APEX Environmental - Monitoring WellsRESOLUTION NO. 2
-99
RESOLUTION AUTHORIZING LICENSE AGREEMENT BETWEEN THE CITY OF
DUBUQUE AND APEX ENVIRONMENTAL, INC., TO INSTALL MONITORING
WELLS ON PUBLIC RIGHT-OF-WAY AT 198 LOCUST STREET
Whereas, Apex Environmental, Inc., on behalt ot Sunoco, Inc., has requested
permission trom the City ot Dubuque to install monitoring wells on City right-ot-way at 198
Locust Street in Dubuque, Iowa tor the purpose ot assessing current groundwater
conditions at and surrounding the property; and
Whereas, the License Agreement Right-ot-Entry tor Site Assessment has been
prepared outlining the responsibilities ot Apex Environmental, Inc. and Sunoco, Inc., in the
installation ot the monitoring wells on public right-ot-way; and
Whereas, the performance ot the activities ot Apex Environmental, Inc., will be at
no cost or expense to the City, and all work will be performed by the Licensee, or its
employees, agents or subcontractors; and
Whereas, it is the desire ot the City Council to enter into said License Agreement
tor the installation ot monitoring wells in the public right-ot-way as requested.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY
OF DUBUQUE, IOWA:
Section 1. The License Agreement tor Right-ot-Entry tor Site Assessment be and
the same is hereby approved.
Section 2. That the Mayor be and is hereby authorized to execute said License
Agreement tor and on behalt ot the City Council.
Passed, approved and adopted this 4th
day of January, 1999
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A
Reliance National
INSURED
Apex Environmental, Inc
15850 Crabbs Branch Way
Rockville MD 20855
COMPANY
B
United Pacific
COMPANY
C
COMPANY
o
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.
co S C POLICY NUMBER I POLICY EFFECTIVE II POLICY EXPIRATION LIMITS
LTR TYPE OF IN URAN E DATE IMM/DDIYYI DATE IMM/DDIYY)
A GENERAL LIABILITY NGB172091401
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 0 OCCUR
OWNER'S & CONTRACTOR'S PROT
6/09/98
6/09/99
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG $
PERSONAL & ADV INJURY
EACH OCCURRENCE
2000000
2000000
1000000
1000000
300000
5000
A AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
X HIRED AUTOS
X NON-OWNED AUTOS
AM" ~.=
ANY AUTO
!
A I EXCESS LIABILITY
m UMBRELLA FORM
I OTHER THAN UMBRELLA FORM
B WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ RINCL
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL
A OTHER
PROFESSIONAL
POLLUTION
LIABILITY
FIRE DAMAGE (Anyone fire)
MED EXP IAny one person)
NKA 16303930 1
6/09/98
6/09/99
COMBINED SINGLE LIMIT
1000000
BODILY INJURY
IPer personl
BODILY INJURY
IPer accident)
PROPERTY DAMAGE
NUA251609101
6/09/98
6/09/99
AUTO ONLY - EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE
AGGREGATE
5000000
5000000
NWA251806801
6/09/98
6/09/99
NTF251254403
EL DISEASE - POLICY LIMIT
EL DISEASE - EA EMPLOYEE
500000
500000
500000
11/29/98
11/29/01
$5,000,000 EA. CLAIM
$5,000,000 AGGREGATE
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
RE: JOB# 4035.002 - SUNOCO
THE CERTIFICATE HOLDER IS INCLUDED AS AN ADDITIONAL INSURED UNDER
GENERAL LIABILITY ONLY, A TlMA.
CITY OF DUBUQUE
ATTN: JANE SMITH
50 W. 13TH STREET
DUBUQUE, IA 52001
..........................1......................
j~,e.Q~f;gZ$f$Ot~$F)
....................................
.... ..................
..
....................................................................................
...........................................
...........................................
....-.................................... ..
:::#iH:~
EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO IIAIl
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE lEFT.
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
LICENSE AGREEMENT RIGHT-OF-ENTRY
FOR SITE ASSESSMENT
THIS AGREEMENT is entered by and between !\oE}( fNyr:RpNM~fl7AL.
(hereafter "the Licensee") and the City of Dubuque, Iowa (hereafter "the
City"), hereafter collectively referred to as the "the Parties".
