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Improvement Contract and Bond_Stackis Construction, Fire Hiydrant Painting Phase IICITY OF DUBUQUE, IOWA FIRE HYDRANT REPAINTING PROJECT PHASE II 2012 IMPROVEMENT CONTRACT THIS IMPROVEMENT CONTRACT (the Contract), made in triplicate, dated for reference purposes the 3rd day of August, 2012, between the City of Dubuque, Iowa, by its City Manager, through authority conferred upon the City Manager by its City Council (City) and Ted Stackis Construction (Contractor). 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 Fire Hydrant Repainting Project Phase 11 2012. 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 Documents 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: Any ordinances and resolutions heretofore adopted by the City Council having to do with the Project; the Request for Quotations; the Contractor's Proposal; and the Specifications, and General Requirements as prepared for the City 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 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. F -1 6. The Contractor has read and understands the specifications including General Requirements and has examined and understands the specifications 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 within 130 consecutive calendar days. 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 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. Upon the completion of the Contract, and the acceptance of the Project by the City, 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 specifications is approximate only and the final payment shall be made by the work covered by the Contract. CONTRACT AMOUNT $57,750.00. F -2 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 less than ten percent (10 %) of the Contract price but in no event be less than $200.00 (Two Hundred 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 and its bond shall be security therefore. CITY OF DUBUQUE, 19WA Y Michael Van Milligen, City Manager President Title CERTIFICATE OF CITY CLERK This is to certify that a cer9fied copy of the above Contract has been filed in my office onhe day of 2012. , 2012. I" City F -3 CITY OF DUBUQUE WATER DEPARTMENT FIRE HYDRANT REPAINTING PROJECT PHASE BIDDER agrees to perform all the work described in the CONTRACT DOCUMENTS for the following unit prices or indicated sums: NOTE: Bids shall EXCLUDE sales tax and all other applicable taxes and fees NO. DESCRIPTION 1 Mobilization and Miscellaneous 2 Traffic Control BID SCHEDULE QUANTITY UNIT PRICE TOTAL PRICE 3 Fire Hydrant Surface Preparation & Repainting 500 4 Supplemental Surface Preparation 40 LS 1-34,('0 15,066 LS a 00 - Cho ' .60 a EA 3 50 HOURS l°� ©`-) (Z , C) TOTAL OF BID FOR PHASE 11 FIRE HYDRANT REPAINTING This bid schedule is submitted by: ® j A Contractor Name The bidder shall submit the Bid Proposal form (page B -2) with this Bid Schedule The bidder's Iowa Registration Number is: C 10.9 4 3 J * The City of Dubuque Water Department reserves the right to increase or decrease the number of hydrants painted subsequent to receipt of bids in order to comply with budget limits. Bid Proposal Page 1 of 2 B -1 CITY OF DUBUQUE, IOWA FIRE HYDRANT REPAINTING PROJECT PHASE II 2012 BID FORM 1 B BID PROPOSAL The bidder hereby certifies that the bidder is the only person or entity interested in this proposal as principal; that an examination has been made of the 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 understands 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 a formal contract and bond, if required by the contract documents, within seven (7) days of the award of the contract by the City Manager, and that the bidder will commence work on the contract within 10 days of the Notice to Proceed, and will complete the work within the specified contract period or pay the liquidated damages stipulated in the contract documents. The bidder now #dges receipt of the following addendum: Contractor IndividuaX Partnership O