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Koppl Pipeline Services Incd.b.a. Koppl Services; 2023-12-05; PWM24-2332UTIL
PWM24-2332UTIL INSERTION VALVE INSTALLATION CONT. NO. 39041 Page 1 General Counsel Approved 6/30/2023 CARLSBAD MUNICIPAL WATER DISTRICT MINOR PUBLIC WORKS CONTRACT INSERTION VALVE INSTALLATION CONT. NO. 39041 This agreement is made on the ______________ day of _________________________, 2023, 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, California, hereinafter referred to as “CMWD”, and Koppl Pipeline Services, Inc., a California corporation d.b.a. Koppl Services, whose principal place of business is 1228 Date Street, Montebello, California 90640 (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, as contained in the Standard Specifications for Public Works Construction “Greenbook”, latest edition and including all errata; Part 1 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: Matt Jacobs (CMWD Project Manager) PAYMENT. The City shall withhold retention as required by Public Contract Code Section 9203. 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. DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 5th December PWM24-2332UTIL INSERTION VALVE INSTALLATION CONT. NO. 39041 Page 2 General Counsel Approved 6/30/2023 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. 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. CONSTRUCTION MANAGEMENT SOFTWARE. Procore Project Management and Collaboration System. This project may utilize the Owner’s Procore (www.procore.com) online project management and document control platform. The intent of utilizing Procore is to reduce cost and schedule risk, improve quality and safety, and maintain a healthy team dynamic by improving information flow, reducing non- productive activities, reducing rework and decreasing turnaround times. The Contractor is required to create a free web-based Procore user account(s) and utilize web-based training / tutorials (as needed) to become familiar with the system. Unless the Engineer approves otherwise, the Contractor shall process all project documents through Procore because this platform will be used to submit, track, distribute and collaborate on project. If unfamiliar or not otherwise trained with Procore, Contractor and applicable team members shall complete a free training certification course located at http://learn.procore.com/procore-certification-subcontractor. The Contractor is responsible for attaining their own Procore support, as needed, either through the online training or reaching out to the Procore support team. It will be the responsibility of the Contractor to regularly check Procore and review updated documents as they are added. There will be no cost to the Contractor for use of Procore. It is recommended that the Contractor provide mobile access for Windows, iOS located at https://apps.apple.com/us/app/procore-construction-management/id374930542 or Android devices located at https://play.google.com/store/apps/details?id=com.procore.activities with the Procore App installed to at least one on-site individual to provide real-time access to current posted drawings, specifications, RFIs, submittals, schedules, change orders, project documents, as well as any deficient observations or punch list items. Providing mobile access will improve communication, efficiency, and productivity for all parties. The use of Procore for project management does not relieve the contractor of any other requirements as may be specified in the contract documents. 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 DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 PWM24-2332UTIL INSERTION VALVE INSTALLATION CONT. NO. 39041 Page 3 General Counsel Approved 6/30/2023 Carol Sanchez 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 (5) years and that debarment by another jurisdiction is grounds for CMWD to disqualify the Contractor or subcontractor from participating in contract bidding. Signature: ___________________________________ Print Name: ___________________________________ 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 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. 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. DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 PWM24-2332UTIL INSERTION VALVE INSTALLATION CONT. NO. 39041 Page 4 General Counsel Approved 6/30/2023 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 three (3) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within seven (7) working days after receipt of Notice to Proceed. CONTRACTOR’S INFORMATION. Koppl Pipeline Services, Inc. 1228 Date Street (name of Contractor) 844802 (street address) Montebello, CA 90640 (Contractor’s license number) C34-Pipeline; C60-Welding - 8/31/2024 (city/state/zip) 323-888-2211 (license class. and exp. date) 1000000314 - 6/30/2025 (telephone no.) asanchez@koppl.com (DIR registration number & exp. date) (e-mail address) 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. [signatures on following page] DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 PWM24-2332UTIL INSERTION VALVE INSTALLATION CONT. NO. 39041 Page 5 General Counsel Approved 6/30/2023 CONTRACTOR KOPPL PIPELINE SERVICES, INC., a California corporation CARLSBAD MUNICIPAL WATER DISTRICT, a Public Agency organized under the Municipal Water Act of 1911, and a Subsidiary District of the City of Carlsbad By: By: (sign here) Carol Sanchez, President & CFO Vicki V. Quiram, General Manager, as authorized by the Executive Manager (print name/title) By: (sign here) (print name/title) If required by CMWD, proper notarial acknowledgment of execution by Contractor must be attached. If a corporation, Agreement must be signed by one corporate officer from each of the following two groups: Group A Group B