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Improvement Contacts_Madison Street Retaining Wall Emergency RepairCITY OF DUBUQUE, IOWA IMPROVEMENT CONTRACT MADISON STREET RETAINING WALL EMERGENCY REPAIR PROJECT THIS IMPROVEMENT CONTRACT (the Contract), made in triplicate, dated for reference purposes the 22nd day of March , 2012, between the City of Dubuque, Iowa, by its City Manager, through authority conferred upon the City Manager by its City Council (City) and McAuliffe Excavating, Inc. of the City of Dubuque, Iowa. 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 Madison Street Retaining Wall Emergency Repair Project (the Project). The Project shall be made to the established grade and to the grades as shown on the profiles and cross sections on file in the City Engineer's office for this Project; 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 Document shall of which provisions and documents are each and all hereby referred to and made a part of this Contract just as much as if the detail statements thereof were repeated herein. 2. Contract Documents shall mean and include the following: All ordinances and resolutions heretofore adopted by the City Council having to do with the Project; the Notice to Bidders; the Contractor's Proposal; and the Plans, 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 shall be retained by the City for a period of thirty (30) days after final completion and acceptance of the Project by the City Council 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 specifications including General Requirements and has examined and understands the plans 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. In addition to the guarantee provided for in the specifications, the Contractor shall also make good any other defect in any part of the Project due to improper construction notwithstanding the fact that said Project may have been accepted and fully paid for by the City, and the Contractor's bond shall be security therefore. 8. The Contractor shall fully complete the Project under this Contract on or before June 15, 2012. 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. THE CITY AGREES: Upon the completion of the Contract, and the acceptance of the Project by the City Council, 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 Tess any liquidated damages provided for in the Contract Documents. The number of units stated in the plans and specifications is approximate only and the final payment shall be made by the work covered by the Contract. CONTRACT AMOUNT $77,433.00 FURTHER CONDITIONS The Contractor hereby represents and guarantees that it has not, nor has any other person for or in its behalf, directly or indirectly, entered into any arrangement or agreement with any other bidder, or with any public officer, whereby it has paid or is to pay any other bidder or public officer any sum of money or anything of value whatever in order to obtain this Contract; and it has not, nor has another person for or in its behalf directly or indirectly, entered into any agreement or arrangement with any other person, firm, corporation or association which tends to or does lessen or destroy free competition in the letting of this Contract and agrees that in case it hereafter be established that such representations or guarantees, or any of them are false, it will forfeit and pay not Tess than ten percent (10 %) of the Contract price but in no event be less than $500.00 (Five Hundred and 00/100 Dollars) as liquidated damages to the City. The surety on the bond furnished for this Contract, shall in addition to all other provisions, be obligated to the extent provided for by Iowa Code § 573.6, relating to this Contract, which provisions apply to said bond. The Contractor agrees, and its bond shall be surety therefore, that it will keep and maintain the Project in good repair for a period of two years after acceptance of the same by the City Council and its bond shall be security therefore. CITY OF DUBUQUE, IOWA By City Manager PRINCIPAL: Bv: Contractor J it rho, Sii atu•e 'Q 1 l Title CERTIFICATE OF CITY CLERK This is 4_;, that a certified coy of the above Contract has been filed in my office on the ;o4y1/,l day of rfieU G , 2012. 