Corporation By: Signature 1-itle Dated: 7 Dated: _ Dated:, f� �?d6 Address c City d State Zip Date .q 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. The bidder shall submit the Bid Schedule form (page B -1) with this Bid Proposal. Bid Proposal Page 2 of 2 L CITY OF DUBUQUE, IOWA Bond # T23 69 73 FIRE HYDRANT REPAINTING PROJECT PHASE II 2042 KNOWN ALL MEN BY THESE PRESENTS: That Ted Stackis Construction as Principal (Contractor) and Employers Mutual Casualty Company as Surety are held firmly bound unto the City of Dubuque, Iowa (City), in the penal sum of $57,750.00 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 3RD day of AUGUST 2012, and duly attested and sealed. WHEREAS, the said Contractor by a Contract. dated August 3, 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 Fire Hydrant Repainting Project Phase If 2012 according to the Contract Documents prepared therefore. It is expressly understood and agreed by the Contractor and Surety 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 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 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 providad by law. The Contractor and Surety hereby bind themselves to the obligations and M 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) years from the date of acceptance of the work under the Contract by 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 and Contract Documents shall be considered as a part of this Bond just as if their terms were repeated herein. Dated at Dubuque, Iowa this 3RD day of AUGUST 2012 i APFEMICInsurance Companies& N0.962013 P.O. Box 712 • Des Moines, IA 50306 -0712 CERTIFICATE OF AUTHORITY INDIVIDUAL ATTORNEY -IN -FACT KNOW ALL MEN BY THESE PRESENTS, that: 1. Employers Mutual Casualty Company, an Iowa Corporation 2. EMCASCO Insurance Company, an Iowa Corporation 3. Union Insurance Company of Providence, an Iowa Corporation 4. Illinois EMCASCO Insurance Company, an Iowa Corporation 5. Dakota Fire Insurance Company, a North Dakota Corporation 6. EMC Property & Casualty Company, an Iowa Corporation 7. Hamilton Mutual Insurance Company, an Iowa Corporation hereinafter referred to severally as "Company" and collectively as "Companies ", each does, by these presents, make, constitute and appoint: LEROY J. BOTTLEY, III, INDIVIDUALLY, DES MOINES, IOWA ..................................................................................... ............................... its true and lawful attorney -in -fact, with full power and authority conferred to sign, seal, and execute its lawful bonds, undertakings, and other obligatory instruments of a similar nature as follows: and to bind each Company thereby as fully and to the same extent as if such instruments were signed by the duly authorized officers of each such Company, and all of the acts of said attorney pursuant to the authority hereby given are hereby ratified and confirmed. The authority hereby granted shall expire APRIL 1, 2014 unless sooner revoked. AUTHORITY FOR POWER OF ATTORNEY This Power -of- Attorney is made and executed pursuant to and by the authority of the following resolution of the Boards of Directors of each of the Companies at a regularly scheduled meeting of each company duly called and held in 1999: RESOLVED: The President and Chief Executive Officer, any Vice President, the Treasurer and the Secretary of Employers Mutual Casualty Company shall have power and authority to (1) appoint attorneys -in -fact and authorize them to execute on behalf of each Company and attach the seal of the Company thereto, bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof, and (2) to remove any such attorney -in -fact at any time and revoke the power and authority given to him or her. Attorneys -in -fact shall have power and authority, subject to the terms and limitations of the power -of- attorney issued to them, to execute and deliver on behalf of the Company, and to attach the seal of the Company thereto, bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof, and