Chairman, President, or Vice-President Secretary, Assistant Secretary, 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: CINDIE K. McMAHON, General Counsel BY: _____________________________ Deputy General Counsel DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 PWM24-2332UTIL INSERTION VALVE INSTALLATION CONT. NO. 39041 Page 6 General Counsel Approved 6/30/2023 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 be Subcontracted Business Name and Address DIR Registration No. License No., Classification & Expiration Date % of Total Contract NONE Total % Subcontracted: 0% The Contractor must perform no less than 50% of the work with its own forces. DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 PWM24-2332UTIL INSERTION VALVE INSTALLATION CONT. NO. 39041 Page 7 General Counsel Approved 6/30/2023 EXHIBIT B One Insertion Valve Installation on Kelly Drive by the Kelly Elementary School Contractor to install a new valve at this location JOB QUOTATION ITEM NO. UNIT QTY DESCRIPTION PRICE 1 LS 1 Contractor to provide labor, equipment, & all work necessary to complete a 12” Hydra-Stop valve insertion installation to AC pipe on Kelly Drive near Kelly Elementary School $7,286 TOTAL AMOUNT NOT TO EXCEED* *$7,286 *Includes taxes, fees, expenses and all other costs. CONTRACTOR PROVISIONS Work to be done during regular hours Monday through Friday. Subject to certified payroll to DIR and prevailing wage rates. CMWD PROVISIONS One 12” Hydra-Stop insertion valve. Location map. Concrete to secure valve body. All necessary and/or required permits, safe access to the site, traffic control, ladders, shoring (if needed), lifting equipment. Excavate a pit for the insertion valve per Koppl’s instruction at a minimum of 5’ of pipe exposed with 2 ½’ of clearance from the pipe to the side of the excavation, and 24” under the pipe. Responsible for backfill and trench resurfacing per City of Carlsbad Standards. DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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 THISCERTIFICATE 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY 5/4/2023 Venbrook Insurance Services6320 Canoga Avenue, 12th Floor Woodland Hills, CA 91367 818-598-8942 www.venbrook.com CA Lic No. 0D80832 Windy West Windy West wwest@venbrook.com Koppl Pipeline Services, Inc. DBA: Koppl Services American Hot Tap; Hot Tap, Ltd 1228 Date St. Montebello CA 90640 74214306 3 3 Certificate Holder is named as Additional Insured under the General Liability policy if required by written contract with the Named Insured but *10 Days Notice of Cancellation for Non-Payment of Premium, 30 Days All Others. City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services P.O. Box 947 Murrieta CA 92564 RE: All Projects with the City only for coverage and limits provided by the policy and the additional insured endorsement. Waiver of Subrogation applies to Workers' Compensation. A 1,000,000US00090775LI23A5/1/2023 5/1/2024 500,000 3 5,000 3 1,000,000 2,000,000 2,000,000 3 3 $5,000 Deductible B AS2-Z91-467294-013 5/1/2023 5/1/2024 1,000,000 3 3 3 Comp/Coll Ded.1,0003PIP Included - HI Only A US00099795LI23A 5/1/2023 5/1/2024 5,000,0003 5,000,000Underlying -3 GL, AL, EL & CPL30 B WC2-Z91-467294-023 5/1/2023 5/1/2024 3 1,000,000Y 1,000,000 1,000,000 Indian Harbor Insurance Company 36940 Liberty Mutual Fire Insurance Company 23035 74214306 | 23-24 GL/AL/XS/WC/POLL/IM | Windy West | 5/4/2023 4:05:50 PM (PST) | Page 1 of 4 DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 ~ LJ □ - ~ R □ □ ~ ..__ - -~ ..__ ..__ ..__ R I I I I I □ POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 10 10 01 © ISO Properties, Inc.,2000 Page 1 of 1 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: The City of Carlsbad (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II – Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B.With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions 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 site 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. Koppl Pipeline Services, Inc. US00090775LI23A 74214306 | 23-24 GL/AL/XS/WC/POLL/IM | Windy West | 5/4/2023 4:05:50 PM (PST) | Page 2 of 4 DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 37 10 01 © ISO Properties, Inc., 2000 Page 1 of 1 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Blanket where required by written contract Location And Description of Completed Operations: Additional Premium: 0.00 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II – Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" at the location designated and described in the schedule of this endorsement performed for that insured and included in the "products-completed operations hazard". Koppl Pipeline Services, Inc. US00090775LI23A 74214306 | 23-24 GL/AL/XS/WC/POLL/IM | Windy West | 5/4/2023 4:05:50 PM (PST) | Page 3 of 4 DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 Koppl Pipeline Services, Inc. WC2-Z91-467294-023 05/01/2023 Liberty Mutual Fire Insurance Company 74214306 | 23-24 GL/AL/XS/WC/POLL/IM | Windy West | 5/4/2023 4:05:50 PM (PST) | Page 4 of 4 DocuSign Envelope ID: FCECCE44-3418-490E-B1C2-16FE1E70FD54 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT· CALIFORNIA 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 wrltten contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. • The additional premium for tt:ris endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. • Schedule Additional premium is a percent of the California Manual Workers Compensation premium. Subject to a minimum premium charge of$ 250 per policy Person or Organization Where required by contract or written agreement prior to loss and allowed by law. Issued by For attachment to Polley No. Issued to we 0403 oa Ed: 04/1984 Job Descrir;;,tion Effective Date Premium$ Page 1 of 1