4&*.aWig K -vin S. Firnsta',City Clerk I *3 CITY OF DUBUQUE, IOWA PERFORMANCE, PAYMENT AND MAINTENANCE BOND KNOWN ALL MEN BY THESE PRESENTS: That McAuliffe Excavating, Inc. as Principal (Contractor) and West Bend Mutual Insurance Co as Surety are held firmly bound unto the City of Dubuque, Iowa (City), in the penal sum of $77,433.00 the same being 100% of the total price of the Contract for the Project herein referred to, lawful money of the United States of America, well and truly to be paid to said City of Dubuque, and to all other parties who, under the provisions of the laws of Iowa, are intended to be protected and secured hereby for which payment we bind ourselves, our heirs, executors, successors and assigns, jointly and severally by these presents. Dated at Dubuque, Iowa, this 22nd day of March duly attested and sealed. , 2012, and WHEREAS, the said Contractor by a Contract dated March 22, 2012 2012, incorporated herein by reference, has agreed with said City of Dubuque to perform all labor and furnish all materials required to be performed and furnished for the Madison Street Retaining Wall Emergency Repair Project (the Project) according to the Contract and Construction Documents prepared therefore. It is expressly understood and agreed by the Contractor and Surety bond that the following provisions are a part of this Bond and are binding upon said Contractor and Surety, to -wit: 1. PERFORMANCE BOND: The Contractor shall well and faithfully observe, perform, fulfill and abide by each and every covenant, condition and part of said Contract and Contract Documents, by reference made a part hereof, for the Project, and shall indemnify and save harmless the City from all outlay and expense incurred by the City by reason of the Contractor's default of failure to perform as required. The Contractor shall also be responsible for the default or failure to perform as required under the Contract and Contract Documents by all its subcontractors, suppliers, agents, or employees furnishing materials or providing labor in the performance of the Contract. 2. PAYMENT BOND: The Contractor and the Surety shall pay all just claims submitted by persons, firms, subcontractors, and corporations furnishing materials for or performing labor in the performance of the Contract on account of which this Bond is given, including but not limited to claims for all amounts due for labor, materials, lubricants, oil, gasoline, repairs on machinery, equipment and tools, consumed or used by the Contractor or any subcontractor, wherein the same are not satisfied out of the portion of the contract price which the City is required to retain until completion of the improvement, but the Contractor and Surety shall not be liable to said persons, firms, or corporations unless the claims of said claimants against said portion of the contract price shall have been established as provided by law. The Contractor and Surety hereby bind themselves to the obligations and conditions set forth in Chapter 573, Code of Iowa, which by this reference is made a part hereof as though fully set out herein. 3. MAINTENANCE BOND: The Contractor and the Surety hereby agree, at their own expense: A. To remedy any and all defects that may develop in or result from work to be performed under the Contract within the period of two (2) year(s) from the date of acceptance of the work under the Contract by the City Council of the City of Dubuque, Iowa, by reason of defects in workmanship or materials used in construction of said work; B. To keep all work in continuous good repair; and C. To pay the City the reasonable costs of monitoring and inspection to assure that any defects are remedied, and to repay the City all outlay and expense incurred as a result of Contractor's and Surety's failure to remedy any defect as required by this section. Contractor's and Surety's agreement herein made extends to defects in workmanship or materials not discovered or known to the City at the time such work was accepted. NOW, THEREFORE, the condition of this obligation is such that if the said Contractor shall perform all of the work contemplated by the Contract in a workmanlike manner and in strict compliance with the plans and specifications, and will pay all claims for labor and materials used in connection with said Project, to indemnify the said City for all damages, costs and expense incurred by reason of damages to persons or property arising through the performance of said Contract, and will reimburse the City for any outlay of money which it may be required to make in order to complete said Contract according to the Construction Documents and will maintain in good repair said Project for the period specified in the Contract where this bond is obligated for maintenance, and will faithfully comply with all of the provisions of Section 573 of the Code of Iowa, then this obligation shall be null and void, otherwise it shall remain in full force and effect. All the conditions of this bond must be fully complied with before the Contractor or the Surety will be released. The Contract, Contractor's Proposal, and Construction Documents shall be considered as a part of this Bond just as if their terms were repeated herein. Dated at Dubuque, Iowa this 9th day of March 2012 CITY OF DUBUQUE, IOWA By: City Manger PRINCIPAL: McAuliffe Excavating, Inc Contractor