any such instrument executed by any such attorney -in -fact shall be fully and in all respects binding upon the Company. Certification as to the validity of any power -of- attorney authorized herein made by an officer of Employers Mutual Casualty Company shall be fully and in all respects binding upon this Company. The facsimile or mechanically reproduced signature of such officer, whether made heretofore or hereafter, wherever appearing upon a certified copy of any power -of- attorney of the Company, shall be valid and binding upon the Company with the same force and affect as though manually affixed. IN WITNESS WHEREOF, the Companies have caused these presents to be signed for each by their officers as shown, and the Corporate seals to be hereto affixed this 18TH day of JANUARY , 2011 Seals `gyp WSU CO `P ,Y & 0 "••, 0- % <cP ....... Fs �WC.,.`OPPOR,Cl�'�C��•� �2 � 2�'�pP OgglT: O ": : o � =vpPPORgr 9� "- o SEAL 3' o 1863 0` m _ ; �; 1953 -'� /OWP ���SUR �UTUq /" U� ` pP ORgr'%i0� 0Rq = = SEAL SEAL _ SEAL -PO 9rH OPKOSP •MOINES \0 �TUAL /NS U TU4� G�92 i 4 �VSURPN� Q FsM01NES LAUREL A. BLOSS Commission Number 183662 a My Comm. Exp. Marl 3,201 ",IA Bruce G. Kelley, Chairman of Companies 2, 3, 4, 5 & ; President of Company 1; Vice Chairman and CEO of Company 7 0"/ �w Michael rreel Assistant Secretary On this 18THday of JANUARY AD 2011 before me a Notary Public in and for the State of Iowa, personally appeared Bruce G. Kelley and Michael Free], who, being by me duly sworn, did say that they are, and are known to me to be the Chairman, President, Vice Chairman and CEO, and /or Assistant Secretary, respectively, of each of The Companies above; that the seals affixed to this instrument are the seals of said corporations; that said instrument was signed and sealed on behalf of each of the Companies by authority of their respective Boards of Directors; and that the said Bruce G. Kelley and Michael Freel, as such officers, acknowledge the execution of said instrument to be the voluntary act and deed of each of the Companies. My Commission Expires March 13, 2014, -Notary Public in and for the State of Iowa CERTIFICATE I, James D. Clough, Vice President of the Companies, do hereby certify that the foregoing resolution of the Boards of Directors by each of the Companies, and this Power of Attorney issued pursuant thereto on January 18, 2011 on behalf of Leroy J. Bottley, III are true and correct and are still in full force and effect. In Testimony Whereof I have subscribed my name and affixed the facsimile seal of each Company this 3Rd day of August 2012 a /_J_� Vice - President ® DATE(MM/DD/YYYY) CERTIFICATE LIABILITY INSURANCE 8/9/2012 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 NAME: Ron McDonald BRADLEY BECK MCDONALD INS PHONE 563- 583 -0638 �CNo563- 556 -8817 A/C No Ext: 198 LOCUST ST E -MAIL ADDRESS: Dubuque, IA 52001 PRODUCER �u INSURED TED STACKIS DBA STACKIS CONSTRUCTION 206 SAUNDERS ST. DUBUQUE, IA 52001 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Pekin Insurance INSURER B: INSURER D: INSURER E INSURER F r1nX1nDAr_1I=0 r1CDTicIr1ATC nu InnRCD- RFVIAinKj NI )MRFR• 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 INSR SUBR WVD _ POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE CI OCCUR X CLOO12032 -3 06/16/12 06/16/13 EACH OCCURRENCE $ 11000,000 PREMISES Ea occurrence $ 100, 000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY E � LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 0OP642874 04/17/12 04/17/13 COMBINED SINGLE LIMIT (Ea accident) $ 11000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ X X $ A X UMBRELLA LAB EXCESS LIAB OCCUR CLAIMS -MADE U0012032 04/21/12 04/21/13 EACH OCCURRENCE $ 1, 0 0 0'000 AGGREGATE $ X DEDUCTIBLE RETENTION $ 10,000 $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y�I OFFICER/MEMBER EXCLUDED? II�EYY (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N /?