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HomeMy WebLinkAboutUtility Service Co Inc; 2017-11-06; PWM18-55UTILTracking#: PWM18-55UTIL CARLSBAD MUNICIPAL WATER DISTRICT MINOR PUBLIC WORKS CONTRACT CLEAN, INSPECT AND DISINFECT C-TANK RECYCLED WATER RESERVOIR This agreement is made on the G~ day of ~~~w , 2017, by the Carlsbad Municipal Water District, a Public Agency organized under the Municipal Water Act of 1911, and a Subsidiary District of the City of Carlsbad, hereinafter referred to as "CMWD", and Utility Service Co., Inc., a Georgia corporation, whose principal place of business is 1230 Peachtree Street NE, Suite 1100, Promenade, GA 30309 (hereinafter called "Contractor"). CMWD and Contractor agree as follows: DESCRIPTION OF WORK. Contractor shall perform all work specified in the Contract documents for the project described by these Contract Documents (hereinafter called "Project"). PROVISIONS OF LABOR AND MATERIALS. Contractor shall provide all labor, materials, tools, equipment, and personnel to perform the work specified by the Contract Documents unless excepted elsewhere in this Contract. CONTRACT DOCUMENTS. The Contract Documents consist of this Contract, exhibits to this Contract, Contractor's Proposal, the Plans and Specifications, the General Provisions, addendum (s) to said Plans and Specifications, and all proper amendments and changes made thereto in accordance with this Contract or the Plans and Specifications, all of which are incorporated herein by this reference. When in conflict, this Contract will supersede terms and conditions in the Contractor's proposal. LABOR. Contractor will employ only skilled workers and abide by all State laws and City of Carlsbad Ordinances governing labor. GUARANTEE. Contractor guarantees all labor and materials furnished and agrees to complete the Project in accordance with directions and subject to inspection approval and acceptance by: Eric Sanders (CMWD Project Manager) WAGE RATES. The general prevailing rate of wages for each craft or type of worker needed to execute the Contract shall be those as determined by the Director of Industrial Relations pursuant to Sections 1770, 1773 and 1773.1 of the Labor Code. Pursuant to Section 1773.2 of the Labor Code, a current copy of the applicable wage rates is on file in the Office of the City Engineer. Contractor shall not pay less than the said specified prevailing rates of wages to all workers employed by him or her in execution of the Contract. Contractor shall be responsible for insuring compliance with provisions of section 1777.5 of the Labor Code and section 4100 et seq. of the Public Contracts Code, "Subletting and Subcontracting Fair Practices Act." The City Engineer is CMWD's "duly authorized officer" for the purposes of section 4107 and 4107 .5. The provisions of Part 7, Chapter 1, of the Labor Code commencing with section 1720 shall apply to the Contract for work. A contractor or subcontractor shall not be qualified to bid on, be listed in a bid proposal, subject to the requirements of Section 4104 of the Public Contract Code, or engage in the performance of any contract for public work, unless currently registered and qualified to perform public work pursuant to Section 1725.5. This project is subject to compliance monitoring and enforcement by the Department of Industrial Relations. CLEAN, INSPECT AND DISINFECT C-TANK RECYCLED WATER RESERVOIR Page 1 of 6 General Counsel Approved 9/27 /16 Tracking#: PWM18-55UTIL Contractor and any subcontractors shall comply with Section 1776 of the California Labor Code, which generally requires keeping accurate payroll records, verifying and certifying payroll records, and making them available for inspection. Contractor shall require any subcontractors to comply with Section 1776. FALSE CLAIMS. Contractor hereby agrees that any contract claim submitted to CMWD must be asserted as part of the contract process as set forth in this agreement and not in anticipation of litigation or in conjunction with litigation. Contractor acknowledges that California Government Code sections 12650 et seq., the False Claims Act, provides for civil penalties where a person knowingly submits a false claim to a public entity. These provisions include false claims made with deliberate ignorance of the false information or in reckless disregard of the truth or falsity of the information. The provisions of Carlsbad Municipal Code sections 3.32.025, 3.32.026, 3.32.027 and 3.32.028 pertaining to false claims are incorporated herein by reference. Contractor hereby acknowledges that the filing of a false claim may subject the Contractor to an administrative debarment proceeding wherein the contractor may be prevented from further bidding on public contracts for a period of up to five years and that debarment by another jurisdiction is grounds for CMWD to disqualify the Contractor or subcontractor from parti ipatin in