it must be accompanied by the required bonds and evidence of insurance. 17.02 Provide Performance and Payment Bonds for this Project that fully comply with the provisions of Texas Government Code Chapter 2253. Administration of Bonds will conform to Texas Government Code Chapter 2253 and the provisions of these Contract Documents. ARTICLE 18—SIGNING OF AGREEMENT 18.01 The City Engineer or Director of Engineering Services will submit recommendation for award to the City Council for those project awards requiring City Council action. The Selected Bidder will be required to deliver the required Bonds and insurance certificates and endorsements along with the executed Contract to the Owner within 10 days. The Contract will be signed by the City Manager or his/her designee after award and the Bidder's submission of required documentation and signed counterparts. The Contract will not be binding upon Owner until it has been executed by both parties. Owner will process the Contract expeditiously. However,Owner will not be liable for any delays prior to the award or execution of Contract. ARTICLE 19—SALES AND USE TAXES 19.01 The Owner generally qualifies as a tax-exempt agency as defined by the statutes of the State of Texas and is usually not subject to any City or State sales or use taxes, however certain items such as rented equipment may be taxable even though Owner is a tax-exempt agency. Assume responsibility for including any applicable sales taxes in the Contract Price and assume responsibility for complying with all applicable statutes and rulings of the State of Texas Comptroller. 19.02 It is the Owner's intent to have this Contract qualify as a "separated contract." ARTICLE 20—WAGE RATES 20.01 This Contract is subject to Texas Government Code Chapter 2258 concerning payment of prevailing wage rates. Requirements for paying the prevailing wage rates are discussed in SECTION 00 72 00 GENERAL CONDITIONS. Bidders must pay not less than the minimum wage shown on this list and comply with all statutes and rulings of the State of Texas Comptroller. Invitation to Bid and Instructions to Bidders 002113-7 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 ARTICLE 21—BIDDER'S CERTIFICATION OF NO LOBBYING 21.01 In submitting its Bid, Bidder certifies that it has not lobbied the City or its officials, managers, employees,consultants,or contractors in such a manner as to influence or to attempt to influence the bidding or contract award process. In the event it reasonably appears that the Bidder influenced or attempted to influence the bidding or award process, the City may, in its discretion, reject the Bid. ARTICLE 22—CONFLICT OF INTEREST 22.01 Bidder agrees to comply with Chapter 176 of the Texas Local Government Code and file Form CIQ with the City of Corpus Christi City Secretary's Office, if required. For more information on Form CIQ and to determine if you need to file a Form CIQ, please review the information on the City Secretary's website at http://www.cctexas.com/government/city-secretary/conflict- disclosure/index. ARTICLE 23—CERTIFICATE OF INTERESTED PARTIES 23.01 Bidder agrees to comply with Texas Government Code section 2252.908 and complete Form 1295 Certificate of Interested Parties as part of this contract, if required. For more information, please review the information on the Texas Ethics Commission website at https://www.ethics.state.tx.us. ARTICLE 24-REJECTION OF BID 24.01 The following will be cause to reject a Bid: A. Bids which are not signed by an individual empowered to bind the Bidder. B. Bids which do not have an acceptable Bid Security, with Power of Attorney, submitted as required by Article 8. C. More than one Bid for same Work from an individual, firm, partnership or corporation. D. Evidence of collusion among Bidders. E. Sworn testimony or discovery in pending litigation with Owner which discloses misconduct or willful refusal by bidder to comply with subject contract or instructions of Owner. F. Failure to have an authorized agent of the Bidder attend the mandatory Pre-Bid Conference, if applicable. G. Bids received from a Bidder who has been debarred or suspended by Owner. H. Bids received from a Bidder when Bidder or principals are currently debarred or suspended by Federal, State or City governmental agencies. I. Bids received from a Bidder identified on a list prepared and maintained by the Texas Comptroller under Chapter 2252 of the Texas Government Code. 24.02 The following may be cause to reject a Bid or cause to deem a Bid non-responsive or irregular. The City reserves the right to waive any irregularities and any or all formalities: A. Poor performance in execution of work under a previous City of Corpus Christi contract. B. Failure to achieve reasonable progress on an existing City of Corpus Christi contract. Invitation to Bid and Instructions to Bidders 002113-8 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 Evidence of Bidder's recurring failure to complete an item of work within a timeframe acceptable to the City or in accordance with a City-accepted schedule is evidence of Bidder's failure to achieve reasonable progress under this subsection. C. Default on previous contracts or failure to execute Contract after award. D. Evidence of failure to pay Subcontractors, Suppliers or employees in accordance with Contract requirements. E. Bids containing omissions, alterations of form, additions, qualifications or conditions not called for by Owner, or incomplete Bids may be rejected. In any case of ambiguity or lack of clarity in the Bid, OWNER reserves right to determine most advantageous Bid or to reject the Bid. F. Failure to acknowledge receipt of Addenda. G. Failure to submit post-Bid information specified in Section 00 45 16 STATEMENT OF EXPERIENCE within the allotted time(s). H. Failure to timely execute Contract after award. I. Previous environmental violations resulting in fines or citations by a governmental entity(i.e. U.S. Environmental Protection Agency, Texas Commission on Environmental Quality, etc.). J. Bidder's Safety Experience. K. Failure of Bidder to demonstrate, through submission of the Statement of Experience, the experience required as specified in Section 00 45 16 STATEMENT OF EXPERIENCE, if that Section is included in the bidding documents. L. Evidence of Bidder's lack of sufficient resources, workforce, equipment or supervision, if required by inclusion of appropriate requirements in Section 00 45 16 STATEMENT OF EXPERIENCE. M. Evidence of poor performance on previous Projects as documented in Owner's project performance evaluations. N. Unbalanced Unit Price Bid: "Unbalanced Bid" means a Bid,which includes a Bid that is based on unit prices which are significantly less than cost for some Bid items and significantly more than cost for others. This may be evidenced by submission of unit price Bid items where the costs are significantly higher/lower than the cost of the same Bid items submitted by other Bidders on the project. O. Evidence of Bidder's lack of capacity to perform the Work. Evidence of capacity to perform the Work will include a factual review of (i) all remaining work or incomplete work items under any existing city or non-city contract; (ii) resources, workforce, equipment and supervision/supervisory staff; (iii) past performance to timely complete the same or similar work in a good and workmanlike manner utilizing same or similar remaining resources or under the same or similar conditions. Evidence of incomplete work items under any existing City-awarded IDIQ or other contract for similar work may constitute a lack of capacity to perform the Work. END OF SECTION Invitation to Bid and Instructions to Bidders 002113-9 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 00 73 00 SUPPLEMENTARY CONDITIONS These Supplementary Conditions amend or supplement SECTION 00 72 00 GENERAL CONDITIONS and other provisions of the Contract Documents. All provisions not amended or supplemented in these Supplementary Conditions remain in effect. The terms used in these Supplementary Conditions have the meanings stated in the General Conditions. Additional terms used in these Supplementary Conditions have the meanings stated below. ARTICLE 1—DEFINITIONS AND TERMINOLOGY SC-1.01 DEFINED TERMS A. The members of the OPT as defined in Paragraph 1.01.A.41 consists of the following organizations: City of Corpus Christi, Texas UA Engineering, Inc. ARTICLE 4—COMMENCEMENT AND PROGRESS OF THE WORK SC-4.04 DELAYS IN CONTRACTOR'S PROGRESS A. The allocation for delays in the Contractor's progress for rain days as set forth in General Conditions Paragraph 4.04.D are to be determined as follows: 1. Include rain days in developing the schedule for construction. Schedule construction so that the Work will be completed within the Contract Times assuming that these rain days will occur. Incorporate residual impacts following rain days such as limited access to and within the Site, inability to work due to wet or muddy Site conditions, delays in delivery of equipment and materials, and other impacts related to rain days when developing the schedule for construction. Include all costs associated with these rain days and residual impacts in the Contract Price. 2. A rain day is defined as any day in which the amount of rain measured by the National Weather Services at the Power Street Stormwater Pump Station is 0.50 inch or greater. Records indicate the following average number of rain days for each month: Month Day Month Days January 3 July 3 February 3 August 4 March 2 September 7 April 3 October 4 May 4 November 3 June 4 December 3 3. A total of 5 rain days for Base Bid Part 1 and 21 rain days for Base Bid Part 2 have been set for this Project. An extension of time due to rain days will be considered only after 43 rain days have been exceeded in a calendar year and the OAR has determined that a Supplementary Conditions 007300- 1 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 detrimental impact to the construction schedule resulted from the excessive rainfall. Rain days are to be incorporated into the schedule and unused rain days will be considered float time which may be consumed by the Owner or Contractor in delay claims. ARTICLE 5 — AVAILABILITY OF LANDS; SUBSURFACE CONDITIONS AND PHYSICAL CONDITIONS; HAZARDOUS ENVIRONMENTAL CONDITIONS SC-5.03 SUBSURFACE AND PHYSICAL CONDITIONS A. Delete Paragraph 5.03 entirely and insert the following: "5.03 Subsurface and Physical Conditions No reports of explorations or tests of subsurface conditions at or contiguous to the Site, or drawings of physical conditions relating to existing surface or subsurface structures at the Site, are known to Owner." SC-5.06 HAZARDOUS ENVIRONMENTAL CONDITIONS AT SITE A. This Supplementary Condition identifies documents referenced in General Conditions Paragraph 5.06 which describe Hazardous Environmental Conditions that have been identified at or adjacent to the Site. No reports of explorations or tests for Hazardous Environmental Conditions at or contiguous to the Site are known to Owner. ARTICLE 6—BONDS AND INSURANCE SC-6.03 REQUIRED MINIMUM INSURANCE COVERAGE INSURANCE REQUIREMENTS CONTRACTOR'S INSURANCE AMOUNTS Provide the insurance coverage for at least the following amounts unless greater amounts are required by Laws and Regulations: Type of Insurance Minimum Insurance Coverage Commercial General Liability including 1. Commercial Form 2. Premises—Completed Operations 3. Explosions and Collapse Hazard 4. Underground Hazard 5. Products/Completed Operations Hazard $1,000,000 Per Occurrence 6. Contractual Liability $2,000,000 Aggregate 7. Broad Form Property Damage 8. Independent Contractors 9. Personal &Advertising Injury Business Automobile Liability-Owned, Non- $1,000,000 Combined Single Limit Owned, Rented and Leased Workers' Compensation Statutory Supplementary Conditions 007300- 2 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 Employer's Liability $500,000/500,000/500,000 Excess Liability/Umbrella Liability $1,000,000 Per Occurrence Required if Contract Price>$5,000,000 Contractor's Pollution Liability / $1,000,000 Per Claim Environmental Impairment Coverage Not limited to sudden and accidental ■ Required ❑ Not Required discharge. To include long-term environmental impact for the disposal of pollutants/contaminants. Required if excavation>3 ft Builder's Risk(All Perils including Collapse) Equal to Full Replacement Cost of Structure and Contents Required for vertical structures and bridges ❑ Required ■ Not Required Installation Floater Equal to Contract Price Required if installing city-owned equipment ■ Required ❑ Not Required ARTICLE 7—CONTRACTOR'S RESPONSIBILITIES SC-7.02 LABOR; WORKING HOURS B. Perform Work at the Site during regular working hours except as otherwise required for the safety or protection of person or the Work or property at the Site or adjacent to the Site and except as otherwise stated in the Contract Documents. Regular working hours are between 7:00 a.m. and 6:00 p.m. unless other times are specifically authorized in writing by OAR. SC-7.04 CONCERNING SUBCONTRACTORS, SUPPLIERS, AND OTHERS A. Add the following sentence to the end of Paragraph 7.04.A: "The Contractor must perform at least 50 percent of the Work, measured as a percentage of the Contract Price, using its own employees." ARTICLE 14—PREVAILING WAGE RATE REQUIREMENTS SC-14.04 PREVAILING WAGE RATES A. The minimum rates for various labor classifications as established by the Owner are shown below: Wage Determination Construction Type Project Type (WD) No TX-21 Heavy Heavy Construction Projects (including Sewer and Water Line Construction and Drainage Projects) Supplementary Conditions 007300-3 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 TX-29 Highway Highway Construction Projects (excluding tunnels, building structures in rest area projects & railroad construction; bascule, suspension & spandrel arch bridges designed for commercial navigation, bridges involving marine construction; and other major bridges). TX-21 Heavy General Decision Number: TX190021 01/04/2019 TX21 Superseded General Decision Number: TX20180031 State: Texas Construction Type: Heavy Counties: Nueces and San Patricio Counties in Texas. HEAVY CONSTRUCTION PROJECTS (including Sewer and Water Line Construction and Drainage Projects) Note: Under Executive Order (EO) 13658, an hourly minimum wage of $10.60 for calendar year 2019 applies to all contracts subject to the Davis-Bacon Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2015. If this contract is covered by the EO, the contractor must pay all workers in any classification listed on this wage determination at least $10.60 per hour (or the applicable wage rate listed on this wage determination, if it is higher) for all hours spent performing on the contract in calendar year 2019. If this contract is covered by the EO and a classification considered necessary for performance of work on the contract does not appear on this wage determination, the contractor must pay workers in that classification at least the wage rate determined through the conformance process set forth in 29 CFR 5.5 (a) (1) (ii) (or the EO minimum wage rate, if it is higher than the conformed wage rate) . The EO minimum wage rate will be adjusted annually. Please note that this EO applies to the above-mentioned types of contracts entered into by the federal government that are subject to the Davis-Bacon Act itself, but it does not apply to contracts subject only to the Davis-Bacon Related Acts, including those set forth at 29 CFR 5.1 (a) (2) - (60) . Additional information on contractor requirements and worker protections under the EO is available at www.dol.gov/whd/govcontracts. Modification Number Publication Date 0 01/04/2019 * SUTX1987-001 12/01/1987 Rates Fringes CARPENTER (Excluding Form Setting) . . . . . . . . . . . . . . . . . . . . . . . . .$ 9.05 Concrete Finisher. . . . . . . . . . . . . . . .$ 7.56 ELECTRICIAN. . . . . . . . . . . . . . . . . . . . . .$ 13.37 2.58 Supplementary Conditions 007300-4 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 Laborers: Common. . . . . . . . . . . . . . . . . . . . . .$ 7.25 Utility. . . . . . . . . . . . . . . . . . . . .$ 7.68 Power equipment operators: Backhoe. . . . . . . . . . . . . . . . . . . . .$ 9.21 Motor Grader. . . . . . . . . . . . . . . .$ 8.72 ----------------------------------------------------------------------------- WELDERS - Receive rate prescribed for craft performing operation to which welding is incidental. ----------------------------------------------------------------------------- Note: Executive Order (EO) 13706, Establishing Paid Sick Leave for Federal Contractors applies to all contracts subject to the Davis-Bacon Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2017. If this contract is covered by the EO, the contractor must provide employees with 1 hour of paid sick leave for every 30 hours they work, up to 56 hours of paid sick leave each year. Employees must be permitted to use paid sick leave for their own illness, injury or other health-related needs, including preventive care; to assist a family member (or person who is like family to the employee) who is ill, injured, or has other health-related needs, including preventive care; or for reasons resulting from, or to assist a family member (or person who is like family to the employee) who is a victim of, domestic violence, sexual assault, or stalking. Additional information on contractor requirements and worker protections under the EO is available at www.dol.gov/whd/govcontracts. Unlisted classifications needed for work not included within the scope of the classifications listed may be added after award only as provided in the labor standards contract clauses (29CFR 5.5 (a) (1) (ii) ) . ----------------------------------------------------------------------------- The body of each wage determination lists the classification and wage rates that have been found to be prevailing for the cited type (s) of construction in the area covered by the wage determination. The classifications are listed in alphabetical order of "identifiers" that indicate whether the particular rate is a union rate (current union negotiated rate for local) , a survey rate (weighted average rate) or a union average rate (weighted union average rate) . Union Rate Identifiers A four letter classification abbreviation identifier enclosed in dotted lines beginning with characters other than "SU" or "UAVG" denotes that the union classification and rate were prevailing for that classification in the survey. Example: PLUM0198-005 07/01/2014. PLUM is an abbreviation identifier of the union which prevailed in the survey for this classification, which in this example would be Plumbers. 0198 indicates the local union number or district council number where applicable, i.e. , Plumbers Local 0198. The next number, 005 in the example, is an internal number used in processing the wage determination. 07/01/2014 is the effective date of the most current negotiated rate, which in this example is July 1, 2014. Union prevailing wage rates are updated to reflect all rate changes in the collective bargaining agreement (CBA) governing this classification and rate. Supplementary Conditions 007300-5 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 Survey Rate Identifiers Classifications listed under the "SU" identifier indicate that no one rate prevailed for this classification in the survey and the published rate is derived by computing a weighted average rate based on all the rates reported in the survey for that classification. As this weighted average rate includes all rates reported in the survey, it may include both union and non-union rates. Example: SULA2012-007 5/13/2014. SU indicates the rates are survey rates based on a weighted average calculation of rates and are not majority rates. LA indicates the State of Louisiana. 2012 is the year of survey on which these classifications and rates are based. The next number, 007 in the example, is an internal number used in producing the wage determination. 5/13/2014 indicates the survey completion date for the classifications and rates under that identifier. Survey wage rates are not updated and remain in effect until a new survey is conducted. Union Average Rate Identifiers Classification(s) listed under the UAVG identifier indicate that no single majority rate prevailed for those classifications; however, 1000 of the data reported for the classifications was union data. EXAMPLE: UAVG-OH-0010 08/29/2014. UAVG indicates that the rate is a weighted union average rate. OH indicates the state. The next number, 0010 in the example, is an internal number used in producing the wage determination. 08/29/2014 indicates the survey completion date for the classifications and rates under that identifier. A UAVG rate will be updated once a year, usually in January of each year, to reflect a weighted average of the current negotiated/CBA rate of the union locals from which the rate is based. ----------------------------------------------------------------------------- WAGE DETERMINATION APPEALS PROCESS 1. ) Has there been an initial decision in the matter? This can be: * an existing published wage determination * a survey underlying a wage determination * a Wage and Hour Division letter setting forth a position on a wage determination matter * a conformance (additional classification and rate) ruling On survey related matters, initial contact, including requests for summaries of surveys, should be with the Wage and Hour Regional Office for the area in which the survey was conducted because those Regional Offices have responsibility for the Davis-Bacon survey program. If the response from this initial contact is not satisfactory, then the process described in 2. ) and 3. ) should be followed. With regard to any other matter not yet ripe for the formal process described here, initial contact should be with the Branch of Construction Wage Determinations. Write to: Branch of Construction Wage Determinations Wage and Hour Division U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, DC 20210 Supplementary Conditions 007300- 6 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 2. ) If the answer to the question in 1. ) is yes, then an interested party (those affected by the action) can request review and reconsideration from the Wage and Hour Administrator (See 29 CFR Part 1.8 and 29 CFR Part 7) . Write to: Wage and Hour Administrator U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, DC 20210 The request should be accompanied by a full statement of the interested party's position and by any information (wage payment data, project description, area practice material, etc. ) that the requestor considers relevant to the issue. 3. ) If the decision of the Administrator is not favorable, an interested party may appeal directly to the Administrative Review Board (formerly the Wage Appeals Board) . Write to: Administrative Review Board U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, DC 20210 4. ) All decisions by the Administrative Review Board are final. ----------------------------------------------------------------------------- END OF GENERAL DECISION TX-29 Highway General Decision Number: TX190029 01/04/2019 TX29 Superseded General Decision Number: TX20180040 State: Texas Construction Type: Highway Counties: Aransas, Calhoun, Goliad, Nueces and San Patricio Counties in Texas. HIGHWAY CONSTRUCTION PROJECTS (excluding tunnels, building structures in rest area projects & railroad construction; bascule, suspension & spandrel arch bridges designed for commercial navigation, bridges involving marine construction; and other major bridges) . Note: Under Executive Order (EO) 13658, an hourly minimum wage of $10.60 for calendar year 2019 applies to all contracts subject to the Davis-Bacon Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2015. If this contract is covered by the EO, the contractor must pay all workers in any classification listed on this wage determination at least $10.60 per hour (or the applicable wage rate listed on this wage determination, if it is higher) for all hours spent performing on the contract in calendar year 2019. If this contract is covered by the EO and a classification considered necessary for performance of work on the contract does not appear on this wage determination, the contractor must pay workers in that classification at least the wage rate determined through the conformance process set forth in Supplementary Conditions 007300-7 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 29 CFR 5.5 (a) (1) (ii) (or the EO minimum wage rate, if it is higher than the conformed wage rate) . The EO minimum wage rate will be adjusted annually. Please note that this EO applies to the above-mentioned types of contracts entered into by the federal government that are subject to the Davis-Bacon Act itself, but it does not apply to contracts subject only to the Davis-Bacon Related Acts, including those set forth at 29 CFR 5.1 (a) (2) - (60) . Additional information on contractor requirements and worker protections under the EO is available at www.dol.gov/whd/govcontracts. Modification Number Publication Date 0 01/04/2019 * SUTX2011-010 08/08/2011 Rates Fringes CEMENT MASON/CONCRETE FINISHER (Paving & Structures) . . .$ 12.64 FORM BUILDER/FORM SETTER Paving & Curb. . . . . . . . . . . . . . .$ 10.69 Structures. . . . . . . . . . . . . . . . . .$ 13.61 LABORER Asphalt Raker. . . . . . . . . . . . . . .$ 11.67 Flagger. . . . . . . . . . . . . . . . . . . . .$ 8.81 Laborer, Common. . . . . . . . . . . . .$ 10.25 Laborer, Utility. . . . . . . . . . . .$ 11.23 Pipelayer. . . . . . . . . . . . . . . . . . .$ 11.17 Work Zone Barricade Servicer. . . . . . . . . . . . . . . . . . . .$ 11.51 PAINTER (Structures) . . . . . . . . . . . . .$ 21.29 POWER EQUIPMENT OPERATOR: Asphalt Distributor. . . . . . . . .$ 14.25 Asphalt Paving Machine. . . . . .$ 13.44 Mechanic. . . . . . . . . . . . . . . . . . . .$ 17.00 Motor Grader, Fine Grade. . . .$ 17.74 Motor Grader, Rough. . . . . . . . .$ 16.85 TRUCK DRIVER Lowboy-Float. . . . . . . . . . . . . . . .$ 16.62 Single Axle. . . . . . . . . . . . . . . . .$ 11.61 ----------------------------------------------------------------------------- WELDERS - Receive rate prescribed for craft performing operation to which welding is incidental. ----------------------------------------------------------------------------- Note: Executive Order (EO) 13706, Establishing Paid Sick Leave for Federal Contractors applies to all contracts subject to the Davis-Bacon Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2017. If this contract is covered by the EO, the contractor must provide employees with 1 hour of paid sick leave for every 30 hours they work, up to 56 hours of paid sick leave each year. Employees must be permitted to use paid sick leave for their own illness, injury or other health-related needs, including preventive care; to assist a family member (or person who is like family to the employee) who is ill, injured, or has other health-related needs, Supplementary Conditions 007300-8 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 including preventive care; or for reasons resulting from, or to assist a family member (or person who is like family to the employee) who is a victim of, domestic violence, sexual assault, or stalking. Additional information on contractor requirements and worker protections under the EO is available at www.dol.gov/whd/govcontracts. Unlisted classifications needed for work not included within the scope of the classifications listed may be added after award only as provided in the labor standards contract clauses (29CFR 5.5 (a) (1) (ii) ) . ----------------------------------------------------------------------------- The body of each wage determination lists the classification and wage rates that have been found to be prevailing for the cited type (s) of construction in the area covered by the wage determination. The classifications are listed in alphabetical order of "identifiers" that indicate whether the particular rate is a union rate (current union negotiated rate for local) , a survey rate (weighted average rate) or a union average rate (weighted union average rate) . Union Rate Identifiers A four letter classification abbreviation identifier enclosed in dotted lines beginning with characters other than "SU" or "UAVG" denotes that the union classification and rate were prevailing for that classification in the survey. Example: PLUM0198-005 07/01/2014. PLUM is an abbreviation identifier of the union which prevailed in the survey for this classification, which in this example would be Plumbers. 0198 indicates the local union number or district council number where applicable, i.e. , Plumbers Local 0198. The next number, 005 in the example, is an internal number used in processing the wage determination. 07/01/2014 is the effective date of the most current negotiated rate, which in this example is July 1, 2014. Union prevailing wage rates are updated to reflect all rate changes in the collective bargaining agreement (CBA) governing this classification and rate. Survey Rate Identifiers Classifications listed under the "SU" identifier indicate that no one rate prevailed for this classification in the survey and the published rate is derived by computing a weighted average rate based on all the rates reported in the survey for that classification. As this weighted average rate includes all rates reported in the survey, it may include both union and non-union rates. Example: SULA2012-007 5/13/2014. SU indicates the rates are survey rates based on a weighted average calculation of rates and are not majority rates. LA indicates the State of Louisiana. 2012 is the year of survey on which these classifications and rates are based. The next number, 007 in the example, is an internal number used in producing the wage determination. 5/13/2014 indicates the survey completion date for the classifications and rates under that identifier. Survey wage rates are not updated and remain in effect until a new survey is conducted. Union Average Rate Identifiers Classification(s) listed under the UAVG identifier indicate that no single majority rate prevailed for those classifications; however, 1000 of the data reported for the classifications was union data. EXAMPLE: UAVG-OH-0010 Supplementary Conditions 007300-9 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 08/29/2014. UAVG indicates that the rate is a weighted union average rate. OH indicates the state. The next number, 0010 in the example, is an internal number used in producing the wage determination. 