` 0 OWC7 6 7 2 9 10/02/11 10/02/12 X WCSTATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 5 00,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 IIW Project No. 12113 -01 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City Of Dubuque is and additional insured on general liability policies including ongoing & completed operations coverage equivalent to ISO CG 2010 0704 & CG 2037 0704.General liability policy is primary & non - contributing. Form CG 2503 0397 "Designated Projects" general liability aggregate limit is included Govermental immunities endorsement(cont) IIW P. C. 4155 Pennsylvania Ave. Dubuque, Ia. 52002 -2628 Attn:Gary Sejkora ELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE {0 1988 -2009 ACORD CORPORATION. All rights ACORD25(2009/09) The ACORD name and logo are registered mark's of ACORD ® DATE (MM DD/YYYY) ACCOR-Ey CERTIFICATE OF LIABILITY 8/9/2012 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 NTA T NAME: BRADLEY BECK MCDONALD INS PHONE 563- 583 -0638 aC,Na:563- 556 -8817 A/C No Ext: 198 LOCUST ST E -MAIL ADDRESS: Dubuque, IA 52001 PRODUCER n� INSURER(S) AFFORDING COVERAGE NAIC# INSURED TED STACKIS DBA STACKIS CONSTRUCTION INSURER A: Pekin Insurance 206 .S'AUNDERS ST. INSURER B: DUBUQUE, IA 52001 INSURER C: INSURER D: INSURER E INSURER F l�r1� /CDA/_CC t r:DTIFIC4TI= NN INnRFp• 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 AWL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE CI OCCUR X CL- 0012032 -3 06/16/12 06/16/13 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 100, 000 MED EXP (Any one person) $ 5, 000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY X PE� LOC PRODUCTS - COMP /OP AGG $ 2, 000, 0 0 0 $ A AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 0OP642874 04/17/12 04/17/13 COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ 1,000,000 BODILY INJURY (Per accident) $ 1,000,000 X PROPERTY DAMAGE (Per accident) $ 1,000,000 X X $ $ A X UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE U0012032 04/21/12 04/21/13 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ DEDUCTIBLE RETENTION $ 10,000 $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? C (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 0 OWC7 6 7 2 9 10/02/11 10/02/12 X OCSTATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 A City Of Dubuque Fire Hydrant Repainting 1 1 IIW Project No: 12113 -01 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach AUUKU 1U1, Aaaltlonai KemarKS bcneaute, IT more Space Is requueu/ is included.Waiver of Subrogation in favor of the City of Dubuque on workers compensation is included. IIW P.C. as additional insured as primary & non - contributory FICATE HOLDER IIW P.C. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 4155 Pennsylvania Ave. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Dubuque, I a. 52002-2628 ACCORDANCE WITH THE POLICY PROVISIONS. Attn• Gary Sejkora � AI ITU/1Df�n DCDDCCCAIT�T6l /F ACORD 25 (2009/09) l \�v v ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 11/23/11 Beyond the expected.` PEKIN INSURANCE NY ' (A STOCK COMPANY) INSURANCE HOME OFFICE 2505 COURT STREET PEKIN, ILLINOIS 61558 COMMERCIAL LINES POLICY COMMON DECLARATIONS RENEWAL POLICY POLICY NO: CL0012032 -I NAME AND ADDRESS OF INSURED: AGENT: 00- 03801 -000 STACKIS CONSTRUCTION BRADLEY - BECK -MC DONALD INSURAN TED STACKIS D13A 206 SAUNDERS DUBUQUE, IA 52001 POLICY PERIOD: FROM 12/30/11 TO 12/30/12 AT 12:01 A.M. STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE. IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. -• • • • ri • • I ICI- � � �I- � � - • �I- � a .. . • I ICI' I. 1 • :I- !! ' • • • I ICI- • . • • �I- • �I• � tl • • . 996.00 418.00 102.00 1,516.00 PREMIUM PAYMENT PLAN: QUARTERLY DIRECT BILL DATE: COUNTERSIGNED 00- 03801 -000 B LEY ECK -MC DONALD INSURAN • 11 • 0 0 1 0 COVERAGE FORMS THAT APPLY TO THE ENTIRE POLICY FOLLOW THIS DECLARATION. COVERAGE FORMS THAT APPLY ONLY TO A PARTICULAR COVERAGE PART FOLLOW THE APPLICABLE COVERAGE PART DECLARATIONS. INCLUDES COPYRIGHTED MATERIAL OF INSURANCE SERVICES OFFICE INC. WITH ITS PERMISSION. COPYRIGHT INSURANCE SERVICES OFFICE. INC. 1983 1984 IL 00 19 06 92 COMMISSION RATE: 20 AGENT'S COPY WK1I4 THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT. THIS ENDORSEMENT DOES NOT GRANT ANY COVERAGE OR CHANGE THE TERMS AND CONDITIONS OF ANY COVERAGE UNDER THE POLICY. 'HSCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT SCHEDULE Terrorism Premium (Certified Acts) $ 10.00 This premium is the total Certified Acts premium attributable to the following Coverage Part(s), Coverage Form(s) and /or Policy(s): General Liability $ 4.00 Inland Marine $ 5.00 Property $ 1.00 Effective January 1, 2006, Terrorism Risk Insurance Program has terminated with respect to (therefore no longer applies to) Commercial Crime and Garage Coverages. No premium is charged for these coverages. In accordance with the Terrorism Risk Insurance Act, we have offered you coverage for losses resulting from an act of terrorism, as defined in the act. You may accept or reject this offer. In the states of Illinois & Iowa, if your policy contains the Commercial Property Coverage Part, and in the state of Wisconsin, if your policy contains the Commercial Property and /or the Inland Marine Coverage Part, a rejection of this offer still provides coverage for fire losses resulting from a certified act of terrorism. Therefore, if you reject the offer of terrorism coverage, that rejection does not apply to fire losses resulting from a certified act of terrorism. Coverage for such fire loss will still be provided in your policy. If you reject the offer described above for terrorism coverage, a premium is still due. To determine this premium charge, multiply the applicable terrorism premium for the Property Coverage and /or Inland Marine Coverage as described above, by .60. Example: $20.00 x .60 = $12.00 Additional information, if any, concerning the terrorism premium: Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Disclosure Of Premium In accordance with the federal Terrorism Risk Insurance Act, we are required to provide you with a notice disclosing the portion of your premium, if any, attributable to coverage for terrorist acts certified under the Terrorism Risk Insurance Act. The portion of your premium attributable to such coverage is shown in the Schedule of this endorsement or in the policy Declarations. B. Disclosure Of Federal Participation In Payment Of Terrorism Losses The United States Government, Department of the Treasury, will pay a share of terrorism losses insured under the federal program. The federal share equals 85% of that portion of the amount of such insured losses that exceeds the applicable insurer retention. However, if aggregate insured losses attributable to terrorist acts certified under IL 09 85 0108 the Terrorism Risk Insurance Act exceed $100 billion in a Program Year (January 1 through December 31), The Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. C. Cap On Insurer Participation In Payment Of Terrorism Losses If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a Program Year (January 1 through December 31) and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. Copyright, ISO Properties, Inc., 2007 Page 1 of 1 AGENT'S COPY P ,heexpected° EKIN INSURANCE M NY EKIN' (A STOCK COMPANY) INSURANCE HOME OFFICE 2505 COURT STREET PEKIN, ILLINOIS 61558 COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS RENEWAL POLICY NAMED INSURED: STACKIS CONSTRUCTION POLICY NO: CL0012032 —I TED STACKIS DBA LIMITS OF INSURANCE: H,�a�' • • tee' � (OTHER THAN PRODUCT'S— OCMPLETED OPERATIONS) $ 2,000,000. PRODUCT'S — COMPLETED OPERATIONS AGGREGATE LIMIT 2,000,000. PERSONAL & ADVERTISING INJURY LIMIT (ANY ONE PERSON OR ORGANIZATION) 1,000,000. EACH OCCURRENCE LIMIT 1,000,000. DAMAGE TO PREMISES RENTED TO YOU LIMIT (ANY ONE PREMISES) 100,000. MEDICAL EXPENSE LIMIT (ANY ONE PERSON) 5,000. FORM OF BUSINESS: INDIVIDUAL DEDUCTIBLE: $0 DEDUCTIBLE APPLIES TO THIS COVERAGE PART CG0001 1001 C30005 0605 CGO062 1202 CGO068 0509 CG2010 0704 CG2037_ 0704 OG2132 0509 CG2147 0798 CG2171 0608 OG2176 0108 032186 1204 CG2187 0107 CG2196 0305 CG2294 1001 CG25 0509 CG5012 1194 CG5021 0107 CG5023 0107 CG5029 0605 CG5034 0605 IL0017 1 IL0019 0692 IL0021 0498 IL0276 0300 IL0985 0108 001696 1005 481T 1078 LOCATION OF ALL PREMISES THAT THIS COVERAGE PART APPLIES TO: 01 206 SAUNDERS DUBUQUE, PAGE 1 OF 2 CG 00 05 06 05 AGENT'S COPY 0EKIN- the expected.