contract bidding. Signature: Print Name: D. Michael Buchanan, VP, Finance & Support Services REQUIRED INSURANCE. The successful contractor shall provide to CMWD, a Certification of Commercial General Liability and Property Damage Insurance and a Certificate of Workers' Compensation Insurance indicating coverage in a form approved by the California Insurance Commission. The certificates shall indicate coverage during the period of the contract and must be furnished to CMWD prior to the start of work. The minimum limits of liability insurance are to be placed with California admitted insurers that have a current Best's Key Rating of not less than "A-:VII"; OR with a surplus line insurer on the State of California's List of Approved Surplus Line Insurers (LASLI) with a rating in the latest Best's Key Rating Guide of at least "A:X"; OR an alien non-admitted insurer listed by the National Association of Insurance Commissioners (NAIC) latest quarterly listings report. Commercial General Liability Insurance of Injuries including accidental death, to any one person in an amount not less than ........ $1,000,000 Subject to the same limit for each person on account of one accident in an amount not less than ....... $1,000,000 Property damage insurance in an amount of not less than ........ $1,000,000 Automobile Liability Insurance in the amount of $1,000,000 combined single limit per accident for bodily injury and property damage. In addition, the auto policy must cover any vehicle used in the performance of the contract, used onsite or offsite, whether owned, non-owned or hired, and whether scheduled or non- scheduled. The automobile insurance certificate must state the coverage is for "any auto" and cannot be limited in any manner. The above policies shall have non-cancellation clauses providing that thirty (30) days written notice shall be given to CMWD prior to such cancellation. The policies shall name CMWD as additional insured. The full limits available to the named insured shall also be available and applicable to CMWD as an additional insured. CLEAN, INSPECT AND DISINFECT C-TANK RECYCLED WATER RESERVOIR Page 2 of 6 General Counsel Approved 9/27 /16 Tracking#: PWM 18-55UTIL WORKERS COMPENSATION AND EMPLOYER'S LIABILITY. Worker's Compensation limits as required by the California Labor Code. Workers· Compensation will not be required if Contractor has no employees and provides, to City's satisfaction, a declaration stating this. BUSINESS LICENSE. The Contractor and all subcontractors are required to have and maintain a valid City of Carlsbad Business License for the duration of the contract. INDEMNITY. The Contractor shall assume the defense of. pay all expenses of defense. and indemnify and hold harmless CMWD and the City of Carlsbad, and its officers, officials, employees and volunteers. from all claims, loss, damage, injury and liability of every kind. nature and description, directly or indirectly arising from or in connection with the performance of the Contract or work; or from any failure or alleged failure of Contractor to comply with any applicable law, rules or regulations including those related to safety and health; and from any and all claims, loss, damages, injury and liability, howsoever the same may be caused, resulting directly or indirectly from the nature of the work covered by the Contract, except for loss or damage caused by the sole or active negligence or willful misconduct of CMWD or City of Carlsbad. The expenses of defense include all costs and expenses including attorneys' fees for litigation. arbitration, or other dispute resolution method. JURISDICTION. The Contractor agrees and hereby stipulates that the proper venue and jurisdiction for resolution of any disputes between the parties arising out of this agreement is San Diego County, California. Start Work: Contractor agrees to start within five (5) working days after receipt of Notice to Proceed. Completion: to Proceed. Contractor agrees to complete work within fifteen (15) working days after receipt of Notice CONTRACTOR'S INFORMATION. JI/ Ill Ill Ill Utility Service Co., Inc. (name of Contractor) 815676 (Contractor"s license number) C33-Painting & Decorating: A-General Engineering Contractor_ 12/31/18 (license class. and exp. date) 1000008458 (DIR registration number) 6/30/2018 (DIR registration exp. date) CLEAN, INSPECT AND DISINFECT C-TANK RECYCLED WATER RESERVOIR 1230 Peachtree Street NE -Suite 1100 (street address) Atlanta, GA 30309 (city/state/zip) 800-942-0722 Page 3 of 6 (telephone no.) 478-987-2991 (fax no.) . sn1chola:,@u~li!)tse~ic;e,_com ( e-mail address) General Counsel Approved 9/27116 Tracking#: PWM18-55UTIL AUTHORITY. The individuals executing this Agreement and the instruments referenced in it on behalf of Contractor each represent and warrant that they have the legal power, right and actual authority to bind Contractor to the terms and conditions of this