WIT N E SSE T H:
WHEREAS, the Licensee has entered into a c tract with~ Dr'L ~. to
assess potential environmental contamination at Lo S pursuant
to requirements of the Iowa Department of Natural Resources (IDNR) and the Iowa
Administrative Code (lAC) 567; and
WHEREAS, pursuant to said contract, the Licensee will investigate and assess
said sites to determine the presence of contamination by taking soil samples and
installing groundwater monitoring wells (hereafter "the Activities"), all in contemplation
of the preparation and submission of a Risk Base Corrective Action (RBCA) assessment
to IDNR by the Licensee; and
WHEREAS, the assessment of said site{s), listed in Exhibit "A" attached hereto
and hereafter referred to as the" Project Property{ies)", may involve the investigation
of adjacent City-owned property, or City-owned street or alley right-of-way, hereafter
referred to as "City Property" or the "City Properties"; and
WHEREAS, the Licensee's performance of the Activities herein provided will be
at no cost or expense to the City and it is recognized that all work will be performed
by the Licensee or its employees, agents, or subcontractors; and
WHEREAS, it is the desire and intention of the Licensee and the City to make
this mutual agreement with respect to access to City Properties and with respect to
the Activities to be conducted upon the said City Properties.
NOW, THEREFORE, for and in consideration of the mutual covenants and
undertakings hereinafter made by the City and the Licensee, the said parties do hereby
agree as follows:
The City hereby grants to the Licensee, its contractors, subcontractors,
and their employees and agents, a temporary license to enter upon City
Properties adjacent to Project Properties for the performance of the
assessment and investigation activities described hereinbelow (the
"Activities"), and the right to enter shall continue in effect until JDNR. f.'Dl!/Cib
. '1\1] -fl.lf r l\u ,~cr..o ^ II . If at that time the Licensee has not
completed all Activities require of it under its contract with the ~..J 10 OCO)
~ CC)M;...htN Y , the City may, through its City Council, extend this
License Agreement for such additional period or periods of time to
reasonably complete the Activities. The expiration of this License
notwithstanding, Licensee shall retain its obligations with respect to the
maintenance and removal of monitoring wells until such time as those
obligations are satisfied, all as provided in Part 5 hereof.
2.
The City represents and warrants that it owns and is lawfully possessed
of all street and alley rights-of-way adjacent to the Project Property(ies)
and that it has full authority to grant and enter into this License
Agreement, provided, however, that the Licensee shall be obligated to
obtain permission from the Iowa Department of Transportation before
conducting any of the Activities hereafter enumerated upon State
highway right-of-way within the City.
3.
The assessment and investigation activities (the "Activities") to be
undertaken by the Licensee may include the following:
The Licensee agrees that its entry upon the City Property(ies) shall be
limited to the performance of said Activities. The Licensee further agrees
to undertake and complete the said Activities upon the City Properties in
a prudent and responsible manner, and in accordance with all applicable
laws and regulations of the City, the State of Iowa, and the United
States, and in accordance with all applicable orders, directives and
regulations of IDNR or other governmental agencies having jurisdiction of
the Activities.
4.
The Licensee agrees to notify the City, at the time it picks up Excavation
Permits for particular Project Properties, of its intent to commence the
Activities upon specific City Properties. The Licensee agrees not to
conduct soil borings or to install groundwater monitoring wells upon the
paved portion of any street or in any street or highway median, without
special written authorization from the Public Works Director.
As to privately owned "underground facilities" located upon City
Property, the Licensee agrees to follow the procedures provided in
Chapter 480 of the Iowa Code regarding obtaining locator service prior
to the commencement of excavation or drilling activities, and that its
responsibility and liability for damage to such facilities shall be
determined in accordance with the provisions of that Chapter.
As to City owned or operated "underground facilities", (including but not
limited to sewer, water, electric, electronic communications, fiber optics,
and traffic control), the City agrees that appropriate City departments or
agencies will provide locator services for its underground facilities as
required by Chapter 480 of the Iowa Code. The Licensee its agents,
employees, contractors or subcontractors, agrees that its responsibility
and liability for damage to underground facilities owned or operated by
the City, shall be determined in accordance with the provisions of
Chapter 480 of the Iowa Code.