° I INSURANCE ANY ,jet (A STOCK COMPANY) INSURANCE HOME OFFICE 2505 COURT STREET PEKIN, ILLINOIS 61558 COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS RENEWAL POLICY NAMED INSURED: STACKIS CONSTRUCTION POLICY NO: CL0012032 -I TED STACKIS DBA LOC. CLASSIFICATION CODE PREMIUM RATE ADVANCE PREMIUM NO. NO. BASIS PREMISES/ PRODUCTS/ OPERATIONS COM PLETED OPERATIONS 01 PER PROJECT AGGREGATE 44444 T- 1 400.000 $ 400.00 01 CARPENTRY- RESIDENTIAL PRO 91340 P- 36400 4.963 $ 181.00 01 CARPENTRY- RESIDENTIAL PRO 91340 P- 36400 5.805 $ 211.00 01 ADDITIONAL INSURED 01 49950 T- 1 50.000 $ 50.00 01 ADDITIONAL INSURED 02 49950 T- 1 50.000 $ 50.00 01 ADDITIONAL INSURED 03 49950 T- 1 100.000 $ 100.00 TERRORISM RISK INSURANCE $ 4.00 PAGE 2 OF 2 OG 00 05 06 05 AGENT'S COPY Seyond the expected." KIN INSURANCE COMrs Y '44e, � PEKINM (A STOCK COMPANY) I N S U R A N C E HOME OFFICE 2505 COURT STREET PEKIN, ILLINOIS 61558 COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS RENEWAL POLICY NAMED INSURED: STACKIS CONSTRUCTION POLICY NO: CL0012032 -I LOC NO. NAMEIADDRESS TYPE OF INTEREST 01 001 CITY OF DUBUQUE, INCLUDING ALL ITS ELECTED & ADDITIONAL INSURED APPOINTED OFFICIALS, ALL ITS EMPLOYEES &VOLUNTEERS, ALL ITS BOARDS, COMMISSIONS & /OR 50 W 13TH STREET DUBUQUE IA 52001 01 002 IIW P.C. ADDITIONAL INSURED 4155 PENSYLVANIA DUBUQUE IA 52002 01 003 CITY OF DUBUQUE, INCLUDING ALL ITS ELECTED & ADDITIONAL INSURED APPOINTED OFFICIALS, ALL ITS EMPLOYEES &VOLUNTEERS, ALL ITS BOARDS, COMMISSIONS & /OR 50 W 13TH STREET DUBUQUE IA 52001 CG 75 00 02 93 AGENT'S COPY C'L0012032 -I This endorsement, effective 12/30/11 forms a part of policy No. CL0012032 -I issued to STACKIS CONSTRUCTION TED STACKIS DBA by PEKIN INSURANCE COMPANY It is agreed that as of the effective date of this endorsement this policy is amended in the following particulars: CITY OF DUBUQUE, IOWA 50 W 13 STREET DUBUQUE IA 52001 GOVERNMENTAL IMMUNITIES ENDORSEMENT THE BELOW WORDING AMENDS THE GENERAL LIABILITY SECTION AS FOLLOWS: NONWAIVER OF GOVERNMEN'T'AL IMMUNITY. WE EXPRESSLY AGREE & STATE THAT THE PURCHASE OF THIS POLICY & THE NAMING OF THE CITY OF DUBUQUE, I0WA. AS AN ADDITIONAL INSURED DOES NOT WANE 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 & AS IT MAY BE AMENDED FROM TIME TO TIME. CLAIMS COVERAGE. WE FURTHER AGREE THAT THIS POLICY OF INSURANCE SHALL COVER ONLY THOSE CLAIMS NOT SUBJECT TO THE DEFENSE OF GOVERNMENTAL IMMUNITY UNDER THE CODE OF IOVA, SECTION 670.4 AS IT NOW EXISTS & AS IT MAY BE AMENDED FROM TIME TO TIME. ASSERTION OF GOVERNMENTAL IMMUNITY. THE CITY OF DUBUQUE, IOWA, SHALL BE RESPONSIBLE FOR ASSERTING ANY DEFENSE OF GOVERNMENTAL IMMUNITY, & MAY DO SO AT ANY TIME & 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. NON- DENIAL OF COVERAGE. WE SHALL NOT DENY COVERAGE UNDER THIS 481T (10 -78) AGENT'S COPY CL0012032 -I This endorsement, effective 12/30/11 forms a part of policy No. CL0012032 -I issued to STACKIS CONSTRUCTION TED STACKIS DBA by PEKIN INSURANCE COMPANY It is agreed that as of the effective date of this endorsement this policy is amended in the following particulars: POLICY & WE SHALL NOT DENY ANY OF THE RIGHTS & BENEFITS ACCRUING TO THE CITY OF DUBUQUE, IONA UNDER THIS POLICY FOR REASONS OF GOVERNMENTAL IMMUNITY UNLESS & UNTIL A COURT OF COMPETENT JURISDICTION HAS RULED IN FAVOR OF THE DEFENSE(S) OF GOVERIUV=AL IMMUNITY ASSERTED BY THE CITY OF DUBUQUE, IOWA. NO OTHER CHANGE IN POLICY. WE & THE CITY OF DUBUQUE AGREE THAT THE ABOVE PRESERVATION OF GOVERNMENTAL IMMUNITIES SHALL NOT OTHERWISE CHANGE OR ALTER THE COVERAGE AVAILABLE UNDER THE POLICY. 