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Signed Contracts_Mark Fondell Excavating for Deconstruction of 2263, 2275 Elm StreetMasterpiece on the Mississippi TO: Michael C. Van Milligen, City Manager FROM: Gus Psihoyos, City Engineer GP SUBJECT: Bee Branch Creek Restoration Project Deconstruction of 2263 & 2275 Elm Street DATE: November 4, 2010 Dubuque Alt - America City 1 ' 2007 Attached is the Short Form Public Improvement Contract between the City of Dubuque and Mark Fondell Excavating (Dubuque, Iowa) for the deconstruction of 2263 and 2275 Elm Street as it relates to the Bee Branch Creek Restoration Project. The Certificate of Liability Insurance has been reviewed and approved by Finance Director Ken TeKippe. Upon execution of the noted documents, please return to the Engineering office for further processing. Attachs. Masterpiece on the Mississippi City of Dubuque Engineering Dept. 50. W. 13th Street Dubuque, IA 52001 (563) 589 -4270 (563) 589 -4205 FAX CITY OF DUBUQUE, IOWA SHORT FORM PUBLIC IMPROVEMENT CONTRACT THIS PUBLIC IMPROVEMENT CONTRACT (the Contract), made in triplicate, between the City of Dubuque, Iowa (City), by its City Manager, through authority conferred upon the City Manager by its City Council and Mark Fondell Excavating (Contractor) of the City of (Contractor Name) 2270 Crown Point Road, Dubuque, Iowa 52002 (Contractors Address - City and State) PROJECT TITLE: Bee Branch - Deconstruction of 2263 & 2275 Elm Street For and in consideration of the mutual covenants herein contained, the parties hereto agree as follows: CONTRACTOR AGREES: 1. To furnish all material and equipment and to perform all labor necessary for (the Project): - Notification to proper regulatory agencies regarding the removal of the building. - Permits obtained for the deconstruction and utility notifications. - Insurance per State requirements. - Project documentation. - Emphasize reuse of building materials versus recycling or landfilling. The work described above shall be completed at the following location(s): Former Commercial Buildings, 2263 & 2275 Elm Street, Dubuque, Iowa 52001 The Project shall be constructed to the existing grades and to any revised grades as described in this Project contract; in strict accordance with the requirements of the laws of the State of Iowa and ordinances of the City of Dubuque relating to public works, and in accordance with the Contract Documents which provisions and documents are each and all hereby referred to and made a part of this Contract just as much as if the detailed statements thereof were repeated herein. Page 1 of 4 2. Contract Documents shall mean and include the following: This Improvement Contract; all ordinances and resolutions heretofore adopted by the City Council having to do with the Project; the Contractor's Proposal; and the conditions described in the Contract, including any Special Conditions, Plans and Specifications and General Requirements as adopted by the City Council for the Project. 3. All materials used by the Contractor in the Project shall be the best of their several kinds and shall be put in place to the satisfaction of the City Manager. 4. The Contractor shall remove any materials rejected by the City Manager as defective or improper, or any of said work condemned as unsuitable or defective, and the same shall be replaced or done anew to the satisfaction of the City Manager at the cost and expense of the Contractor. 5. Five percent (5 %) of the Contract price may be retained by the City for a period of thirty (30) days after final completion and acceptance of the Project by the City Manager to pay any claim that may be filed within said time for labor and materials done and furnished in connection with the performance of this Contract and for a longer period if such claims are not adjusted within that time, as provided in Iowa Code Chapter 573. The City shall also retain additional sums to protect itself against any claim that has been filed against it for damages to persons or property arising through the prosecution of the work and such sums shall be held by the City until such claims have been