08/29/2014 indicates the survey completion date for the classifications and rates under that identifier. A UAVG rate will be updated once a year, usually in January of each year, to reflect a weighted average of the current negotiated/CBA rate of the union locals from which the rate is based. ----------------------------------------------------------------------------- WAGE DETERMINATION APPEALS PROCESS 1. ) Has there been an initial decision in the matter? This can be: * an existing published wage determination * a survey underlying a wage determination * a Wage and Hour Division letter setting forth a position on a wage determination matter * a conformance (additional classification and rate) ruling On survey related matters, initial contact, including requests for summaries of surveys, should be with the Wage and Hour Regional Office for the area in which the survey was conducted because those Regional Offices have responsibility for the Davis-Bacon survey program. If the response from this initial contact is not satisfactory, then the process described in 2. ) and 3. ) should be followed. With regard to any other matter not yet ripe for the formal process described here, initial contact should be with the Branch of Construction Wage Determinations. Write to: Branch of Construction Wage Determinations Wage and Hour Division U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, DC 20210 2. ) If the answer to the question in 1. ) is yes, then an interested party (those affected by the action) can request review and reconsideration from the Wage and Hour Administrator (See 29 CFR Part 1.8 and 29 CFR Part 7) . Write to: Wage and Hour Administrator U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, DC 20210 The request should be accompanied by a full statement of the interested party's position and by any information (wage payment data, project description, area practice material, etc. ) that the requestor considers relevant to the issue. 3. ) If the decision of the Administrator is not favorable, an interested party may appeal directly to the Administrative Review Board (formerly the Wage Appeals Board) . Write to: Administrative Review Board U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, DC 20210 Supplementary Conditions 007300- 10 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 4 . ) All decisions by the Administrative Review Board are final. ----------------------------------------------------------------------------- END OF GENERAL DECISION ARTICLE 19—PROJECT MANAGEMENT AND COORDINATION SC-19.21 COOPERATION WITH PUBLIC AGENCIES C. For the Contractor's convenience, the following telephone numbers are listed: Public Agencies/Contacts Phone Number City Engineer 361-826-3500 UA Engineering, Inc. 361.991.8550 Jeff Coym, PE 361.991.8550 Traffic Engineering 361-826-3547 Police Department 361-882-2600 Water/Wastewater/Stormwater 361-826-1800 (361-826-1818 after hours) Gas Department 361-885-6900 (361-885-6942 after hours) Parks & Recreation Department 361-826-3461 Street Department 361-826-1875 City Street Div. for Traffic Signals 361-826-1610 Solid Waste & Brush 361-826-1973 IT Department(City Fiber) 361-826-1956 AEP 1-877-373-4858 AT&T 361-881-2511 (1-800-824-4424 after hours) Grande Communications 1-866-247-2633 Spectrum Communications 1-800-892-4357 Crown Castle Communications 1-888-632-0931 (Network Operations Center) Centuryl-ink 361-208-0730 W i ndstrea m 1-800-600-5050 Regional Transportation Authority 361-289-2712 Port of Corpus Christi Authority Engr. 361-882-5633 TxDOT Area Office 361-808-2500 Corpus Christi ISD 361-695-7200 Supplementary Conditions 007300- 11 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 ARTICLE 25—SHOP DRAWINGS SC-25.03 CONTRACTOR'S RESPONSIBILITIES A. Provide Shop Drawings for the following items: Specification Section Shop Drawing Description SEE SECTION 0133 01 SUBMITTAL REGISTER FOR REQUIRED SHOP DRAWINGS ARTICLE 26—RECORD DATA SC-26.03 CONTRACTOR'S RESPONSIBILITIES A. Submit Record Data for the following items: Specification Section Record Data Description SEE SECTION 0133 01 SUBMITTAL REGISTER FOR REQUIRED RECORD DATA END OF SECTION Supplementary Conditions 007300- 12 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 00 30 00 BID ACKNOWLEDGEMENT FORM ARTICLE 1—BID RECIPIENT 1.01 In accordance with the Drawings, Specifications, and Contract Documents, this Bid Proposal is submitted by J �7,-flCzCC 1 e w', (type or print name of company)on:2:00 PM on Wednesday,August 28,2019 for Project No. E10053,Whitecap WWTP Odor Control and Bulkhead Rehabilitation. 1..02 Submit Bids, Bid Security and all attachments to the Bid (See Section 7.01 below) to the City's electronic bidding website at www.CivCastUSA.com. To submit the original bid security or if submitting hard copy bids, please send to: City of Corpus Christi City Secretary's Office 1201 Leopard Street Corpus Christi,Texas 78101 Attention: City Secretary Bid—Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 ARTICLE 2—BIDDERS'S ACKNOWLEDGMENTS 2.01 Bidder proposes and agrees, if this Bid is accepted,to enter into an Agreement with Owner on the form included in the Contract Documents, to perform all Work specified or indicated in Contract Documents for the Contract Price indicated in this Bid or as modified by Contract Amendment. Bidder agrees to complete the Work within the Contract Times established in the Agreement or as modified by Contract Amendment and comply with the all other terms and conditions of the Contract Documents. 2.02 Bidder accepts all of the terms and conditions of SECTION 00 21 13 INVITATION TO BID AND INSTRUCTIONS TO BIDDERS, including those dealing with required Bonds. The Bid will remain subject to acceptance for 90 days after the opening of Bids. 2.03 Bidder acknowledges that Owner, at its discretion, will correct mathematical errors contained in the Bid and will conform bid items in accordance with SECTION 01 29 01 MEASUREMENT AND BASIS FOR PAYMENT. 2.04 Bidder accepts the provisions of the Agreement as to liquidated damages in the event of its failure to complete Work in accordance with the schedule set forth in the Agreement. 2.OS Bidder acknowledges receipt of the following Addenda: Addendum No. Addendum Date Signature Acknowledging Receipt 1,C' Bid Acknowledgement Form 003000- 1 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 ARTICLE 3—BIDDER'S REPRESENTATIONS 3.01 The Bidder has examined and carefully studied the Contract Documents and the other related data identified in the Bidding Documents. 3.02 The Bidder has visited the Site and become familiar with and is satisfied as to the general, local, and Site conditions that may affect cost,progress,and performance of the Work. 3.03 The Bidder is familiar with Laws and Regulations that may affect cost,progress,and performance of the Work. 3.04 The Bidder has carefully studied the following Site-related reports and drawings as identified in the Supplementary Conditions: A. Geotechnical Data Reports regarding subsurface conditions at or adjacent to the Site; B. Drawings of physical conditions relating to existing surface or subsurface structures at the Site; C. Underground Facilities referenced in reports and drawings; D. Reports and drawings relating to Hazardous Environmental Conditions,if any,at or adjacent to the Site;and E. Technical Data related to each of these reports and drawings. 3.05 The Bidder has considered the: A. Information known to Bidder; B. Information commonly known to contractors doing business in the locality of the Site; C. Information and observations obtained from visits to the Site;and D. The Contract Documents. 3.06 The Bidder has considered the items identified in Paragraphs 3.04 and 3.05 with respect to the effect of such information, observations,and documents on: A. The cost, progress,and performance of the Work; B. The means, methods, techniques, sequences, and procedures of construction to be employed by Bidder;and C. Bidder's safety precautions and programs. 3.07 Based on the information and observations referred to in the preceding paragraphs,Bidder agrees that no further examinations,investigations,explorations,tests,studies,or data are necessary for the performance of the Work at the Contract Price,within the Contract Times,and in accordance with the other terms and conditions of the Contract Documents. 3.08 The Bidder is aware of the general nature of Work to be performed by Owner and others at the Site that relates to the Work as indicated in the Contract Documents. Bid Acknowledgement Form 003000-2 Whitecap WWTP Odor Control and Bulkhead Rehabilitation,Project No.E10053 Rev 10/2018 5.03 Material misstatements in the documentation submitted to determine the Bidder's responsibility, including information submitted per SECTION 00 45 16 STATEMENT OF EXPERIENCE, may be grounds for rejection of the Bidder's Bid on this Project. Any such misstatement,if discovered after award of the Contract to such Bidder,may be grounds for immediate termination of the Contract. Additionally, the Bidder will be liable to the Owner for any additional costs or damages to the Owner resulting from such misstatements, including costs and attorney's fees for collecting such costs and damages. ARTICLE 6—TIME OF COMPLETION 6.01 Bidder will complete the Work required to be substantially completed within 40 days for Base Bid Part 1 and within 180 days for Base Bid Part 2 after the date when the Contract Times commence to run as provided in Paragraph 4.01 of the General Conditions. Bidder will complete the Work required for final payment in accordance with Paragraph 17.16 of the General Conditions within 70 days for Base Bid Part 1 and within 210 days for Base Bid Part 2 after the date when the Contract Times commence to run. ARTICLE 7—ATTACHMENTS TO THIS BID In compliance with the Bid Requirements in SECTION 00 2113 INVITATION TO BID AND INSTRUCTIONS TO BIDDER/S,the following are made a condition of this Bid: J A. Bid Security. V B. SECTION 00 30 00 BID ACKNOWLEDGEMENT FORM and documentation of signatory authority. ,/C. SECTION 00 30 01 BID FORM. ,/D. SECTION 00 30 02 COMPLIANCE TO STATE LAW ON NONRESIDENT BIDDERS. ✓E. SECTION 00 30 05 DISCLOSURE OF INTEREST. -/F. SECTION 00 30 06 NON-COLLUSION CERTIFICATION. ✓G. SECTION 0045 16 STATEMENT OF EXPERIENCE ARTICLE 8—DEFINED TERMS 8.01 The terms used in this Bid have the meanings indicated in the General Conditions and the Supplementary Conditions. The significance of terms with initial capital letters is described in the General Conditions. ARTICLE 9—VENUE 9.01 Bidder agrees that venue shall lie exclusively in Nueces County,Texas for any legal action. ARTICLE 10—ETHICAL BEHAVIOR 10.01 Bidder certifies that Bidder's officers,employees and agents will not attempt to lobby or influence a vote or recommendation related to this Bid,directly or indirectly,through any contact with City Council members or other City officials from the date the Bid is submitted to the City until a Bid Acknowledgement Form 003000-4 Whitecap WV,/TP Odor Control and Bulkhead Rehabilitation,Project No.E10053 Rev 10/2018 Contract is executed by the City Manager or designee,except that comments are allowed to be made at a public meeting held under the Texas Open Meetings Act. ARTICLE 11—SIGNATORY REQUIREMENTS FOR BIDDERS 11.01 Bidders must include their correct legal name,state of residency,and federal tax identification number in the Bid Form. 11.02 The Bidder, or the Bidder's authorized representative, shall sign and date the Bid Form to accompany all materials included in the submitted Bid. Bids which are not signed and dated in this manner,or which do not contain the required documentation of signatory authority may be rejected as non-responsive. The individual(s)signing the Bid must have the authority to bind the Bidder to a contract,and if required,shall attach documentation of signatory authority to the Bid Form. 11.03 Bidders who are individuals("natural persons"as defined by the Texas Business Organizations Code§1.002),but who will not be signing the Bid Form personally,shall include in their bid a notarized power of attorney authorizing the individual designated as their authorized representative to submit the Bid and to sign on behalf of the Bidder. 11.04 Bidders that are entities who are not individuals shall identify in their Bid their charter or Certificate of Authority number issued by the Texas Secretary of State and shall submit with their Bid a copy of a resolution or other documentation approved by the Bidder's governing body authorizing the submission of the Bid and designating the individual(s)authorized to execute documents on behalf of the Bidder. Bidders using an assumed name(an"alias")shall submit a copy of the Certificate of Assumed Name or similar document. 11.05 Bidders that are not residents of the State of Texas must document their legal authority to conduct business in Texas. Nonresident Bidders that have previously registered with the Texas Secretary of State may submit a copy of their Certificate of Authority. Nonresident Bidders that have not previously registered with the Texas Secretary of State shall submit a copy of the Bidder's enabling documents as filed with the state of residency,or as otherwise existing. Bid Acknowledgement Form 003000-5 Whitecap WWTP Odor Control and Bulkhead Rehabilitation,Project No.E10053 Rev 10/2018 Bid Acknowledgement Form 003000-6 Whitecap WW`rP Odor Control and Bulkhead Rehabilitation,Project No.E10053 Rev 10/2018 04 30 01 BID FORM Project Whitecap WWTP Odor Control and BUIkhe7d(Rehabilitation Name: Project E10053 Number: Owner: City of Corpus Christi Bidder — OAR: Designer. UA Engineering,Inc, Basis of Bid ( ESriYATEC F><i f r DEa UESCRrl�rro uMri arrIT Fn f:L . i quartrtTv � araouNT BASE BID PART 1:ODOR CONTROL SYSTEM PART 1A-GENERAL(per SECTION 01 29 01 MEASUREMENT AND BASIS FOR PAY4IENIT) 1A1 Mobilization(5%Max.of Part 1) LS 1 IA2 Bonds&Insurance(Part 1) L5 1 b pbD 1A3 Allowance For Unanticipated Adjustments LS 1 a "•i Vii':aa ` �:r,:'�' .t°'" SUBTOTAL PART JA-GENERAL(Items IA1 thru IA31 Q PART 1B-BIOTRICKLING FILTER(per SECTION 0129 01 IlEASURERIENT AND BASIS FOR PAYIAENT) 181 Demolition Existing Fans,Ductwork 1B2 Reroute Existing Lines LS 1 Bioair ECoFilter EF41 Biotr-rckling Filter Unit w/Blower•Eiectrical Control I �S 183 LS Panel&Water Control Panel 1 .5-4)01 7q) 3U 1B4 Modifications To Existing Ductwork LS 1 IBS Misc-Utilities&Yard Piping LS 1 SUBTOTAL PART 16-810TRICKUNG FILTER (Items 101 thru 1B5) PART 1C-ELECTRICAL(per SECTION 0129 01 IAEASURDAENT AND BASIS FOR PAVAENT) 1C1 Electrical Demolition LS 11 1C2 Motor Control Center Breaker&Bucket EA I C7 1C3 1"PVC Conduit LF 40 1C4 I"Aluminum Coruiuit LF 20 ICS I"Flex Conduit LF 10 �OC' IC6 N12 THWN Copper 600V LF 200 1C7 NEMA 4x Junction Box EA 1 1C8 Misc.Electrical,5upports,Grounding LS 1 zoo SUBTOTAL PART 1C-ELECTRICAL(1C1 THRU 1CB) a p(Go6iR)o BID SUMMARY BASE BID PART 1:ODOR CONTROL SYSTEM SUBTOTAL PART 1A-GENERAL(items IA1 thru 1A3) 4,10, Cid SUBTOTAL PART 1B-BIOTRICKLING FILTER(Items 161 thru IBS) QCT SUBTOTAL PART IC-ELECTRICAL{Items 10 thru IC8] 76 000 TOTAL PROJECT BASE BID PART 1(PARTS 1A THRU SCM 77,07, ContractTimes Bidder agrees to reach Substantial Completion in days Bidder agrees to reach Final Completion in days Page 1 of 1 Nd Farm-base Did Part 1(ODOR CWkTROQ Whitecip VJWTP Otlor Control and Bulkhead Replacement,Project No.E10053 10/2015 00 30 01 BID FORM Addendum No.2 Attachment No.2 Page 1 of 1 Project Whitecap WWTP Odor Control and Bulkhead Rehabititation Name: Project E1005A Number: Owner: City of Cor us Christi Bidder. I r OAR: _ Oesigner.JUA Engineering,Inc. Basis of Bid tx*Trtoer, Iters DESCRIPTION UtrrT ESTIMATED UANTITY t]NITPRICf AV.aUrr BASE BID PART 2: BULKHEAD REHABILITATION PART 2A-GENERAL(per SECTION 01 29 01 MEASURE HENT AND BASIS FOR PAYMENT) 2A1 Mobilization(5°S Max.of Part 2) LS 1 2A2 Bonds&Insurance(Part 2) LS 1 .046 OD 2A4 Stormwater Pollution Prevention Plan LS 1 I 2A5 Inlet Protection EA 3 2A6 JErosion Protection Matting sY 1,800 2A.7 I Hydrornulch Seeding SY 1,600 2A8 JAIlawance For Unanticipated Repairs LS 1 �_'.tD'? 0 SUBTOTAL PART 2A-GENERAL(Items 2A1 thru 2A8) PART 28•BULKHEAD REHABILITATION(per SECTION 0129 01 MEASUREMENT AND BASIS FOR PAYMENT) 281 Remove and Replace Chain Link Fence LF 1,392 282 Remove and Replace Wooden Dock and Walkway LF 12 2B3 Preparation and Cleaning of Existing Bulkhead Cap LF 3,255 28A Existing Concrete Cap Point Repair (Includes Cracks, Spalls & Exposed LF 529 +y Rebar 7S 2B5 Vinyl Box Sheet Pile&Concrete Pile Cap lOption 1 or Option 2) LF 3,255 ( r 2B6 lGrading of Area Behind Bulkhead SY 1,800 j 'Q SUBTOTAL PART 2B-BULKHEAD REHABILITATION (Items zal thru 2B61 fesi BID SUMMARY BASE BID PART 2:BULKHEAD REHABILITATION SUBTOTAL PART 2A-GENERAL(Items 2A1 thru 2A8) SUBTOTAL PART 26-REHABILITATION (Items 2B1 thru 2B6) TOTAL PROJECT BASE BID PART 2(PARTS 2A THRU 2B) p Contract Ti mes Bidderagrees to reach Substantial Completion in 180 days Bidderagrees to reach Final Completion in 210 days Page 2 of l Bid Form-Base Bid Part I IBULKHEAD REHAB)Whitecap%'A TP Odor Cpntrvl and Bulkhead Rehabilitation,Pra)en No,E10053 101MIS 00 30 02 COMPLIANCE TO STATE LAW ON NONRESIDENT BIDDERS Chapter 2252 of the Texas Government Code applies to the award of government contract to nonresident bidders. This law provides that: "a government entity may not award a governmental contract to a nonresident bidder unless the nonresident underbids the lower bid submitted by a responsible resident bidder by an amount that is not less than the amount by which a resident bidder would be required to underbid the nonresident bidder to obtain a comparable contract in the state in which the nonresident's principal place of business is located." "Nonresident bidder" refers to a person who is not a resident of Texas. "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. Check the statement that is correct for Bidder. EX Bidder qualifies as a nonresident bidder whose principal place of business or residency is in the State of ::�-c.4� v�.e, ❑ Bidder (includes parent company or majority owner) qualifies as a resident bidder whose principal place of business is in the State of Texas. The Owner will use the information provided in the State of Texas Comptroller's annual publication of other states' laws on contracts to evaluate the Bids of nonresident Bidders. Bidder: Company Name: �-`arQ� 0UYtL� R`4 (typed or printed) By: (signature attach evidence of authority to sign) 1 nn Name: J •S. �C`Q .�`:�G4MP,�w (typed or printed) a ORATE Title: = �4 uJ` C c :may Business address: :� { `\ r j, 0111 \\` Phone: Email: END OF SECTION Compliance to State Law on Nonresident Bidders 003002-1 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 10/2018 00 30 05 City of Corpus Christi Disclosure of Interest CITY OF CORPUS CHRISTI DISCLOSURE OF INTEREST City of Corpus Christi Ordinance 17112, as amended, requires all persons or firms seeking to do business with the City to provide the following information. Every question must be answered. If the question is not applicable, answer with"NA". See reverse side for Filing Requirements,Certifications and definitions. COMPANY NAME: J S. ��Uw^- uRn_ P.O.BOX: ADDRESS fry S �r1 CITY: n i STATE: ZIP: 31363 FIRM IS: 1. Corporation 2. Partnership 8 3. Sole Owner F14. Association u 5. Other DISCLOSURE QUESTIONS If additional space is necessary, please use the reverse side of this page or attach separate sheet. 1. State the names of each "employee" of the City of Corpus Christi having an ownership interest" constituting 3%or more of the ownership in the above named"firm." Name No �i-0— Job Title and City Department(if known) 2. State the names of each "official" of the City of Corpus Christi having an "ownership interest" constituting 3% or more of the ownership in the above named"firm." Name Title 3. State the names of each "board member" of the City of Carpus Christi having an "ownership interest" constituting 3%or more of the ownership in the above named"firm." Name �f Z)0 Board, Commission or Committee 4. State the names of each employee or officer of a"consultant"for the City of Corpus Christi who worked on any matter related to the subject of this contract and has an "ownership interest" constituting 3% or more of the ownership in the above named"firm." Name KConsultant City of Corpus Christi 00 30 05–1 Whitecap WWTP Odor Control and Bulkhead Rehabilitation,Project No.E10053 Rev 01/2016 FILING REQUIREMENTS If a person who requests official action on a matter knows that the requested action will confer an economic benefit on any City official or employee that is distinguishable from the effect that the action will have on members of the public in general or a substantial segment thereof,you shall disclose that fact in a signed writing to the City official, employee or body that has been requested to act in the matter, unless the interest of the City official or employee in the matter is apparent. The disclosure shall also be made in a signed writing filed with the City Secretary. [Ethics Ordinance Section 2-349 (d)] CERTIFICATION I certify that all information provided is true and correct as of the date of this statement, that I have not knowingly withheld disclosure of any information requested; and that supplemental statements will be promptly submitted to the City of Corpus Christi, Texas as changes occur. Certifying Person: c� .S -- ' ( Title: _ PCtJ), k f\ - (Type or Mitt) Signature of Certifying Person:_ Date: 1179- DEFINITIONS 179.DEFINITIONS a. "Board member." A member of any board, commission, or committee appointed by the City Council of the City of Corpus Christi,Texas. b. "Economic benefit". An action that is likely to affect an economic interest if it is likely to have an effect on that interest that is distinguishable from its effect on members of the public in general or a substantial segment thereof. c. "Employee." Any person employed by the City of Corpus Christi, Texas either on a full or part-time basis, but not as an independent contractor. d. "Firm." Any entity operated for economic gain, whether professional, industrial or commercial, and whether established to produce or deal with a product or service, including but not limited to, entities operated in the form of sole proprietorship, as self-employed person, partnership, corporation, joint stack company, joint venture,receivership or trust, and entities which for purposes of taxation are treated as non-profit organizations. e. "Official." The Mayor, members of the City Council. City Manager, Deputy City Manager, Assistant City Managers, Department and Division Heads, and Municipal Court Judges of the City of Corpus Christi,Texas. f. "Ownership Interest." Legal or equitable interest, whether actually or constructively held, in a firm, including when such interest is held through an agent, trust, estate, or holding entity. "Constructively held" refers to holdings or control established through voting trusts, proxies, or special terms of venture or partnership agreements." g. "Consultant."Any person or firm, such as engineers and architects, hired by the City of Corpus Christi for the purpose of professional consultation and recommendation. City of Corpus Christi 003005-1 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No, E10053 Rev 01/2016 00 30 06 NON-COLLUSION CERTIFICATION STATE OFTEN COUNTY OF W4-EG 5 NkCIVAlAr) OWNER: City of Corpus Christi,Texas 1201 Leopard Street Corpus Christi,Texas 78401 CONTRACT: Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Bidder certifies that it has not been a party to any collusion among Bidders in the restraint of freedom of competition by agreement to submit a Bid at a fixed price or to refrain from bidding; or with any official or employee of the Owner as to quantity, quality, or price in the prospective contract, or any other terms of said prospective contract; or in any discussion between Bidders and any official of the Owner concerning exchange of money or other thing of value for special consideration in the letting of a contract. Company Name: "rLn c4 (typeb or printed) yL�[/� (signature attach evidence of authority to sign)V Name: C J J . 7 1 V`` � (typed or printed) .. . Title: UJ ! �'\'� ?�F �QORA7F I� 1 �J , Business address: _''' W ENS \ l \\ l 1611VI\\ Phone: qIYMS-5023 Email: ? k are^ (�? 1J 6e. END OF SECTION Non-Collusion Certification 003006-1 Whitecap WW-TP Odor Control and Bulkhead Rehabilitation, Project No. E10053 10/2018 THE AMERICAN INSTITUTE OF ARCHITECTS 90 AIA Doi ,ainc gal A310 Bid Bond BOND # MBC1908282 KNOW ALL MEN BY THESE PRESENTS, that we J.S. HAREN COMPANY 1175 Highway 11 N Athens,TN 37303 as Principal,hereinafter called the Principal, and MERCHANTS BONDING COMPANY (MUTUAL) P.O.Box 14498 Des Moines,IA 50306-3498 a corporation duly organized under the laws of the State of IA as Surety,hereinafter called the Surety,are held and firmly bound unto City of Corpus Christi,TX 1201 Leopard St Corpus Christi,TX 78401 (Here insert full name:,and address or legal utle or Owner) as Obligee,hereinafter called the Obligee, in the sum of Five Percent of Amount Bid----------__________________-____Dollars ( $ 5.00% of attached bid), for the payment of which sum well and truly to be made,the said Principal and the said Surety, bind ourselves, our heirs, executors,administrators, successors and assigns,jointly and severally, firmly by these presents. WHEREAS,the Principal has submitted a bid for Whitecap WWTP Order Control& Bulkhead Rehab Project,Corpus Christi,TX (Here insert full name,address and description orproject) NOW,THEREFORE, if the Obligee shall accept the bid of the Principal and the Principal shall enter into a Contract with the Obligee in accordance with the terms of such bid and give such bond or bonds as may be specified in the bidding or Contract Documents with good and sufficient surety for the faithful performance of such Contract and for the prompt payment of labor and material furnished in the prosecution thereof, or in the event of the failure of the Principal to enter such Contract and give such bond or bonds, if the Principal shall pay to the Obligee the difference not to exceed the penalty hereof between the amount specified in said bid and such larger amount for which the Obligee may in good faith contract with another party to perform the Work covered by said bid then this obligation shall be null and void, otherwise to remain in full force and effect. Signed and sealed this 28th day of August 2019 J. S. HAREN COMPANY (Principal) (Seal) \0�%1Y1C1,1{lollllnllrr111� t ss) (Title) QORArF B O¢ :w~W MERCHANTS NDING COMP NY (MUTUAL) ZZitness) Titl CCc ly L.Berry,$fonds o/ -east,Inc. 1030 17"Avenue South Nashville,TN 37212 (615)321-9700 AIA DOCUMEM'A310 BID BOND AIA® FEBRUARY 1970 ED THE AMERICAAt_ INSTITUTE OF ARCHITECTS, 1735 N.Y.AVE„N.W.WASHINGTON,D.C. 20006 1 WARNING: Unlicensed photocopying violates U.S.copyright laws and is subject to legal prosecution. WORKERS COMPENSATION EXPERIENCE RATING Risk Name: J S HAREN CO Risk ID: 917515522 Via" Rating Effective Date: 10/01/2018 Production Date: 05/1012018 State: INTERSTATE 17-LOUISIANA Firm ID: Firm Name. J S HAREN CO Carrier. 12637 Policy No. DTAUB591OB24514 Eff Date: 10/01/2014 Exp Date: 1010112015 Ell A Vim ON 3724 1.79 .19 5,088, 91 171 3724 1.79 .19 7,892 141 271 5221 3.17 .21 3,867 123 26 5221 3,17 .21, 2,493 79 17 5606 .60 .191 6,749 40 8 5606 .601 4,352 26 5 9807 1 EMPLOYERS LMIUT 0 0 9807 [EMPLOYERS LIABILIT 0 0 Total Act Inc Policy Total. 30,441 Premium: 1,524 Losses: 17-LOUISIANA Firm ID: Firm Name: J S HAREN CO Carrier. 15318 Policy No. DTNUB5910824515 Eff Date: 10101/2015 Exp Date: 10/01/2016 oil 3724 1.79 .19 11,901 213 40 5606 .60, 19 53,750 323 61 9807 EMPLOYERS LIABILrr 0 0 Total Act Inc Policy Total: 65,851 SP ruebmei'cutm: 1,853 11-ones: 0 17-LOUISIANA Firm ID: Firm Name: J S HAREN CO Carrier 15318 Policy No. DTHUS5910824516 Eff Date: 10101/2016 Exp Date: 10101/2017 -C a_:T Lit r7 11 3724 1.79 .19 40,496 725 138 5163 1.44 .21 3,974 57 12 9807 EMPLOYERS L[ABILIT 0. .0 Total Act Inc Policy Total:. 44,47�SP uljectrn: 2,354 Losses: 0 T;E- I-79 .19 1.44 .21 23-MISSISSIPPI Fiffin ID: Firm Nam(P.- J S HAREN CO Carrier: 27243 Policy No. WC535S531660014 Eff Date: 02/2112014 Exp Date: 08105/2014 f q�djltk"! a 1111 NO EXPOSURE DEVELO 0 . 0 _9848 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Tote I; Subject 751 Losses: 0 QCopynght 199b2018,All rights reserved. This product is compfteclof compilations and information which Ora the pr0priatary and exeLsIve property ethe National council aft- Cemp"rsation Insurance,Inc.(NCCI). No further use,dissemination,sale,transfer,assignment or disposition of this product in whole or in part.may be made without the prof Written c.n.nt of NCCI.This product Is fumWwyd'As Is"As available'-fth an defects!and Includes Information eyallable at the time of publication only.NCCI makes no roprogentavone or warranties of any kind hoisting to the product and hereby expressly qrscisims any and all express,statutory,or Implied warranties,including the implIed warranty of merchantabully,ftne fe.r a particular purpose,accuracy,completeness,currentness,or correctness of any Information of product furnished hereunder.All responsibility for the use of and for any and all results carved or obtained through the use of the product am the and user's and NCCI shall not have any Ilabolty thereto. -TOW by Pollcy Year of at cases$20130 or less. 0 Disease Loss X Ex-Medical Coverage U USL&Hw C estasirophic Loss r=Employers Liability Lou #Limited Low Page 6 of 12 WORKERS COMPENSATION EXPERIENCE RATING Risk Name:J S HAREN CO Name Risk ID: 917515522 Rating ating Effective Date: 10/01/2018 Production Date. 05/1012018 State: INTERSTATE 10-GEORGIA Firm ID: Firm Name., J 8 HAREN CO Carrier, 13579 Policy No. DTNUS591OB24515 Eff Date: 10/01/2015 Exp Date: 1010112016 LPM. AINMM OF SUBROGAT 0 0 3724 1.50 M 3,090 46 10 1 2 88 27 3,850 115 31 9807 JEMPLOYERS LIABIUT 0�— - 0 �Subject Total Act Inc Policy Total: Premium: 634 Losses: 0 10-GEORGIA Firm ID: Firm Name: J S HAREN CO Carder. 12637 Policy No. DTHUSS91OB24516 Eff Date: 10/01/2016 Exp Oats: 10/01/2017 a 0930 WAVER OF SUBROGAr 0 0 3724 1.50 .22 4,542 68 15 9801 EAVLOYERS LIABILIT .. 0— ]subject Total Act Inc 1Polley Total: 4, Premium: 236 Losses: 0 17-LOUISIANA Firm ID: Firm Name: J S HAREN Co Carrier 30120 Policy No. 143744 Eff Date: 02t21/2014 Exp Date: 10101/2014 XWO! A I' 0931 ISHORT RATE PENALTY 0 0 5221 3.17 .211 6.991 222 47 .:ILIT _I 9812 EMPLOYERS LIA131LIT 9W PODITIONAL PREMIUM 0 Subject Total Act Inc Policy Total:— 6,991 Premium: 828 Losses: 0 ®Copyright 1993-2018,Ali rights reserved. This product is oDmprised Of compiiallon3 and information wtuich ara the proprietary and exclusive Property ofthe National Comp#nsatlon Insurance,Inc(NCCl). No furthar use,dissamina&n.sale,transfer,assignment or Mspositlon of this product.In"ale a Coun4lon Thisror in Part,may be meds wfthoLn the Prior wT*tft,,n c"o��u o prior comers cf NCCLduct is furnishad'As is"As available'With all defect' Incluclas informatl*n avallat)[0 at the time of PUbllCat0n only,NC01 makes no representailons or warrairejel sherry kind relating to the product and hereby Wressly disclaims any and all express,statutory,or Implied warranties,including he i for a porwar Purpose,accuracy,completeness,curren"es,or correctness of any Information or product turnishad hereunder.AU resPon3lb9'mPl'8d"w"Inly of merchantability.ftess ,al is derived of Obtained through the use of the product we the and users and NCCI shall not have any RatalrTly thereto. -1y for thew"of and far any and all results ;'-7atelby Poll�cyYaar of aa cases$2000 or less. D Disease Lass X Ex-Medical Coverage U L)SL&Hvv C Catastrophic Loss E Employers UaVlty Loss #Urn-led Loss Page 5 of 12 WORKERS COMPENSATION EXPERIENCE RATING AV ra, Risk Name: J S HAREN CO Risk ID: 917515522 Rating Effective Date:10/01/2018 Production Date: 0511012018 State: INTERSTATE 03-ARKANSAS Flim ID: Firm Name: J S HAREN CO Carrier: 12610 Policy No. DTHUB591OB24516 Eff Date: 10/01/2016 Exp Date: 10/0112017 �11 00 47 0930 WAIVER OF SUBROGAT - 0 0 3724 11-07 .341 660 7 2 5183 .67 .37 160,WS 1,076 398 5606 33 .341 57,63127 - 190 65 0 9807 EMPLOYERS LIABILIT 0 Subject Total Act Inc Premium: Policy Total: 218,8 Premium! 5,352 Losses: 0 10-GEORGIA Firm 10: Firm Name: J S HAREN CO Carrier: 27995 Policy No. WC038600739201 Eff Date: 02121/2014 Exp Data: 10/0112014 8183 2AS 27 g4.44-0 535 144 2 9812"EBMAPLOYERS LMILIT 0 0 Subject Total Act Ino Policy Total: 24, Premium: 3,0591 Losses: ni 10-GEORGIA Firm ID: Firm Name: J S HAREN CO Carrier. 