481T (1078) AGENT'S COPY 11/23/11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY • „ • • • '; This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations CITY OF DUBUQUE, INCLUDING ALL ITS ELECTED & CITY OF DUBUQUE FIRE HYDRANT REPAINTING PRCUE APPOINTED OFFICIALS, ALL ITS EMPLOYEES &VOLUNTEERS, ALL ITS BOARDS, COMMISSIONS & /OR- AUTHORITIES & THEIR BOARD MEMBERS, EMPLOYEES & VOLUNTEERS 50 W 13TH STREET DUBUQUE IA 52001 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. CG 2010 07 04 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Copyright, ISO Properties, Inc., 2004 AGENT'S COPY 11/23/11. �•- -• - ADDITIONAL INSURD OWNERS, OR CONTRACTORS - SCHEDULED PERSON O.' ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART l X104 @1111 Name of Person or Organization (Additional Insured) IIW P. C. 4155 PENSYLVANIA DUBUQUE IA 52002 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) 1. SECTION II - Who Is An Insured is amended to include as an insured the person(s) or organization(s) shown in the schedule for whom you are performing operations, when you and such person or organization have agreed in a written contract effective during the policy period stated on the Declarations Page (hereinafter referred to as the "Policy Period ") and executed prior to the "bodily injury" or "property damage" for which coverage is sought, that you must add that person or organization as an additional insured on a policy of liability insurance (herinafter referred to as the "Additional Insured "). The Additional Insured is covered only with respect to vicarious liability for "bodily injury" or "property damage" imputed from You to the Additional Insured as a proximate result of your ongoing operations performed for that Additional Insured during the Policy Period. 2. It is further understood that the designation of any person or organization as an Additional Insured does not increase the scope or limits of coverage afforded by this policy. 3. With respect to the coverage afforded to the Additional Insured, the following additional exclusions apply: This insurance does not apply to: a. Liability for "bodily injury" or "property damage" arising out of the rendering of, or the failure to render, any professional services, including, but not limited to: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. b. Liability for "bodily injury" or "property damage" arising out of or in any way attributable to the claimed negligence or statutory violation of the Additional Insured, other than vicarious liability which is imputed to the Additional Insured solely by virtue of the acts or omissions of the Named Insured. c. Liability for "bodily injury" or "property damage" proximately caused by your ongoing operations, which takes place, in whole or in part, after the earlier of: (1) the date that all work called for in the written contract with the Additional Insured has been completed, as defined in the definition of "products- completed operations hazard" herein; or (2) the end of the Policy Period. Includes copyrighted material of Insurance CG 50 29 06 05 Services Office, Inc., with its permission. Page 1 of 2 AGENT'S COPY 4. SECTION III - Limits of Insurance is amended to include: a. The limits of insurance applicable to the Additional Insured are: (1) those specified in the written contract that requires the person or organization to be added as an Additional Insured; or (2) as stated on the Declarations Page of this policy, whichever is less. These limits of insurance are inclusive of, and not in addition to the limits of insurance shown on the Declarations Page. If other insurance of any type is written by us and applicable to the Additional Insured, the maximum recovery under all coverage forms or policies combined may equal but not exceed the highest applicable per occurrence and aggregate limit of insurance under one coverage form or policy providing coverage, whether primary or excess. 