settled, adjudicated or otherwise disposed of. 6. The Contractor has read and understands the City of Dubuque Standard Specifications including General Requirements and has examined and understands the project description described in Section 1 and any attached Special Conditions herein referred to and agrees not to plead misunderstanding or deception because of estimates of quantity, character, location or other conditions surrounding the same. 7. The Contractor shall guarantee for a period two years and make good any other defect in any part of the Project due to improper construction or material performance notwithstanding the fact that said Project may have been accepted and fully paid for by the City. The guarantee shall commence on the date that the City pays full compensation for the complete performance of this contract. 8. The Contractor shall fully complete the Project under this Contract on or before November 25, 2011 (DATE) 9. To the fullest extent permitted by law, the Contractor shall indemnify and hold harmless the City from and against all claims, damages, losses and expenses, including but not limited to attorneys' fees, arising out of or resulting from performance of the Contract, provided that such claim, damages, loss or expense is attributable to bodily injury, sickness, disease or death, or injury to or destruction of property (other than the Project itself) including loss of use resulting there from, but only to the extent caused in whole or in part by negligent acts or omissions of the Contractor, the Contractor's subcontractor, or anyone directly or indirectly employed by the Contractor or the Contractor's subcontractor or anyone for whose acts the Contractor or the Contractor's subcontractor may be liable, regardless of whether or not such claim, damage, loss or expense is caused in part by a party indemnified hereunder. Page 2 of 4 10. Unless otherwise specified in the Contract Documents, prior to the commencement of any work on the Project and at all times during the performance of this Contract, the Contractor shall provide evidence of insurance which meets the requirements of the City's Insurance Schedule for Artisan Contractors or General Contractors. THE CITY AGREES: Upon the completion of the Contract, and the acceptance of the Project by the City Manager, the City agrees to pay the Contractor as full compensation for the complete performance of this Contract, the amount determined for the total number of units completed at the unit prices stated in the Contractor's Proposal and less any liquidated damages provided for in the Contract Documents. The number of units stated in the contract, special conditions and contractors proposal is approximate only and the final payment shall be made by the work covered by the Contract. CONTRACT ESTIMATED AMOUNT $ 8,800.00 THE MAXIMUM CONTRACT AMOUNT SHALL BE LIMITED TO AN INCREASE OF 1 0 LISTED ESTIMATED AMOUNT. By: Michael C. Van Milligen City Manager CITY OF D,J$UQUE, IOWA CONTRACTOR: By % OF THE ABOVE Max' 1c d a(' ICGc vft+i t'1 Thc . Company Dame �� Signature licArY--- 11-onde k I Printed Name n ,- Title )O-2to -t Date CONTRACTOR ACKNOWLEDGEMENT OF ATTACH D SPE IA ONDITIONS: By: ignature Date Printed Name /i7C5/ Page 3 of 4 Title The following special conditions shall apply to this Project: The attached bid proposal of October 11, 2011 is part of this contract. -The site is to be left in a mow -able condition. All debris, whether inside the building or outside the building shall be removed from the site and properly disposed and any costs incurred shall be incidental to the Lump Sum contract price. REV. 07/07 Page 4 of 4 CITY OF DUBUQUE, IOWA BEE BRANCH - 2263 & 2275 ELM STREET DECONSTRUCTION CIP: 7201654 BID FORM NO, DESCRIPTION 1 Deconstruction of 2263 & 2275 Elm Street, Complete BID FORM 1A UNIT TOTAL QUANTITY PRICE PRICE 1 LS 4`61`606.6b 481(600. 