By: Si President Title SURETY: Bv: West Bend Mutual Insurance Co rety C any Signature Attorney -in -fact Title Dubuque, IA 52001 City, State, Zip Code 563 - 556 -5441 x1428 Telephone Olivia Schmitt Attorney In -Fact I No. 1152097 WEST BEND A PWtUAL 1N6UkANCt COMPANY'. Power of Attorney Know all men by these Presents, That West Bend Mutual insurance Company, a corporation having its principal office in the City of West Bend, Wisconsin does make, constitute and appoint: David H. Fritz, Diana Hedrick, Keith Sindberq, Olivia Schmitt, Charles Andracchio, Kevin Ehrlich, Laura Weiskircher lawful Attorney(s) -in -fact, to make, execute, seal and deliver for and on its behalf as surety and as its act and deed any and all bonds, undertakings and contracts of suretyship, provided that no bond or undertaking or contract of suretyship executed under this authority shall exceed in amount the sum of: $2,000,000 This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of Directors of West Bend Mutual Insurance Company at a meeting duly called and held on the 21st day of December, 1999. Appointment of Attorney -In -Fact. The president or any vice president, or any other officer of West Bend Mutual Insurance Company may appoint by written certificate Attorneys -in -Fact to act on behalf of the company in the execution of and attesting of bonds and undertakings and other written obligatory instruments of like nature. The signature of any officer authorized hereby and the corporate seal may be affixed by facsimile to any such power of attorney or to any certificate relating therefore and any such power of attorney or certificate bearing such facsimile signatures or facsimile seal shall be valid and binding upon the company, and any such power so executed and certified by facsimile signatures and facsimile seal shall be valid and binding upon the company in the future with respect to any bond or undertaking or other writing obligatory in nature to which it is attached. Any such appointment may be revoked, for cause, or without cause, by any said officer at any time. In witness whereof, the West Bend Mutual Insurance Company has caused these presents to be signed by its president undersigned and its corporate - al to be hereto duly attested by its secretary this 1st day of March, 2009. Attest /I , I Ja J. Pa Se tary State of Wisconsin County of Washington On the 1st day of March, 2009 before me personally came Kevin A. Steiner, to me known being by duly sworn, did depose and say that he resides in the County of Washington, State of Wisconsin; that he is the President of West Bend Mutual Insurance Company, the corporation described in and which executed the above instrument; that he knows the seal of the said corporation; that the seal affixed to said instrument is such corporate seal; that is was so affixed by order of the board of directors of said corporation and that he signed his name thereto by like order. * SEAL, #' Kevin A. Steiner Chief Executive Officer 1 President .�tb...F uyw,.enl * i NOTARY * Joh uweil PUBLIC ,`? Executive Vice President - Chief Legal Officer Notary Public, Washington Co. WI ***-9P w19• My Commission is Permanent The undersigned, duly elected to the office stated below, now.the incumbent in West Bend Mutual Insurance Company, a Wisconsin corporation authorized to make this certificate, Do Hereby Certify that the foregoing attached Power of Attorney remains in full force effect and has not been revoked and that the Resolution of the Board of Directors, set forth in the Power of Attorney is now in force. Signed and sealed at West Bend, Wisconsin this day of M &MIA_ , 20 j Z. GoRPORArF'.t° '•.� SEALS_` Dale J. Kent Executive Vice President - Chief Financial Officer Notice: Reproductions are not binding on the company. Any questions concerning this Power of Attorney may be directed to the Bond Manager at NSI, a division of West Bend Mutual Insurance Co. 8401 Greenway Blvd. Suite 1100 1 P.O. Box 620976 j Middleton, WI 53562 1 ph (608) 410 -3410 1 www.wmbi.com MCAUL -2 OP ID: OP A T & CERTIFICATE OF LIABILITY INSURANCE DATE 03 /09DlYYYY) 1 03/09/12 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 563 - 556 -5441 TRICOR, Inc. - Dubuque SOD Iowa Street 608- 723 -6440 Dubuque, IA 52001 q Kevin Ehrlich, CIC, CRM CONTACT Kevin L Ehrlich PHONE FAX (A/c. No :563- 556 -5441 1 (Arc. No): 608- 723 -6440 -.) E -MAIL ADDRESS: kehrlich @tricorinsurance.COm INSURER(S) AFFORDING COVERAGE NAIC 1/ INSURER A: United Fire & Casualty Co LIABILITY COMMERCIAL GENERAL LIABILITY INSURED McAuliffe Excavating Jeff McAuliffe /Jim Kemp 9393 Kemp Road Dubuque, IA 52003 INSURER B: 60400841 INSURER C: 02121/13 INSURER D: $ 1,000,000 INSURER E: $ 100,000 JNSNRFRF• S 5,000 • ION NUMBER: vTHIS 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 