Agreement. CONTRACTOR CARLSBAD MUNICIPAL WATER DISTRICT UTILITY SERVICE CO., INC., a Georgia corporation ·•-\: D. Michael Buchanan, VP, Finance & Support Services (print name/title) (sign here) J. Shane Albritton, Corporate Secretary (print name/title) By: s/General Manager as he Executive Manager If required by CMWD, proper notarial acknowledgment of execution by Contractor must be attached. lf_§ corporation, Agreement must be signed by one corporate officer from each of the following two groups: Group A Group B Chairman, Secretary, President, or Assistant Secretary, Vice-President CFO or Assistant Treasurer Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation. APPROVED AS TO FORM: CELIA A. BREWER, General Counsel BY: -~<//e~L ....... ~_.,_~~~~- Deputy Generaicounsei' 2?f ~ ~..(U,~£-eNJ~ )(~ ?~/4-c CLEAN, INSPECT AND DISINFECT C-TANK RECYCLED WATER RESERVOIR Page 4 of 6 General Counsel Approved 9/27/16 Tracking#: PWM18-55UTIL EXHIBIT A LISTING OF SUBCONTRACTORS BY GENERAL CONTRACTOR Set forth below is the full name and location of the place of business of each sub-contractor whom the Contractor proposes to subcontract portions of the Project in excess of one-half of one percent of the total bid, and the portion of the Project which will be done by each sub-contractor for each subcontract. NOTE: The Contractor understands that if it fails to specify a sub-contractor for any portion of the Project to be performed under the contract in excess of one-half of one percent of the bid, the contractor shall be deemed to have agreed to perform such portion, and that the Contractor shall not be permitted to sublet or subcontract that portion of the work, except in cases of public emergency or necessity, and then only after a finding, reduced in writing as a public record of the Awarding Authority, setting forth the facts constituting the emergency or necessity in accordance with the provisions of the Subletting and Subcontracting Fair Practices Act (Section 4100 et seq. of the California Public Contract Code). If no subcontractors are to be employed on the project, enter the word "NONE." SUBCONTRACTORS Portion of Project to Business Name and Address DIR Registration License No., %of be Subcontracted No. Classification & Total Expiration Date Contract Total % Subcontracted: The Contractor must perform no less than fifty percent (50%) of the work with its own forces. CLEAN. INSPECT AND DISINFECT C-TANK RECYCLED WATER RESERVOIR Page 5 of 6 General Counsel Approved 9/27116 Tracking#: PWM18-55UTIL EXHIBIT B CLEAN, INSPECT AND DISINFECT C-TANK RECYCLED WATER RESERVOIR Carlsbad Municipal Water District to provide the following: • Off-site disposal of sediment/debris from the tank • Waive construction meter and water fees JOB QUOTATION ITEM UNIT QTY DESCRIPTION PRICE NO. Clean, Inspect and Disinfect C-Tank Recycled Water Reservoir in one (1) day. Exterior and interior paint 1 Job samples taken and analyzed at a certified laboratory. Comprehensive written report will be submitted detailing the condition of the tank. $6,100 TOT AL NOT TO EXCEED $6,100 *Includes taxes, fees, expenses and all other costs. CLEAN. INSPECT AND DISINFECT C-TANK RECYCLED WATER RESERVOIR Page 6 of 6 General Counsel Approved 9/27 /16 • ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) ~ 10 1212017 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA, INC N_AME: -------------------PHONE FAX 445 SOUTH STREET JA/h_No Ext): ----------(A/C,No): MORRISTOWN, NJ 07962-1966 E-MAIL Attn Mornstown.CertRequest@marsh.com Fax 212-948-0979 ADDRESS: --- INSURER(S) AFFORDING COVERAGE NAIC# --------- 100055-USG-GAWU-17-18 _ tNSURER A : Liberty Mutual Fire Insurance Com_p_ariy_ 23035 ---------------- INSURED INSURER B: N/A NIA UTILITY SERVICE CO. INC. PO BOX 1350 INSURER C: Liberty Insurance Corporation 42404 PERRY. GA 31069 INSURER D: INSURER E: ---- INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-010144257-01 REVISION NUMBER: 1 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 ADDL SUBR -POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INS:n wvn POLICY NUMBER IMM/OD/YYYYI IMM/DD/YYYY\ A X COMMERCIAL GENERAL LIABILITY TB2-641-444 728-04 7 03/01/2017 03/0112018 EACH OCCURRENCE $ 2,000.000 ----------DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMI~§ [E<3_9c<0urrengej ___ $ 2,000 000 M~D EXP (~ny one pe'.sor:) $ 10.000 PERSONAL & ADV INJURY $ 2.000,000 ---------------- GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3 000,000 --- X POLICY PRO-LOC PRODUCTS -COMP/OP AGG $ 3,000,000 JECT OTHER $ A AUTOMOBILE LIABILITY AS2-641-444728-067 03/01/2017 03/01/2018 COMBINED SINGLE LIMIT/ $ 2,000,000 l~~-~_gqgen_t2_ X ANY AUTO BODILY INJURY (Per person) $ --OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED -----NON-OWNED PROPERTY DAMAGE $ --AUTOS ONLY AUTOS ONLY (Per accident) i $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ -------- DED RETENTION$ $ C WORKERS