00 TOTAL $1$(7)0, SEE OTHER SIDE OF SHEET BID PROPOSAL The bidder hereby certifies that they are the only person or persons interested in this proposal as principals; that an examination has been made of the plans, specifications, and contract form, including the special provision contained herein, and of the site of the work, and the bidder understands that the quantities of work shown herein are approximate only and are subject to increase or decrease; and further understand that all quantities of work, whether increased or decreased, are to be performed at the unit price as stipulated herein; the bidder proposes to furnish all necessary machinery, equipment, tools, labor and other means of construction, and to furnish all materials specified in the manner and time prescribed and to do the work at the prices herein set out. The bidder further agrees to execute an informal contract, if required by the contract documents, within seven (7) days of the award of the contract by the City Council, and that they will commence work on or about ten (10) days after the date of the contract, and will complete the' work within' the" specified contract period or pay the liquidated damages stipulated in the contract documents. The bidder acknowledges receipt of the following addendum: Dated: Dated: Dated: PRINCIPAL: 1140t,r1C Contractor 3 Individual ( ) Partnership ( ) Corporation (() By: U3y Title (2d10 Grp )n t?oi n-- • Address City State Zip Pk °I L I Date Note: To be completed by out of State bidders. The State of does ( ) / does not ( ) utilize a percentage preference for in -state bidders. The amount of preference is percent. OP ID: DH A. R° CERTIFICATE OF LIABILITY INSURANCE I DATE 10 /25D/YYYY) 11 10/25/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 TRICOR, Inc. - Dubuque 563 556 5441 500 Iowa Street 608 - 723 -6440 Dubuque, IA 52001 Keith M. Sindberg CONTACT Keith Sindberg PHONE FAX We No Ext):563- 556 -5441 INC. No): 608- 723 -6440 ADDRESS: ksindberg @tricorinsurance.com PRODUCER CUSTOMER ID #:FONDE -1 INSURER(S) AFFORDING COVERAGE NAIL # INSURED Mark Fondell Excavating Inc 2270 Crown Point Rd Dubuque, IA 52002 INSURER A :United Fire & Casualty Co LL X INSURER B : X INSURER C: 60357661 INSURER D : 03/05/12 INSURER E : $ INSURFR F PREMISES MI E MSES ( ( TO occurrence) COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INRR SUBR wvn POLICY NUMBER POLICY EFF IMM /DD/YYYYI POLICY EXP IMM/DD/YYYYI LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LL X BILITY OCCUR X 60357661 03/05/11 03/05/12 EACH OCCURRENCE $ 1,000,000 PREMISES MI E MSES ( ( TO occurrence) $ 100,000 CLAIMS -MADE MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: —1 POLICY X jF(a _ LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 60357661 03/05/11 03/05/12 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 60357661 - 03/05/11 _ 03/05/12 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 X DEDUCTIBLE RETENTION $ 10000 $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory inNH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N I A X 60357661 03/05/11 03/05/12 X TOCSTATU- OT ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City of Dubuque is an addtl ins on the gen liab ongoing & completed ops per CG7150 & CG7103 attached. Gen Liab is primary & non - contributing. Per Project Aggr applies. Government Immunities Endorsement attached. A waiver of subrogation on the work comp applies per attached form. yroier•t • Bee Branch - Deconstruction of 2263 R 7275 Elm Street CERTIFICATE HOLDER CANCELLATION CITYDBQ City of Dubuque Engineering Dept. 50 W. 13th St. Dubuque, IA 52001 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 Keith M. Sindberg © 1988- 0 r 9 ACO D CO ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD ION. All ri. reserved. ENDORSEMENT 60357661 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CITY OF DUBUQUE, IOWA ADDITIONAL INSURED ENDORSEMENT THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART SPEC END (0000) THE CITY OF DUBUQUE, IOWA, INCLUDING ALL ITS ELECTED AND APPOINTED OFFICIALS, ALL ITS EMPLOYEES AND VOLUNTEERS, ALL ITS BOARDS, COMMISSIONS AND /OR AUTHORITIES ADN THEIR BOARD MEMBERS, EMPLOYEES, AND VOLUNTEERS, ARE INCLUDED AS ADDITIONAL INSUREDS WITH RESPECT TO LIABILITY ARISING OUT OF THE INSURED'S WORK AND /OR SERVICES PERFORMED FOR THE CITY OF DUBUQUE, IOWA. THIS COVERAGE SHALL BE PRIMARY TO THE