11223 Policy No. DTAUB591OB24514 Eff Date: 10t01/20114 Exp Date: 10101/2015 0930 WAIVER OF SUBROGAT 0 0 UE65N 05 F N 41,175 16,500 724 1.50 22J U 115,706 521 -- 3724 1.50 .22 22,376 336 74 5183 2.19 .27 28,786 630 170 5183 2.19 --27 18,560 406 1110 12211 2.96 .27 21,524 641 173 SUI 2.98 271 33.385 995 269 -;jW .55 221 8.468 47 10 5806 S5 .221 5,459 30 7 -9807 EMPLOYERS LIABILIT 1 0 0 9807 EMPLOYERS LMIUT 0 Subject JTotal Act Inc , Premium;tdipy Total. 173 13.606 Losses, 41J,175 CQpyNM1993-2018,Ari fights rexorved. This product is ccmpriaod of comp7atfoas and InformaWn whtch are Ilia proprietary and exclusive prop"of the National Council on Cn"l1anlneuwcA,Inc.(NCCl), No further use,dissemination,sale.transfer,anignme M or disposition of this product,In whole Orin pail,may be made whhw the prior,Tftten consent :=of NCO.ThW product is fumLshad'As I s 'As avoiLablo''L'�h ail defects'and irdudes Information evadable at the time of publication only.NCCJ makes no representations or warro t as of any kind relating to the productand hereby expressly d1"Ims any and all statstatutory,press,stao ,or Implied warranties,including the impiled—mmiy 011nenchantabMty tar a palmier purpose.40CUr2CYr COMPletens"e-currentness,or conractness cfvny Information or product furnished hereunder.AA reiponsibility for the Lisa of and for any and ai(fatness darted or chwned ittrough the use of the product are the end user's and NCCI shall not have any liability thereto. 7–Toig,by P.1k-y Y..of of�—..$2000 or Is.- 0 D----o Loss X Ex-Madical Coverage U USLAHW C CAsseophic Loss E Employers Liability Lou #Limled Loss Page 4 of 12 WORKERS COMPENSATION EXPERIENCE RATING N Risk Name:J S HAREN CO Risk ID: 917515522 Rating Effective Date:10/01/2018 Production Date: 05/10/2018 State: INTERSTATE 03-ARKANSAS Firm ID: Firm Name: J S HAREN CO Carrier. 27995 Poifcy No. WC038600739201 Eff Date: 02/21/2014 EXP Date: 10/01/2014 3724 1.07 .34 2,488 27 g a. 5183. .67 .37 10,1201 68 25 5213 1.61 .34 20;858 333 113 5221 1.26 ,37 1,776 22 g 6217 1.38 .34 10;001 138 47 9812 EMPLOYERS LIABILIT p 0 Subject Total Act Inc Ill Total: 45, Premium: 2,776 Losses: 0 034MANSAS Firm ID: Firm Name: J S HAREN CO Carrier. 15318 Policy No. DTAUBS91 OB24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 0930 WAIVER OF SU13ROGAT 0 0 3724 1 1.07 .34 329 4 1 3724 1.07 .34 511 5 2 5183 .67 .37 109 1 0 5183 .67 .37 71 0 0 Subject Total Act Inc IlPollcy Total: 1,0 Premium: 39 Losses: 0 03,ARKANSAS Firm ID: Firm Name: J S HAREM CO Carrier. 12610 Policy No. DTNUB5910824515 Eff Date: 10/01/2015 Exp Date: 10/01/2016 r 0930 WAIVER OF SUBROGAT 0 0 5183 .67 .37 127,757 856 317 9807 EMPLOYERS LIABILIT 0 0 Subject Total Act Inc 1policy,Total: 127,7 Premium: 4,116 Losses: 0 m Copyright 79932018,Atl dghta reserved. Th�product le comprised of camp{ledans end IrrfamtatiOn which are the prcprieta and excivarre Compervatian Insu anc�,lnc (NCCI). No turthar use,d aeeminaUon,sa{e,transfer,assf nmaM or dla ry rt,may property of Urs Natlonel council on g position dthis product,In whole or In part,may be made wflhout the prior wrritfsn canes a of NCCI.Thb product Is fumtshad'Ae is"Aa avallabla'1N%h aH detects'and fndudea infbnnkon avallable at the tame of pubikcation only.NCCI makes no re wan'entle9 of any k&rd rslaling to the product and hereby axpresaty dieaiaima any and alt e�resa,statutory,or Impiled warrantisq,Inauding the implied warren Presentatlonq or far a pertiwlst purpose,acarracy,cample9onaas,curcerrtrrssa,or corrnctrtesa alany faformadon or product fumishad hereunder.All respanalbAlly for the use a�d far a y�dIlIty,r{ft� derived a obtained through the use dt the product are Ihq end users and NCCI shell not have any Itabildy thereto. all 'Tafel by PdicyYear of aB caeoe 520411 or lass. D Oleeaae Loan X Ex-Medical Coverage C Catastrophic Loss E Employers Llability Loss #LlmNod Loss U USLdMW Page 3 of 12 WORKERS COMPENSATION EXPERIENCE RATING Risk Name: J S HAREN CO Risk ID: 917515522 • Rating Effective Date: 10/01/2018 Production Date: 05/10/2018 State: INTERSTATE 01-ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier. 27995 Policy No. WC038600739201 Eff Date: 02121/2014 Exp Data: 10/01/2014 1111INWOrSURE DEVELO 0 0 9848NAL PREMIUM 0 0 4remlum: ubject Total Act Inc Policy Total: 87 Losses: 0 01-ALABANW Firm ID: Firm Name, J S HAREN CO Carrier. 13579 Policy No. OTAUB5910B24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 li a -r g :�•: �: I r" €, ,let 0930 AVER OF SUBROGAT 0 0 3724 120 .28 1,391 17 5 3724 120 .28 897 11 3 5183 1.07 .32 884 9 3 5183 1.07 .321 1,370 15 5 9807 EMPLOYERS LiABIUT 0 0 9807 EMPLOYERS LIABILiT 0 0 Subject Total Act Inc Policy Total` 4, Premium: 247 Lasses: p 01-ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier. 15318 Policy No. DTNUB5910B24515 Eff Onto: 10/01/2015 Exp Date: 10/01/2016 nom. •. 1111 No EXPOSURE DEVELO 0 0 Subject Total Act Inc Policy Total: Premium: 0 Losses: p 01-ALABAMA Firm ID: Firm Name: J S HAREN CO / Carrier. 15318 Policy No. DTHUB591OB24516 Eff Date: 10101/2016 Exp Date: 10/01/2017 jjj+++ :l•1 A!S all .;s,f l _ -.-, �..�r -s F" �. ....�w�: 0930 WANER OF SUBROGAT 0 0 EBGSBbO 06 F 6,703 6,703 3724 1.20 .28 33,599 403 1 5183 1.07 .32 5,022 54 17 5606 .51 .28 42,315 216 60 9807 JEMPLOYERIS LIABILIT 0 0 141 Subject Total Act Inc Policy Total: 80,93 Premium: 3,582 Losses: 6,703 a Copyrigh1199-12018,Aul rights reserved. This product in oomprisad of compilations and Information which are the propriatary,and exduslva property of the National Counczon m CoWeaticn Insurance•Inc.{NCCI}. No further use,dlesamint or atlan,salt,tronsicr,amgnmartd1sposiGol of this product in whole or Fn pail,maybe meds without the peiorwrttten oanpnt of NCCL This product la flrmishod'As Is' Am available' 1Nith all de facts'and includes Information available at the time of pubkutien only.NCCI makes no reprosantationa or wwmntias of any WM reWkV to the product and hereby expressly disdalms any and all express,statutory,or ImpCed warranties,IrsdudnB the implied warranty of marcll"bllily,fMeas for a q 1i r Siad through ra use f he eness, aremi ass the end user's and o shall indIXha ti any bliability product fumished. hereunder.All responalbTRy for the usa of and for any and ag results produc •--r;@ by Policy Year or aG cases 52000 or less. fl Disease Loss X Ex-Madlcal Coverage U U9LSHW C rooseophic Loss E Employers Liability Loss 9 Limited Loss Page 2 of 12 WORKERS COMPENSATION EXPERIENCE RATING IV Risk Name:J S HAREN CO Risk ID: 917515522 Rating Effective Date:10/01/2018 Production Date: 05/10/2018 State: INTERSTATE ;'SIfie � w�� s AL .09 519 725 206 0 23,000 8,703 61703 AR .10 1,740 2,727 987 0 22,050 0 0 GA .09 3,24 4,370 1,128 24,675 31,250 411175 48,500 LA .08 1,642 2,040 398 0 45,000 0 0 MS .09 311 415 104 0 28,500 0 0 NO .09 112 149 37 0 30,000 0 0 OK .09 2, 3,512 948 199,592 33,500 216,092 16,500 TN .10 13,06E 20,371 7,283 0 21,375 16,672 16,672 7x .09 5,097 8,231 3,134 0 25,125 4,431 4,431 vA .09 C 0 0 0 27,500 0 0 1.0128,31 42,54 14,225 224,267 25,420 277,279 53,012 t< %a uFIN � Ems=, (I) C`(1 -A)+G (A) (F) (J) - Actual 53,012 51,187 20,184 424,383 (E) C-(1 -A)+G (A).(C) (K) Expected 14,225 51,187 2,548 67,960 tP�` Factors 1.49 1.83 RATING REFLECTS A DECREASE OF 70%MEDICAL ONLY PRIMARY AND EXCESS LOSS DOLLARS WHERE ERA IS APPLIED. THE ARAP FACTOR SHOWN IS FOR THOSE STATES CONTAINED ON THIS RATING THAT HAVE APPROVED THE ARAP PROGRAM AND IS CALCULATED BASED ON THE STATE WITH THE HIGHEST APPROVED MAXIMUM ARAP SURCHARGE.THE MAXIMUM ARAP SURCHARGE MAY VARY BY STATE. PLEASE REFER TO EACH STATE'S APPROVED RULES FOR THE APPLICABLE MAXIMUM ARAP SURCHARGE. THE TENNESSEE CODE ANNOTATED SECTION 50-6-501 REQUIRES EVERY PUBLIC OR PRNATE EMPLOYER THAT IS SUBJECT TO THE WORKERS COMPENSAT10N STATUTE TO"ESTABLISH AND ADMINISTER A SAFETY COMMITTEE IN ACCORDANCE WITH RULES ADOPTED PURSUANT TO T.C.A.SECTION 50.6-502 IF THE EMPLOYER HAS AN EXPERIENCE MODIFICATION RATE EQUAL TO OR GREATER THAN 1.2.e o Copydght 1993.2918,Xl dGMs reserved.This product Is comprised of compilations and Inforniatlon whlch ore the proprietary and exclusive property of the National Council on Conpenubon Insurance,Inc.{NCCI). No further use,dissemination,sale,transfer,assignment or dhpositlsn of this product,in whole cr In part,may be Mede without Bre prior written conrerd of NCCI.This product Is fumished"As is""As available"With all defer'and Includes Information svailab{e at the time of publication only-NCCI makes no rapfesentations or e,mm 4as of eery kind relating to the product and hereby expressly disclaims any and all express,staMory,or tinpried warranties,Including the Impiled wemarty of marcher dabilNy ryytass for s particular purpose,accuracy,completeness,currentness,or correctness of any fnformatton or product furnished hereunder.All responsibipy for the use of and for any and all res ft derived or obtained through the use of the product are tho and user's and NCCI shall not have any liability thereto. Page 1 of 12 Table 1—Organization Information Organization doing business as: I J. S . 11aren Company Previous History with City of Corpus Christi List the 5 most recent projects that have been completed with the City of Corpus Christi. Project Name Year 1 McBride Lane Lift Station & Force Main E14054 2019 2 Whitecap WWTP UV Disinfection System E10179 2018 3 ONSWTP Flouride E15233 2017 4 ONSWTP Chlorine E16332 2016 5 Greenwood WWTP Emmissions & odor Control E10047 2016 Construction Site Safety Experience Provide Bidders Experience Modification Ratio (EMR) History for the last 3 years. Provide docurnentotion of the EMR. Year 12018 JEMR 11 . 83 1 Year 12017 1 EMR J 1 . 70 1 Year 120161EMR 1 . 48 Previous Bidding and Construction Experience—Answer all question Yes or No. Has Bidder or a predecessor organization been debarred within the last 10 years? List debarring entities below and provide full details in a separate attachment if yes. NO X YES Has Bidder or a predecessor organization been disqualified as a bidder within the last 10 years? List Projects below and provide full details in a separate attachment if yes. NO X YES Has Bidder or a predecessor organization been released from a bid or proposal in the past 10 years? List Projects below and provide full details in a separate attachment if yes. NO X YES Has Bidder or a predecessor organization ever defaulted on a project or failed to complete any work awarded to it? List Projects below and provide full details in a separate attachment if yes. NOS YES Has Bidder or a predecessor organization been involved in claims or litigation involving project owners within the last 10 years? List Projects below and provide full details in a separate attachment if yes. NO_'y = YES Have liens or claims for outstanding unpaid invoices been filed against the Bidder for services or materials on any projects begun within the preceding 3 years? Specify the name and address of the party holding the lien or making the claim, the amount and basis for the lien or claim, and an explanation of why the lien has not been released or that the claim has not been paid if yes. NO X YES Statement of Experience 0045 16-S Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 TABLE 1—ORGANIZATION INFORMATION Organization doing business as: I J. S . Haren company Business Address of Principal Office 1175 Hwy 11 Nthens, TN 37303 Telephone No. 423-745-5000 Website I www.jsharen.com Form of Business (check one) Corporation ❑ Partnership ❑ Individual If a Corporation State of Incorporation TN Date of Incorporation 1991 Chief Executive Officer's Name J. S . Haren President's Name J. S. Haren Vice President's Name(s) Secretary's Name 4ennifer Adkin Treasurer's Name If a Partnership N/A Date of Organization I Form of Partnership: ❑ General ❑ Limited If an Individual N/A Name Ownership of Organization List of companies, firms, or organizations that own any part of the organization. Names of Companies, Firms, or Organizations Percent Ownership none Organization History List of names that this organization currently, has, or anticipates operating under including the names of related companies presently doing business. Names of Organizations From Date To Date none Indicators of Organization Size Average number of current full-time employees 75 Average estimate of revenue for the current year 1 $12, 000 , 000 Statement of Experience 004516-4 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 i moderate violations under the TCEQ's regulations for documentation of Compliance History, 30 Texas Administrative Code,Chapter 60.2(c)(1)and(2). 3. "Environmental Protection Agency" includes, but is not limited to the Texas Commission on Environmental Quality (the "TCEQ"), the United States Environmental Protection Agency (the "EPA"), the U.S. Fish and Wildlife Service, the U.S. Army Corps of Engineers, the Texas Department of State Health Services,the Texas Parks and Wildlife Department,the Structural Pest Control Service,agencies of local governments responsible for enforcing environmental protection laws or regulations,and similar regulatory agencies of other states of the United States. B. In determining the responsibility of the Bidder,the Owner will consider the following in regards to Table 4: 1. Whether the Bidder's response in reveals more than two (2) cases in which final orders have been entered by the Occupational Safety and Health Review Commission (the "OSHRC") against the Bidder for serious violations of Occupational Safety and Health Administration("OSHA")regulations within the past five(5)years. 2. Whether the Bidder's response reveals more than one(1) case in which Bidder has received a citation or for which final orders have been entered from an environmental protection agency for violations within the past five(5)years. 3. Whether the Bidder's response reveals that the Bidder has been convicted of a criminal offense or has been subject to a judgment for a negligent act or omission, which resulted in serious bodily injury or death,within the past ten (10)years. C. The Owner may consider the responses to each question in Table 4 separately when determining the responsibility of the Bidder. The Owner may also consider the cumulative impact of the information generated by the Bidder's responses. ARTICLE 4—PROVIDE INFORMATION TO DEMONSTRATE THE ABILITY OF THE BIDDER TO PROVIDE SUBCONTRACTING OPPORTUNITIES THAT WILL MEET THE OWNER'S ESTABLISHED GOALS FOR MINORITY,MBE,AND DBE PARTICIPATION IN THE PROJECT. LIST ALL WORK TO BE PERFORMED BY QUALIFIED MINORITY, MBE AND DBE-PROPOSED SUBCONTRACTORS OR SUPPLIERS IN TABLE S. INCLUDE PERCENTAGES OF WORK SUBCONTRACTED TO EACH TO DEMONSTRATE COMPLIANCE WITH OWNER'S STATED GOALS. Statement of Experience 004516-3 Whitecap WWTP Odor Control and Bulkhead Rehabilitation,Project No.E10053 Rev 10/2018 Bidder must provide the services of the proposed key personnel for the life of the Project as a condition of qualification. Failure to provide the proposed Key Personnel may result in the disqualification of the Bidder and may void the award of the Contract. C. Provide information for each primary and alternate candidate that includes: technical experience, managerial experience,education and formal training and a work history which describes project experience, including the roles and responsibilities for each assignment. Additional information demonstrating experience that meets the minimum requirements should also be included. D. The Project Manager and Project Superintendent must have at least 5 years of recent experience in the management and oversight of projects of a similar size and complexity to this Project. This experience must include scheduling of manpower and materials,safety,coordination of Subcontractors,experience with the submittal process,Federal and State wage rate requirements and contract close-out procedures. The Project Superintendent is to be present at the Site at all times that Work is being performed. Foremen must have at least 5 years of recent experience in similar work and be subordinate to the Project Superintendent. Foremen cannot act as a superintendent without prior written approval from the Owner. 2.06 Provide information on the project experience and past performance of the organization. A. Provide information on projects that have been awarded to the Organization in the last 5 years in Table 3. Attach additional pages if necessary. Experience must include the satisfactory completion of at least five similar projects within the last 5 years for the Bidder's organization that are equal to or greater in size and magnitude than the current Project. B. In determining the responsibility of the Bidder, the Owner will consider the Bidder's past projects and any substandard quality of workmanship on completed projects. The Owner will consider whether the Bidder's past project experience shows substandard quality of workmanship, issues related to a substandard appearance of the completed work,the amount of warranty or rework required, problems with durability and maintainability of the completed project, and problems with the lack of quality of documentation provided. In addition to the work produced, the Owner may consider issues related to the quality of construction practices, responsiveness to the owner's needs during construction,an inability to work in the spirit of partnering and any non-responsiveness of the Bidder to make warranty corrections. Information to make this determination will come from Owner's interviews with references provided for this project. By listing reference contact information in this Statement of Experience,Bidder indicates its approval for OPT to contact the individuals listed as a reference. ARTICLE 3—SAFETY EXPERIENCE REQUIREMENTS 3.01 The Bidder agrees that pursuant to Section 252.0435 of the Local Government Code,the Owner will consider the safety record of the Bidder prior to awarding contracts. The Owner has adopted the following written definitions and criteria for determining the Bidder's safety record. 3.02 The Bidder's safety record will be used to determine if the Bidder can be deemed responsible. 3.03 Provide general information about the safety record of the organization as required in Table 4. A. For purposes of providing this information,the following terms shall have the following meanings: 1. "Bidder" includes the firm,corporation, partnership,or other legal entity represented by the Bidder or anyone acting for such firm,corporation,partnership,or other legal entity submitting the bid. 2. "Citations" include notices of violation, notices of enforcement, suspension/revocation of state or federal licenses or registrations, fines assessed pending criminal complaints, indictments, convictions, administrative orders, draft orders, final orders, and judicial final judgments. Notice of Violations and Notice of Enforcement received from the TCEQ shall include those classified as major violations and Statement of Experience 004S16-2 Whitecap WWTP Odor Control and Bulkhead Rehabilitation,Project No.E10053 Rev 10/2018 004516 STATEMENT OF EXPERIENCE ARTICLE 1—REQUIREMENT TO PROVIDE A STATEMENT OF EXPERIENCE 1.01 To be considered a responsive Bidder, the three lowest Bidders must complete and submit the Statement of Experience within 5 days after the date Bids are due,or earlier if required by the Bid Documents,to demonstrate ✓ the Bidders'responsibility and ability to meet the minimum requirements to complete the Work. Failure to submit the required information in the Statement of Experience may result in the Owner considering the Bid non- responsive and result in rejection of the Bid by the Owner. The Bid Security of the Bidder will be forfeited if Bidder fails to deliver the Statement of Experience in an attempt to be released from its Bid. Bidders may be required to provide supplemental information if requested by the Owner to clarify, enhance or supplement the information provided in the Statement of Experience. 1.02 Bidders must provide the information requested in this Statement of Experience using the forms attached to this Section. A copy of these forms can be provided in Microsoft Word to assist with the preparation of the Statement of Experience. Information in these forms must be provided completely and in detail. Information that cannot be totally incorporated in the form may be included in an attachment to the form. This attachment must be clearly referenced by attachment number in the form, and the attached material must include the attachment number on every sheet of the attachment. The attachment must include only the information that responds to the question or item number to which the attachment information applies. 1.03 The Bidder may also be required to supply a financial statement,prepared no later than 90 days prior to the City Engineer's request, signed and dated by the Bidder's owner, president or other authorized party, specifying all current assets and liabilities. ARTICLE 2—EXPERIENCE REQUIREMENTS 2.01 The Bidder agrees that, in addition to determining the apparent low Bid, the Owner will consider the responsiveness of the Bids and the responsibility of the Bidders in awarding a Contract for this Project. Information that indicates the Bidder or a Subcontractor is not responsible or that might negatively impact a Bidder's ability to complete the Work within the Contract Time and for the Contract Price may result in the Owner rejecting the Bid. 2.02 If none of the three apparent low Bidders are deemed responsible,the Owner may notify the next apparent low Bidders in order,who will then be required to submit the Statement of Experience for review,until a Contract is awarded or all Bids have been rejected. 2.03 The Bidder is responsible for the accuracy and completeness of all of the information provided by the Bidder or a proposed Subcontractor in response to this Statement of Experience. 2.04 Provide general information about the organization as required in Table 1. Describe the organizational structure of the Bidder's organization as it relates to this Project in Table 2. 2.05 Provide resumes for the key personnel that will be actively working on this Project.\/ A. Key personnel include the Project Manager, Project Superintendent, Safety Manager and Quality Control Manager. If key personnel are to fulfill more than one of the roles listed above, provide a written narrative describing how much time will be devoted to each function,their qualifications to fulfill each role,and the percentage of their time that will be devoted to each role. If the individual is not to be devoted solely to this Project,indicate how that individual's time is to be divided between this Project and other assignments. B. The Bidder may provide resumes for an alternate individual if the Bidder is not able to commit to one individual for the Project at the time the Bid is submitted. Qualifications of these individuals will be considered in determining whether the experience of the Bidder meets the minimum requirements. The Statement of Experience 00 4516-1 Whitecap WWTP Odor Control and Bulkhead Rehabilitation,Project No.E10053 Rev 10/2018 �.-Corporations Section �t."C E OF Hope Andrade P.o.Box 13697 ?� Secretary of State Austin,Texas 78711-3697 W x Office of the Secretary of State CERTIFICATE OF FILING OF J.S. Haren Company File Number: 801081739 The undersigned, as Secretary of State of Texas, hereby certifies that an Application for Registration for the above named Foreign For-Pr6fit Corporation to transact business in this State has been received in th'1's office and has been found to conform to the applicable provisions of law. ACCORDINGLY, the undersigned, as Secretary of State, and by virtue of the authority vested mi the secretary by law,hereby issues this certificate evidencing the authority of the entity,to transact business in this State from and after the effective date shown below for the purpose or purposes set forth in the application under the name of J.S.Haren Company The issuance of this certificate does not authorize the use of a name in this state in violation of the rights of another under the federal Trademark Act of 1946,the Texas trademark law,the Assumed Business or Professional Name Act,or the common law. Dated: 02/02/2009 Efrective: 02/02/2009 '004f +�J Hope Andrade COD. Secretary of State Come visit us on the internet at hupJ/www.sos.state.U.us/ Phone: (512)463-5555 Fax: (512)463-5709 Dial:7-1-1 for Relay Services _ - - --Prcparcd-by--1✓ida-6=u=drrr T f COIVJF Tli� ��� PEUM being the sole�� . . . AA1Y,. as.is molder of I S ARBN the following takes by,t�,d��� Y � Meeting oftheandWratify CM9ty of aM to a foxuail WMEAStheammholder tie duds dii+sctox 101 (c), and•thehlbwIn Proms .of the kt by is X48.18 To ,a?�pa�on and the Chut,�al `�e C uat of 1. n.o�.Ne+w Off, The Pons whose v� SAXW below► acre °Mto serve for a.pedod of one, until , "qualify; f>uur 'Pro Auk JAL.Adkim Asst':Sectary; C8=m&a L.Raft . 2. mon of DO=Mcnb. the didy mod Presume„ aay two of the other duly elected off ' a *gUbrlp or behalf of the *0k ° 4BlomtiY,wed of of e'#o (viOvAe any. lam.des on b sVf.the n00 'Y and Power tdo huh tart i�the r corporation routieus IN MINEs w MF,theabove for on behalf of the moa this the mons oWOW talo by the mWmWgmd Lday of ' 2009 , G©R,o `•,.,a J 3ltyler Hares,Shateholder MERCHANT BONDING COMPANY. POWER OF ATTORNEY Know All Persons By These Presents,that MERCHANTS BONDING COMPANY(MUTUAL)and MERCHANTS NATIONAL BONDING,INC., both being corporations of the State of Iowa(herein collectively called the"Companies")do hereby make,constitute and appoint,individually, Gregory E Nash;Kelly L Berry;Phillip H Condra their true and lawful Attomey(s)-in-Fact, to sign its name as surety(ies) and to execute, seal and acknowledge any and all bonds, undertakings, contracts and other written instruments in the nature thereof, on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. This Power-of-Attomey is granted and is signed and sealed by facsimile under and by authority of the following By-Laws adopted by the Board of Directors of Merchants Bonding Company(Mutual) on April 23, 2011 and amended August 14,2015 and adopted by the Board of Directors of Merchants National Bonding,Inc.,on October 16,2015. 'The President, Secretary,Treasurer, or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and authority to appoint Attomeys-in-Fact, and to authorize them to execute on behalf of the Company,and attach the seal of the Company thereto,bonds and undertakings,recognizances,contracts of indemnity and other writings obligatory in the nature thereof." "The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attorney or Certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the Company,and such signature and seal when so used shall have the same force and effect as though manually fixed." In connection with obligations in favor of the Florida Department of Transportation only,it Is agreed that the power and aut hority hereby given to the Attomey-in-Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department of Transportation making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of its obligations under its bond. In connection with obligations in favor of the Kentucky Department of Highways only,it is agreed that the power and authority hereby given to the Attomey-in-Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner- Department of Highways of the Commonwealth of Kentucky at least thirty(30)days prior to the modification or revocation. In Witness Whereof,the Companies have caused this instrument to be signed and sealed this 5th day of April 2017 06 CQ. g4... %+''..00•� �'p�-,004,•.•Oq* MERCHANTS BONDING COMPANY(MUTUAL) 'ya 9„-.�O MERCHANT NATIONAL BONDING,INC. 2003 1933By cS •,��jy. ..�JtL•,. `••� .......^`.�•�+ President STATE OF IOWA ��"" "'�'� `''••`'`� COUNTY OF DALLAS ss. On this this 5th day of April 2017 before me appeared Larry Taylor,to me personally known,who being by me duly sworn did say that he is President of MERCHANTS BONDING COMPANY(MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the seals affixed to the foregoing instrument are the Corporate Seals of the Companies;and that the said instrument was signed and sealed in behalf of the Companies by authority of their respective Boards of Directors. �VSLIAI s AUCK K.GRAM 0 Commission Dumber 767430 z .•. r My Commission Wires April 1,2020 Notary Public (Expiration of notary's commission does not invalidate this instrument) I,William Warner,Jr.,Secretary of MERCHANTS BONDING COMPANY(MUTUAL)and MERCHANTS NATIONAL BONDING,INC.,do hereby certify that the above and foregoing is a true and correct copy of the POWER-OF-ATTORNEY executed by said Companies,which is still in full force and effect and has not been amended or revoked. In Witness Whereof,I have hereunto set my hand and affixed the seal of the Companies on this 28th day of August 2019 ,�,.�aZiONgi �AN6 CQ. :_ - •a:'- ,0.3,,x. 2003 :�' 193 y R;c; J.`: secretary POA 0018 (3117) •`'•'•........o• •,,.:�.•``.... WORKERS COMPENSATION EXPERIENCE RATING &P Risk Name: J S HAREN CO Risk ID: 917516522 J S H Ing Effec Rating ng Mectie Date: 10/01/2018 Production Date: 05110/2018 State: INTERSTATE I 23-MISSISSIPPI Firm ID: Firm Name: J S HAREN CO Carrier: 12637 Policy No. DTNUB591OB24515 Eff Date: 1010112016 Exp Date: 1010112016 if 0930 WANERO. F. SUBRQGA.T y 0 --- 01 3724 1.61 25 . 20,301 321 821 9607 EMPLOYERS UABIUT p 0 Subject Total Act Inc Policy Total: 20,301Premium: 11,40 Lossas: 0 23-MMSISSIPPI Firm ID: Firm Name: J S HAREN Co Carrier. 12637 Polfcy No. DTHUB5910824516 Eff Date: 10/01/2016 UP Dato.- 10/01/2017 0930 AIVER 3724 1.61 .25 5,436 88 22 9807 EMPLOYE Subject Total Act Inc lPolicyTotal: 5, Premium: 297 32-NORTH CAROLINA Finn ID: Firm Name: J S HAREN Co Carrier. 21873 Policy No. R2WC599624 Eff Date: 03/08/20 14 I It r ��jj EXP Date: 10/01/2014 NOW L I-�41i N�"2 ITI I i 71,64- 162171 2.20 "I 1 10 0 0 9848 DITIONAL PREMIUM 0 0 �Stjbject Total Act Inc Policy Total- J - Premium: 45 Losses: 0 CopAht 1993-2018,AN rights reserved. This product is comprised Of tomplMons,and infotmavan which are the proprietary and exclusive property of the Nadonal Council�on ComparmtIon Insurance,Inc,(NCCI). No further use,dissemination,safe,transfer,assignment or disposition of this product,in whole or in part may be made wIthDutthepHw on consent of NOGI.This product is fumlshod'As Is"As availabla"With all defects*and includes Information avallablo at nty. , m as Y�o wrta the NCCI alk r6presenwon,., warrardes of arty kind relating to the product and hereby expressly disclaims any and all express,statutory,or implied Warranties.in ucting the Implied warranty of merchentablity,Atnes, fora PortOL1181 PUPO",accuracy,complateneu,currentness,or conedneve of any Iff'ofmation or product fumishad hereunder.AB res for the LA0 of and forte and all results delved or oblainod through ft Liao of the product are the and user's and NCCI shelf not have any llaM4 thereto. "Total by PdicY Year of sh cases$2000 or less. D Disease Lose X Ex•ivledlcsl Coverage C cartaftnNu I— E Employers Uat:114 Loss #Limned Lou U LiST-111Y Page 7 of 12 WORKERS COMPENSATION EXPERIENCE RATING a , Risk Name: J S HAREN CO Risk ID: 917515522 r Rating Effective Date:10/01/2018 Production Date: 05/10/2018 State: INTERSTATE 32-NORTH CAROLINA Firm ID: Firm Name: J S HAREN CO Carrier: 13579 Policy No. DTAUS591 OB24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 Code, �POCte► R � >4,�� �� � a s .� �. 