5.
Within a reasonable time after completion of each step of any of the
Activities on City Properties, the Licensee shall cause any tools,
equipment, materials except for any groundwater monitoring wells placed
hereon to be removed, and shall restore said Properties to the condition
they were in prior to commencement of said Activities.
The obligation to remove and properly abandon each particular
groundwater monitoring well upon City Properties shall remain the
responsibility of the Licensee until each such monitoring well is properly
removed and abandoned as required by applicable State or Federal law or
regulation, as evidenced by a well closure report issued by a certified well
driller. Alternatively, the obligation of the Licensee with regard to
particular monitoring wells shall be deemed discharged upon the Public
Works Directors's receipt, acceptance, and execution of an agreement,
in form acceptable to the Legal Department, executed by the owner of
the adjacent Project Property, pursuant to which the said property owner
agrees to accept responsibility for the operation and maintenance of said
monitoring well and for its removal and abandonment as above provided.
The Licensee agrees that the City may retain its street excavation bond
until its obligation to remove monitoring wells is deemed discharged as
herein provided.
The Licensee agrees that unless deemed discharged it will promptly
remove and properly abandon any monitoring well located upon City
Property when it is notified by the City that the City Property upon which
the well is located is required for municipal purposes, including but not
limited to street, sewer, traffic control, or water utility construction or
repair. The City agrees to review the proposed location of monitoring
wells, if provided in advance of their installation, and to advise the
Licensee if a proposed monitoring well location will conflict with planned
construction activities. The City's failure to advise of such conflicts shall
not excuse the Licensee of its obligation to remove monitoring wells to
accommodate such construction activities by the City.
The parties further agree that unless Licensee is deemed discharged, then
in the event the Licensee fails to properly maintain any monitoring well
or the area immediately adjacent thereto, or fails to remove a monitoring
well after being advised that the City Property upon which it is located
is required for municipal purposes, the City may either (a) deny Licensee
access thereto, or (b) declare the said monitoring well a nuisance, cause
same to be removed, and assess the costs of abatement against the
Licensee, or against the Project Property or Properties for whose benefit
the well was installed, all as provided in Iowa Code Section 364.12.
6.
This Agreement is intended and shall be construed only as a temporary
license to enter and conduct the Activities upon City Properties and not
as a grant of easement or any other interest therein.
7.
This Agreement shall be binding upon the parties hereto and upon their
respective successors, representatives, heirs, and assigns. This
agreement shall also be binding upon all current and future invitees on
City Properties, if any.
8.
The Licensee agrees to the extent Licensee is negligent to defend,
indemnify, and hold harmless the City, its officers, agents, and
employees from and against all manner of actions, liabilities, claims,
causes of action, suits, debts, accounts, losses, damages, and attorneys'
fees including but not limited to property damage or bodily injury,
including death at anytime resulting therefrom, incurred by the City, its
officers, agents, or employees, by the Licensee or its officers, agents,
employees, contractors, or subcontractors, or by any third party, arising
out of the performance of the Activities upon City Property by Licensee,
or arising out of the existence, operation, maintenance, or removal of
monitoring wells on City Property by Licensee, or arising out of or
occasioned by the Licensee's failure to perform any act as herein
required.
9. The Licensee shall purchase and maintain insurance as required through
the duration of this Agreement. All policies shall be in the amount, limits,
forms, and with companies satisfactory to the City. Certificates of
insurance required herein shall state that, "30 days written notice will be
given to the City before the policy is canceled. All certificates of
insurance shall be approved by the City five (5) business days prior to
commencement of the Activities on City Properties.
The Licensee shall purchase and maintain the following insurance, amounts,
coverages and limits:
WORKERS COMPENSATION:
Coverage A:
Coverage B:
Statutory State of Iowa
Employers' Liability
$100,000 each accident
$100,000 each employee by disease
$500,000 policy limit by disease
AUTOMOBILE LIABILITY:
Bodily Injury and Property Damage limit of liability of $1,000,000 combined
single limit or equiValent.