ADDITIONAL INSUREDS, AND NOT CONTRIBUTING WITH ANY OTHER INSURANCE OR SIMILAR PROTECTION AVAILABLE TO THE ADDITIONAL INSUREDS, WHETHER OTHER AVAILABLE COVERAGE BE PRIMARY, CONTRIBUTING OR EXCESS. CITY OF DUBUQUE, IOWA GOVERNMENTAL IMMUNITIES ENDORSEMENT (FOR USE WHEN INCLUDING THE CITY AS AN ADDITIONAL INSURED) All other terms, conditions, limitations and agreements of the policy remain unchanged. SPEC END (0000) 60357661 CONT SPECEND 00 01 ENDORSEMENT SPEC END P (0000) 1. NONWAIVER OF GOVERNMENT IMMUNITY. THE INSURANCE CARRIER EXPRESSLY AGREES AND STATES THAT THE PURCHASE OF THIS POLICY AND THE INCLUDING OF THE CITY OF DUBUQUE, IOWA AS AN ADDITIONAL INSURED DOES NOT WAIVE ANY OF THE DEFENSE OF GOVERNMENTAL IMMUNITY AVAILABLE TO THE CITY OF DUBUQUE, IOWA UNDER CODE OF IOWA SECTION 670.4 AS IT NOW EXISTS AND AS IT MAY BE AMENDED FROM TIME TO TIME. 2. CLAIMS COVERAGE. THE INSURANCE CARRIER FURTHER AGREES THAT THIS POLICY OF INSURANCE SHALL COVER ONLY THOSE CLAIMS NOT SUBJECT TO THE DEFENSE OF GOVERNMENTAL IMMUNITY UNDER THE CODE OF IOWA SECTION 670.4 AS IT NOW EXISTS AND AS IT MAY BE AMENDED FROM TIME TO TIME. 3. ASSERTION OF GOVERNMENT IMMUNITY. THE CITY OF DUBUQUE, IOWA SHALL BE RESPONSIBLE FOR ASSERTING ANY DEFENSE OF GOVERNMENTAL IMMUNITY, AND MAY DO SO AT ANY TIME AND SHALL DO SO UPON THE TIMELY WRITTEN REQUEST OF THE INSURANCE CARRIER. NOTHING CONTAINED IN THE ENDORSEMENT SHALL PREVENT THE CARRIER FROM ASSERTING THE DEFENSE OF GOVERNMENTAL IMMUNITY ON BEHALF OF THE CITY OF DUBUQUE, IOWA. 4. NON - DENIAL OF COVERAGE. THE INSURANCE CARRIER SHALL NOT DENY COVERAGE UNDER THIS POLICY AND THE INSURANCE CARRIER SHALL NOT DENY ANY OF THE RIGHT AND BENEFITS ACCRUING TO THE CITY OF DUBUQUE, IOWA UNDER THIS POLICY FOR REASONS OF GOVERNMENTAL IMMUNITY UNLESS AND UNTIL A COURT OF COMPETENT JURISDICTION HAS RULED IN FAVOR OF THE DEFENSE(S) OF GOVERNMENTAL IMMUNITY ASSERTED BY THE CITY OF DUBUQUE, IOWA. 5. NO OTHER CHANGE IN POLICY. THE INSURANCE CARRIER AND THE CITY OF DUBUQUE IOWA AGREE THAT THE ABOVE PRESERVATION OF GOVERNMENTAL IMMUNITIES SHALL NOT OTHERWISE CHANGE OR ALTER THE COVERAGE AVAILABLE UNDER THIS POLICY. CITY OF DUBUQUE, IOWA CANCELLATION AND MATERIAL CHANGES ENDORSEMENT THIRTY (30) DAYS ADVANCE WRITTEN NOTICE OF CANCELLATION, NON - RENEWAL, RE DUCTION IN INSURANCE COVERAGE AND /OR LIMITS AND TEN (10) DAYS WRITTEN NOTICE OF NON - PAYMENT OF PREMIUM SHALL BE SENT TO: CITY OF DUBUQUE, 50 W 13TH ST, DUBUQUE, IOWA 52001 THIS ENDORSEMENT SUPERSEDES THE STANDARD CANCELLATION STATEMENT ON THE CERTIFICATE OF INSURANCE TO WHICH THIS ENDORSEMENT IS ATTACHED. All other terms, conditions, limitations and agreements of the policy remain unchanged. PREMIUM 250 SPEC END P (0000) CG 71 03 05 06 ULTRA LIABILITY PLUS ENDORSEMENT COMMERCIAL GENERAL LIABILITY EXTENSION ENDORSEMENT SUMMARY OF COVERAGES This is a summary of the various additional coverages and coverage modifications provided by this endorsement. No coverage is provided by this summary. Coverage for non -owned watercraft is extended to 51 feet in length * Voluntary Property Damage Coverage $5,000 Occurrence with a $10,000 Aggregate * Care, Custody and Control Property Damage Coverage $25,000 Occurrence with a $100,000 Aggregate - $500 Deductible * Product Recall Expense $25,000 Each Recall Limit with a $50,000 Aggregate - $1,000 Deductible * Water Damage Legal Liability - $25,000 * Increase in Supplementary Payments: Bail Bonds to $1,000 and Loss of Earnings to $500 * For newly formed or acquired organizations - extend the reporting requirement to 180 days * Automatic Additional Insured Owners, Lessees or Contractors - Automatic Status When Required in Construction Agreement With You * Automatic Additional Insured - Vendors * Automatic Additional Insured - Lessor of Leased Equipment Automatic Status When Required in Lease Agreement With You * Automatic Additional Insured - Managers or Lessor of Premises * Additional Insured - Engineers, Architects or Surveyors Not Engaged by the Named Insured * Additional Insured - Employee Injury to Another Employee * Primary Additional Insured * Expanded Fire Legal Liability to include Explosion, Lightning