7 0930 WAIVER OF SUBROGAT 0 0 3724 1.13 .221 696 8 2 3724 1.13 221 1,080 12 3 5183 1.50 .251 2,010 30 8 5183 1.50 .25 3,117 47 12 5606 .45 .22 1,205 5 1 5606 .45 .22 1,869 S 2 9807 JEMPLOYERS LIHBILIT 0 0 9807 JEMPLOYERS LIABIIJT 0 0 Subject Total Act Inc Policy Total: 9,9 Premium: 827 Losses: 0 32-NORTH CAROLINA Firm ID: Firm Name: J S HAREN CO Carrier. 15318 Policy No. DTNUB591OB24515 Eff Date: 10/01/2015 Exp Date: 10/01/2016 coed 'L..,s{� ie1 site W, dF 0930 WAIVER OF SUBROGAT 0 0 1111 NO EXPOSURE DEVELO 0 0 �SubjectTotal Act Inc Palicy Ttotai: Premium: 100 Loastltt: 0 32-NORTH CAROLINA Firm ID: Firm Name: J S HAREN CO Carrier: 15318 Policy No. DTHUB591OB24516 Eff Date: 10/01/2016 Exp Date: 10/01/2017 0930 AIVER OF SUBROGAT 0 0 3724 1.13 .22 3,432 39 9 9807 EMPLOYERS LIABILIT 0 0 suejt�c Total Act In policy Total: 3,43 Prremlum: 257 Losses: 0 ®CopyNhf 1993'2018,A9 rights reserved. This product Is comprised of compilations and Infomurtlon which are to proprietary and exclusive property of tha Netionai Counoll on Compensation Insurance,Inc.(NCCI). No further use,disaeminatMn,sale,transfer,assignment or disposition of this product,In whole or In part,may be msda without the prior written conxerrt of NCCI.This product is fumished'As is••As evallabla'Ninth alt defects'and Includes Infamuition available at the time of publication only,NCCI makes no represent flons or werws0as of any kind reisting to the product and hereby axpressly disclaims arty and at express,statutory,or Impfied warranties,Including the implied warranty of merthantabil y,fNness faa particular purpose,accuracy,complaleneas,currentness,or correctness of any irftnnation or product furnished hereunder.All responsib3ity,for the use of and for any and oil resuks darned or obtained through the use of the product are the and user's and NCCI shall not have any(lability thereto. •Totrt by Policy Year of s9 cases$2000 or less. D Disease Loan X 6c-Medical Coverage U UStEHW C Catastrophic Loss E Employers Liability Lou p Umbled Loss Page 8 of 12 WORKERS COMPENSATION EXPERIENCE RATING Risk Name: J S HAREN GO Risk 10: 9 175175522 671 1 Rating Effecttve Data:10/01/2018 Production Date: 05/1012018 State: INTERSTATE L 35-OKLAMOMA Firm ID: Firm Name: J S HAREN GO Carrior. 13579 Policy No. DTAU8591OB24514 Eff Date: 10101/2014 //"`Exp Date: 10101/2()15 i7 I 0930 JWAVER OF SUBROGAT 0 0 E3S0873 :09 0 216,092 16.5001 137241 1.551 .271 29,173 4521 122 137241 1.551 .271 45,249 7011 189 15183 [ 2.071 .291 1,1491 24 7 J 51831 2.071 -291 7411 15 41 15221 1 2.211 291 2501 6 21 15221 1 2211 .291 3891 9 31 15606 1 .551 .271 14,370 79 21 156061 .551 .271 22,288 123 33 6217 2.19 .27 5,491 120 32 1 6217 2-191 .271 3,641, 78, 21 9807 JEMPLOYERS LIABILIT 01 a .9807 JEMPLOYERS.LIABIUT 01 a Subject Total Act Inc 1112ollcy Total: 122,641 1 Premium:ml urn, 5,942 Losses: 216,092 35-OKLAHOMA Firm ID: Finn Marko: J S HAREN CO Carrier. 15318 Policy No. DTNUS5910824515 Eff Data: 10/01/2015 UP Date. 10/01/2016 0C r a 'i L W 2 qty far " 0930 WAIVER OF SUBROGAT 0 0 3724 1.551 .271 88,549 1,373 371 56016 .551 .271 1.620� 9 2 9807 EMPLOYERS LIABILIT I 0 0 Subject Total Act Inc Policy Total, 80,1 Premium: 5,409 Losses: 35-OKLAHOMA Firm ID: Finn Name: J S HAREN GO Carrier. 15318 Policy No. DTHUBS91OB24516 Eff Date: 10/01/2016 Exp Date: 10101/2017 0930 WAIVER OF SUBROGAT 0 0 3-724 1.551 .271 32,065 497 134 5606 .551 .271 4,800, 26 7 ----------- 9807 EMPLOYERS LIABILIT 01 0 STotal Act Inc- 777 Policy Total: 36$8Premium: 1,861 Losses: 0 c copyright 19932018,AJ rights reserved. This product Is comprised of compilations and Information which are the proprietary and Oxclushis PmllortY of the National 6Tu;nd—1 on— Ctompansartion Insurance,Inc.(NCCI). No further use,dissemination,sale,transfer,assignment or disposition of this product In whole or in part,may be made vftout the Prforwriflon omerri of NCCI.This pmducl In furnished'As is''As available'Wrth all defects'and includes Information evallable at the time of publication only.NCCI makes no representation,or waffar4as of any kind relating to the product and hereby expressly disdains arty and all express,statutory.or Implied warranties,Including the implied warranty Of merchantability,ftess A�Lpda:cv=ose.accuracy.completeness,currentness,or correctness of any Information of product furnished hereunder.Ail responsibility for the use of and for any and all results d n through the use of the product are the end users and NCCI shall not have any IlabifAy ftralla. •7*1 try�Polley Year of aa cams$2000 or lou. 0 Disease Low X Ex-Madkuw Coverage U usLdHW �� C catastrophic Lou E Employers Liability Loss 9 Limited Loss Page 9 of 12 WORKERS COMPENSATION EXPERIENCE RATING &9Risk Name:J S WAREN CO Risk ID: 917515522 1 71 Rating Effective Date: 10101/2018 Production Date: 05/10/2018 State: INTERSTATE 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carder. 80144 Policy No. 6C28U132E17607614 Eff Date: 02121/2014 Exp Date: 10/11/2014 taew It tw!- Wtiiid 0042 2.18 .381 74,019 1,614 613] EZX6095 09 F 7,237 7,237 5183 .98 .351 115,707 1,134 3971 5606 .46 .30 167,271, 769 231 88101 .07 .421 151,2761 106 45 9807 JEMPLOYERS L"IUT 01 01 Pub9tTotal Act Inc Policy Total. 54$,27 Premium:17,649 Losses: 7 237 41TENNESSEEFirm ID, Firm Name: J S HAREM CO Carrier. 11223 Policy No. DTAUB591OB24514 Eff Date: 1010/2014 ExpDato: 10/01/2015 WIN 100421 2,181 .38 30,897 674 256 0042 2.18 38 47,921 1,045 397 5183 .98 .35 142,1711 1,393 488 18 5 51V .98 .35 91,6631 898 314 18 5606 .46 .30 61,8251 264 85 56061 .46 .301 95,893! 441 132 8810 1 -071 .421 90,004 63 26 8810 1 .071 .421 139,599 98 41 9807 JEMPLOYERS I-Mil-IT 0 . 0 9807 EMPLOYERS LIABILIT 0 0 9841 DRUG FREE CREDIT . 01 0 9841 DRUG FREE CREDIT, o0 �Subject l Total Act Inc Policy ,,,, ,P cy Total: 6 Premium: 19,258 Losses: 0 a CopyrTgN 19932018,M rights reserved. This product Is comprised of compilations and information which are the proprietary and exclusive property i3fthaNational Counclion : mpL,,nonlniurince,im.(NCCI). No further use,dissemination,sale,transfer,assignment or dispoMDn Of this product,in whole or in part,may be made without the pflorwrittan iss .ofif NCCI.This product Is furnished'As Is 'As uvallabla"With all defects'and includes Information available at the time of pubft8fiGn only.NCCI makes no representation*or WarranifiS of any kind relaling to the product and hereby expreasty disciaima any and all express.statutory,or Implied warranties,including the Implied warranty of merchantability,ftess for a particular purpose,accuracy.completeness,CurrentringS,or correctnessol any Information or product furnished hereunder.NI respcnslbiPity for the use of and for any and all're$Ufta derived Or Obtained through the use of the product are the and users and NCCI shall not have any Ilablifty thereto. •T - - ---TU-SL&HW ,tai by Pvicy Year of ag cases$2000 or less. D Disease Loss X Ex-Medical Coverage C Catsilrophl:Loss E Employers Liability Less #Limited Loss Page 10 of 12 WORKERS COMPENSATION EXPERIENCE RATING RA AV Risk Rating Name: J S HAREN CO Risk Risk ID: 917515522 Rating Effective Date: 10/01/2018 Production Date: 05/10/2018 State: INTERSTATE 7 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carrier. 12610 Policy No. DTNUS591OB24615 Eff Date: 10101/2015 Exp Date: 10/01/2016 X4 N 1 -4 JIM, ; 00421 2.18 .381 166,829 3,637 1,3821 5183 .98 .35 153,001 1,4991 52 5606 .46 .30 152,993 7041 2111 8810 071 .421 205,7661 144 60 9807 EMPLOYERS LIABILIT 1 0 0 9841 DRUG FREE CREDIT I 0 0 Subject Tata) Inc, Polley Total: 678,5A8ro Premium: 22,722 Leases: 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carler. 13439 PolicyNo. DTHUB591OB24516 Eff Date. 10101/2016 Exp Date: 10/01/2017 ref' a ON2 Z181 .381 128,392 2,7991 1,064 E8C5118 09 F 9,435 9,435 01930 WAIVER OF SUBROGAT 0 0 61831 .98 .35 150,094, 1,471 515 5606 .46 30 307,412 1,414 424 8810 .071 -42 262,1891 184 77 9307 EMPLOYERS LLABILIT 1 01 0 ISubject Total Act Inc Policy Total: 848,08112remilum: 17,215 Losses: 9,435 42-TEXAS Firm ID: Firm Name; J S HAREN CO Carrier. 29939 Policy No. 0001248839 Eff Data: 0212112014 Exp Date, 10/01/2014 r.0- 5183 1.13 .39 31,670 358 140 5606 j .29 .381 86,213 250 95 Subject Total Act Inc Policy Total: 117,8OPreralurn: 4,152 Losses: 0 o ccpyTight 19932018.M d"reserved. This product Is comprised of oGmpl]aWns and Indormat;on which are the proprietary and exclusive properly of the National Council on ' '0 "Council _ be made ,an Compensation Insurance,Inc.(NCGI). No further use,cilsoorrineon,sale,transfer,araignment or disposition of this product,in whole or In Part,may consent of NCCL This product Is furnished wAs Is''As svOsbla'Vith air defects'and:ndudes Information available at the time of publication only. wiftulthe Prior written Mations NCOP makes no raprosentaflorts or warreibes of any l6indrelafing to the product and hereby expressly disclaims any and ad]express,stabAory,arimpfled warranties,including the Imptied warranty of merahantabmy,fitness as ,�o for a Fsrtl=ar PUJ13054,8=r9q,completeness,currentness,or correcinass at any Information or productfum4hod horounder.A-4 re2Pcns'h1l!tYfDrthe use of and far any all resu.1tx dartv9d of obtained through the use of the product ere the and users and ISICCIshall not have any r*NIrtythereto. •Tots: by Policy Year of oU cma MOO or less. 0 Disease Losa X Ex-moolfcal Coverage U JS L&,HW C CgfjqVopWr Loss E Employers I-Jability Loss p Urnited Lost Page 11 Of 12 WORKERS COMPENSATION EXPERIENCE RATING ou" Risk Name:J S HAREN CO Risk ID: 917515522 Rating Effective Date:10101/2018 Production Date: 05/10/2018 State: INTERSTATE 42-TEXAS Firm ID: Firm Name: J S HAREN CO . Carrier: 12637 Policy No. DTAUB591OB24514 Eff Date, 10/01/2014 Exp Date: 10101/2015 'U, 06tA aimM 3724 1,08 .38 .53,403 577 219 E2E305 06 F 4,431 4,431 3724 1.08 .38 83,178 898 341 5183 1.13, 39 6,675; 75 29 5183 1.13 .39 10,396 117 46 5606 .29 .38 62,684 182 69 5606 .29 .38 97,632 2831 108 SubjectTotal Act Inc Policy Total: 313,94promium: 7,1561 Losses: 4.431, 42 TEXAS Firm ID: Firm Name: J S HAREN CO Carrier: 13579 Policy No. DTNUB591OB24515 Eff Date: 10/01/2015 Exp Date: 10/01/2016 4 3724 1.08 .38 116,851 1,262 480 .5606 .29 .38 173,102 — 602 191 Subject Total Act Inc 89, Premium: 11 Policy Total: 289,511 Premium: 5,740 Losses: 0 42-TEXAS Finn ID, Firm Name: J S HAREN CO Carrier 13579 Policy No. DTHUB591OB24516 Eff Date: 10101/2016 Exp Date. 10101/2017 =oil 3724 1.08 .38 300,313 3,201.232 -56-06 .219 .38 167,032 484 184 Subject Total Inc 7 07 PolicyTotal: 467,3!!gl�nmlunr- 11,103 Losses: 0 454ARGINIA Firm ID: Firm Name: J S HAREN CO Carrier. 13579 Policy No. DTHUB591OB24516 Eff Date: 1010112016 Exp Date: 1010112017 -M lill NO EXPOSURE DEVEL6 0 0 Subject Total Act Inc Policy Total: Premium: 0 Losses: 0 ol Zpnu — 71 0 C.Qy ht 1993-2018,As rights reserved.This product is tomprisad at compilations and Information which are the proprietary and exclusive properly of the National Council on -ou'c"" Uon Irmninca,Inc.(NCCI). No further use,dimarnfrurtlon,sale,transfer,assignment or dispoOdon of this product in vMolo at In part,may N made without the prior wndLn =17f NCOL This product Is furnished'As la' 6valLable''With ail defacW"includes JnfcnmstJon avadlabla at the Grate of publication only.NCC/makes no representations or U; �-b ,'L= wampass of any kind relating to the product and hereby expressly disclaims any and all express,statutory,of implied warranties,including the implied warranty of merchantablJ4,fitness , re for a particular purpose,accuracy,completeness,currantness,or correctness cfarty information or product furnished hereunder.Al responsibility for the Use of and fanny and all result derived or obtained thrut4h the use of the product are the end usa(s and NC-01 shall not have any Ratillity thereto. •Total by Policy Year of e9 casae 52000 ar lass.. Disease Laos X Ex-Med"Covarat;a U USLfiHW 0 Catosirophle Loss E Employers Uabddy Loss N Urrilled Loss Page 12 of 12 P-0 WORKER"3 COMPENSATION EXPERIENCE RATING (AqV Risk Name: J S HAREN CO Risk ID.- 917515522 Rating Effective Date: 10/01/2017 Production Date: 05/05/2017 State: INTERSTATE rsscea� AI. .09 34 488 143 0 22,875 AR .10 3,12 4,788 1,661 0 0 0 22,800 2,200 2,200 GA .09 3,10 4,188 1,088 24,675 30,125 L+ .08 1,62 2,017391 0 43,125 41,175 1$,$00 MS .09 27 378 102 p 27,125 0 0 NC .09 9 126 300 0 p 30,250 0 OK .09 3,05 41089 1,034 156,040 37,000 0 TN .10 14,04 21,336 0 22 7,294 172,540 16,500 ,250 Tx .09 3,71 6,063 2,353 2,918 24,750 7,237 7,237 A {I3 3�Cciiss D spec et7 E 23,849 20,931 10 29,377 43,473 14,09fi 181,590 25,846 228,766 47,176 (1) C'(1 -A)+G (A) (F) (J} Actual 47,176 62,285 18,159 117,620 Expected 14,096 52,285 2,938 69,319 {J Factors 1.49 1.70 RA71NG REFLECTS A DECREASE OF 70%MEDICAL ONLY PRIMARY AND EXCESS LOSS DOLLARS WHERE ERA IS APPLIED. THE ARAP FACTOR SHOWN IS FOR THOSE STATES CONTAINED ON THIS RATING THAT HAVE APPROVED THE ARAP PROGRAM AND IS CALCULATED BASED ON THE STATE WITH THE HIGHEST APPROVED MAXIMUM ARAP SURCHARGE.THE MAXIMUM ARAP SURCHARGE MAY VARY BY STATE.- PLEASE REFER TO EACH STATE'S APPROVED RULES FOR THE APPLICABLE MAXIMUM ARAP SURCHARGE. THE TENNESSEE CODE ANNOTATED SECTION 50-6501 REQUIRES EVERY PUBLIC OR PRIVATE EMPLOYER THAT IS SUBJECT TO THE WORKERS COMPENSATION STATUTE TO"ESTABLISH AND ADMINISTER A SAFETY COMMITTEE IN ACCORDANCE WITH RULES ADOPTED PURSUANT TO T.C.A.SECTION 50-6-502 IF THE EMPLOYER HAS AN EXPERIENCE MODIFICATION RATE EQUAL TO OR GREATER THAN 1.2.• Copyr ght 19J3 2017,All rights reserved. This product is comprised of compilations and information which are the proprietary and axdusive ro Compensation Insurance,Fnc.(NCCi}. No further uso,disseminatlan,sale,transfer,asalanment or dlepoeltion of this product,in whale or in part,mayy be made without th®ndl an aonsant o4NGGh Thio producE is famished"As Is'-As avaSlable--4MIh all defects"and incudes InfarmaGan available at tho lime of publlcaUon only,NCCt makes no repress �Qen warraP tlesof any kind relating t e�m�lateness,eurreninoss,ar corirecainess of en Infoon agtr dud fumisplhed hereundte6SAl!reading�e Impi� �nty°f merchanlats lily,Titness fora artialar purpose,accura p ponsibiflty far the use of and for an derived or oblainad through the use of the product are the end user's and NCC!shgl9 not have any I ablGty thereto. y and all resuits Page 1 of 11 WORKERS COMPENSATION EXPERIENCE RATING N—� Risk Name: J S HAREN CO Risk ID: 917515522 Rating Effective Date: 10/01/2017 Production Date: 05/05/2017 State: INTERSTATE 01 ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier: 27995 Policy No. WC038600739200 Eff Date: 02/211/y2013 Exp Date: 02/21/2014 rQB ")i "w% �..�,')ti'p3 {Qli"�.rj'��7d� BCtei'�j�j Rte; p R724 ►1l° 'S `ST��elt f'3i �1.50 .29 17,424 4 261 .. 76( 3724 1.50L .291 11,224 168 49 9807 ADDITIONAL PREMIUM 0 0 9807 JADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 28, Premium: 3,839 Losses: 0 01-ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier: 27995 Policy No. WC038600739201 Eff Dake: 02121/2014 UP Date: 10/01/2014 ss a 1111 NO EXPOSURE UNIT R 0 0 9848 DITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: Premium: 87 Losses: 0 01-ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier: 13579 Policy No. DTAUS591OB24514 Eff Date: 10/01/2014 Exp Date: 10101/2015 e 0930 DITIONAL PREMIUM 0 0 3724 1,50 ,29 1,391 21 6 3724 1.50 .29 897 13 4111 5183 1.10 .32 1,370 15 5 5183 1.10 .32 884 10 3 9807 ADDITIONAL PREMIUM 9807 ADDITIONAL PREMIUM 0 Subject % I JTotal Act Inc Policy Total: 4,54 Premium: 247 Losses: 0 ttt 01-ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier: 15318 Policy No. DTNUB591OB24515 Eff Date: 10/01/2015 Exp Date: 10/01/2016 1111 NO EXPOSURE UNIT R 0 0 Subject Total Act Inc Policy Total: Premium: 0 Losses: 0 -------------------------- 0 Copyright 1993.2017,Alf nghts reserved. This product is comprised of compilations and information which are the proprietary and exclusive property of the National Council an Compensation insurance,Inc.(NCCI). No further use,dissemination,sale,transfer,assignment or disposition of t16s product,in whole or in part,may be made without the prior written consent of NCCL This product is furnished'As is' available''With all defects'and Includes Information available at the time of pubticalion only,NCCI makes no representations or for a particular of any pu kind a tt ugato the product and hereby expressly disclaims any and all express,statutory,or implied warranties,including the Implied warranty of merchantability,fitness derived or obtained through the use ofnass,currentness.or correctness duct are the end user's and NGCIfayliatrmaatSo�nurl abiti product the eco furnished hereunder.All responsibility Use of and for any and all raaults 9 a y ty -Total by Policy Year of all cases 32000 or less. 0 Disease Loss X Ex-Madical Coverage U USLEHW C Catastrophic Loss E Employers Liability Loss p Limped Loss Page 2 of 11 WORKERS COMPENSATION EXPERIENCE RATING N Risk Name: J S HAREM CO Risk D I . 917515522 Rating Effective Date: 10/01/2017 Production Date: 05/05/2017 State: INTERSTATE 03-ARKANSAS Firm ID: Firm Name: J S HAREN CO Cartier 27995 Policy No. WC038600739200 Eff Date 02121/2013 Exp Date: 02/21/2014 .N.-11TM.� x,i? e irrp'F ryt i1 f 4. `(�Ir s,i .? .rf I I '}„ �" S��' 1:05 �r�, "rvi[ i �� .,'�� Y}• 3724 1.20 341 151,224 1,815 6171 11JUU111L)IM0 06 0 2,200cx r 2,200 3724 1.20 .34 97,410 1,169 397 9807 JAUU111UNAL PREMIUM 0 0 9807 DIl"IONAL PREMIUM 0 0 Subject Total Act Inc LP0IIcy Total: 248,63 Premium: 15,407 Losses: 2,200 03-ARKANSAS Firm ID: Firm Name: J S WAREN CO Carrier: 27995 Policy No. WC038600739201 Eff Date: 02/21/2014 Earp Bate: 10/01/2014 m ,0 e., r o� es s' 137241 1.20 .341 2,488 30 10 5183 .85 .37 10,120 861 32 5213 1.96 .34 20,658 405 138 5221 1.53 .36 1,776 27 10 6217 1.58 .33]-Io 158 52 9812 JADDITIONAL PREMIUM 0 0 SubJect Total Act Inc Policy Total: 45, Premium: 2,776 Losses. 0 03-ARKANSAS Firm ID: Firm Name: J S HAREN CO Carrier: 15318 Policy No. DTAUB591OB24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 r ` N-PON911 1 s 0934 DDITIONAL PREMIUM 0 0 3724 1.20 .341 329 4 1 3724 1.20 .341 511 6 2 5183 .851 71 1 0 5183 j .85.1 1091 1 0 Subject Total Act Inc Policy Total: 1,02 Premium: 39 Losses: 0 ®Copyright 1993-2017,All rights reserved. This product Is comprised of compilations and Information which are the proprietary and exclusive Property of the National the p on Compensation Insurance,Inc,(NCCI). No further use,dissemination,sale,transfer,assignment or disposition of this product,In whole or in part,may bs made without the prior written consent of NCCI,This product is fumished'As Is' available' all defects'and Includes Information available at the time at publipUon only.NCCI makes no representations in warranties of any kind retailing to the product and hereby expressly disclaims any and all express,statutory,or Implied warranties,I ctuding the Implied warranty of merchantabiWty,fior tness for a particular purpose,accuracy,completeness,currentness,or correctness of any Informadon or product furnished hereunder.Alaobill for the Use of and for any and a!1 results derived or obtained through the use of the product are the and user's and NCCI shall not have any liability thereto. Total by Policy Year of all cases$2000 or less. D Disease Loss X Ex-Medical Coverage U USLdFiW C Catastrcphic Loss E Employers Liability Loss 4 Limited Loss Page 3 of 11 WORKERS COMPENSATION EXPERIENCE RATING N Risk Mame: J S HAREN CO Risk ID: 917515522 Rating Effective Date: 10/01/2017 Production Date: 05/0512017 State: INTERSTATE 03-ARKANSAS Firm ID: Firm Name: J S HAREN CO Carrier: 12610 Policy No. DTNUB591OB24515 Eff Date: 10/01/2015 EXP Date: 10/01/2016 R ".�'" 0930 ADDITIONAL PREMIUM 0 0 5183 .85 .37 127,757 1,086 402 9807 DDITIONAL PREMIUM 01 0 SubJect Total Act Inc Policy Total: 127,75 Premlum: 4,1181 Losses: 0 10-GEORGIA Flan ID: Firm Name: J S HAREN CO Carrier: 27995 Policy No. WC038600739201 Eff Date: 02121/2014 Exp Date: 10/01/2014 5183 2.06 .27 24,440 503 136 9812 JADDITIONAL PREMIUM 01 0 Subject Total Act Inc Policy Total: 24, Premium: 3,059 Losses: 0 10-GEORGIA Firm ID: Firm Name: J S HAREN CO Carrier: 11223 Policy No. DTAU8591OB24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 t - 0930 ADDITIONAL PREMIUM 0 0 E2E6509 05 F 41,175 16,500 3724 1,641 23 34,706 569 131 3724 1.64 .23 22,376 367 84 5183 2.06 .27 18,560 382 103 5183 2.06 .27 28,786 593 160 5221 2.79 .27 33,385 931 251 5221 2.79 .27 21,524 601 162 5606 .60 .23 8,468 51 12 5606 .60 .23 5,459 33 8 9807 DDITIONAL PREMIUM 0 0 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 173,2 Premium: 13,606 Losses: 41,175 C Copyright 1993-2017,All rights reserved. This product Is comprised of compilations and information which are the proprietary and exclusive property of the National Council on Compensation Insurance,Inc-(NCCI). No further use,dissemination,sale,transfer,assignment of disposition of this product,in whole or In part,may be made without the prior written Consent of NCCI.This product is furnished'As is''As available* With all defects'and includes information available at the lima of publication only.NCCI makes no representations or warranties of any kind relating to the product and hereby expressly disclaims any and all express,statutory,or implied warranties,Including the implied warranty of merchantability,fitness for a padicufar purpose,accuracy,completeness,currentness,or correctness of any information or product furnished hereunder.All responsibility for the use of and for any and all results derived or obtained through the use of the product are the end user's and NCCI shall not have any liability thereto. Total by Policy Year of all cases 52000 or less. D Disease Loss X Ex-Madiral Coverage U USL&HW C Catastrophic Loss E Employers Liability Loss If Limited Loss Page 4 of 11 WORKERS COMPENSATION EXPERIENCE RATING N Risk Name:J S HAREN CO Risk 917515522 • Rating Effective Date: 10/01/2017 Production Date: 05/05/2017 State: INTERSTATE i0-GEORGIA Firm ID: Firm Name: J S HAREN CO Carrier: 13579 Pollcy No. DTNUS5910I324515 Eff Date: 10/01/2015 Exp Date: 10/01/2016 m tz 0930 DDITIONAL PREMIUM p 0 "� 3724 1.64 23 3,090 51 12 5221 1 2.79 .27 3,850 107 29 9807 DITIONAL PREMIUM p Subject Total Act Inc Policy Total: 6,94 Premium: 634 Losses: 17-LOUISIANA Firm ID: Firm Name: J S HAREM CO Carrier 30120 Policy No 143744 Eff Date 02/21/2013 Exp Date: 02/21/2014 C de r r3e :,., �xp�CfOd�R �zxn t lad_ $� 137241 1.82 .19 16,6031 302 57 137241 1,82 .19 10,694 195 37 5183 1.73 .21 5781 10 2 5183 1.73 . .21 372 6 1 5606 .64 .191 16,458 105 20 5606 .64 .191 10,6021 68 L 13 9812 ADDITIONAL PREMIUM 0 0 9812 DITIONAL PREMIUM 0 0 9848 ADDITIONAL PREMIUM 0 0 Subject JTotal Act Inc 113olicy Total: 55,30 Premium: 3,787 Losses: 0 17-LOUISIANA Firm ID: Firm Name: J 5 HAREN CO Carrier: 30120 Policy No. 143744 Eff Date: 02/21/2014 Exp Date: 10101/2014 §e; _ 'r syicpetrted 0931 PREMIUM-SHORT REMIUM.SHORT RATE ATE° 0 5221 3.46 .21 6,991 242 5=1 9812 DDITIONAL PREMIUM 0 0 9848 ADDITIONAL PREMIUM 0 0� - t• Subject Total Act Inc Policy Total: 6,991 Premium: 828 Losses: 0 Q Copyright 19932017,All rights reserved. This product is comprised of eompllations and Information which are the proprietary and exclusive property of the NaUonel Councll an Compensstton insurance,Inc.{NCC 1). No further use,dissemination,sale,transfer,assignment or disposition of this product,In whole or in part,maybe made without the o� consent of MCI.This product is furnished'As Es""As available' all defects'and Includes Information available at the time of publication rt- NCC/makes no out th representations ten warranties of any km rafating to the product and hereby expressly disclaims any and all express,statutory,or Implied warranties,Including the implied warranty of merchantability.fior tness for a particular purpose,accuracy,comptateness,currentness,or correctness of any information or product furnished hereunder.All responsibility for the use of and for any and aresults derived orobtafned through the use of the product are the end users and NCCI shag not have any liability thereto. Total by Policy Year of all cases$2000 or lass. D Disease Loss X Ex-Medical Coverage U USLdHW C Catastrophic Loss E Employers Liability Loss #Limited Loss Page 5 of 11 WORKERS COMPENSATION EXPERIENCE RATING N Risk Name:J S HAREN GO Risk ID: 917515522 Rating Effective Date: 10/01/2017 Production Date: 05/05/2017 State: INTERSTATE 17-LOUISIANA Firm ID. Firm Name: J S HAREN CO Carrier: 12637 Policy No. DTAUB591OB24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 ' e ��Y;D" ' ,4�ay�rf5ll�:��?'��'� N ipe�t '•= r• fracp;prim �`` �I�fm iaata'� , ��� » rA �n�� Y�.� r xr �•f3 X' y ,_f o-" trp � t^. �� , it.-r 7 t L F � � �f . A•ct'�rf '" i, SC'4n 5 h' + "."i'L'f C"r• Yrr' ,X " r� -a� 4 -i'iT_ j -hAf+S: �.• KTId - e S...x v .�b� e$ } t 'LdBse _.. $1�1"4r„rr,`yi; '•' ' r.`(a a " �o>fs 4'0 3724 1.82 .19 5,088 93 18 3724 1.82 .19 7,892 144 27 5221 3.46 .21 3,867 134 28 5221 3.46 .21 2,493 86 18 5606 .64 .19 4,352 28 5 5606 .64 A9 6,749 43 8 9807 ADDITIONAL PREMIUM 0 0 9807 JADDITIONAL PREMIUM 01 0 Subject Total Act Inc Pollcy Total: 30,441 Premium: 1,524 Losses: 0 17-LOUISIANA Firm ID: Finn Name: J S HAREN GO Carrier: 15318 Policy No. DTNUB591OB24515 Eff Date: 10/01/2015 Exp Date: 10/01/2016 �n spa r z' 8 ,a� + s .. Cjaji IM �ifl 6• T 3724 1.82 .19 11,9011 2171 41 5606 .64 .19 53,7501 344 65 9807 JAMITIONAL PREMIUM 0 0 Subject [Total Act Inc Policy Total: 65,651 Premium: 1,853 Losses: fl 23-MISSISSIPPI Firm ID: Firm Name: J S HAREN CO Carrier: 27243 Policy No. WC535S531660013 Eff Date: 02/21/2013 Exp Date: 02/21/2014 Ams 1111 NO EXPOSURE UNIT R 0 0 1111 NO EXPOSURE UNIT R 0 0 9848 DITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: Premium: 100Losses: 0 23-MISSISSIPPI Firm ID: Firm Name: J S HAREN CO Carrier. 27243 Policy No. WC535S531660014 Eff Date: 02J21/2014 Exp Date: 08/0512014 L`Ori9 � QII r3 t5� EXp11cfad a� Y rL0550S. �4 1111 NO EXPOSURE UNITR 0 0 9848 ADDITIONAL PREMIUM 0 0 Lf Subject I Total Act Inc Total: Premium: 75 Losses: 0 a copyni;N 1993-2017,All rights reserved. This product is comprised of compilations and information which are the proprietary and exclusive property of the National Council on compensa@on Insurance,Inc.(NCCI), No further use,dissemination,sale,transfer,assignment or disposition of this product,In whole or in pari,may be made without the prior written consent of NCCI.This product is fumished'As is--As availabie"With atr defects'and Includes Information available at the time of publication only.NCCI makes no representations or warranfEes of any idnd relating to the product and hereby expressly disclaims any and all express,statutory,or Implied warranties,Including the implied warranty of merchaniabilkty,Fitness toe a particular purpose,.accuracy,completeness,currentness,or correctness of any information or product furnished hereunder.AJI responsibility for the use of and for any and all rs derived or obtained through the use of the product are the end user's and NCCI shalt not have any liability thereto. -Total by Policy Year of all cases$2000 or less. 0 Disease Loss X Ex-Medical Coverage U USLBHW C Catastrophic Loss E Employers Llabifty,Loss Al Limited Loss Page 6 of 11 WORKERS COMPENSATION EXPERIENCE RATING U47 Risk Name:J S HAREN CO Risk ID: 917515522 Rating Effective Date: 10/01/2017 Production Date: 05/05/2017 State: INTERSTATE 23-MISSISSIPPI Firm ID: Firm Name: J S HAREN CO Carrier: 12637 Policy No DTNUB5910824515 Eff Date. 10/01/2015 7 Exp Date: 10/01/2016 � r { a fit= I " �• r . .r �.1q'��`7,371 5w���SGE"B :.,,u�.''• ;si} � z ...-,, d k.. <:r ti-:.: .tL�S •! - .t•d.,,;1: �{ �;�:��.�. ' y, � `�� ��i�"��'••. �l r-r 0930 DDITIONAL PREMIUM p 3724 1.86 .27 20,301 378 102 98Q7 DDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 20,301 Premium: 1,451 Losses: 0 32-NORTH CAROLINA Firm ID: Firm Name: J S HAREN CO Carrier: 21873 Policy No. R2WC599624 Eff Date: 03/0812014 Ex bate: y P 10/01/2014 itt, I' e y. 6217 2.3a .21 10 - .o , � •p 9848 ADDITIONAL PREMIUM p 0 Subject Total Act Inc 1 Policy Total: Premium: 45 Losses: 0 32-NORTH CAROLINA Firm Ib: Firm Name: J S HAREN CO Carrier: 13579 Policy No. DTAUB5910B24514 Eff Date: 1010112014 Ex Daae: od"4 Vi " 10/01/201 S a v t a 0930 JADDITIONAL PREMIUM 0 0 3724 1.25 .21 696 9 2 137241 1.25 .21 1,080 14 3 1 ,51831 1.68 .25 2,010 34 g 1 ,51831 1.68 .25 3,117 52 13 5606 .54 .21 1,869 10 2 5606 .54 .21 1,205 7 1 9807 ADDITIONAL PREMIUM 0 0 9807 DDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 9,97 Premium: 627 Losses: d 32-NORTH CAROLINA Firm ID: Firm Name: J S HAREN CO Carrier: 15318 Policy No. DTNUB591 OB24515 Eff Date: 10101./2015 EXP Date: 10/01/2016 SR ate,, w GFj}t �iY P t 'e',�`-. ,�`-. �q, Sys- j � ����� `�f, ' .,� z�}'r � r C'•k� lk�.`� �'' �bS� @{}■- ria' i t ge '�F.:sn,^3- t !}17� i � f L r 0930 ADDITIONAL PREMIUM 0 0 1111 NO EXPOSURE UNIT R 0 0 Subject Total Act Inc Policy Total 0 Premium: 100 Losses: 0 0 Copynght 1993-2017,All rights reserved. This product is comprised of compilations and information which are the proprietary and e Compensston Insurance,Inc.(NCCI). No further use,dlsseminaiicn,sale,transfer,assignmentzduatre property of the National council an or disposition of this product,in whole or in part,may be made without the prior written consent ofNCCI.This product a lab furnished'As Is"As availe'-With all defects'and includes Informallon available at the time of Of only.NCCI makes lith representations ie warranties of any kind relating to the product and hereby expressly disclaims any and all express,statutory,or Implied warranties,Including the implied warranty of merrhantabiFty,fitor ness for a particular purpose,accuracy,completeness,currentness,or correctness of any information or product furnished hereunder.All responsibility for the use of and for derived or obtained through the use of the product are the and user's and NCCI shall not have any haWfity,thereto, any and all results Total by Policy Year of an cases s2000 or leas. D Disease Loss X Ex-Madical Coverage C Caiastra rc Loss U USL6HW � E Employers Liability Loss #Limited toss Page 7 of 11 WORKERS COMPENSATION EXPERIENCE RATING V—% Risk Name: J S HAREN CO Risk ID: 917515522 Rating Effective Date: 10/01/2017 Production Date: 05/05/2017 State: INTERSTATE 35-OKLAHOMA Firm ID: Firm Name: J S HAREN CO Carrier: 19976 Policy No. 02673406131 Eff pate: 02/21/2013 Exp Date: 10/01/2013 5183 2.41 28 5,543 134 38 9807 DDITIONAL PREMIUM 0 0 Subject Total Act Inc Pollcy Total: 5, Premium: 477 Losses: 0 35-OKLAHOMA Firm ID: Finn Name: J S HAREN CO Carrier: 19976 Policy No. 02673406132 Eff Date: 10/01/2013 Exp Date: 10/01/2014 5183 2.41 .28 4,388 106 30 9807 ADDITIONAL PREMIUM 0 0 9848 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 4,38 Premium: 467 Losses: 0 35-OKLAHOMA Firm ID: Firm Name: J S HAREN CO Carrier: 13579 Pollcy No. DTAUB59.10B24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 M12.03 PREMIUM 0 0 E3S0873 09 O 172,540 16,500 29,173 592 148 , . 45,249 919 230 5183 2.41 .281 741 18 5 5183 2.41 .281 1,149 28 8 5221 2.79 .281 250 7 2 5721 1 2,79 .281 389 11 3 5606 .59 .251 22,288 131 33 5606 .59 25 14,370 85 21 6217 2.76 .25 3,541 98 25 6217 2.76 -25 5,491 152 38 9807 ADDITIONAL PREMIUM 0 0 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 122,641 Premium: 5,942 Losses: 172,540 [derived yright 1993-2017,All rights reserved. This product Is comprised of compilations and information which are the proprietary and exclus ve property of the National councll on nsation frisurame,Inc.