COMMERCIAL GENERAL LIABILITY:
General Aggregate limit
Products-Completed Operation Aggregate limit
Personal and Advertising Injury limit
Each Occurrence limit
Fire Damage limit (anyone occurrence)
Medical Payments
$2,000,000
$1,000,000
$1,000,000
$1,000,000
$ 50,000
$ 5,000
OR
Combined Single Limit
Medical Payments
$2,000,000
$ 5,000
UMBRELLA OR EXCESS LIABILITY: *
$
.
.. To be determined on a case-by-case basis.
Coverage is to include: occurrence form, premises/operations/products/
completed operations coverage, independent contractors' coverage, contractual
liability, broad form property damage, personal injury, City of Dubuque named
as an additional insured with 30 days written notice of change or cancellation.
Certificates of insurance evidencing the aforementioned insurance requirements
shall be filed with the Public Works Director. All insurance policies shall be
issued by companies licensed to do business in Iowa or by companies
satisfactory to the City.
10. Upon request by the City, the licensee agrees to provide to the City,
within 10 days of request, copies of:
(a) all reports, including raw sampling data, which it has therefore
made or shall thereafter make to the IDNR, or any other
governmental agency; and
(b)
all correspondence, including further orders or directives, which it
received from the IONR, or any other governmental agency;
relating to assessment or remediation of any particular Project
Property or to adjacent City Property(ies}.
.
11. Notices, reports, or correspondence required to be given or sent by this
Agreement shall be directed to the following:
If to the City:
Michael Koch
Public Works Director
City of Dubuque
50 W. 13th Street
Dubuque, IA 52001-4864
If to the Licensee:
Such notices shall be delivered or sent by mail. Notices shall be deemed
given when placed in the mail, postage paid.
12. The undersigned warrant that they have full power and authority to
execute and deliver this Agreement. The City further warrants that it has
full power and authority to bind the current and future invitees on City
Properties.
IN WITNESS HEREOF, Aor'x +;:'lJ/(oI1MPJ-QI and the City have executed two
(2) original copies of this Agreerrient on the dates specified immediately adjacent to
their respective signatures.
CITY OF DUBUQUE, IOWA
MEMORANDUM
December 30, 1998
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT: Apex Environmental, Inc., - Monitoring Well
Sunoco, Inc. - 198 Locust
Public Works Director Mike Koch is recommending that a request from Apex
Environmental, Inc., to install monitoring wells within the public right-of-way at 198
Locust be approved.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
Michael C. Van Milligen
MCVM/j
Attachment
cc: Barry Lindahl, Corporation Counsel
Tim Moerman, Assistant City Manager
Mike Koch, Public Works Director
THE CITY OF DUBUQUE, IOWA
MEMORANDUM
December 29, 1998
TO: Michael C. Van Milligen, City Manager
FROM: Michael A. Koch, Public Works Director
SUBJECT: Apex Environmental, Inc. - Monitoring Well
Sunoco, Inc. - 198 Locust
INTRODUCTION
This is in repsonse to a December 1, 1998, request from Apex Environmental, Inc.,
to install monitoring wells within the public right-of-way at 198 Locust.
DISCUSSION
Apex Environmental, Inc., has been retained by Sunoco, Inc., to conduct
subsurface environmental investigations at the Sunoco, Inc., site at 198 Locust
Street. Apex Environmental is planning to install three monitoring wells, with
possible additional wells depending upon the extent of the contamination. All work
will be in compliance with IDNR requirements and will be abandoned in compliance
with the Iowa Administrative Code. Well locations include Locust Street at Second
Street and the alley directly to the east of the site. Attached is a map which
identifies these locations.
The City's approval would be in the form of a License Agreement between Apex
Environmental, Inc., and the City which outlines the responsibilities of Apex
Environmental, provides an indemnity to the City, and requires proof of liability
insurance for placement of monitoring wells on City property.
The License Agreement provides that the City shall have no liability for any
environmental contamination occurring on the subject property, on City property, or
on adjacent private property as a result of contamination from the property owner's
site. In addition, the property owner agrees that when a monitoring well is no
longer needed for monitoring purposes, or if advised by the City that the City
property upon which the wells are located is required for municipal purposes, the
property owner shall remove the wells from City property and abandon them in
compliance with all Federal, State and local laws.