and Sprinkler Leakage * Automatically included - Aggregate Limits of Insurance (per location) * Automatically included - Aggregate Limits of Insurance (per project) * Knowledge of occurrence - Knowledge of an "occurrence ", "claim or suit" by your agent, servant or employee shall not in itself constitute knowledge of the named insured unless an officer of the named insured has received such notice from the agent, servant or employee * Unintentional failure to disclose all hazards. If you unintentionally fail to disclose any hazards existing at the inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non - renewal. * Liberalization Condition * Mobile equipment to include snow removal, road maintenance and street cleaning equipment less than 1,000 lbs GVW * Blanket Waiver of Subrogation * Property Damage - Borrowed Equipment Property Damage Liability - Elevators Bodily Injury Redefined Extended Property Damage Damage to Media Legal Liability - $50,000 REFER TO THE ACTUAL ENDORSEMENT FOLLOWING ON PAGES 2 THROUGH 15 FOR CHANGES AFFECTING YOUR INSURANCE PROTECTION CG 71 03 05 06 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTORS BLANKET ADDITIONAL INSURED - LIMITED PRODUCTS - COMPLETED OPERATIONS COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Additional Premium: (If no entry appears above, information required to complete applicable to this endorsement.) 1. A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract or written agreement; but the written contract or written agreement must be: 1. Currently in effect or becoming effective during the term of this policy: and 2. Executed prior to the "bodily injury", or "property damage ". B. The additional insured status will apply only with respect to your liability for "bodily injury" or "property damage" which may be imputed to that person(s) or organization(s) directly arising out of "your work" at the location designated and described in the written contract or written agreement performed for that additional insured and only for that liability included in the "products- completed operations hazard ". C. When coverage provided under this endorsement does apply to "bodily injury" or "property damage" arising out of the "products - completed operations hazard ": 1. Such coverage will not apply subsequent to the first to occur of the following: a. The expiration of the period of time required by the written contract or written agreement; b. Five years from the completion of "your work" on the project that is the subject of the written contract or written agreement. this CG 71 50 03 06 endorsement will be shown in the Declarations as c. The expiration of any applicable statute of limitations or statute of repose with respect to claims arising out of "your work ". 2. Such coverage will not exceed the limits of liability required by the written contract or written agreement even if the limits of liability stated in the policy exceed those limits. This endorsement shall not increase the limits stated in Section III - LIMITS OF INSURANCE. 2. With respect to the insurance afforded to any additional insured under this endorsement, the following additional exclusionary language shall apply: This insurance does not apply to "bodily injury" or "property damage" arising out of the rendering of, or the failure to render, any professional architecture, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. 3. With respect to the coverage provided under this endorsement, Paragraph 4.b. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is deleted and replaced with the following language: CG 71 50 03 06 Page 1 of 2 WC 00 03 13 (4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed onlywhen this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on 3/5/11 Policy No. 60357661 of the at 12:01 A.M. standard time, forms a part of (DATE) United Fire & Casualty Company (NAME OF INSURANCE COMPANY) issued to Mark Fondell Excavating Inc. Premium $ Keith Sindbertg Authorized Representative 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 Blanket WC 00 03 13 (4-84) Copyright 1982, 1983 National Council on Compensation Insurance.