(NCCI). No further use,dtsseminalion,sale,transfer,assignment ar disposition of this product,in whale or in part,may be made without the prior written t of NCCI.This product is furnished Is* available""With all defects'and includes information available at the time of publication only.NCC makes no representations or ties of any kind relating to the product and hereby expressly disclaims any and all express,statutory,or implied warranties,Including the implied warranty of merchantability,fitness particular purpose,accuracy,completeness,currentness,or correctness of any information or product fumshed hereunder.All responsibility for Ina use of and for any and all results or obtained through the use of the product are the and user's and NCCI shall not have any habitity thereto. Total by Policy Year of aft cases$2000 or less. C Disease Loss X Ex-Madic-al Coverage U USLBhiW C Catasbmpbic Loss E Employers Liability Loss #Limited Loss Page 8 of 11 WORKERS COMPENSATION EXPERIENCE RATING Risk Name:J S HAREN CO Risk ID: 917515 522 Rating Effective Date: 10/01/2017 Production Date: 05/05/2017 State: INTERSTATE 35-OKLAHOMA Firm ID: Firm Name: J S HAREN CO Carrier: 15318 Policy No. DTNUB5910824515 Eff Date; 10/01/2015 Exp Date: 10/01/2016 Coe LFt �q1Hlillkl—� Pac r• 4,EV�r161 4' 16-1 r�'[SR `t10x`�5 0930 QDITIONAL PREMIUM 0 0 ' 3724 2.03 .25 88,549 1,798 450 5606 .59 .25 1,620 10 3 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 90,169 Premium: 5,409 Losses: 0 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carrier: 80144 Policy No. 6C28UB5B81664413 Eff Date: 02/21/2013 Exp Date: 02121/2014 r; 100421 2.60 .371 23,9491 623 231 0042 1 2.60 .37 15,440 401 148 151831 1.22 .33 63,8221 7791 257 161831 1.22 331 41,149 502 166 5606 .61 J .291 109,351 6671 193 5606 .61 .29 70,503 430 125 8610 .07 .40 143,723 101 40 8810 .07 .40 92,664 65126 9607. DITIONAL PREMIUM 01 0 9807 DITIONAL PREMIUM 0 L 0 Subject Total Act Inc Policy Total: 580,601 Premium: 14,847 Losses: 0 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carrier_ 80144 Policy No. 6C28UB2E17607614 Eft Date: 02/21/2014 Exp Date: 10/11/2014 Coda ELR at`� #'a Erol ifaLlO � 0042 1 2.60 .371 74,019 1,924 712 EZX0095 09 F 7,237 7,237 5183 1 1.22 .33 115,707 1,4121 466 5606 .61 .29 167,2711 1,020 296 8810 1 .07 .40 151,2761 106 42 9807 ADDffIONAL PREMIUM 0 0 Subject ITotal Act Inc Policy Total: 508,273 Premium: 17,649 Losses: 7,237 m Copyright 1993.2017,Alt rights reserved. This product is comprised of compifations and information which are the proprietary and exclusive property 0 the National Council an Compensallon Insurance,Inc.(NCCI). No further use,dissemination,sale.transfer,asskgnmant or disposition of this pmdu,,in whole or in part,may be made without the prior written consent of NCCL This product is furnished'As is''As available'"With all defects'and includes Information available at the time of publication only.NCCI makes no representations or warranties of any kind relating to the product and hereby expressly 6sclaims any and all express,statutory,or implied warranties,including the implied warranty of merchant ability, ess fitn for a particular purpose,accuracy,completeness.currentness,or correctness of any Information or product furnished hereunder.All responsibility for the use of and for derived orobtalned through the use of the product are the and user's and NCCI shall not have any liability thereto. any and all results Total by Pokry Year of all cases$2000 or less. D Disease Loss X Ex-Medical Coverage U UsUluw C Catastrophic Loss E Employers Liability Loss p LlmRed Loss Page 9 of 11 -NCCI INC 11/Cl/ 901 PENINSULA CORPORATE CIRCLE BOCA RATON FL 33487-1362 s 5/512017 CONFIDENTIAL J S HAREN CO 1175 HIGHWAY 11 N ATHENS TN 37303-7541 Dear Madam or Sir. The National Council on Compensation Insurance, Inc.(NCCI),headquartered in Boca Raton, Florida,is the nation's largest information company serving the workers compensation marketplace. Our services Include the calculation of your workers compensation experience rating(rating).NCCI is committed to offering employers the most technologically advanced services possible to ensure the most secure,efficient,and timely delivery of experience ratings.You can access your experience ratings electronically,as well as provide your email address for notification of experience rating revisions. Your experience rating worksheet is now available for rating effective date 10/1/2017. Please log on to our website with the following information: Website Address: www.ncci.00m/worksheets Risk ID: 917515522 PIN:TCthtTBG The website will guide you through the process to receive your rating and all revisions to this rating effective date. Many things impact your experience rating,Including the number of claims,incurred losses(the amount of medical and lost wage benefits paid to your injured employees and the amount held in reserve to pay future benefits),and how often and how severely your employees are injured. Experience rating compares the actual claims costs of your company to the claims oasts of other companies In your industry._ If your claims history is lower than the average for your Industry,your rating will be lower than 1.00, and your premium generally will decrease. If your claims experience is higher than your industry's average,your rating will be higher than 1.00,and your premium generally will Increase.The experience rating factor is located at the bottom right comer of the calculation worksheet. For a detailed explanation of experience rating and how it is calculated,please select the Experience Rating education links on the left side of the website.Should you have any questions regarding this letter,please call our Customer Service Center at 800-NCCI-123(800-622-4123)and select the Experience Rating option,or email our Customer Service Center at customer_service@ncci.com. i.com. Sincerely, Experience Rating Department WORKERS COMPENSATION EXPERIENCE RATING Risk Name-:J S HAREN CO Risk ID: 917515522 • Rating Effective Date: 10/01/2017 Production Date: 05105/2017 State; INTERSTATE 41-TENNESSEE Firm ID: Firm Name; J S HAREN CO Cartier, 11223 Policy Na DTAUB5910B2451,1 Eff Data 10/01/2014 Exp Date: 10/01/2015 dd�r i r" ay�rC�1 "sem�,,,,ecfe ' i a¢ - �.:. ro:- r. ..w r.,:�-fGi -r'C' �7�i�VF�fl�r+t� :: �w'L'7 �,T",• 0042 2.60 .37 47,921 1,z46 461 0042 2.60 .37 30,897 803 297 5183 1,22 .331 91,663 1,118 3$9 5183 1.22 .33 142,171 1,734 572 5606 .61 .291 61,825 377 109 5606 .61 .291 95,893 585 170 8810 ,07 .40 90,004 63 25 8810 .071 139,599 98 39 9807 JADDITIONAL PREMIUM 0 0 9807 ADDITIONAL PREMIUM 0 0 9841 DRUG FREE CREDfT 0 0 9841 DRUG FREE CREDIT 0 sses Subject Total Act Inc P olicy Total: 699,97 Premium: 77;79,26]81L20 : 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carrier: 12610 Pollcy No. DTNUS591OB24515 Eff pate: 10/0`112015 Exp Date: 10/01/2016 a t 1 i P iPr tti: frit a 0042 2.60 .371 166,829 4,338 1,605 5183 1.22 .33 153,001 1,867 616 5606 1 .6.1 .29 152,993 933 271 8810 .07 .40 205,766 944 58 9807 DITIONAL PREMIUM 0 0 9847 DRUG FREE CREDIT 0 0 Subject Total Act Inc Policy Total: 678,58 Premium: 22,7221Losses: 0 42-TEXAS Firm ID: Firm Name: J S HAREN CO Carrier: 29939 Policy No. 0001248839 Eff Date: 02/21/2013 Exp Date: 02/21/2014 ..wee xy.<. 5183 1.28 ,40 20,289 260 104 9980742472 06 F 19,418 96,500 5183 1.28 .40 13,069 167 67 5606 .31 .38 156,382 485 184 5606 .31 .381 100,733 312 119 Subject Total Act Inc 113ollcyTotal: 290,47 Premium: 8,267 Losses: 19,418 ®Copyright 1993-2017,All rights reserved. This product is comprised of compliabons and information which are the proprietary and exdus ve property of the Natlonal Council on Compensation Insurance,Inc.(NCCI). No further use,disseminalion,sale,transfer,assignment or disposition of this product,in whole or In part,may be made without the prior wdtien consent of NCC).This product is furnished"As Is'"As available""with all defects'and Includes Information available at the time of pubPicallon only,NCCI makes no representation a or warranties of any kind relating to the product and hereby expressly disclaims any and all express,statutory,or implied warranties,Including the Implied warranty of merchanlabikty,fitness for a particular purpose,accuracy,completeness,currentness,or corracmess of any Information or product furnMed hereunder.All responsibility for the use of and for any and all results derived orobtained through the use of the product are the end user's and NCCI shall not have any liability thereto. Total byPollcy Year of all cases$2900 or less. D Msease Loss X Ex-Medical Coverage U USL3HW C Catasmphic Loss E Employers Liability Loss #Limited Loss Page 10 of 11 WORKERS COMPENSATION EXPERIENCE RATING CAM" Risk Name: J S HAREN CO Risk ID: 917515522 Rating Effective Date: 10/01/2017 Production Date: 05105/2017 State: INTERSTATE 42-TEXAS Firm ID: Firm Name: J S HAREN CO Carrier: 29939 Policy No. 0001248839 Eff Date: 02/21/2014 Exp Date: 10101/2014 5,183 1.28 .40 31,670 405 162 5606 .31 .38 86,213 2671 101 Subject Total Act Inc Policy Total: 117,88 Premium: 4,152 losses: 0 42-TEXAS Firm ID: Firm Name: J S HAREN CO Carrier: 12637 Policy No. OTAUB5910624514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 3724 1.15 .39 83,178 957 373 E2E3895 06 F 4,431 4,431 3724 1.15 .391 53,403 614 239 5183 1.28 .40 6,675 85 34 5183 1.28 ,40 10,396 133 53 5606 1 .31 .38 62,684 194 74 5606 .31 .38 97,632 303 115 Subject Total Act Inc Policy Total: 313,961 Premium: 7,156 losses: 4,431 42-TEXAS Firm ID: Firm Name: J S HAREN CO Carrier: 13579 Policy No. DTNUB591OB24515 Eff Date: 10/01/2015 Exp Date: 10/01/2016 t�h V�n� � �� k�E.r�''fS'�i�e$'�# h[. �'f'l�"i �" y�Y � µ • "� 3724 1.15 .391 116,8511 1,344 524 5606 .31 .38 173,102 537 204 Subject Total Act Inc Policy Total: 289,95 Premium: 5,740 Losses: 0 ®Copyright 1993.2017,Ail rights reserved. This product is compri sad of compilations and information which are the proprietary and exclusive property of the National Council on Ccr petlion Insurance,Inc.(NCCI). No further use,dissemination,sale,transfer,assignment of disposition of this product,in whole or In part,may be made without the priorwritten consent of NCCI.This product is furnished'As Is' As available''With all defects'and includes information available at use time of publication only.NCCI makes no representations or warranties of any kind relating to the product and hereby expressly disclaims any and all express,statutory,of implied warranties,Including the implied warranty of merchantability,fitness for a particular purpose,accuracy,completeness,currentness,or correctness of any information or product fumished hereunder.Ali responsibility for the use of and for any and all results derived or obtained through the use of the product are the end user's and NCCI shall not have any liabligy thereto. "Total by policy Year of all cases$2000 or less. 0 Disease Loss X Far-Medical Coverage U USLdtiW C Catastrophic Loss E Employers Liability Loss 4 Limited Loss page 11 of 11 WORKERS COMPENSATION EXPERIENCE RATING Risk Name: J S HAREN CO • Rating Effective Date: 10/01/2016 Risk!D: 9]75]5522 Production Date: 05/06/2016 State: INTERSTATE 8tte li'4It Ex :Ex A'. cess Expected " Ezp P,rfmci r=xt`Losses AL. Losses Less©s I asses Ballaatf Aet Idc.Losat3s' Ac't.:f?rir .09 58 828 240 s kosst�s AK 10 2,5 0 22,375 3,606 1,156 0 0 .09 3,11 4,201 1,088 0 18,875 2.185 2,185 .08 1,38 1,730 70,162 750 S .O9 342 54,1602 418,375 46,000 NC .09 10 140 0 0 25,250 0 0 OK 32 0 .08 3, 14 30,125 0 TN 09 4,161 1,058 270,560 37,875 0 0 11,75 17,406 5,654 286,560 16,000 Tx 09 3,931 6,570 . 0 22,500 7,237 2 639 3 418 7,237 01 (B (C}ala!`xcess D 23 750 23,949 Wt Losses D E }Ex{srcted (E}Exp PrGn (F};4;t Exc [G}Ba9laat , v,�n 20 431 _ } Losers .Li9saes Lasses �! }Aat OB 26,434 I#i'• . . ios> (I)Act Prim�3 38,643 12,209 325,747Cashes;' =t. �v t Primary tosses 25 579 371'.769 - 46,022 Re# 6fex }s"Nrl.i� � ' vr•-y N . Actual 46,022 49,634 (J) (€} 29,317 124,973 Expected 12,209 49,634 (K) 2,379 AR/[P 64,222 tNAARAP ` ExA, od Factors 1.48 (J}/(K RATING REFLECTS A DECREASE OF 70%MEDICAL ONLY PRIMARY AND EXCESS LOSS 1.95 DOLLARS WHERE ERA IS APPLIED. THE ARAP FACTOR SHOWN IS FOR THOSE STATES CONTAINED ON THIS RATING THAT HAVE APPROVED THE ARAP PROGRAM AND IS CALCULATED BASED ON THE STATE WITH THE HIGHEST APPROVED MAXIMUM ARAP SURCHARGE,THE MAXIMUM ARAP SURCHARGE MAY VARY BY STATE. PLEASE REFER TO EACH STATE'S APPROVED RULES FOR THE APPLICABLE MAXIMUM ARAP SURCHARGE. THE TENNESSEE CODE ANNOTATED SECTION 50-6-501 REQUIRES EVERY PUBLIC OR PRIVATE EMPLOYER THAT IS SUBJECT TO THE WORKERS COMPENSATION STATUTE TO"ESTABLISH AND ADMINISTER A SAFETY COMMITTEE IN ACCORDANCE WITH RULES ADOPTED PURSUANT TO T.C.A.SECTION 50-6-502 IF THE EMPLOYER HAS AN EXPERIENCE MODIFICATION RATE EQUAL TO OR GREATER THAN 1.2." ®Copyright 1997-2016,All rights reservad. This product Is comprised of compilatlons and Informatlon which are the ro rieta and exclusive Property Compensation Insurance,Inc.(NCCtJ. No further use,disseminatlon,sale,transfer,assignment or disposillon of this product n whole or in an, consent of NCCI.This product is furnished'As is''As available,wjU all defects,and includes Information available at the time of ubiicaUon may be p of the National Council on warranties of any kr reiatlng to the product and hereby expressly d'rscfaims any and all express,statutory,or im lied warranties,inciudin the only. N cl made without ra the Prior wriflen fora Particular cy, P ly.NCCI makes no representations or Pa purpose,accur-d corn eteress,currentness,or correctness of any information or Product furnished hereunder.All responsFbility Far the use Of and for any and ity results derived orot;Wrled throrou h P g P warranty of for any all'fitness g the use afi the product are the and user's and NCCI shall not have any fiabllity thereto. Page 1 of 11 WORKERS COMPENSATION EXPERIENCE RATING &AVM? Risk Name: J S HAREN CO Risk 10: 917515522 Rating Effective Date: 10/01/2016 Production Date: 05/06/2016 state: INTERSTATE 01-ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier: 90468 Policy No. WCV8009567 Eff Date: 1010112012 Exp Date: 02/21/2D13 Code ELI�t D Payroll Expected Exp Prlm GIa1m beta I.1 OF r "lo Lowes Lostss Act Jno r Act Prim 4bsees Lo 5183 1.22 31 sses 24,436 298 92 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 24,43 Premium: 1,109 Losses: 0 01-ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier: 27995 Policy No. WC038600739200 Eff Date: 02/21/2013 Godb Exp Date: 02/21/2014 i �-r !'�tyrbl{ }� FJcper4e� L�qp rPrlt `jafnl at IJ F s, �t rt. R:3t10 v -M "•�QSSAS_' .r'110�Ii�5� 1 ., t l; '' aYt x r 'r�IC, Z��� ��i4�� T y7 �Sg8 x 3724 1.62 .281 17,424 282 79 3724 1.62 201 11,224 182 51 9807 ADDITIONAL PREMIUM .p 0 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 28, Premium: 3,639 Losses: 0 01-ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier: 27995 Policy No WC038600739201 Eff Date 02/21/2014 7 ��od h ! k!At EXP Dat . 1120 rip �yj, e" 1010 14 .aUNQ, a Rt BiM0. # 1A� 1111 NO EXPOSURE UNIT R p 0 *��.: 9848 ADDITIONAL PREMIUM p 0 Subject Total Act Inc Policy Total: Premium: 87 Losses: d 01-ALABAMA Firm ID: Firm Name: J S HAREN CO Carrier: 13579 Policy No. DTAUB5910824514 Eff Date: 10/01/2014 Exp Date; 10f01/2015 Cada Ef R D Payroll , Eacpeed F ,Prim 13fa1m Data' [J (3 sAct 1 itl�IO L098C8 PO$Se 0930 ADDITIONAL PREMIUMQ§88s p 0 3724 1 1.62 .28 1,391 23 6 3724 1.62 .28 897 15 4 5183 1.22 .31 884 11 3 5183 1.22 . .311 1,370 17 5 9807 JADDITIpNAL PREMIUM 0 0 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 4,54 P'remlum: 247 Losses: f 0 + da Copyright 1993-201fi,All rights reserved. This product is comprised of compilations and information which are the proprietary and exclusive property of the Natrortaf Council an Compensation insurance,Inc.(NCCI), No further use,dtsseminallon,sale,transfer,assignment or disposition of this product,in whole or In Part,may be made without the prior written consent ofNCCI.This product is furnished'As Is"As available'"With all defects'and includes Information available at the time of publication only.NCCI makes no representations or warranties of any kind relating to the product and hereby expressly disclaims any and all express,statutory.or implied warranties,including the irnpNed warranty of merchantabrG fdness for a particular purpose,accuracy,completeness,currentness,or correctness of any information or product furnished hereunder.All res nsibiq for �" derived or obtained through the use of the product are the end user's and NCCI shall not have any Lability thereto. 70 y �$use of and for any and all results "Total by Policy Year or art cases$2000 or less, D Disease Loss X Ex•Medical Coverage C Catastrophic Loss E Employers Liability Loss a Limhad Loss U USLdHW Page 2 of 11 I? WORKERS COMPENSATION EXPERIENCE RATING Risk Name: J S HAREN CO Risk ID: 917515522 16 Rating Effective Date: 10/01/2016 Production Date: 05/06/2016 State: INTERSTATE 03-ARKANSAS Finn ID: Firm Name: J S HAREN CO Carrier: 27995 Policy No. WC038600739200 Eff Date: 02/21/2013 Exp Date; 02/21/2014 CodeELFt D- Payroll Expected ' sop rlm Clafrtrl}ata IJ OP r Act Inc Ratio .Laisaes Losses A . Prfrfi 3724 1.i 3 _ .32 97,410 1,101 352 1000130393 Og/ O sea 'r 2,185 2185 11 � 3724 1.13 .32 151,224 1,709 547 Mita 9807 DDITIONAL PREMIUM 9807 ADDITIONAL PREMIUM 0 0 r.1CLrti Subject Total Act Inc 1 C1 Policy Total: 248,6 Premium: 15,407 Losses: 2,185 03-ARKANSAS Firm 1D: Firm Name: J S HAREN CO Caller 27995 Policy Na WC038600739201 Eff Date: 02/21/2014 Exp Date: 10/01/2014 �. LexP t _fu� fa .3724 1.13 32 2 x. ,488 2g g t: 5183 .97 .35 10,120 98 34 5213 2.26 `.32 20,658 467 149 5221 1.64 .35 1,776 29 10 6217 1.62 —32 10,001 162 52 9812 DDITIONAL PREMIUM 0 0 Subject Total Act Inc . Policy Total: 45,0 Premium: 2,776 Losses: a 03-ARKANSAS Firm ID: Firm Name: J S HAREN CO Carrier: 15318 Policy No DTAUB591OB24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 Code ECR . 113- Payroll ' ,, � Eupecte I: �rirri . d �fa1m Data� Id OF Aet3ne z , ..,..s .�•i Ratio .' 14 898 -s. "L�os es �z a 5{,r t, 9-�+ y � i � ?�,"tA�rP�.++ar1 0930 obITIONAL PREMIUM p 0 3724 1.13 .32 329 4 1 3724 1:13 .32 511 6 5183 .97 .35 109 1 0 5183 97 .35 71 1 0 Subject Total Act Inc Policy Total. 1,020 Premium: 391 Losses; 0 10-GEORGIA Firm ID: Firm Name: J S HAREN CO Carrier: 90468 Policy No. WCV8009567 Eff Date: 10/01/2012 Exp Date: 02/21/2013 Code' f:LR `f} Payrollzpe""clad Ezp Prlm Claim Data. !3 OI" Ratio Losses Losses Act ina Act Prim' Losses,-. Losses 1111 INO EXPOSURE UNIT R 0 0 Subject Total Act Inc Policy Total: Premium: 0 Losses; 0 ®Copyright 1993-2016,All rights reserved. This product is comprised of compilations and information which are the proprietary and exclusive property pf the National Council on Compensation Insurance.Mc.(NCCI}, No furlhar use,dissemina4on,sale,transfer,assignment or disposition of this product.In whole or In part,may be made without the prior written consent afNCCl.Thio product is furnished"Ps is`"As available"With alt defects'and includes information available at the time of publication only.NCCI makes no representations to warranties of any kind rola@ng to the product and hereby expressly d SGalm3 any artd al!express,stalulory,or implied warranties,including the Implied warranty of merchant tation,fior tness for a paticular purpose,acpuacy,completeness,currentness,ar correctness o}any information or product furnished hereunder.A!I responsibility for the use of and for any and all results dedvedorobtalned thnsughthe use of the product are the end useYs and NCCI shell not have any liability thereto. 'Total byPoaoy Yaer of atl eases$2pp0 ar less. D Disease Loss C Catastrophic Loss E Empbyes Liability Loss qX LEimx-iMteeddLoss Coverage U USLA,NW Page 3 9 of 11 WORKERS COMPENSATION EXPERIENCE RATING ONM Risk Name: J S HAREN CO Risk ID: 917515522 Rating Effective Date: 10/01/2016 Production Date: 05/06/2016 State: INTERSTATE 10-GEORGIA Firm ID: Firm Name: J S HAREN CO Carrier: 27995 Policy No. WC038600739201 Eff Date: 02/21/2014 Exp Date: 10/01/2014 Cede `SLR p- PayrollExpectec# Ezp Prim Cialm Data IJ OF Kano Act Primt ct dss. r'-6 8aes 5183 1.99 .27 24,440 486 131 9812 ADDITIONAL PREMIUM 0 0 Subject total Act Inc Policy Total: 24, Premium: 3,059 Losses: 0 10-GEORGIA Firm ID: Firm Name: J S HAREN CO Carrier: 11223 Policy No. DTAUB591OB24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 Cade t;Ltt t3 P�yroil Eifpected amp Pttm Claim bate R! OF Lasses Act jnc y 'A , Prim �C± � 'Sir : Irl 5 0930 ADDITiONAL.PREMIUM 0 0 PE6509 09 . O 70,162 16,000 1,\kLc 3724 1.92 .23 22,376 430 9911 3724 1..92 .231 34,746 666 153 5183 1 1.99 .27 28,786 5731 155 5183 1 1.99 .27 18,560 369 100 5221 1 2,89 .271 33,385 965 261 5221 2.89 ..271. 21,524 622 168 5606 .65 .23 8,468 55 13 5606 65 .23 5,459 35 g 9807 DITiONAL PREMIUM 1 0 p 9807 ADDITIONAL PREMIUM p 0 Subject Total Act Inc Policy Total: 173,2 Premium: 13,606 Losses: 70,162 174LOUISIANA Firm ID: Firm Name: J S HAREN CO Carrier: 90468 Policy No. WCV8009567 Eff Date: 10/01/2012 Exp Date: 022(21/2013 Cd°de� r� r P5/ro r 1 `edE � 1 '.:...e. ..� .Y..! .c-,,, . '�:^ '•.i I" .4,: . _ 5183 1.77 .21 16;379 290 61 5606 .63 .19 11,660 73 14 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 28,03 Premlum: 1,030 Losses: 0 0 Copyright 1993.2016,Ali rights reserved. This product is comprised of compilations and information which are the proprietary and exclusive property of the National Couneil on Compensation Insurance,Inc,(NCCI). No further use,Osseminattcn,sale,transfer,assignment or disposition of this product,in whole or In part,may be made without the prior written consent of NCCI.This product is furnished'As Is""As available'With all defects'and includes information available at the time of publication only.NCCI makes no representations or warranties Of any kind relating to Lha product and hereby expressly disclaims any and all express,statutory,or implied warranties,including the implied warranty of merchantability,fitness for a particular purpose,accuracy,completeness,currentness,or correctness of any information or product furnished hereunder.Atl responsibillly for the use of and for any and all resLlts derived or Obtained through the use of the product are the end users and NCCI shall not have any liability thereto. Total by Po&cy Year of all eases$2000 or loss. O Disease Loss X EX-Medlcal Coverage U USL6HW C Catastrophic Loss E Employers Liability Lass #Limited Loss Page 4 of 11 WORKERS COMPENSATION EXPERIENCE RATING 0/iffig Risk Name: J S HAREN CO Risk ID71917515522 Rating Effective Date: 10/01/2016 Production Date: 05/06/2016 State: INTERSTATE 17-LOUISIANA Firm ID: Firm Name: J S HAREN CO Carrier: 30120 Policy No. 143744 Eff Date: 02/21/2013 Exp Date 02/21/2014 Coda ELR . .D- Payroll > Expected Erq�Prim Claim Data W OF se Rtio Losses Ldas : Act1rlc ActpNm Ldssgs iJe� _ 3724 1.69 .19 ses 16,603 281 53 3724 1.69 .19 10,694 181 34 5183 1.77 .21 372 7 1 5183 1.77 .21 578 10 2 5606 63 .19 16,458 104 20 5606 .63 ,19 10,602 67 13 9812 DDITIONAL PREMIUM 0 0 9812 ADDITIONAL PREMIUM 0 0 9848 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 55,30 Premium: 3,787 Losses: 0 17-LOUISIANA Firm ID: Firm Name: J S HAREN CO Carrier 30120 Pollcy N❑ 143744 Eff Date 02/21/2014 Exp Date 10/01/2014 Cotf� t.jlt lv r Payrdll Exr�ectedP Prim '_ "CialmDtlta IJ OF 7dcf�ije ` ����tt Prt11! 0931 PREMIUM-SHORT RATE 0 p 5221 3.21 .21 6.991 224 47 9812 DDITIONAL PREMIUM 0 0 9848 DDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 6,991 Premium: 828 Losses: 0 17-LOUISIANA Firm ID: Firm Name: J S HAREN CO Carrier: 12637 Policy No DTAUS591OB24514 Eff Date; 10/01/2014 Exp Date 10/01/2015 3724 1.69 .19 5,088 86 16 3724 1.69 .19 7,892 133 25 5221 3.21 .21 .2,493 80 17 5221 3.21 .21 3,867 124 26 5606 .63 .19 4,352 27 5 5606 .63 .19 6,749 43 8 9807 ADDITIONAL PREMIUM 0 0 9807 ADDfTIONAL PREMIUM p 0 Subject Total Act Inc Policy Total: 30,441 Premium: 1,524 Losses: 0 6)Copyright 1993-2016,All rights reserved. This product Is comprised of compilations and information which are the proprietary and exdusive properly of the National Council on Compensation Insurance,Inc.(NCCI). No further use,dissemination,sale,transfer,assignment or disposition of thfs product,in whole or In part,may be made without the prior wdnen consent of NCCI.This product is furnished'As Is—As available Weth all dedecta-and incudes information available ai the time of publication only.NCCI makes no representations or warranties of any kind relating to the product and hereby expressly disclaims any and all express,statutory,or implied warranties,including the impred warranty of mePresentat on fitness for a particular purpose,accuracy,completeness,currentness,or correctness of any information or product furnished hereunder.All responsibility for the use of and for an and all results derived or obtained through the use of the product are the end user's and NCCI shall not have any liability thereto. y Total by Policy Year of all cases$2000 or less. D Disease Loss X Ex-Medical Coverage C Catastrophic Loss E Employers Liability Loss #Limited Loss U USL6FfW Page 5 of 11 WORKERS COMPENSATION EXPERIENCE RATING N Risk Name: J S HAREM CO Risk ID: 917515522 Rating Effective Date: 10/01/2016 Production Date: 05/06/2016 State: INTERSTATE 23WISSISSIPPI Firm ID: Firm Name: J S HAREN CO Carrier: 27243 Policy No. WC535S531660013 Eff Date: 02/21/2013 Exp Date: 02/21/2014 Code 15'LR D- I ayWII. m'. . Clalnt Data , 11: OF Act Inc Act Prim r ftaBo Ldls .. Ldss'a ' Cosset Losses_ 1111 NO EXPOSURE UNIT R 0 0 1111 NO EXPOSURE UNIT R 0 0 9848 ADDITIONAL PREMIUM 0 0 Abject Total Act Inc Pollcy Total: emium: 100 Losses: 0 23-MISSISSIPPI Firm ID: Firm Name: J S HAREN CO Carrier: 27243 Policy No. WC5358531660014 Eff Date. 02/21/2014 Exp Date: 08105/2014 Cado Et.R D Payirdll E�tpectedP rjfn Gia Data 1,1 $ltltld A���yc�fP rdt. I±;atlo -'a - ..,�-41sas i 7:dlises °. s Y ✓aF P dj:4l $l1 3`�w �tk.}.QE y4Cj 1111 NO EXPOSURE UNIT R 0 0 9848 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: Premium: 75 Losses: 0 32-NORTH CAROLINA Firm ID: Firm Name: J S HAREN CO Carrier: 21873 Policy No. R2WC599624 Eff Date: 03/08/2014 Exp Date: 10/01/2014 .,.�y ;,,y 1 y Y�atlltl� fil �. t MI61 F , '6217 "2.56 '.21 10 0 0 984$ ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 1 Premium: 45 Lasses: 0 32-NORTH CAROLINA Firm 10: Firm Name: J S HAREN CO Carrier: 13579 Policy No. DTAUB591OB24514 Eff Date: 10/0112014 Exp Date: 10/01/2015 tibio ELR Dr; payraii ; ,`' lEicpbted F-?�p rim txlafi eta` tJ;t7E r VAct`tnc, > i tActPrlm= Italia 'Ltiiisaes SLosf�ast =k ^x >oaea 0930 ADDITIONAL PREMIUM 0 0 3724 1.34 .21 696 9 2 3724 1.34 .21 1,080 14 3 5183 1.93 .241 2,010 39 9 5183 1.93 ' .24 3,117 60 14 5606 .62 .21 1,205 7 1 5606 .62 .21 1,869 12 3 9807 ADDITIONAL PREMIUM 0 0 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 9,97 Premium: 627 Losses: 0 z Copyright 1993.2016,All rights reserved.This product is comprised of compilations and Information which are the proprietary and exclusive property of the National Council on Compansadon lnaurance,Inc.(NCCI). No further use,dissemination,sale,transfer,assignment or disposition of this product,in whole Orin part,maybe made without the prior written consent of NCCI.This product is fumished'As is'-As available''With all defects and Includes Information avaIR00 at the time of publication only.NCCI makes no ropresentations or warranties of any kind relasng to the product and hereby expressly disclaims any and all express,statutory,or implied warranties,incfuding the implied warranty of merchantability,filneas for a partieolar purposn,accuracy,completeness,currentness,or correctness of any Information or product furnished hereunder.All responsibility for the use of and for any and a!I results derived or obtained through the use of the product are the end user's and NCCI shall not have any liabllily thereto. Total ty Policy Year of all cases$2000 or less. D Disease Loss X Ex-Medical Coverage U t1SL&HW C Catastrophic Loss E Employers Liability Loss it Limited Loss Page 6 of 11 WORKERS COMPENSATION EXPERIENCE RATING Risk Name: J S HAREN CO Risk ID: 917515522 • Rating Effective Date: 10/01/2016 Production Date: 05/06/2016 State: INTERSTATE 35-OKLAHOMA Firm 10: Firm Name: J S HAREN CO Carrier: 90468 Policy No. WCV8009567 Eff Date: 10/01/2012 Exp Date: 0212112013 Coda ELR D Payroll Expected Exp Prim CCalm Data IJ"bF Acct Inc Ratio Losaos :_ Losses , Losses Losses ' 51831 3.23 .271 44,780 1,446 390 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 44,78 Premium: 4,089 Losses; 0 35.OKLANOMA Firm ID: Firm Name: J S WAREN CO Carrier: 19976 Policy No. 02673406131 Eff Date: 02/21!2013 Exp Date: 10/01/2013 Cods a=LR' r d Payroll Ekpected Exp Prlrri'., GIa1mr -ti--- l l'Oi� Actlr c MAet Prfrri r L!1#ses 5183 .3.231 27 5,543 179 48 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 5,54 Premium: 477 Losses: 0 35-OKLANOMA Firm ID: Firm Name: J S HAREN CO Carrier: 19976 Policy No. 02673406132 Eff Date: 10/01/2013 Exp Date: 10/01/2014 Code ELIC b Payroll Expected tcxpPrlrn Ctair6Dafa id 'OF 21 5163 3.23 .271 4,388 142 .. 38 9807 DITIONAL PREMIUM 0 0 9848 DITIONAL PREMIUM 0 0 Subject Total Act Inc PollcyTotal: 4,38 Premium: 467 Losses: 0 C Copyright 1993.2016,A9 rights reserved. This product is comprised of compilations and information which are the proprietary and exclusive property of the National Council on Compensation Insurance,Inc.(NCCI). No further use,dissemination,sale,transfer,aeslgnment or disposition of this product,in whole or in part,may be made without the prior written conserd of NCCI-This product is fumished'As is' As available''With all defects'and includes Information available at the time of publication only.NCCI makes no representations or warran5es of any kind relating to the product and hereby expressly disclaims any and all express,statutory,or implied warranties,including the implied warranty of merchantability,fitness for a particular purpose,accuracy,completeness,currentness,or correctness of any information or product furnished hereunder.All responsibility for the use of and for any and all results derived orobtalned through the use of the product are the and users and NCCI shall not have any liability thereto. Total by Policy Year of all cases$2000 or toss. D Disease Loss X Ex-Medical Coverage U USL3HV✓ C Catastrophic Loss E Employers Liability Loss p Limited Loss Page 7 of 11 WORKERS COMPENSATION EXPERIENCE RATING AVD9,011 Risk Name: J S HAREN CO Risk ID: 917515522 • Rating Effective Date: 10/01/2016 Production Date: 05/06/2016 State: INTERSTATE 35-OKLAHOMA Firm ID: Firm Name: J S HAREN CO Carrier: 13579 Policy No. DTAU8591 OB24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 Code 'ELR D- Payroll E4eoted Exp Pilin Claim Data I aF Act tine , Act Prfni l Ratio Lo§sea:; Los'ses Coarse ' Losses ��vi V 0930 ADDITIONAL PREMIUM 0 0 E3S0873 09 O 286,560 16,000 �,I 3724 2.37 .24 29,173 691 166 3724 J 2.37 .24 45,249 1,072 257 5183 1 3,23 .27 741 24 6 5183 1 3.23 .27 1,149 37 10 5221 1 3.46 .261 250 9 2 5221 1 3,46 .26 389 13 3 5606 1 .71 .25 14,370 102 26 5606 1 .71 ;25 22,288 158 40 6217 1 3.18 .25 3,541 113 28 6217 3.18 ,25 5,491 175 44 9807 ADDITIONAL PREMIUM 0 0 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Pollcy Total: 122,641 Premium: 5,942 Losses: 286,560 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carrier: 90468 Policy No. WCV8009567 Eff Date: 10/01/2012 Exp Date: 02/21/2013 Codef� �D Pa roil >f E1Yp PtirFraI kIK i3afit` $� r °` t ss * 0042 3,09 36 4,840 150 53 5183 1.50 .32 22,342 335 107 8810 09 .39 82,066 74 29 9807 ADDITIONAL PREMIUM 0 0 9841 DRUG FREE CREDIT 0 0 Subject Total Act Inc Policy Total: 109,24 Premium: 1,803 Losses: 0 ®Copyright 1993-2016,All rights reserved. This product is comprised of compilations and information which are the proprietary and exclusive property of the National Council on Compensation Insurance,Inc.