RECOMMENDATION
All the appropriate documents including a map of the well locations and proof of
liability insurance have been submitted by Apex Environmental, Inc., and have been
approved by City staff. I would therefore recommend that the request to install
monitoring wells on the City property adjacent to 198 Locust be approved. I would
further recommend that the City Council adopt the attached resolution authorizing
the Mayor to execute the attached License Agreement Right-of-Entry for Site
Assessment.
ACTION TO BE TAKEN
The City Council is requested to adopt the attached resolution authorizing the
Mayor to execute the License Agreement with Apex Environmental, Inc.
APEX
environmental, inc.
10052 Justin Drive
Suite L
Urbandale, IA 50322
Telephone 515-727-8025
Facsimile 515-727-8028
December 1, 1998
Michael Koch
Public Works Director
City of Dubuque
50 W. 13th Street
Dubuque, Iowa 52001-4864
RE: Request for permission of installation of Monitoring Wells in
City Right-of-Way near 198 South Locust Street.
Dear Mr. Koch:
As per the City of Dubuques' requirements, this letter is written as a request for
permission to initiate the work detailed below. As part of an Environmental assessment for
Sunoco Inc. (R&M), Apex plans to install groundwater monitoring wells as various locations
within the city right of ways (not in streets) as highlighted on the attahced map. Drilling of the
monitoring wells will be performed by an Apex subcontractor, Shirley Environmental, using a
truck mounted drilling rig utilizing hollow stem augers. The actual number of monitoring wells
will be determined based on the extent of the contamination. All wells will be completed with a
flush mounted 9" well cover set in concrete. Utilit clearance will be obtained throught the Iowa
One Call System and will include city owned utilities. Drilling will be scheduled upon permission
being granted from the City of Dubuque and should be completed within 3 days of
commencement. A final well location map will be mailed to the City of Dubuque for records.
If you have any questions concerning the enclosed material, please call me at (515) 727-8025.
Sincerely,
Apex Environmental, Inc.
James Marke, CPG
Program Manager
cc:
CERTIFICATE OF LIABILITY INSURANC
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Inc.
ACORDN
PRODUCER
Robertson Ryan & Assoc.,
o East Mason Street
lwaukee WI 53202
one: 414-271-3575
INSURERS AFFORDING COVERAGE
Shirley Enviro Testin
Rte 1 Box 3064 Suite
Nebraska City HE 68410
COVERAGES
A I Su Ius Lines Ins Co
I SURERB: Massachusetts Ba Insurance Co
I SURER C:
SURER D:
INSURER E:
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
'rf~ TYPE OF INSURANCE POLICY NUMBER b~~lfiMMlD67YYi . DATE (MMID~ LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
~
A X COMMERCIAL GENERAL LIABILITY 8199916 01/10/98 01/10/99 FIRE DAMAGE (Anyone fire) $ 50000
X i CLAIMS MADE 0 OCCUR MED EXP (Anyone person) $ 5000
X Professional E&O PERSONAL & ADV INJURY $ 2000000
-
_ $1,000,000 GENERAL AGGREGATE $2000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2000000
I POLICY n ~~g: n LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $1000000
B ...!. ANY AUTO ADC5532548 01/10/98 01/10/99 (Ea accident)
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
f--
X HIRED AUTOS BODILY INJURY
I-- $
~ NON-0WNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
~ ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
~ OCCUR o CLAIMS MADE AGGREGATE $
$
~ DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND X I TORY LIMITS I IVER'-
B EMPLOYERS' LIABILITY WDC5507431 01/10/98 01/10/99 $100000
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE $100000
E.L. DISEASE - POLICY LIMIT $ 500000
OTHER
DESCRIPTION OF OPERATlONSlLOCATIONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
General Liability coverage includes Pollution $1,000,000. Ci ty of Dubuque
is named as Additional Insured on the General Liability.
CERTIFICATE HOLDER I y I ADDITIONAL INSURED; INSURER LETTER: A CANCELLATION
CITYOF2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRmEN
-
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO so SHALL
Ci ty of Dubuque IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
50 W 13th St REPRESENTATIVES.
Dubuque IA 52001 AUTHORIZED REPRESENTATIVE
!
I Michael R. Schulte
ACORD 25-S (7/97)
ACORD CORPORATION 1991