1LTR TYPE OF INSURANCE INSR wvn POLICY NUMBER IMM /ODNYYY) (MMIDDP(YYYI LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY X 60400841 02/21/12 02121/13 EACH OCCURRENCE $ 1,000,000 PREM IS (Ea occurrence) $ 100,000 MED EXP (Anyone person) S 5,000 CLAIMS -MADE X OCCUR PERSONAL 8 ADV INJURY 5 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 GEN 'L AGGREGATE LIMITAPPLIESPER- GA —I POLICY 111 i ,TR-i• Fl LOC $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS T ^ X SCHEDULED AUTOS NON-OWNED AUTOS 60400841 02/21/12 02121/13 COMBINED SINGLE LIMIT (Ea accident) S 1,000,000 BODILY INJURY (Per person) S BODILY INJURY (Por accident) $ (PerracEci accident) $ $ X UMBRELLA IJAB EXCESS LIAB X OCCUR CLAIMS -MADE 60400841 02/21/12 02121/13 EACH OCCURRENCE $ 3,000,000 AGGREGATE 5 3,000,000 S DED 1 X I RETENTION $ 0 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YN OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below / A X 60400841 02/21/12 02121113 X ITORYUNITS1 1°11Y E.L. EACH ACCIDENT $ 100,000 E.L DISEASE • EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT 5 500,000 A A Property Section Equipment Floate 60400841 60400841 02121/12 02/21/12 02/21/13 02/21113 DESCRIPTION OF OPERATIONS/LOCATIONS (VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) City of Dubuque is addl insrd on a primary, non- contributory basis including ongoing and compl ops. A Waiver of Subro applies in favor of the City of Dbq in regards to the GL and WC poi. Waiver of Govt. Immunities also applies. Notice of cncl is ammended to 30 days per the attch form. Project: Madison St Retaining Wall Emergency Repair CERTIFICATE HOLDER CANCELLATION CITYDBQ City of Dubuque 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 Kevin Ehrlich, CIC, CRM ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CG 71 03 06 11 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 $2 000 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 Ibs 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 16 FOR CHANGES AFFECTING YOUR INSURANCE PROTECTION CG 71 03 0611 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 15 *29020930* 111 1 1 1 11111 IIIQ 11111 11111 l 11 u 60400841 CG 71 63 0409 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 PREMIUM 250 The City of Dubuque, Iowa, including all its elected and appointed officials, all its employees and volunteers, all its boards, commissions and/or authorities and 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) 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 defenses 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 this 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 rights 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. CG 71 63 04 09 *28020920x 1 1111110111 1111111111111 11 1 1 Page 1 of 2 11 CG 71 63 04 09 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 the policy. CITY OF DUBUQUE, IOWA CANCELLATION AND MATERIAL CHANGES ENDORSEMENT Thirty (30) days Advance Written Notice of Cancellation, Non - Renewal, Reduction 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. Note: Endorsements above per 'Urban Standard Specifications For Public Improvements', Addendum No. 2 effective July 24, 2001. CG 71 63 04 09 Page 2 of 2 0101 02 -21 -2012 POLICY NUMBER: 60400841 WORKERS COMPENSATION AND EMPLOYERS LIABILITY SUPPLEMENTAL DECLARATIONS Premium Basis Total Estimated Annual Remuneration Rate Per $100 of Remuneration Estimated Annual Premium CONTINUED 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. Form WC000313 applies to: *CITY OF DUBUQUE 50 W 13TH ST DUBUQUE, IA 52001 *PORTZEN CONSTRUCTION INC 205 STONE VALLEY DR DUBUQUE, IA 52003 *CLEMEN CONSTRUCTION INC & GREEN INDUSTRIAL 6191 CENTURA CT DUBUQUE IA 52002 IA LOC# 01 8360 -8364 KEMP CT DUBUQUE, IA 52003 -9721 5606 CONTRACTOR- PROJECT MANAGER, CONSTRUCTION IF ANY 2.240 0 EXECUTIVE /MANAGER /SUPERINTENDENT 6217 EXCAVATION & DRIVERS 348,000 6.770 23,560 7228 TRUCKING: LOCAL HAULING ONLY -& DRIVERS IF ANY 8.560 0 8810 CLERICAL OFFICE EMPLOYEES NOC IF ANY .290 0 IA LOC# 01 DEPT# 02 CITY OF DUBUQUE 8360 -8364 KEMP CT DUBUQUE, IA 52003 -9721 6217 EXCAVATION & DRIVERS IF ANY 6.770 0 0930 ADDITIONAL PREMIUM- WAIVER OF SUBROGATION 100 IA LOC# 01 DEPT# 03 PORTZEN CONSTRUCTION INC 8360 -8364 KEMP CT DUBUQUE, IA 52003 -9721 6217 EXCAVATION & DRIVERS CONTINUED ON WC -2S IF ANY 6.770 0 WC -23 (01 95) INSURED COPY *62021260* 11 I 1111 111 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 only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on Policy No. issued to Premium $ of the at 12:01 A.M. standard time, forms a part of (DATE) (NAME OF INSURANCE COMPANY) 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 WC 00 03 13 (4-84) Copyright 1982, 1983 National Council on Compensation Insurance. *06019410* 11 11 11 III HII 11 1 II