(NCCI). No further use,dissemination,sale,transfer,assignment or disposition o1 this product,In whole or In part,may be made without the prior written consent of NCCI.This product Is furnished'As is'"As available"Wdh all defects'and includes information available M the time of publication only.NCCI makes no representations or warranties of any kind relating to the product and hereby expressly disclaims any and ell express,statutory,or Implied warranties,including the implied warranty of merchanlabltity,fitness for a pedicular purpose,accuracy,completeness,currentness,or correctness of any intarmation or product furnished hereunder.All responslbility,rex the use of and for any and all results deovod or ebtafned through the use of the product are the end user's and NCCI shall not have any Gab Illy!hereto. Total ey Policy Year of all cases$20b0 or less. D Disease Loss X Ex-Medical Coverage U USLSHW C Catastrophic Loss 6 Employers Liability Lass tf Limited Loss Page 8 of 11 WORKERS COMPENSATION EXPERIENCE RATING NRisk Name:J S HAREN CO Risk ID: 917515522 Rating Effective Date: 10/01/2016 Production Date: 05106/2016 State: INTERSTATE 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carrier: 80144 Policy No. 6C28UB5B81664413 Eff Date: 02/21/2013 Exp Date: 02/21/2014 Code ELRJ D-' Payroll. Expected Exti prim Claim Data .. IJ CIF Act Inc Act Pft Ratio Losses Losses. Lotstses LLasSeS. 0042 1 3.09 .351 23,949 740 259 0042 3.09 .35 15,440 477 167 5183 1 1,50 .321 41,149 617 197 5183 1 1.50 .321 63,822 957 306 5606 1 .70 .28109,351 1 765 214 5606 1 .70 .28 70,503 494 138 8610 1 .09 .39 143,723 129 50 8810 1 .09 .39 92,664 83 32 9807 ADDITIONAL PREMIUM 0 0 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Polley Total: 560,601 Premium: 14,847 Losses: 0 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carrier: 80144 Policy No. 6C28UB2E17607614 Eff Date: 02/21/2014 Exp Date: 10/1112014 Code ELiZ^ i1- Payroll fafpbctedz15 prim Clalrh Data tJ OP AbWnc', Act Prim ` RatiS 74,019 Losse 2,287 L ri,: .;.�o&aei8 Losses os9es 0042 3.09 $p0 (ZX0095 09 F 7,237 7,237 5183 1,50 .321 115,707 1,736 556 5606 .70 .28 167,271 1,171 328 8810 .09 .39 151,276 136 53 9807 ADDITIONAL PREMIUM 0 0 Subject Total Act Inc Policy Total: 508,27 Premium: 17,649 Losses: 7,237 ®Copyright 1993-2016,All rights reserved. This product is comprised of compilations and information which are the proprietary and exclusive proparty of the National Council on Compensation Insurance,Inc.(NCCI), No further use,dissemination,sale,transfer,assignment or disposition of this product,In whole or ion part,maybe made without the prior written consent of NCCI.This product Is fumished'As is* As available"With all defects'and Includes Information ava{Pablo at the time of publication only.NCCI makes no representations or warranties of any kind relating to the product and hereby expressly disclalms any and all express,statutory,or implied warranties,Including the implied warranty or merchantabifily fitness for a particular purpose,accuracy,completeness,currentness,or correctness of any Information or product furnished hereunder.All responsibiJ4 for the use or and for any and at;results denvW or obtained through the use of the product are the end user's and NCCI shall not have any liability thereto. Total by Policy Year of all cases 52000 or less. D Disease Loss X Ex-Medical Coverage U USLBHW C CatastrcpNc Loss E Employers Liability Loss R Limited Loss Page 9 of 11 WORKERS COMPENSATION EXPERIENCE RATING o Risk Name: J S HAREN CO Risk ID: 917515522 Rating Effective Date: 10/0112016 Production Date: 05/0612016 State: INTERSTATE 41-TENNESSEE Firm ID: Firm Name: J S HAREN CO Carrier: 11223 Policy No. DTAUB5910824514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 .Code ELR.: :D- . Payrf5ll i•" Expected Exp frim Claim Data: JJ OF Act fnc Act,Pdm Ratio GotsBes :: Lae9®s'a :`.Losses Lo13'ses' 0042 3.09 ,35 47,921 1,481 518 0042 3.09 .35 30,897 955 334 5183 1.50 .321 142,171 2,133 683 5183 1.50 .32 91,663 1,375 440 5606 .70 .28 61,825 433 121 5606 .70 .28 95,893 671 188 8810 .09 .39 139,599 126 49 8810 .09 .39 90,004 81 32 9807ADDITIONAL PREMIUM 0 0 9807' ADDITIONAL PREMIUM 0 0 9841 DRUG FREE CREDIT 0 0 Su 9841 DRUG FREE CREDIT 0 0 bject Total Act Inc Policy Total: 699,97 Premium: 19,268Losses: 0 42-TEXAS Firm ID: Firm Name: J S HAREN CO Carrier: 90468 Policy No. WCV8009567 Eff Date: 10101/2012 Exp Date: 02/21/2013 Cotle E!its Q Pay�oilctect Exi prim a t dItrkDhta Dp >7k ": f P Lwq '`�1,.i•-'r" 7'^�,F�UO k �54 I. �S;i.e K.. �.a.. - w�5.. .�_ _ M"n, ;5- � ,.r�; 5183 1.42 .41 109,845 1,560 640 5606 .32 .40 176,670 565 22fi Subject Total Act Inc Policy Total: 286,51 Premium: 8,964 Losses: 0 42-TEXAS Firm ID: Firm Name: J S HAREN CO Carrier: 29939 Policy No. 0001248839 Eff Date: 02/21/2013 Exp Date: 02121/2014 Cede FLit D" t yrolf xpeCtBd Flip prim GEalyd Date: fJ;a1= Ac£tnu Act PYrni ' motto Loses .; !©sses ._' Lnsi'sesX ses M5183 1.42 .41 20,289 288 118 99R0742472 06 F 19,418 16,000 �N jell 1.42 .41 13,069 186 76 .32 .40 100,733 322 129 5606 .32 .40 156,382 500 200 Subject Total Act Inc Policy Total: 290,47 Premium: 8,267 Losses: 19,418 ®Copyright 1993-2016,All rights reserved. This product Is comprised of oompilations and Information which are the proprietaryand exclusive property of the National Council on Compensation Insurance,Inc.(NCC!). No further use,disseminatlon,sale,transfer,assignment or disposition of this product,in whole or In part,may ba made withoul the prior written consent of NCCI.This product Is furnished'As is 'As available''With all defects'and includes information available at the time of public340n only.NCCI makes no representations or warranties or any kind relating to the product and hereby expressly disclaims any and all express,statutory,or implied warranties,including the implied warranty of merchantability,fitness for a particular purpose,accuracy,completeness,currentness,or correctness of any information or product furnished hereunder.Al responsibility for the use of and for any and all results delved or obtained through the use of the product are the and user's and NCCI shall not have any liability thereto. •Total by Policy Year of all cases$2000 or less. D Disease Loss X Ex-Medical Coverage U U5LBHw C Catastrophic LOSS E Employers Liability Loss #Limited Loss Page 10 of 11 WORKERS COMPENSATION EXPERIENCE RATING Risk Name: J S HAREN CO Risk ID: 917515522 Rating Effective Date: 10/01/2016 Production Date: 05/06/2016 State: INTERSTATE 42-TEXAS Firm ID: Firm Name: J S HAREM CO Carrier: 29939 Policy No. 0001248839 Eff Date: 02/21/2014 Exp Date: 10/01/2014 Code ELR D Payroll Expected Exp Prim Claim Date IJ OF Act Inc Act.Prim Ratio Losses Losses - - ' Losses ."Loss'es 5183 1.42 .41 31,670 450 185 5606 .32 .40 86,213 276 110 Subject Total Act Inc Policy Total: 117,88 Premium: 4,152 Losses: p 42-TEXAS Firm ID: Finn Name: J S HAREN CO Carrier: 12637 Policy No. DTAUB591 OB24514 Eff Date: 10/01/2014 Exp Date: 10/01/2015 Code ELP. t7 Palrroll Ezpeeted Eicp Prlln Clam Iyeta IJ:'Op 'Act 'A' " R;jo s Coseelr :tostiea hoaaes:' 37241 1.22 .391 53,403 652 2541 E2E3895 06 F 4,431 4,431 3724 1.22 .39183,178 1,015 396 ,Cu 5183 1.42 .41 6,675 95 39 5183 1.42 .41 10,396 148 61 5506 .32 .40 62,684L-- 201 80 5606 .32 .40197,632 312 125 Subject Total Act Inc Policy Total: 313,96 Premlum: 7,156 Losses: 4,431 da Copyright 1993"2016,Al rights reserved- This product is comprised of compilations and information which are the proprietary and exclus)ve property of the National Council on Compensation insurance,Inc.(NCCI). No further use,dissemination,sate,transfer,assignment or disposition of this product.In whole or in part,may be made without the prior written consent of NCCI.This product is fumished'As la"'As available' all defects'and includes Information available al the tlmo of publication only.NCCI makes no representations or warranties of any kind relating to the product and hereby expressly disclaims any and all express,statutory,or implied warran ties,including the implied warranty of merchantability,fitness for a pancular purpose,accuracy,completeness,currentness,or correctness of any information or product furnished hereunder.AIS responsibility for the use of and for any and all results derived or obtained through the use of the product are the and user's and NCCI shall not have any Gabiilty thereto. TOIsI by Poficy Year of ag cases$2000 or less. C Disease Loss X Ex-Madical Coverage U USLdHW C Catastrophic Loss E Employers Liability Loss #Limited Loss Page 11 of 11 Table 2—Project Information Organization doing business as: J. S . Haren Company Proposed Project Organization Provide a brief description of the organizational structure proposed for this project indicating the names and functional roles of proposed key personnel and alternates. Provide resumes for Project Manager, Superintendent, Safety Manager and Quality Control Monoger. Position Primary Alternate Project Manager J. S . Haren John Haren Superintendent Mitch Dunker Mitchell Koutny Safety Manager Mitch Dunker Mitchell Koutny Quality Control Manager Mitch Dunker Mitchell Koutny Division of work between Bidder and Proposed Subcontractor and Suppliers Provide a list of Work to be self-performed by the Bidder and the Work contracted to Subcontractors and Suppliers for more than 10 percent of the Work(based on estimated subcontract or purchase order amounts and the Contract Price). Name of Entity Performing the Estimated Percentage Description of Work Work of Contract Price Concrete J. S. Haren Company 1 Excavation J. S. Haren Company 12% Piping J. S. Haren Company 190 Equipment Install J. S. Haren Com an 2 Electrical Square E Services 12% Directional Drilling (broing ) Issaccs Directional Erill 3% Subcontractor Construction Site Safety Experience Provide Experience Modification Ratio (EMR) History for the last 3 years for Subcontractors that will provide Work valued at 25%or more of the Contract Price. Provide documentation of the EMR. Subcontractor N/A Year I EMR Year I 1EMR I Year EMR Subcontractor N/A Year EMR I Year I JEMR I I Year I 1EMR Statement of Experience 004516-6 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 J. S. Haren 3131 Lee Highway, Athens, TN 37303 Education Georgia Institute of Technology, Atlanta, GA Bachelor of Civil Engineering Degree earned in June 1979 Work Experience J. S. Haren Company, President 1987-Present J. S. Haren Company is a heavy construction company performing wastewater treatment plants, water treatment plants, sewer lines and water lines. My responsibilities have included establishing the construction company, establishing bonding, insurance coverages and selecting key personnel. Primary responsibilities at this time include overall company administration, construction management, recruiting, project management, estimating and equipment acquisition. Projects I have managed range from $100,000 to $11 million numbering in excess of 250 projects. Haren Construction Company, Vice President& Construction Mgr. 12185-12187 Responsibilities included selecting and bidding projects, execution of projects, purchasing of materials and subcontracts, selecting and purchasing major pieces of construction equipment, participation in discussions with bonding company, coordination and input to accountant by establishing estimated gross profits, assist with tax planning for corporation, recruitment and development of key personnel including project manager and superintendents. Projects include 25 water/wastewater projects ranging .in size from $200,000 to $3.5 million. McDevitt& Street Company-Benteen Division, Project Manager 5184-12185 Responsibilities included establishing the final guaranteed maximum price (GMP), negotiations with owner to an acceptable GMP, managing project from jobsite location, establishing and executing the project schedule, purchasing all materials, bidding and negotiating all subcontractors. Also monitoring and controlling labor budget in conjunction with project superintendent, monitoring and controlling overall job cost and change orders and maintaining owner and architect relationships. Projects: Morgan Keegan Tower, Memphis, TN (23 story office tower) $19.1 million The Winston Plaza, Alcoa, TN (17 story hotel) $16.5 million 1 McDevitt& Street Company-Benteen Division, Project Manager 12181-11182 During this time period Benteen Division was bidding many projects. The division was relatively new without a large backlog. I prepared estimates for projects ranging from $5 million to $18 million and assisted in estimates in excess of $55 million. Also during this period I constructed the McDevitt & Street Company, Equipment Division Office Building. This project was a $500,000 structure. Haren Construction Company, Project Manager& Estimator 6179-11181 Projects: Turtletown Elementary School, Athens Utility Waterline Extension, Etowah Water Treatment Facility Addition and Etowah Housing Authority Site Improvements, Bledsoe County Comprehensive High School. 2 John Haren Tennessee Experience: Projekt Manager, JT S. Haren Company May2010-Present WWTP Chlorination Improvements--Calvin, OK 2010 Water Treatment Plant Improvements--Etowah,TN 2011 WTP Filter &Clearwell Imp.--McAlester, OK 2011 Pea Ridge Lift Station Expansion--Temple,TX 2012 2008 Southside Pump Station Imp.--Nacogdoches, TX 2012 C.C. Williams WWTF Replacement of Scum Baffles 1 &2—Mobile, AL 2012 Setco Pump.Station Rehabilitation—Idabel, OK 2012 Water System Improvements—Pittsburg, OK 2013 2011 WWTP Headworks Improvements—Greeneville, TN 2013 Water System Improvements—Pittsburg, OK 2013 Water Treatment Plant&System Improvements—Athens,TN 2013 Disinfection System Improvements—Robinson, TX 2014 Seguin Connection—Seguin,TX 2014 Mechanical Screen Replacement—Prairie View,TX 2015 Disinfection By-Product Control Implementation—Chickasha, OK 2015 WWTP Clarifier&Weir Baffle Repair—Houston, TX 2015 WWTF Phase I Improvements—IGngsland,TX 2015 Woodlawn Road Pump Station Improvements—]amestown, TN 2016 Booster Station Emergency Standby Generators—Stillwater, OK 2016 WWTP Digester Improvements--Blue Ridge, GA 2016 WWTP Efficiency Enhancements—Kingston,TN 2017 WTP Filter Media Replacement—Chickasha, OK 2017 Unitec WWTP Improvements—Laredo,TX 2017 WWTP Clarifier Improvements—Center, TX 2017 Unitec WWTP Improvements-Laredo,TX 2018 WTP Improvements-Vernon, AL 2018 Lift Station Improvements-Post, TX 2018 Northeast WTP Prison Pump Mod-Abilene,TX 2018 WWTP Rehab of Existing Sludge Drying Beds-Portland, TX 2019 WWTP Improvements Clarifier_Rehab-Vernon,TX 2019 Wastewater System Improvements-Sherwood, AR 2019 Coddle Creek WTP Settling Basins Upgrades-Concord, NC 2019 Rocky River Regional WWTP, Thickener Mechanism Replac-Concord, NC 2019 Education: University of Tennessee at Chattanooga (UTC) 2010 B.S. Industrial Management University of Tennessee at Chattanooga (UTC) 2012 M.S. Engineering Management Mitchell Dunker Experience Project Superintendent, J. S. Haren Company Nov 08-Present Manages.numerous water treatment plant improvements. See recent projects. Safety training, manages employees and works closely with subcontractors. Maintenance Supervisor, CMC Recycling April 08 Oversee maintenance for repair of Shredder, Down Streem and SSE systems. Manage employees, work with subcontractors, safety training. Project Superintendent, WPC Industrial Contractors June 05-Feb 08 Complete demo and disposal of pre-existing buildings, piping, tanks. Responsible for management of project employees from hiring to evaluating.. Complete facility upgrade including two 2.5 million gal holding tanks, under and above ground piping. Installation of all instrumentation and equipment with multiple tie-ins, construction of office and pump buildings. Project Superintendent, RJ Sullivan, Pompano, FL Mar 03-June 05 Complete demolition, removal and disposal of existing lift station and all buildings. Rebuild to include site work, buildings, electrical, piping, setting pumps, and new generators. Developed and trained day labor staff for permanent hire positions. Responsible for equipment including maintenance and repair. Project Superintendent, Robinson Construction, Orem, UT Jan 94-Feb 03 U. S. Army Veteran 1973-1978 Veterans Preference: VEDA and VRA Recent Prolects Blacksford Wastewater Treatment Facility, Jacksonville, FL 2005-2008 Palm Beach County Utilities Lift Station 5229, Palm Beach, FL 2003-2005 Amoco Projection Sulpher Creek Plant, Evanston, WY 1998-2003 Project included bridges, roadways, water and sewer treatment and gas plant. 1 Sewer Treatment Division 272, Salt Lake City, UT 1997-1998 Project included complete upgrade of existing plant to include demolition, office buildings, installing new pumps, piping generator system, concrete work, tie ins, sewage bypass systems and electrical. Wastewater Treatment Plant Improvements, Brownsville, TN 2008 Gresham, Smith & Partners Angelia Howard 731-613-2034 Wickham Sports Complex Lift Station, Sapulpa, OK 2009 TetraTech, Inc. Joe Holland 918-249-3909 Main Pumping Station Upgrade, Whiteville, TN 2009 King Engineering Jim Hunter 901-323-1000 Doshier Farm WWTP Screw Pumps, Temple, TX 2009 KPA Engineers Tommy Valle 254-760-8498 Trickling Filter Bearing Replacement; Omaha, NE 2011 Omaha Public Works Rick Murch 402-444-3915 Sewer Pump Station #4 Rehabilitation; Pocahontas, AR 2011 DeClerk-Throesch Ben DeClerk 870-892-9412 Refurbish Screw Pumps; Shawnee, OK 2012 Shawnee Municipal Authority Brian McDougal 405-878-1560 Jasper WTP High Service Pump#4; Wichita Falls, OK 2012 Corlett, Probst& Boyd Dean Hinton 940-723-1455 San Felipe Springs WTP; Del Rio, TX 2013 City of Del Rio, TX Mitch Lomas 830-774-9604 Faulkner Lake WWTP Influent Pump Station; North Little Rock, AR 2014 N. Little Rock Sewer Committee Rick Rall 501-945-7186 Greenwood ISD Reverse Osmosis Treatment System; Midland, TX 2014 Greenwood Independent School District Doug Young 432-683-6461 Eastside Lift Station Upgrade; Rowlett, TX 2015 City of Rowlett, TX New Water Treatment Plant; Wheeler, TX 2016 City of Wheeler, TX Wastewater Treatment Plant Improvements 2016 City of McKenzie, TN Gabrielle Kline 731-352-3608 2 Greenwood WWTP Emissions& Odor Control Improvements 2016 City of Corpus Christi, TX ONSWTP Facilities Feed Optimization Improvements 2017 City of Corpus Christi, TX Whitecap WWTP UV Disinfection System Upgrades 2018 City of Corpus Christi, TX McBride Lift Station and Force Main Repairs Current City of Corpus Christi, TX 3 MITCHELL KOUTNY 2721 Painted Pony Drive Murfreesboro, TN 37128 Experience: Project Superintendent, J. S. Haren Company July 2013 to Present Manage watertwastewater treatment plant improvements WWTP Improvements—Kenedy,TX $2,069,500 Unitec WWTP Improvements—Laredo,TX $1,340,000 Whitecap WWTP UV Disinfection System—Corpus Christi,TX $5,266,998 Stokes Pump Station Upgrade—Hot Springs,AR $2,317,000 Durant Fish Hatchery—Phase 1,Caddo,OK $1,774,000 Southern Hills Sanitary Sewage Lift Station Replacement Ardmore,OK $135,500 Duncan Water System Improvements,Duncan,OK $502,000 Water Plant Improvements,Westlake,LA $822,000 Raw Water Intake Modifications, Mountain View,AR $1,547,000 Mechanical Screen Replacement,Prairie View,TX $298,000 Sewer Lift Station Improvements, Dauphin Island,AL $227,763 Water System Improvements, Pittsburg,OK $122,000 Grit Removal Improvements, New Iberia, LA $354,000 Headworks Improvements,Greeneville,TN $396,450 Project Foreman, Bell & Associates 2007 to 2013 Operator, Carpenter, Concrete Foreman, Mortenson 2003 to 2007 Table 3—Projects Awarded during the Last 5 Years Organization doing business as: J. S . Haren Company Proiect Information Project Name Caddo, OK Description Reference Contact Information Project Owner See Attached Name/Title Telephone Email Project Designer Project Budget and Performance Original Final Contract #Contract # Days Contract Price Price Days Late Issues/Claims/ Litigation: Project Information Project Description Name St . Simons Island, GA Reference Contact Information Project Owner See Attached Name/Title Telephone Email Project Designer Project Budget and Performance Original Final Contract #Contract # Days Contract Price Price Days Late Issues/Claims/ Litigation: Project Information Project Name Rowlette, TX Description Reference Contact Information Project Owner See Attached Name/Title Telephone Email Project Designer Project Budget and Performance Original Final Contract #Contract # Days Contract Price Price L Days Late Issues/Claims/ Litigation: Statement of Experience 004516-7 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 Table 3—Projects Awarded during the Last 5 Years--Not including City of Corpus Christi Projects Organization doing business as: J. S . Haren Company Project Information Project Midland, TX Description Name Reference Contact Information Project Owner See Attached Name/Title Telephone Email Project Designer Project Budget and Performance Original Final Contract #Contract # Days Contract Price Price Days Late Issues/Claims/ Litigation: Project Information Project Name Trion, GA Description Reference Contact Information Project Owner See Attached Name/Title Telephone Email Project Designer Project Budget and Performance Original Final Contract #Contract # Days Contract Price Price Days Late Issues/Claims/ Litigation: Project Information Project Name Charlotte, NC Description Reference Contact Information Project Owner See Attached Name/Title Telephone Email Project Designer Project Budget and Performance Original Final Contract #Contract # Days Contract Price Price Days Late Issues/Claims/ Litigation: Statement of Experience 004516-8 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 Table 3—Projects Awarded during the Last 5 Years—Not including City of Corpus Christi Projects Organization doing business as: J. S . Haren Company Project Information Project Name Greenville, TN Description Reference Contact Information Project Owner See Attached Name/Title Telephone Email Project Designer Project Budget and Performance Original Final Contract #Contract # Days Contract Price Price Days Late Issues/Claims/ Litigation: Proiect Information Projec Name 't Cowan TX Description Reference Contact Information Project Owner See Attached Name/Title Telephone Email Project Designer Project Budget and Performance Original Final Contract #Contract # Days Contract Price Price Days Late Issues/Claims/ Litigation: Project Information Project Name Del Rio, TX Description Reference Contact Information Project Owner See Attached Name/Title Telephone Email Project Designer Project Budget and Performance Original Final Contract #Contract # Days Contract Price Price Days Late Issues/Claims/ Litigation: Statement of Experience 004516-9 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 ##of Issuesf Contract #Days COMP. Claims! PR JECT BID AMT FINALAMT Days Late DATE OWNER ENGINEER DESCRIPTION Utiaatton: Durant Fish Hatchery-Phase 1 $1,774,000.00 $1,837,446.44 270 0 12115 OK Dept.of Wildlife Garver LLC Raw water intake including concrete 0 Caddo,OK PO Box 53448 3010 Gaylord Pkwy wetwell,24"discharge piping&river OK City,OK 73152 Frisco,TX 75034 intake screens Paul Haley Lance Klement 405.522-8896 972-377-7480 Dunbar Crede W WTP Headworks $491,000.00 $491,000.00 210 0 2115 Brunswick-Glynn Co Thomas&Hutton Eng Concrete influent structures, 0 St.Simons Island,GA Joint Water&Sewer PO Box 2727 replacement of meth screen,re-piping 700 Gloucester Street Savannah,GA 31405 at grit structure Bnmswick,GA 31520 Fred Sororian Lisa Bums 912-7214128 912-261-7126 Eastside Lift Station Upgrades $1,530,826.00 $1,548,186.00 180 0 6115 City of Rowlett Grantham&Associates Submersible pump replacement,electrical 0 Rowlett,TX 6570 Naaman Forest Blvd 4310 Industrial VFD's added,surge system added Rowlett,TX 75088 Garland,TX 75044 Sherrelle Diggs Brace Grantham 972412.6178 972-864.2333 Greenwood ISD Reverse Osmosis $857,000.00 $781,220.00 250 0 12114 Greenwood ISD Parkhill Smith&Cooper Provided Greenwood School with a new 0 Water Treatment System 2700 FM 1379 4222 85'Street reverse osmosis water treatment Midland,TX Midland,TX 79706 Lubbock,TX 79423 system in a metal bldg with the Doug Young Brian Stephens addition of 4 new 25k gal storage tanks 432-683-6461 806473-2200 Solids Removal at Hays State Prison $373,000.00 $379,044.46 210 0 11114 GA Dept.of Corrections Goodwyn Mill&Cawood Construction of 18"pipe line,screen 0 Trion,GA PO Box 1529 101 E.Washington St wetwell&JWC grinder/screen Forsyth,GA 31209 Greenville,SC 29601 installation,new electrical services& Allan Burgamy Tim Blaydes pump controls 478-992-5310 865-527--0460 Vest Water Filtration Plant Flow $703,800.00 $627,745.83 120 0 5115 Char-Meek Utilities CDM Smith Changing R-O-F controllers on 6 filters 0 Monitoring&Control Improvements 301 S.McDonald St. 5100 Brookshire Blvd and additing 36"water meter. Charlotte,NC Charlotte,NC 28216 Charlotte,NC 28204 Chuck Cowherd Laurin Kennedy 704-391-5101 704-3424546 W WTP Headworks Improv $396,450.00 $396,450.00 180 0 9113 Greeneville Water&Light Gresham,Smith&Partner Bar screen replacement 0 Greeneville,TN l I I 1 Northshore Drive PO Box 368 Greeneville,TN 37744 Knoxville,TN 37919 423.638-3148 865-521-6777 Eric Frye Eric Gamble WWTP Headworks&Clarifier Improv. $377,000.00 $403,731.23 210 0 12/15 City of Cowan Goodwyn Mills&Cawood Headworks improvements,clarifier imp., 0 Cowan,TN 301 Cumberland St E 3310 W End Ave,Ste 420 &W WTP upgrades Cowan,TN 37318 Nashville,TN 37203 Kenny Henshaw Bryant Griffin 931-308-3515 615-333.7200 San Felipe Water Treatment Plant $2,494,296.17 $2,494,296.17 347 0 3113 City of Del Rio Black&Veatch Raw water intake pump impeller 0 Del Rio,TX 114 W Main Street 14100 San Padre Ave replacement,discharge valves,pipe Del Rio,TX 78840 San Antonio,TX 78232 modifications,sand sepermor units, Mitch Lomas Kira Iles pressure relief valve,piping and other site 830-774-9604 210-404-1330 work Table 4—Safety Record Questionnaire and Statement of Bidder's Safety Experience Organization doing business as:]—j. s. Haren company Bidder's Safety Record and Experience Has the Bidder received any Citations for violations of OSHA within the past five (5) years? List Citations below(date and location of Citation) and provide full details in a separate attachment if yes.The full details must include the type of violation or offense, the final disposition of the violation or offense, if any, and the penalty assessed. NO ✓ YES Has the Bidder received any Citations forviolations of environmental protection laws or regulations within the past five(5)years? List Citations below (date and location of Citation) and provide full details in a separate attachment if yes. The full details must include the type of violation or offense, the final disposition of the violation or offense, if any, and the penalty assessed. NO ✓ YES Has the Bidder, within the past ten (10) years, been convicted of a criminal offense or been subject to a judgment for a negligent act or omission,which resulted in serious bodily injury or death? List convictions or judgments below and provide full details in a separate attachment if yes. NO / YES The Owner will consider the following information as additional support to make a determination as to the responsibility of the Bidder.The Bidder must answer the following questions and provide evidence that it meets minimum OSHA construction safety standards and has a lost time injury rate that does not exceed the limits established below: 1 Does the Bidder have a written construction safety program? KYes ❑ No 2 Does the Bidder conduct regular construction site safety inspections? sfYes _ No 3 Does the Bidder have an active construction safety training program? Yes ❑ No 4 Does the Bidder, or affected subcontractor, have competent persons in the following areas (as applicable to the scope of the current Project): A. Scaffolding Yes ❑ No ❑ N/A B. Excavation Yes ❑ No ❑ N/A C. Cranes & Hoists c� Yes ❑ No ❑ N/A D. Electrical Ld Yes ❑ No ❑ N/A Statement of Experience 0045 16- 10 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 Table 4—Safety Record Questionnaire and Statement of Bidder's Safety Experience Organization doing business as: J. S. Haren Company E. Fall Protection if Yes ❑ No ❑ N/A F. Confined Spaces dYes o No o N/A G. Material Handling e1 Yes o No o N/A H. Demolition Gr Yes o No o N/A 1. Steel Erection of Yes ❑ No ❑ N/A J. Underground Construction d Yes ❑ No o N/A Does the Bidder have a lost time injury rate and a total recordable injury rate of less than 5 or equal to the national average for North American Industrial Classification System i Yes o No ("NAICS")Category 23 for each of the past five(5)years?Provide the Bidder's OSHA 300 and 300A logs for the past five(5)years in a separate attachment. Does the Bidder have an experience modifier rate of 1.0 or less? Provide the Bidder's 6 NCCI workers' compensation experience rating sheets for the past five (5) years in a ❑Yes s(No separate attachment. Has the Bidder had any OSHA inspections within the past six (6) months? Provide 7 documentation showing the nature of the inspection,the findings,and the magnitude of o Yes s(No the issues in a separate attachment if yes. Statement of Experience 00 45 16-11 Whitecap WWTP Odor Control and Bulkhead Rehabilitation,Project No.E10053 Rev 10/2018 5 Y g O 8 O ul of i Il 31 42 ° W �L d �� � d IRAQ JLLD ts a Lo CD Q g N MIS p \lv�i\T DC7 �3 m � 9 o _ CQ Q N HH b m h 8 � S h � o y a n B � P A m N b C r io s r i N iw 'i F 0 3 y � g W p U SYYt C r S O "o _ T 12 V1 �' o s �e o CDo tos O /F Y•. 8 cl cn �� ��` �$ � �.• `off _ ��� Qo 1e `� _ � �� d W y J � o � g i' -�� C 4 Sx.� E� - O•C � ._ g yy ` m ' 'y m a ` �Q. �� QK�� IF}S O@ � I WYi � R`• m E a T Fav, a tyy�,� •}�4. o C� O _ j �Y ` �p EL m m - •�/i � m m � q 5..���F .