5. Section IV - Other Insurance is amended to include: a. The coverage provided to the additional insured under this endorsement shall be excess over any other insurance, whether collectible or not, and regardless of the solvency of the underlying insurer. 6. This endorsement shall not be interpreted to provide blanket additional insured coverage. This endorsement adds only the additional insured specifically named above. Includes copyrighted material of Insurance Page 2 of 2 CG 50 29 06 05 Services Office, Inc., with its permission. 9 11/23/11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations CITY OF DUBUQUE, INCLUDING ALL ITS ELECTED & 50 W 13TH STREET CITY OF DUBUQUE FIRE HYDRANT REPAINTING PROJECT DUBUQUE IA 52001 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard ". CG 20 37 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 of 1 AGENT'S COPY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 1 0 0 a 0 • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): CITY OF DUBUQUE FIRE HYDRANT REPAINTING PROJECT I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A, and for all medical expenses caused by accidents under Section I - Coverage C, which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products- completed operations hazard ", and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits ". 11/23/11 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A, and for all medical expenses caused by accidents under Section I - Coverage C, which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: CG 25 03 05 09 Copyright, Insurance Services Office, Inc., 2008 Page 1 of 2 AGENT'S COPY fi the expected.° PEKIN INSURANCE COMPANY ® 1M fW COMPANY Y■ (A STOCK COMPANY) INSURANCE HOME OFFICE 2505 COURT STREET PEKIN, ILLINOIS 61558 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE ACCOUNT NUNIBER: OOMDS222 RENEWAL POLICY FCIJCY NIMBER FEFLACEVSB T CF RS< ICM. NUMBER OOWC76729 C IOOWC76729B ITEM 1. NONE AND A1STESS CF INSU.FM STACKIS CONSTRUCTION TED STACKIS DBA 206 SAUNDERS ST DUBUQUE, IA 52001 -0911 08/26/11 FEBIPL ID UAEB�S) LE30L STATUS 48- 2928790 INDIVIDUAL (tu�Illp#" o ..c u 10/02/11 TO 10/02/12 12:01 AM STANDVD VVE AT INIFE6 MNUt G AJDTEBS ITEM 3. A WCF3<86 024INSAIICN INSUF*NCE PART CNE CF THE FCUCX AFRJEB TO TFE VVU4EM O34UP rATICN LAW CF THE STATE USTED IOWA Q HvFLoE;s LIABILITY INS PARE TWO CF THE FQJCY APPUES TO TFE WCR< IN EACH STATE LISTED IN ITEM 3A THE LIMITS CF CUR LIABILITY LWER PART TWO AFE BCDILY INJURY BY AQ7CENTT 100,000 EACH AGODEVT BCDILY INJL.RY BY DID 500,000 POLICY LIMIT BCDLY INJURE' BY T]ISEaSE 100,000 EACH BVIPLOYB= C ODER STATES INSURANCE PARE TH:EE CF THE FCUCY APRJES TO THE STATBa IF ANY, USTED HBO ALL STATES AND US TBRTCRES B(aPT NQ CH WA WV (LMIL JLLY 1, 2008), WY, PIBZTO RIGQ THE US VIR3N ISLAM AND STATES DBSCNATED IN ITEM 3A D THS P JCY INCLUL6 THESE E00:EBV1� AND SO-®UM WC000001 0402 WCOOOOOT 0603 WC000404 0484 WC000421CO908 WC000422AO908 WC00000OB0711 WC000318 0492 WC000313 0484 ITEM 4. THE PFEMILM RR THS FCUCY WILL BE CE WIMD BY CLR MN4 -ALS CF RJEE CIASSIFICYAIICNS, ROTE AND WING FLANS ALL IN 03MTICN FECIJFED BB_OIV IS SUBJECT TO VERR(A -ICN AND CHWCE BY ALDT. TA- CARPENTRY - CONSTRUCTION OF RESIDEN 5645 TA- WAIVER OF OUR RIGHT TO RECOVER 0930 IA- SCHEDULE CREDIT /DEBIT 9887 IA- EXPENSE CONSTANT 0900 IA- TERRORISM 9740 IA- CATASTROPHE 9741 PFEMILM BASIS RATE PER EFTIMATED TOTAL ESTIMATED $100 CF ANA14L ANNUAL fE UE:A -nCN FEMU�A'n N PFEMILM $40,000.00 10.340 4,136.00 300.000 300.00 .850 665.00- 260.00 $40,000.00 .020 8.00 $40,000.00 .010 4.00 MINIMUM PRMILM 550.00 TOTAL ESTIMATED ANNUAL PFEMILM 4,043.00 THS INFiJM ICN PACE WITH "FQJCY FR:)ASICNS' 031F1ETES THE ABOdE NLAEBqD FQJCY CIOMMISSION: 10.00/ 7.50/ 5.00 WC 00 00 01 (04- 02) AGENT'S COPY OOWC76729C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 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 co ntract 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 CITY OF DUBUQUE 350 W 6TH ST STE 312 DUBUQUE IA 52001 WC 00 03 13 (04 -84) Copyright 1983 National Council on Compensation Insurance. AGENT'S COPY