COMPENSATION 1 WA7-64D-444728-017 (AOS) 03/01/2017 03/0112018 X PER OTH- ____ STATUTE __ ER C AND EMPLOYERS' LIABILITY YIN WC7-641-444728-107 (WI) 03/01/2017 03/01/2018 ANYPROPRIETOR/PARTNER/EXECUTIVE 0 E L EACH ACCIDENT $ 2.000.000 OFFICER/MEMBER EXCLUDED? N/A ------- (Mandatory in NH) E L DISEASE -EA EMPLOYEE $ 2,000.000 If yes. describe under E_L DISEASE -POLICY LIMIT $ 2.000.000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE FOR WORK TO BE DONE ON THE CITYS UNDERGROUND WATER RESERVOIR THE CITY OF CARLSBAD. ITS OFFICIALS. EMPLOYEES AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED (EXCEPT WORKERS COMPENSATION) WHERE REQUIRED BY WRITTEN CONTRACT. THIS INSURANCE IS PRIMARY AND NON-CONTRIBUTORY OVER ANY EXISTING INSURANCE AND LIMITED TO LIABILITY ARISING OUT OF THE OPERATIONS OF THE NAMED INSURED AND WHERE REQUIRED BY WRITTEN CONTRACT CERTIFICATE HOLDER CANCELLATION CARLSBAD MUNICIPAL WATER DISTRICT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1635 FARADAY AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CARLSBAD.CA 92008 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi MukherJee ._N.a'VU><C)I,,,.. ~ © 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: AS2-641-444728-067 COMMERCIAL AUTO CA 20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization whom you have agreed in writing to add as an additional insured, but only to coverage and minimum limits of insurance required by the written agreement. and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An lnsured provision contained in Paragraph A.1. of Section II -Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I -Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 481013 © Insurance Services Office, Inc., 2011 Page 1 of 1 Policy Number: AS2-641-444728-067 Issued By: I,iberty Mutual Fire lns1-:.:car.ce co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement m odffies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE UABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Other Person(s)/ Email Address or Organization(s): address: -··-·------- mailing As per file with :;;ompany As per file wi::h company Number! Days I Notice: 60 A. If we cancel this policy for any reason other than nonpayment of premium, we will notif-J the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only, our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011, Liberty Mutual Group of Companies. All rights reserved. Includes copyrighted material of Insurance Services Office. Inc. with its permission. Page 1 of 1 POLICY NUMBER: TB2-641-444728-047 / COMMERCIAL GENERAL LIABILITY CG 2010 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 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. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. lf coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 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 C. Wrth respect to the insurance afforded to these additional insureds, the following is added to Section Ill -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations: whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): All persons or organizations with whom you have entered into a written contract or agreement, prior to an "occurrence" or offense, to provide additional insured status. Location(s) Of Covered Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 2010 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: TB2-641-444728-047 COMl'vERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS-COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABlLITYCOVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 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" 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". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. lf coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the mast we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement: or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): All persons or organizations with whom you have entered into a written contract or agreement, prior to an "occurrence" or offense, to provide additional insured status. Location And Description Of Completed Operations All locations as required by a written contract or agreement entered into prior to an "occurrence" or offense. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 0413 © Insurance Services Office, Inc., 2012 Page 1 of , Policy Number TBl-641-444728-047 Issued by LIBERTY MUTUAL FIRE INSL"RA.NCE COMPA~Y THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY -UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / i Email Address or mailing address: Number Days Notice: Organization{s): : Per schedule on file with Per schedule on file with the broker 30 the broker A If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged LIM 99 01 0511 © 2011 Liberty Mutual Group of Companies. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1