�Ll': C� � `A C N C °C U]� p � �b wa o,I 0 iq • o a o �CNJ w fj N u p V � a > o C zg t Q v C Mimi_I L N' O 0 oz oft, H v m Ei bm r cc E e5 E ` g'5 a 16 Cl n au p4 F �8 'Oqgg ' 80 `L 5i. CIO p c`o- ° Y C 3 x a ,� 9 5 ks$ 4J C 737 C o w H t F � F° vs2i CYL a8 N � HISg i ^� o S C C13 13 Y ~ c c f4 oj $ a ontoo cLIN, ❑ N p o � FIE oil60 o O @I H - qg ugs W p u s OSHASs Form 300A M".01r4m) Year 2018 Summary of Work-Related Injuries and Illnesses UA.Department ofUbor WO nnemaOnn�mOOwmMMamttearreet MWmndes�--arproamcnn�aaa gkeesaeaoaumMtluMp'sb yar.RememeertomrMerr nen tegmvmny Orotae ermma em aompkem 11skvft Lee COM fAebAV"OnbedMmedok each eamgmy.Ther.6dietombbake, Establishment Information asiolgama)wMe added eeeenbbssam easypapeotMebp.ff awhwnomamtwrft d' FrMb}asa Axamarm�esa mdbetr Aeve Merrtd&MVIewEa OSHA Faro 300br Yaw mmme JSHmm Cmaem 8e mebny.i}reyetrOtane/6Ntedadememam OSHA lam3a er�estdvderrt Sw2g CFR 100#3A&0"IrIbCOWMenhu aft ror0naerdetabm theewaupmiftma tardrase Arae. Strad 1175HWmavll NOM Number*I Cesare City Athan sulle Tmnnmmme 21p 37303 kMatloY desaydm(9.g..Ymmmdmedmdermede 0a0ms} Total number of Total number of Total number of eases Tota)number of Ca+ebedbn doa0ts caste wM days wb job transferor other recordable away from work restriction cam Stamlam mdu*W clefm&etlm ISM N known(04,SIC 3715) 0 0 0 0 (ti) (H) (I} (J) OR NoMArnodean hhjWW cpsuxetbn(MAIM.lily w Ca&.32e212) z 3 7 1 1 0 NumbsrofOaya - Employment Information Total number of Total numbor of days of . days away from job banetar or matrkdat Ar^W average mwnbm ofemplorms rr1 Wn� Tabs ware wonrmlpenempbyeea lam :Laj up 0 0 year Ito M Injury and)Ones Typae Sign here Totel manber of WmeNegly fob"Ode dooanm may tatdt In a Me. (M) (1)Injury 0 A)Poisoning 0 (2)Skin Disorder 0 (6)Meering loss 0 IoeNYytlW ttieva we,mkmd thfedoomremand tfim the 0eatdnry krwMedpe the eMrme metas.aoaaam,eaq (3)Rosphtory Condition 0 (6)M Other Illnesses 0 423.74645000 ,tYtO,e Post this Summary page from February 1 to April 30 of the yearfo0owtng the year covered by the faro Flan nam Pomonpr➢rq bsdwtartYeWkwondtdonmtlar iscaw ktw+enpeFumme ry rmpma,longaroeMer3»hntreall of l gas-Qadetenoadad,mdaarpwoeod nwiaerrnemteramdkdanPdon.Pereoraaa ndragWedbrmpOdbtAemmdmdMrme8m lNmatl dvk"amrm*"W0M9,od lnn*w.tlpedsmmyoosaah eta90mmanEmoem/mpeeodNedtleaoUeaaalmtae[N80wwWara dlnr.03MOMmd2ga4rea.ammN3W200Wra AsA.NW,Vbd*%AAOC20210L OOndaed0amrcMadtmslotho a. Table 5 -Demonstrated Minority, MBE, DBE Participation Organization doing business as J . S . Haren Company Project Subcontractors and Suppliers Provide a list of anticipated Minority, MBE, DBE Subcontractors or Suppliers contracts that will be used to demonstrate compliance with the Owner's Minority/ MBE/ DBE Participation Policy Name Work to be Provided Estimated% of Contract Price Statement of Experience 004516-12 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 ARTICLE 5—CERTIFICATION 5.01 By submitting this Statement of Experience and related information, Bidder certifies that it has read this Statement of Experience and that Bidder's responses are true and correct and contain no material misrepresentations and that the individual signing below is authorized to make this certification on behalf of the Bidder's organization. The individual signing this certification shall attach evidence of individual's authority to bind the organization to an agreement. Bidder: J. S . Haren Company (typed or printed) By: �/, {individuoi's signature) Name: J. S . Haren (typed or printed) Title: President (typed or printed) Designated Representative: Name: J. S . Haren Title: President Address: 1175 Hwy 11 N Athens, TN 37303 Telephone No.: 423-745-5000 Email: j sharen@j sharen.com END OF SECTION Statement of Experience 004516-13 Whitecap WWTP Odor Control and Bulkhead Rehabilitation, Project No. E10053 Rev 10/2018 SC 0 � N U yea na o n n+e� 1$52 00 52 23 AGREEMENT This Agreement, for the Project awarded on October 29, 2019, is between the City of Corpus Christi (Owner) and J.S. Haren Company (Contractor). Owner and Contractor agree as follows: ARTICLE 1—WORK 1.01 Contractor shall complete all Work as specified or indicated in the Contract Documents. The Work is generally described as: Whitecap WWTP Odor Control and Bulkhead Rehabilitation Prosect No. E10053 ARTICLE 2—DESIGNER AND OWNER'S AUTHORIZED REPRESENTATIVE 2.01 The Project has been designed by: Jeff Coym, P.E.—Vice President UA Engineering, Inc. 5350 South Staples, Suite 425 Corpus Christi, TX 78411 acoymC@Ila.com 2.02 The Owner's Authorized Representative for this Project is: Brett Van Hazel, PMP—Assistant Director of Construction City of Corpus Christi—Engineering Services 4917 Holly Road, Bldg,#5 Corpus Christi, TX 78411 ARTICLE 3—CONTRACT TIMES 3.01 Contract Times A. The Work is required to be substantially completed within 150 days for Base Bid Part 1 and within 180 days for Base Bid Part 2 after the date when the Contract Times commence to run as provided in the Notice to Proceed and is to be completed and ready for final payment in accordance with Paragraph 17.16 of the General Conditions within 180 days for Base Bid Part Agreement 005223- 1 E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation Rev 8/2019 I and within 210 days for Base Bid Part 2 after the date when the Contract Times commence to run. B. Performance of the Work is required as shown in Paragraph 7.02 of the General Conditions. C. Milestones, and the dates for completion of each,are as defined in Section 0135 00 SPECIAL PROCEDURES. 3.02 Liquidated Damages A. Owner and Contractor recognize that time limits for specified Milestones, Substantial Completion, and completion and readiness for Final Payment as stated in the Contract Documents are of the essence of the Contract. Owner and Contractor recognize that the Owner will suffer financial loss if the Work is not completed within the times specified in Paragraph 3.01 and as adjusted in accordance with Paragraph 11.05 of the General Conditions. Owner and Contractor also recognize the delays, expense, and difficulties involved in proving in a legal or arbitration proceeding the actual loss suffered by Owner if the Work is not completed on time. Accordingly, instead of requiring any such proof, Owner and Contractor agree that as liquidated damages for delay (but not as a penalty): 1. Substantial Completion: Contractor shall pay Owner $1,000 for each day that expires after the time specified in Paragraph 3.01 for Substantial Completion until the Work is substantially complete. 2. Completion of the Remaining Work: Contractor agrees to pay Owner$400 for each day that expires after the time specified in Paragraph 3.01 for completion and readiness for final payment until the Work is completed and ready for final payment in accordance with Paragraph 17.16 of the General Conditions. 3. Liquidated damages for failing to timely attain Substantial Completion and Final Completion are not additive and will not be imposed concurrently. 4. Milestones: Contractor agrees to pay Owner liquidated damages as stipulated in SECTION 0135 00 SPECIAL PROCEDURES for failure to meet Milestone completions. 5. The Owner will determine whether the Work has been completed within the Contract Times. B. Owner is not required to only assess liquidated damages, and Owner may elect to pursue its actual damages resulting from the failure of Contractor to complete the Work in accordance with the requirements of the Contract Documents. ARTICLE 4—CONTRACT PRICE 4.01 Owner will pay Contractor for completion of the Work in accordance with the Contract Documents at the unit prices shown in the attached BID FORM. Unit prices have been computed in accordance with Paragraph 15.03 of the General Conditions. Contractor acknowledges that estimated quantities are not guaranteed, and were solely for the purpose of comparing Bids, and final payment for all unit price items will be based on actual quantities, determined as provided in the Contract Documents. Total Price: Base Bid Part 1 plus Base Bid Part 2 $ 1,916,000.00 Agreement 005223- 2 E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation Rev 8/2019 ARTICLE 5—PAYMENT PROCEDURES 5.01 Submit Applications for Payment in accordance with Article 17 of the General Conditions. Applications for Payment will be processed by the OAR as provided in the General Conditions. 5.02 Progress Payments; Retainage: A. The Owner will make progress payments on or about the 25th day of each month during performance of the Work. Payment is based on Work completed in accordance with the Schedule of Values established as provided in the General Conditions. B. Progress payments equal to the full amount of the total earned value to date for completed Work minus the retainage listed below and properly stored materials will be made prior to Substantial Completion. 1. The standard retainage is 5 percent. C. Payment will be made for the amount determined per Paragraph 5.02.13, less the total of payments previously made and less set-offs determined in accordance with Paragraph 17.01 of the General Conditions. D. At the Owner's option, retainage may be increased to a higher percentage rate, not to exceed ten percent, if progress on the Project is considered to be unsatisfactory. If retainage in excess of the amount described above is held prior to Substantial Completion,the Owner will place the additional amount in an interest bearing account. Interest will be paid in accordance with Paragraph 6.01. E. At the Owner's option, Owner may pay Contractor 100 percent of the Work completed, less amounts withheld in accordance with Paragraph 17.01 of the General Conditions and less 200 percent of OAR's estimate of the value of Work to be completed or corrected to reach Substantial Completion. Owner may, at its sole discretion, elect to hold retainage in the amounts set forth above for progress payments prior to Substantial Completion if Owner has concerns with the ability of the Contractor to complete the remaining Work in accordance with the Contract Documents or within the time frame established by this Agreement. Release or reduction in retainage is contingent upon and consent of surety to the reduction in retainage. 5.03 Owner will pay the remainder of the Contract Price as recommended by OAR in accordance with Paragraph 17.16 of the General Conditions upon Final Completion and acceptance of the Work. ARTICLE 6—INTEREST ON OVERDUE PAYMENTS AND RETAINAGE 6.01 The Owner is not obligated to pay interest on overdue payments except as required by Texas Government Code Chapter 2251. Invoices must comply with Article 17 of the General Conditions. 6.02 Except as specified in Article 5, the Owner is not obligated to pay interest on moneys not paid except as provided in Texas Government Code Chapter 2252. Agreement 005223-3 E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation Rev 8/2019 ARTICLE 7—CONTRACTOR'S REPRESENTATIONS 7.01 The Contractor makes the following representations: A. The Contractor has examined and carefully studied the Contract Documents and the other related data identified in the Bidding Documents. B. The Contractor has visited the Site and become familiar with and is satisfied as to the general, local, and Site conditions that may affect cost, progress, and performance of the Work. C. The Contractor is familiar with Laws and Regulations that may affect cost, progress, and performance of the Work. D. The Contractor has carefully studied the following Site-related reports and drawings as identified in the Supplementary Conditions: 1. Geotechnical Data Reports regarding subsurface conditions at or adjacent to the Site; 2. Drawings of physical conditions relating to existing surface or subsurface structures at the Site; 3. Underground Facilities referenced in reports and drawings; 4. Reports and drawings relating to Hazardous Environmental Conditions, if any, at or adjacent to the Site; and 5. Technical Data related to each of these reports and drawings. E. The Contractor has considered the: 1. Information known to Contractor; 2. Information commonly known to contractors doing business in the locality of the Site; 3. Information and observations obtained from visits to the Site; and 4. The Contract Documents. F. The Contractor has considered the items identified in Paragraphs 7.01.D and 7.01.E with respect to the effect of such information, observations, and documents on: 1. The cost, progress, and performance of the Work; 2. The means, methods, techniques, sequences, and procedures of construction to be employed by Contractor; and 3. Contractor's safety precautions and programs. G. Based on the information and observations referred to in the preceding paragraphs, Contractor agrees that no further examinations, investigations, explorations, tests, studies, or data are necessary for the performance of the Work at the Contract Price, within the Contract Times, and in accordance with the other terms and conditions of the Contract Documents. H. The Contractor is aware of the general nature of Work to be performed by Owner and others at the Site that relates to the Work as indicated in the Contract Documents. I. The Contractor has correlated the information known to the Contractor, information and observations obtained from visits to the Site, reports and drawings identified in the Contract Agreement 005223-4 E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation Rev 8/2019 Documents, and all additional examinations, investigations, explorations, tests, studies, and data with the Contract Documents. J. The Contractor has given the OAR written notice of all conflicts, errors, ambiguities, or discrepancies that the Contractor has discovered in the Contract Documents,and the written resolution provided by the OAR is acceptable to the Contractor. K. The Contract Documents are generally sufficient to indicate and convey understanding of all terms and conditions for performance and furnishing of the Work. L. Contractor's entry into this Contract constitutes an incontrovertible representation by Contractor that without exception all prices in the Agreement are premised upon performing and furnishing the Work required by the Contract Documents. M. CONTRACTOR SHALL INDEMNIFY, DEFEND AND HOLD HARMLESS THE OWNER'S INDEMNITEES IN ACCORDANCE WITH PARAGRAPH 7.14 OF THE GENERAL CONDITIONS AND THE SUPPLEMENTARY CONDITIONS. ARTICLE 8—ACCOUNTING RECORDS 8.01 Accounting Record Availability: The Contractor shall keep such full and detailed accounts of materials incorporated and labor and equipment utilized for the Work consistent with the requirements of Paragraph 15.01 of the General Conditions and as may be necessary for proper financial management under this Agreement. Subject to prior written notice,the Owner shall be afforded reasonable access during normal business hours to all of the Contractor's records, books, correspondence, instructions,drawings, receipts,vouchers, memoranda,and similar data relating to the Cost of the Work and the Contractor's fee. The Contractor shall preserve all such documents for a period of 3 years after the final payment by the Owner. ARTICLE 9—CONTRACT DOCUMENTS 9.01 Contents: A. The Contract Documents consist of the following: 1. Solicitation documents. 2. Specifications, forms, and documents listed in SECTION 00 0100 TABLE OF CONTENTS. 3. Drawings listed in the Sheet Index. 4. Addenda. 5. Exhibits to this Agreement: a. Contractor's Bid Form. 6. Documentation required by the Contract Documents and submitted by Contractor prior to Notice of Award. B. There are no Contract Documents other than those listed above in this Article. C. The Contract Documents may only be amended, modified, or supplemented as provided in Article 11 of the General Conditions. Agreement 005223-5 E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation Rev 8/2019 ARTICLE 10—CONTRACT DOCUMENT SIGNATURES ATTEST CITY OF CORPUS CHRISTI °'9'ta"v='9^ byI--H,e Digitally signed by Mark Van Vleck IN Reeeo-t,ben.o-�ty 1I—CU o-tv Mark Van VIeck s buy se° 01 1118'113131 b "a=`°m,`-°s Date:2019.11.14 10:42:05-06'00' Date.zot st tt a t t a7a7�osoo Rebecca Huerta Mark Van Vleck City Secretary Assistant City Manager M2019-181 AUTHORIZED APPROVED AS TO LEGAL FORM: BY COUNCIL 10-29-2019 Digitally byKent MCuyat R R Digitally Sl��yyned b RH/AB DN.cn Kent Mcllya, RH�AB g Y g Y <� ema,kenmc�c e m us Date:2019.11.18 11:29:00-06'00' Date 2019.11.13 13'.57'.37-06'00' Assistant City Attorney ATTEST(IF CORPORATION) CONTRACTOR Digitally signed byCassandra Haren Cassandra Haren Date:2019.11.0514:55:48-05'00' J.S. Haren Company Digitally signed by J S Haren (Seal Below) By. J S Haren Date:2019.11.0514:56:45-05'00' Note: Attach copy of authorization to sign if Title: President person signing for CONTRACTOR is not President, Vice President, Chief Executive Officer, or Chief 1175 Hwy 11 North Financial Officer Address Athens, TN 37303 City State Zip 423/745-5000 4237455252 Phone Fax Jsharen@jsharen.com EMail END OF SECTION Agreement 005223-6 E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation Rev 8/2019 00 6113 PERFORMANCE BOND BOND NO. TXC611997 Contractor as Principal Name: LS. Haren Company Mailing address (principal place of business): 1175 Hwv 11 North Athens, TN 37303 Owner Name: City of Corpus Christi, Texas Mailing address (principal place of business): Engineering Services 1201 Leopard Street Corpus Christi, Texas 78469 Contract Project name and number: Protect No. E10053 Whitecap WWTP Odor Control and 84ikhead Rehabilitation Award Date of the Contract: October 29, 2019 Contract Price: $1.916.000.00 Bond Late of Bond: November 4th, 2019 (Date of Bond cannot be earlier than Award Date of the Contract) Surety Name: Merchants Bonding Company (Mutual) Mailing address (principal place of business): P.O. Box 14498 Des Moines, IA 50306-3498 Physical address (principal place of business): 6700 Westown Parkway West Des Moines, IA 50266-7754 Surety is a corporation organized and existing under the laws of the state of: IA By submitting this Bond, Surety affirms its authority to do business in the State of Texas and its license to execute bonds in the State of Texas. Telephone (main number): (800)678-8171 Telephone (for notice of claim): (800)678-8171 Local Agent for Surety Name: Scott D. Chapman Address: USI Insurance Services, LLC 25025 NI -45 Freeway, Suite 525 The Woodlands, TX 77380 Telephone: (832)702-8344 Email Address: Scott.Chapman@usi.com The address of the surety company to which any notice of claim should be sent may be obtained from the Texas Dept of insurance by calling the following toll-free number: 1-800-252-3439 Performance Bond 00 6113 -1 E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation 7-8-2014 Surety and Contractor, intending to be legally bound and obligated to Owner do each cause this Performance Bond to be duly executed on its behalf by its authorized officer, agent or representative. The Principal and Surety bind themselves, and their heirs, administrators, executors, successors and assigns, jointly and severally to this bond. The condition of this obligation is such that if the Contractor as Principol faithfully performs the Work required by the Contract then this obligation shall be null and void; otherwise the obligation Is to remain in full force and effect. Provisions of the bond shall be pursuant to the terms and provisions of Chapter 2253 and Chapter 2269 of the Texas Government Code as amended and all liabilities on this bond shall be determined in accordance with the provisions of said Chapter to the same extent as If It were copied at length herein. Venue shall lie exclusively in Nueces County, Texas for any legal action. Contractor as Principal J.S. Haren Company Signature: ` Surety Merchants Bonding Company (Mutual) Signature:X c-. 4, Name: J • S. i-iA-��+"� Name:Kell L. Ber Attomey-in-Fact y y Title: —Pres 1 6(..Q,t t tie 0 . CO—. Title: Attorney -in -Fact Email Address: JSkIt/tr) @ y Email Address: Kelly@BondsSoutheast.com ������'.t"""""<<,,i„ ��Np,FZ NC' -O ' 1',�N N .S ��•\``° 114!!/nmamooa (Attach Power of Attorney and place surety seal below) END OF SECTION Performance Bond E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation 006113-2 7-8-2014 MERCFIANi.S BONDING COMPANY. POWER OF ATTORNEY Know All Persons By These Presents, that MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., both being corporations of the State of Iowa (herein collectively called the "Companies") do hereby make, constitute and appoint, individually, Gregory E Nash; Kelly L Berry; Phillip H Condra their true and lawful Attomey(s)-in-Fact, to sign its name as surety(ies) and to execute, seal and acknowledge any and all bonds, undertakings, contracts and other written instruments in the nature thereof, on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. This Power-of-Attomey is granted and is signed and sealed by facsimile under and by authority of the following By -Laws adopted by the Board of Directors of Merchants Bonding Company (Mutual) on April 23, 2011 and amended August 14, 2015 and adopted by the Board of Directors of MerchantsNational Bonding, Inc., on October 16, 2015. "The President, Secretary, Treasurer, or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and authority to appoint Attorneys -in -Fact, and to authorize them to execute on behalf of the Company, and attach the seal of the Company thereto, bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof." "The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attomey or Certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the Company, and such signature and seal when so used shall have the same force and effect as though manually fixed." In connection with obligations in favor of the Florida Department of Transportation only, it is agreed that the power and aut hority hereby given to the Attorney -in -Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department of Transportation making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of its obligations under its bond. In connection with obligations in favor of the Kentucky Department of Highways only, it is agreed that the power and authority hereby given to the Attorney -in -Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner - Department of Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modification or revocation. In Witness Whereof, the Companies have caused this instrument to be signed and sealed this 5th day of April , 2017 . ..... ai— _ : 2003 ...*,,e : y-. 1933 e: By v'• 'v. ., . ��.. • • STATE OF IOWA .''""`''' COUNTY OF DALLAS ss. On this this 5th day of April 2017 , before me appeared Larry Taylor, to me personally known, who being by me dp4y swop did say that he is President of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; an(thaY.tfi ' ' seals affixed to the foregoing instrument are the Corporate Seals of the Companies; and that the said instrument was signed and sealed.,i�f'a• of the Companies by authority of their respective Boards of Directors. .'4 rt-?► ti MERCHANTS BONDING COMPANY (MUTUAL) MERCHANT NATIONAL BONDING, INC. President �tAt s AUCIA K. GRAM Commission Number 767430 My Commission Expires April 1, 2020 (Expiration of notary's commission does not invalidate this instrument) 01..:4.. k. Notary Public I, WIGam Warner, Jr., Secretary of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., do hereby certify that the above and foregoing is a true and correct copy of the POWER-OF-ATTORNEY executed by said Companies, which is still in full force and effect and has not been amended or revoked. In Witness Whereof, I have hereunto set my hand and affixed the seal of the Companies on this 4th day of November , 2019 . POA 0018 (3/17) 4RPOq q • 1‘ 00.t.e'7.,,a1 • • a'• 1933 C: Secretary . ��. •r,,• • b •a. • •. 00 6116 PAYMENT BOND BOND NO. TXC611997 Contractor as Prindpal Name: J.S. Haren Company Mailing address (principal place of business): 1175 Hwy 11 North Athens, TN 37303 Owner Name: City of Corpus Christi, Texas Mailing address (principal place of business): Engineering Services 1201 Leopard Street Corpus Christi, Texas 78469 Contract Project name and number: Project No. E10053 Whitccap WWTP Odor Control and Bulkhead Rehabilitation Award Date of the Contract: October 29, 2019 Contract Price: 51,916,000.00 Bond Date of Bond: November 4th, 2019 (Date of Bond cannot be earlier than Award Date of Contract) Surety Name: Merchants Bonding Company (Mutual) Mailing address (principal place of business): P.O. Box 14498 Des Moines, IA 50306-3498 Physical address (principal place of business): 6700 Westown Parkway West Des Moines, IA 50266-7754 Surety is a corporation organized and existing under the laws of the state of: IA By submitting this Bond, Surety affirms its authority to do business in the State of Texas and its license to execute bonds In the State of Texas. Telephone (main number): (800)678-8171 Telephone (for notice of claim): (800)678-8171 Local Agent for Surety Name: Scott D. Chapman Address: USI Insurance Services, LLC 25025 N 1-45 Freeway, Suite 525 The Woodlands, TX 77380 Telephone: (832)702-8344 Email Address: Scott.Chapman@USI.com The address of the surety company to which any notice of claim should be sent may be obtained from the Texas Dept. of Insurance by calling the following toll-free number: 1-800-252-3439 Payment Bond Form 00 6116 -1 E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation 7-8-2014 Surety and Contractor, intending to be legally bound and obligated to Owner do each cause this Payment Bond to be duly executed on its behalf by its authorized officer, agent or representative. The Principal and Surety bind themselves, and their heirs, administrators, executors, successors and assigns, jointly and severally to this bond. The condition of this obligation is such that if the Contractor as principal pays all claimants providing labor or materials to him or to a Subcontractor in the prosecution of the Work required by the Contract then this obligation shall be null and void; otherwise the obligation is to remain in full force and effect. Provisions of the bond shall be pursuant to the terms and provisions of Chapter 2253 and Chapter 2269 of the Texas Government Code as amended and all liabilities on this bond shall be determined in accordance with the provisions of said Chapter to the same extent as if it were copied at length herein. Venue shall Ile exclusively in Nueces County, Texas for any legal action. Contractor as Principal J.S. Haren Company Signature: c74";(4,64------ Surety Merchants Bonding Company (Mutual) Signature: i.� J( ,, , Name: V '' Mare r\ Name: Kelly L. Berry,) Attorney-in- ct Title: -Pr e5 i( .AJ t Title: Attorney-in-Fact Email Address: 3Sihli2f) ca:8h pC,tt?J) • CO-- , Email Address: Kelly@BondsSoutheast.com :,O Pot. y , .. z" /kc �4/e� ma (Attach Power of Attorney and place surety seal below) END OF SECTION Payment Bond Form E10053 Whitecap WWTP Odor Control and Bulkhead Rehabilitation 006116-2 7-8-2014 MERCHANT`. BONDING COMPANY POWER OF ATTORNEY Know All Persons By These Presents, that MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., both being corporations of the State of Iowa (herein collectively called the "Companies") do hereby make, constitute and appoint, individually, Gregory E Nash; Kelly L Berry; Phillip H Condra their true and lawful Attorney(s)-in-Fact, to sign its name as surety(ies) and to execute, seal and acknowledge any and all bonds, undertakings, contracts and other written instruments in the nature thereof, on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. This Power -of -Attorney is granted and is signed and sealed by facsimile under and by authority of the following By -Laws adopted by the Board of Directors of Merchants Bonding Company (Mutual) on April 23, 2011 and amended August 14, 2015 and adopted by the Board of Directors of Merchants National Bonding, Inc., on October 16, 2015. "The President, Secretary, Treasurer, or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and authority to appoint Attorneys -in -Fact, and to authorize them to execute on behalf of the Company, and attach the seal of the Company thereto, bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof." "The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attorney or Certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the Company, and such signature and seal when so used shall have the same force and effect as though manually fixed." In connection with obligations in favor of the Florida Department of Transportation only, it is agreed that the power and aut hority hereby given to the Attorney -in -Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts required by the State of Florida Department of Transportation. It is fully understood that consenti ng to the State of Florida Department of Transportation making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of its obligations under its bond. In connection with obligations in favor of the Kentucky Department of Highways only, it is agreed that the power and authority hereby given to the Attorney -in -Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner - Department of Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modification or revocation. In Witness Whereof, the Companies have caused this instrument to be signed and sealed this 5th day of April 2017 . .1%0Nq.•0\119 C1M•. :Z:2 • o- 6%. • Cd . -0- • rn• • :Q :z •Z:— o; � 2003 : ��; : y. 1933 By , •....•:,'• • �jy•. . •''�1•• President •• STATE OF IOWA COUNTY OF DALLAS ss. On this this 5th day of April 2017 , before me appeared Larry Taylor, to me personally known, who being by me duly sworn did say that he is President of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the seals affixed to the foregoing instrument are the Corporate Seals of the Companies; and that the said instrument was signed and sealed' in behalf • of the Companies by authority of their respective Boards of Directors. MERCHANTS BONDING COMPANY (MUTUAL) MERCHANTS NATIONAL BONDING, INC. ALICIA K. GRAM Commission Number 767430 My Commission Expires April 1, 2020 \&- Notary Public (Expiration of notary's commission does not invalidate this instrument) I, William Warner, Jr., Secretary of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., do hereby certify that the above and foregoing is a true and correct copy of the POWER-OF-ATTORNEY executed by said Companies, which is still in full farce and effect and has not been amended or revoked. In Witness Whereof, I have hereunto set my hand and affixed the seal of the Companies on this 4th day of November , 2019 . • :‘Z.• -p- V�:G: : .,• -o- o;�: • v 2003 .o. :.:c -s_:2.... 1933 : c: ••, • :'a... 6�A.. • ted . •.... -• ,, .• POA 0018 (3/17) Secretary ACORD® 9 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYIr) 11/12/2019 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(les) 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). PRODUCER Brock Insurance Agency 823 Chickamauga AvenueDRESS: P.O. Box 460 Rossville GA 30741 CONTACT Deena Lamb NAME: PHONE (706) 866-3394 FAX (706) 861-4619 A/C. No. Ext): (A/C, No): deenal@brockins.com INSURER(S) AFFORDING COVERAGE NAM 0 INSURER A : The Travelers Indemnity Company of America 25666 INSURED J. S. Haren Company 1175 Highway 11 North Athens TN 37303 INSURER B : The Travelers Indemnity Company 25658 INSURER C : Travelers Property Casualty Company of America 25674 INSURER D : The Charter Oak Fire Insurance Company 25615 INSURER E : EACH OCCURRENCE$ INSURER F : COVERAGES CERTIFICATE NUMBER: CL19111218199 REVISION NUMBER: THIS IS TO CERTIFY THAT THE INDICATED. NOTWITHSTANDING CERTIFICATE MAY BE ISSUED EXCLUSIONS AND CONDITIONS POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR LTR TYPE OF INSURANCE y ur ADDL tNSD SUDR WVD POLICY NUMBER POLrCY FF (MM/DDIYYYY) POLICY EXP (MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y DTCOOF796197-TIA-19 10/01/2019 10/01/2020 EACH OCCURRENCE$ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 300,000 MED EXP (Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GENLAGGREGATE X LIMIT APPLIES POLICY [1 PRO -T OTHER: PER: GENERAL AGGREGATE $2,000,000 LOC PRODUCTS - COMP/OPAGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY Y Y DT -810 -0F799728 -IND -19 10/01/2019 10/01/2020 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 XI BODILY INJURY (Per person) $ - - BODILYINJURY(Peraccident) $ _ _ _ PROPERTY DAMAGE (Per accident) $ ` C X - tnuIBRELLA UAB EXCESS UABCLAIMS-MADE HOCCUR DTSM-CUP-8J380799 10/01/2019 10/01/2020 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED X RETENTION $10,000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N NIA Y UB7J031590-19-26-G 10/01/2019 10/01/2020 X STATUTE OTH- ER E.L. EACH ACCIDENT $ 500,000 Y E.L. DISEASE - EA EMPLOYEE $ 500,000 below E.L. DISEASE - POLICY LIMIT 500,000 $ D Installation Floater QT-660-9D916778-COF-19 10/01/2019 10/01/2020 limit 1,500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS Re: Whitecap VWVTP Odor Control Certificate holder is listed as additional Compensation, General Liability / VEHICLES & Bulkhead insured and auto policies. (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Rehabilitation Project E10053 with respect to the General Liability and Auto policies. Waiver of Subrogation applies under the Worker's 30 days notice of cancellation applies. CERTIFICATE HOLDER CANCELLATION City of Corpus Christi Engineering Services 1201 Leopard Street Corpus Christi I TX 78401 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE y ur ACORD 25 (2016103) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �CoI CERTIFICATE OF LIABILITY INSURANCE �r�.•� DATE ` ) 11/08/2019 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 POUCIES 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may requite an endorsement. A statement on this certificate does not confer rights to tato certificate holder in lieu of such endorsement(s). _ PROOUCER JOHN M BROWN INSURANCE AGENCY INC 750 N FRANKLIN ST STE 208 CHICAGO IL 60654-3545 =WY Erich Frank EEL Ex*888-973-0016 Not MX 888 6192230 - moms, efrank@farmerbrown.com U4SURER(S)AFFOROINO COVERAGE RAC 8 INsURERA: Westchester Surplus Unes Insurance Company 10172 INSURED JS Haien Company 1175 Highway 11 N Athens TN 37303-7541 INSURER B: INSURER C: INSURER D : S INSURER E : e4suRER F : ATE NUMBER: 01 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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. JTYPE OF INSURANCE PQM ICY NLI#IB>FR POUCY EFF POLICY mu)8 COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE S E To RENTED ES Me occurrence) CLAIMS.MOCCURADE a MED EXP (Any ore person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE IS GENL AGGREGATE LIMIT APPLIES PER: poUCv ❑JPRE&❑ Loc OTHER: PRODUCTS - COVPIOP AGO S $ AUTOMOBsE - WISIUTYcdrassiEct ANY AUTO OWNED AUTOS ONLY AAUTO IRED ONLY _ ^ SCHEDULED AUTOS AUTOS ONLY SIMILE LOUT Ma accident) S BODILY INJURY (Per pennon) S BODILY INJURY (Par accident) 5 PROPERTY DAMAGE d� ! S S UMBRELLA UM EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE i AGGREGATE S S DEO RETENTIONS WORKERS AND OFFICBT/ME (Faanssdatory It yak DESCRIPTION COMPENSATION EMPLOYERS' LIABILITY Y / N I8EREXCWD®? b NH) OPERATIONS below N / A PER STATUTE ER E.L EACH ACCIDENT S E.L.DISEASE - EA EMPLOYEE S E.L DISEASE - POLICY LIMIT $ A Contractors Pollution Liability Y G71758163 001 11/08/2019 11/08/2020 General Aggregate llml Pollution Liability S2,DOo,000 $1,000,000 DESCRIPTIO! OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 1*1. Additional Remarbrs Schedule, may be attached (r more space la required) Contract 0 E1005313409 White Cap Blvd„ Corpus Christi, Texas 78418 Certificate holier Is also a scheduled additional insured. CANCELLATION City of Corpus Christi 1201 Leopard st Corpus Christi. Texas 78469 I SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE c.s1 Ar... ACORD 25 (2018103) ®1888-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - AUTOMATIC STATUS IF REQUIRED BY WRITTEN CONTRACT (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that: a. You agree in a written contract or agreement to include as an additional insured on this Coverage Part; and b. Has not been added as an additional insured for the same project by attachment of an endorse- ment under this Coverage Part which includes such person or organization in the endorsement's schedule; is an insured, but: a. Only with respect to liability for "bodily injury" or "property damage" that occurs, or for "personal injury' caused by an offense that is committed, subsequent to the signing of that contract or agreement and while that part of the contract or agreement is in effect; and b. Only as described in Paragraph (1), (2) or (3) be- low, whichever applies: (1) If the written contract or agreement specifical- ly requires you to provide additional insured coverage to that person or organization by the use of: (a) The Additional Insured — Owners, Les- sees or Contractors — (Form B) endorse- ment CG 20 10 11 85; or (b) Either or both of the following: the Addi- tional Insured — Owners, Lessees or Con- tractors — Scheduled Person Or Organi- zation endorsement CG 20 10 10 01, or the Additional Insured — Owners, Lessees or Contractors — Completed Operations endorsement CG 20 3710 01; the person or organization is an additional in- sured only if the injury or damage arises out of "your work" to which the written contract or agreement applies; (2) If the written contract or agreement specifical- ly requires you to provide additional insured coverage to that person or organization by the use of: CG D6 04 0219 (3) (a) The Additional Insured — Owners, Les- sees or Contractors — Scheduled Person or Organization endorsement CG 20 10 07 04 or CG 20 10 04 13, the Additional Insured — Owners, Lessees or Contrac- tors — Completed Operations endorse- ment CG 20 37 07 04 or CG 20 37 04 13, or both of such endorsements with either of those edition dates; or (b) Either or both of the following: the Addi- tional Insured — Owners, Lessees or Con- tractors — Scheduled Person Or Organi- zation endorsement CG 20 10, or the Ad- ditional Insured — Owners, Lessees or Contractors — Completed Operations en- dorsement CG 20 37, without an edition date of such endorsement specified; the person or organization is an additional in- sured only if the injury or damage is caused, in whole or in part, by acts or omissions of you or your subcontractor in the performance of "your work" to which the written contract or agreement applies; or If neither Paragraph (1) nor (2) above applies: (a) The person or organization is an addi- tional insured only if, and to the extent that, the injury or damage is caused by acts or omissions of you or your subcon- tractor in the performance of "your work" to which the written contract or agree- ment applies; and (b) Such person or organization does not qualify as an additional insured with re- spect to the independent acts or omis- sions of such person or organization. The insurance provided to such additional insured is subject to the following provisions: a. If the Limits of Insurance of this Coverage Part shown in the Declarations exceed the minimum limits required by the written contract or agree- ment, the insurance provided to the additional in- sured will be limited to such minimum required limits. For the purposes of determining whether © 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 2 COMMERCIAL GENERAL LIABILITY this limitation applies, the minimum limits required by the written contract or agreement will be con- sidered to include the minimum limits of any Um- brella or Excess liability coverage required for the additional insured by that written contract or agreement. This provision will not increase the limits of insurance described in Section 111— Limits Of Insurance. b. The insurance provided to such additional insured does not apply to: (1) Any "bodily injury', "property damage" or "personal injury" arising out of the providing, or failure to provide, any professional archi- tectural, engineering or surveying services, including: (a) The preparing, approving, or fairing to prepare or approve, maps, shop draw- ings, opinions, reports, surveys, field or- ders or change orders, or the preparing, approving, or failing to prepare or ap- prove, drawings and specifications; and (b) Supervisory, inspection, architectural or engineering activities. (2) Any "bodily injury' or "property damage" caused by "your work' and included in the "products -completed operations hazard" un- less the written contract or agreement specifi- cally requires you to provide such coverage for that additional insured during the policy period. c. The additional insured must comply with the fol- lowing duties: (1) Give us written notice as soon as practicable of an "occurrence" or an offense which may result in a claim. To the extent possible, such notice should include: (a) How, when and where the "occurrence" or offense took place; (b) The names and addresses of any injured persons and witnesses; and (c) The nature and location of any injury or damage arising out of the "occurrence" or offense. (2) If a claim is made or "suit" is brought against the additional insured: (a) Immediately record the specifics of the claim or "suit' and the date received; and (b) Notify us as soon as practicable and see to it that we receive written notice of the claim or "suit' as soon as practicable. Immediately send us copies of all legal pa- pers received in connection with the claim or "suit', cooperate with us in the investigation or settlement of the claim or defense against the "suit', and otherwise comply with all policy conditions. (4) Tender the defense and indemnity of any claim or "suit' to any provider of other insur- ance which would cover such additional in- sured for a loss we cover. However, this con- dition does not affect whether the insurance provided to such additional insured is primary to other insurance available to such additional insured which covers that person or organiza- tion as a named insured as described in Par- agraph 4., Other Insurance, of Section IV — Commercial General Liability Conditions. (3) Page 2 of 2 © 2017 The Travelers Indemnity Company. All rights reserved. CG D6 04 0219 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XTEND ENDORSEMENT FOR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general coverage description only. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. Who Is An Insured — Unnamed Subsidiaries B. Blanket Additional Insured — Governmental Entities — Permits Or Authorizations Relating To Operations PROVISIONS A. WHO IS AN INSURED — UNNAMED SUBSIDIARIES The following is added to SECTION II — WHO IS AN INSURED: Any of your subsidiaries, other than a partnership, joint venture or limited liability company, that is not shown as a Named Insured in the Declarations is a Named Insured if: a. You are the sole owner of, or maintain an ownership interest of more than 50% in, such subsidiary on the first day of the policy period; and b. Such subsidiary is not an insured under similar other insurance. No such subsidiary is an insured for "bodily injury' or "property damage" that occurred, or "personal and advertising injury" caused by an offense committed: a. Before you maintained an ownership interest of more than 50% in such subsidiary; or b. After the date, if any, during the policy period that you no longer maintain an ownership interest of more than 50% in such subsidiary. For purposes of Paragraph 1. of Section 11— Who Is An Insured, each such subsidiary will be deemed to be designated in the Declarations as: CG D316 0219 C. D. E. F. B. Incidental Medical Malpractice Blanket Waiver Of Subrogation Contractual Liability —Railroads Damage To Premises Rented To You a. An organization other than a partnership, joint venture or limited liability company; or b. A trust; as indicated in its name or the documents that govern its structure. BLANKET ADDITIONAL INSURED — GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO OPERATIONS The following is added to SECTION II — WHO IS AN INSURED: Any governmental entity that has issued a permit or authorization with respect to operations performed by you or on your behalf and that you are required by any ordinance, law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of such operations. The insurance provided to such govemmental entity does not apply to: a. Any "bodily injury', "property damage" or "personal and advertising injury" arising out of operations performed for the govemmental entity; or b. Any "bodily injury' or "property damage" included in the "products -completed operations hazard". © 2017 The Travelers Indemnity Company. AU rights reserved. Page 1 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. COMMERCIAL GENERAL LIABILITY C. INCIDENTAL MEDICAL MALPRACTICE 1. The following replaces Paragraph b. of the definition of "occurrence" in the DEFINITIONS Section: b. An act or omission committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to a person, unless you are in the business or occupation of providing professional health care services. 2. The following replaces the last paragraph of Paragraph 2.a.(1) of SECTION II — WHO IS AN INSURED: Unless you are in the business or occupation of providing professional health care services, Paragraphs (1)(a), (b), (c) and (d) above do not apply to "bodily injury" arising out of providing or failing to provide: (a) "Incidental medical services" by any of your "employees" who is a nurse, nurse assistant, emergency medical technician or paramedic; or (b) First aid or "Good Samaritan services" by any of your "employees" or "volunteer workers", other than an employed or volunteer doctor. Any such "employees" or "volunteer workers" providing or failing to provide first aid or "Good Samaritan services" during their work hours for you will be deemed to be acting within the scope of their employment by you or performing duties related to the conduct of your business. 3. The following replaces the last sentence of Paragraph 5. of SECTION III — LIMITS OF INSURANCE: For the purposes of determining the applicable Each Occurrence Limit, all related acts or omissions committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to any one person will be deemed to be one "occurrence". 4. The following exclusion is added to Paragraph 2., Exclusions, of SECTION I — COVERAGES — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY: Sale Of Pharmaceuticals "Bodily injury' or "property damage" arising out of the violation of a penal statute or ordinance relating to the sale of Page 2 of 3 pharmaceuticals committed by, or with the knowledge or consent of, the insured. 5. The following is added to the DEFINITIONS Section: "Incidental medical services" means: a. Medical, surgical, dental, laboratory, x-ray or nursing service or treatment, advice or instruction, or the related furnishing of food or beverages; or b. The furnishing or dispensing of drugs or medical, dental, or surgical supplies or appliances. 6. The following is added to Paragraph 4.b., Excess Insurance, of SECTION IV — COMMERCIAL GENERAL LIABIUTY CONDITIONS: This insurance is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to any of your "employees" for "bodily injury" that arises out of providing or failing to provide "incidental medical services" to any person to the extent not subject to Paragraph 2.a.(1) of Section II — Who Is An Insured. D. BLANKET WAIVER OF SUBROGATION The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If the insured has agreed in a contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of: a. "Bodily injury" or "property damage" that occurs; or b. "Personal and advertising injury" caused by an offense that is committed; subsequent to the execution of the contract or agreement. E. CONTRACTUAL LIABILITY — RAILROADS 1. The following replaces Paragraph c. of the definition of "insured contract" in the DEFINITIONS Section: c. Any easement or license agreement; © 2017 The Travelers Indemnity Company. All rights reserved. CG D3 16 0219 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 2. Paragraph f.(1) of the definition of "insured contract' in the DEFINITIONS Section is deleted. F. DAMAGE TO PREMISES RENTED TO YOU The following replaces the definition of "premises damage" in the DEFINITIONS Section: "Premises damage" means "property damage" to: COMMERCIAL GENERAL LIABILITY a. Any premises while rented to you or temporarily occupied by you with permission of the owner; or b. The contents of any premises while such premises is rented to you, if you rent such premises for a period of seven or fewer consecutive days. CG D3 16 0219 © 2017 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 3 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. BROAD FORM NAMED INSURED B. BLANKET ADDITIONAL INSURED C. EMPLOYEE HIRED AUTO D. EMPLOYEES AS INSURED E. SUPPLEMENTARY PAYMENTS — INCREASED LIMITS F. HIRED AUTO — LIMITED WORLDWIDE COV- ERAGE — INDEMNITY BASIS G. WAIVER OF DEDUCTIBLE — GLASS PROVISIONS A. BROAD FORM NAMED INSURED The following is added to Paragraph A.1., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: Any organization you newly acquire or form dur- ing the policy period over which you maintain 50% or more ownership interest and that is not separately insured for Business Auto Coverage. Coverage under this provision is afforded only un- til the 180th day after you acquire or form the or- ganization or the end of the policy period, which- ever is earlier. B. BLANKET ADDITIONAL INSURED The following is added to Paragraph c. in A.1., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: Any person or organization who is required under a written contract or agreement between you and that person or organization, that is signed and executed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to be named as an addi- tional insured is an "insured" for Covered Autos Liability Coverage, but only for damages to which CA T3 53 02 15 H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF USE — INCREASED LIMIT 1. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES — INCREASED LIMIT J. PERSONAL PROPERTY K. AIRBAGS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS M. BLANKET WAIVER OF SUBROGATION N. UNINTENTIONAL ERRORS OR OMISSIONS this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section II. C. EMPLOYEE HIRED AUTO 1. The following is added to Paragraph A.1., Who Is An Insured, of SECTION II — COV- ERED AUTOS LIABILITY COVERAGE: An "employee" of yours is an "insured" 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 busi- ness. 2. The following replaces Paragraph b. in B.5., Other Insurance, of SECTION IV — BUSI- NESS AUTO CONDITIONS: b. For Hired Auto Physical Damage Cover- age, the following are deemed to be cov- ered "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 an "employee's" name, with your © 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL AUTO permission, while performing duties related to the conduct of your busi- ness. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". D. EMPLOYEES AS INSURED The following is added to Paragraph A.1., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: Any "employee" of yours is an "insured" while us- ing a covered "auto" you don't own, hire or borrow in your business or your personal affairs. E. SUPPLEMENTARY PAYMENTS — INCREASED LIMITS 1. The following replaces Paragraph A.2.a.(2), of SECTION II — COVERED AUTOS LIABIL- ITY COVERAGE: (2) Up to $3,000 for cost of bail bonds (in- cluding bonds for related traffic law viola- tions) required because of an "accident" we cover. We do not have to furnish these bonds. 2. The following replaces Paragraph A.2.a.(4), of SECTION II — COVERED AUTOS LIABIL- ITY COVERAGE: (4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $500 a day be- cause of time off from work. F. HIRED AUTO — LIMITED WORLDWIDE COV- ERAGE — INDEMNITY BASIS The following replaces Subparagraph (5) in Para- graph B.7., Policy Period, Coverage Territory, of SECTION IV — BUSINESS AUTO CONDI- TIONS: (5) Anywhere in the world, except any country or jurisdiction while any trade sanction, em- bargo, or similar regulation imposed by the United States of America applies to and pro- hibits the transaction of business with or within such country or jurisdiction, for Cov- ered Autos Liability Coverage for any covered "auto" that you lease, hire, rent or borrow without a driver for a period of 30 days or less and that is not an "auto" you lease, hire, rent or borrow from any of your "employees", partners (if you are a partnership), members (if you are a limited liability company) or members of their households. Page 2 of 4 (a) With respect to any claim made or "suit" brought outside the United States of America, the territories and possessions of the United States of America, Puerto Rico and Canada: (i) You must arrange to defend the "in- sured" against, and investigate or set- tle any such claim or "suit" and keep us advised of all proceedings and ac- tions. (ii) Neither you nor any other involved "insured" will make any settlement without our consent. (iii) We may, at our discretion, participate in defending the "insured" against, or in the settlement of, any claim or "suit". (iv) We will reimburse the "insured" for sums that the "insured" legally must pay as damages because of "bodily injury" or "property damage" to which this insurance applies, that the "in- sured" pays with our consent, but only up to the limit described in Para- graph C., Limits Of Insurance, of SECTION II — COVERED AUTOS LIABILITY COVERAGE. (v) We will reimburse the "insured" for the reasonable expenses incurred with our consent for your investiga- tion of such claims and your defense of the "insured" against any such "suit", but only up to and included within the limit described in Para- graph C., Limits Of Insurance, of SECTION II — COVERED AUTOS LIABILITY COVERAGE, and not in addition to such limit. Our duty to make such payments ends when we have used up the applicable limit of insurance in payments for damages, settlements or defense expenses. (b) This insurance is excess over any valid and collectible other insurance available to the "insured" whether primary, excess, contingent or on any other basis. (c) This insurance is not a substitute for re- quired or compulsory insurance in any country outside the United States, its ter- ritories and possessions, Puerto Rico and Canada. © 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission. You agree to maintain all required or compulsory insurance in any such coun- try up to the minimum limits required by local law. Your failure to comply with compulsory insurance requirements will not invalidate the coverage afforded by this policy, but we will only be liable to the same extent we would have been liable had you complied with the compulsory in- surance requirements. (d) It is understood that we are not an admit- ted or authorized insurer outside the United States of America, its territories and possessions, Puerto Rico and Can- ada. We assume no responsibility for the furnishing of certificates of insurance, or for compliance in any way with the laws of other countries relating to insurance. G. WAIVER OF DEDUCTIBLE — GLASS The following is added to Paragraph D., Deducti- ble, of SECTION 111 — PHYSICAL DAMAGE COVERAGE: No deductible for a covered "auto" will apply to glass damage if the glass is repaired rather than replaced. H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF USE — INCREASED LIMIT The following replaces the last sentence of Para- graph A.4.b., Loss Of Use Expenses, of SEC- TION 111— PHYSICAL DAMAGE COVERAGE: However, the most we will pay for any expenses for loss of use is $65 per day, to a maximum of $750 for any one "accident". I. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES — INCREASED LIMIT The following replaces the first sentence in Para- graph A.4.a., Transportation Expenses, of SECTION III — PHYSICAL DAMAGE COVER- AGE: We will pay up to $50 per day to a maximum of $1,500 for temporary transportation expense in- curred by you because of the total theft of a cov- ered "auto" of the private passenger type. J. PERSONAL PROPERTY The following is added to Paragraph A.4., Cover- age Extensions, of SECTION III — PHYSICAL DAMAGE COVERAGE: Personal Property We will pay up to $400 for "loss" to wearing ap- parel and other personal property which is: (1) Owned by an "insured"; and CA T3 53 02 15 COMMERCIAL AUTO (2) In or on your covered "auto". This coverage applies only in the event of a total theft of your covered "auto". No deductibles apply to this Personal Property coverage. K. AIRBAGS The following is added to Paragraph B.3., Exclu- sions, of SECTION III — PHYSICAL DAMAGE COVERAGE: Exclusion 3.a. does not apply to "loss" to one or more airbags in a covered "auto" you own that in- flate due to a cause other than a cause of "loss" set forth in Paragraphs A.1.b. and A.1.c., but only: a. b. c. If that "auto" is a covered "auto" for Compre- hensive Coverage under this policy; The airbags are not covered under any war- ranty; and The airbags were not intentionally inflated. We will pay up to a maximum of $1,000 for any one "loss". L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS The following is added to Paragraph A.2.a., of SECTION IV — BUSINESS AUTO CONDITIONS: Your duty to give us or our authorized representa- tive prompt notice of the "accident" or "loss" ap- plies only when the "accident" or "loss" is known to: (a) You (if you are an individual); (b) A partner (if you are a partnership); (c) A member (if you are a limited liability com- pany); (d) An executive officer, director or insurance manager (if you are a corporation or other or- ganization); or (e) Any "employee" authorized by you to give no- tice of the "accident" or "loss". M. BLANKET WAIVER OF SUBROGATION The following replaces Paragraph A.5., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — BUSINESS AUTO CONDI- TIONS : 5. Transfer Of Rights Of Recovery Against Others To Us We waive any right of recovery we may have against any person or organization to the ex- tent required of you by a written contract signed and executed prior to any "accident" or "loss", provided that the "accident" or "loss" arises out of operations contemplated by © 2015 The Travelers Indemnity Company. All rights reserved. Page 3 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL AUTO such contract. The waiver applies only to the person or organization designated in such contract. N. UNINTENTIONAL ERRORS OR OMISSIONS The following is added to Paragraph B.2., Con- cealment, Misrepresentation, Or Fraud, of SECTION IV — BUSINESS AUTO CONDITIONS: The unintentional omission of, or unintentional error in, any information given by you shall not prejudice your rights under this insurance. How- ever this provision does not affect our right to col- lect additional premium or exercise our right of cancellation or non -renewal. Page 4 of 4 © 2015 The Travelers Indemnity Compa ny. AU rights reserved . CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission. POLICY NUMBER: DT-CO-0F796197-TIA-19 ISSUE DATE: 10-16-19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ENTITY - NOTICE OF CANCELLATION/NONRENEWAL PROVIDED BY US This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCELLATION: Number of Days Notice of Cancellation: 30 NONRENEWAL: Number of Days Notice of Nonrenewal: 30 PERSON OR ORGANIZATION: ANY PERSON OR ORGANIZATION TO WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OR NONRENEWAL OF THIS POLICY WILL BE GIVEN, BUT ONLY IF: 1. YOU SEND US A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF THE CANCELLATION OR NONRENEWAL OF THIS POLICY; AND 2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS ENDORSEMENT. ADDRESS: THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN SUCH WRITTEN REQUEST FROM YOU TO US. PROVISIONS: A. If we cancel this policy for any statutorily permit- ted reason other than nonpayment of premium, and a number of days is shown for cancellation in the schedule above, we will mail notice of cancel- lation to the person or organization shown in the schedule above. We will mail such notice to the address shown in the schedule above at least the number of days shown for cancellation in the schedule above before the effective date of can- cellation. B. If we decide to not renew this policy for any statu- torily permitted reason, and a number of days is shown for nonrenewal in the schedule above, we will mail notice of the nonrenewal to the person or organization shown in the schedule above. We will mail such notice to the address shown in the schedule above at least the number of days shown for nonrenewal in the schedule above be- fore the expiration date. IL T4 0012 09 © 2009 The Travelers Indemnity Company Page 1 of 1 POLICY NUMBER:DT-810-0F799728-IND- 19 ISSUE DATE: 1011119 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ENTITY - NOTICE OF CANCELLATION PROVIDED BY US This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCELLATION: Number of Days Notice of Cancellation: 30 PERSON OR ORGANIZATION: ANY PERSON OR ORGANIZATION TO WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OF THIS POLICY WILL BE GIVEN, BUT ONLY IF: 1. YOU SEND US A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF THE CANCELLATION OF THIS POLICY AND, 2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS SCHEDULE. ADDRESS: THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN SUCH WRITTEN REQUEST FROM YOU TO US.. PROVISIONS: if we cancel this policy for any statutorily permitted reason other than nonpayment of 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 the schedule above. We will mail such notice to the address shown in the schedule above at least the number of days shown for cancellation in the schedule above before the effective date of cancellation. IL T4 05 0311 © 2011 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 TRAVELERS) ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 03 13 (00) - 001 POLICY NUMBER: UB -7J031590 -19-26-G WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. SCHEDULE DESIGNATED PERSON: DESIGNATED ORGANIZATION: ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. DATE OF ISSUE: 10-18-19 ST ASSIGN: PAGE 1 OF1 TRAVELERS) ONE TOWER SQUARE HARTFORD CT 06183 ENDORSEMENT WC 99 06 R3 (00) - 001 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY POLICY NUMBER: UB -7J031590 -19-26-G NOTICE OF CANCELLATION TO DESIGNATED PERSONS OR ORGANIZATIONS The following is added to PART SIX — CONDITIONS : Notice Of Cancellation To Designated Persons Or Organizations If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice to each person or organization at its listed address at least the number of days shown for that person or organiza- tion before the cancellation is to take effect. You are responsible for providing us with the information necessary to accurately complete the Schedule below. if we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or address of such designated person or organization provided to us is not accurate or complete, we have no responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation. SCHEDULE Name and Address of Designated Persons or Organizations: Number of Days Notice ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OF THIS POLICY WILL BE GIVEN , BUTONLY IF: 1. YOU SEE TO IT THAT WE RECEIVE A WRITTEN REQUEST TO PROVIDE SUC HNOTICE, INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZ ATION,AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF TH ECANCELLATION OF THIS POLICY; AND 2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS ENDORSEMENT. ADDRESS: THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN SUCH WRIT TENREQUEST FROM YOU TO US. 30 All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by DATE OF ISSUE: 10-18-19 ST ASSIGN: © 2013 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 ADDITIONAL COVERAGES Ref # Description Employee Benefits - Aggreate Coverage Code Form No. Edition Date Limit 1 2,000,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Uninsured motorist combined single limit Coverage Code UMCSL Form No. Edition Date Limit 1 500,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Drug Free Credit Coverage Code DRUGF Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Experience Mod Factor 1 Coverage Code EXPO1 Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Expense constant Coverage Code EXCNT Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Premium discount Coverage Code PDIS Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description WC & Employer's liability Coverage Code WCEL Form No. Edition Date Limit 1 500,000 Limit 2 500,000 Limit 3 500,000 Deductible Amount Deductible Type Premium Ref # Description Terrorism Coverage Code TERRO Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Catastrophe Coverage Code CATAS Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV Copyright 2001, AMS Services, Inc.