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Home My WebLink AboutResolution - 2002-R0470 - Letter Of Award - Clear Water Co. - 10_24_2002Resolution No. 2002-RO470 October 24, 2002 Item No. 39 RESOLUTIO BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK THAT the Mayor of the City of Lubbock BE and is hereby authorized and directed to execute for and on behalf of the City of Lubbock, a Letter of Award for bottled water & water treatment systems - annual pricing - per ITB Bid ##215-02/BM, by and between the City of Lubbock and Clear Water Company of Lubbock, Texas and related documents. Said Letter of Award is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the Citv Council this 24th day of October , 2002. ATTEST: Rebecca Garza, City Secretary APPROVED AS TO CONTENT: VaWA"�� Victor Kilman, Purchasing Manager APPROVED AS TO FORM: William de Haas Contract Manager/Attorney gs/ccdocs/ltrofaward-Clear water Co. res Oct. 11, 2002 Resolution No. 2002-RO470 October 24, 2002 Item No. 39 P.O. Box 2000 Lubbock, Texas 79457 (806) 775-2167 • Fax (806) 775-2164 October 24, 2002 Bobby Tadlock Clear Water Company 8212 Ithaca Avenue, Suite E-18 Lubbock,TX 79423 Office of Purchasing RE: ITB #215-02/BM — BOTTLED WATER & WATER TREATMENT SYSTEMS — ANNUAL PRICING Dear Mr. Tadlock: Clear Water Company has been awarded the items noted below for Bottled Water & Water Treatment Systems - Annual Pricing based on your response to the City of Lubbock Invitation to ITB #215-02/BM. 1. A Purchase Order will be issued by the City of Lubbock and covers the category of items shown below, and no other, during the period beginning October 24, 2002 and ending October 23, 2003. The City of Lubbock shall not be responsible for payment of any invoices except those orders placed pursuant to this agreement. 2. Category of Items: (Annual Quantity) 1. 60 more/less Initial Installation of each water -dispensing unit for five -gallon bottle @ $0.00 each 2. 5 more/less Initial Installation of each water -dispensing unit for two and one- half gallon bottle @ $0.00 each 3. 720 more/less Monthly rental fee for five -gallon water dispensing unit @ $0.00 each 4. 60 more/less Monthly rental fee for two and one-half gallon water dispensing unit @ $0.00 each 5. 3000 more/less Monthly purchase and delivery of bottled water in five -gallon containers @ $3.99 each 6. 960 more/less Monthly purchase and delivery of bottled water in two and one- half gallon containers @ $2.50 each 7. 480 more/less Monthly purchase and delivery of bottled water in one -gallon containers @ $1.25 each 3. Clear Water Company's bid dated September 25, 2002, is incorporated into and made a part of this agreement. 4. Prices: As quoted. 5. All invoices shall be directed to: City of Lubbock Accounts Payable PO Box 2000 Lubbock, Texas 79457 6. The City of Lubbock reserves the right to enforce the performance of this contract in any manner prescribed by law or deemed to be in the best interest of the City of Lubbock in the event of breach or default of this agreement. The City of Lubbock reserves the right to terminate this agreement with a thirty (30) day written notice in the event Clear Water Company fails to perform in accordance with their proposal dated September 23, 2002. IVIQyul APPROVED AS TO CONTENT: qt�� K____ Victor Kilman Purchasing Manager APPROVED AS TO FORM: illiam D. de Haas Contract Manager/Attorney cc: Bob Prather, Health Department Sherry Stevens, Water Utility Administration Vendor File ATTEST: Rebecca Garza City Secretary Me # 215-0218M, Bottled Water and Water Treatment Systems -Annual Pricing SUBMITTO: Resolution No. 2002-R0470 CITY OFLUBBOCK PURCHASING DEPARTMBVT ift 1625137H SrF E r, RM L04 CITY OF W BBO CK TDCAS LUBBOCK, TX 79401-3830 AN MUAL CONTACT PEFWN: ORTU oPPLOYNITY TO END EMPLOYERINVITATION TEL- 806.775.2167 FAX 806.775.21614 http://purchasing.cl.lubbock.tx.us TITLE NUMBER: SUBMITTAL DEADLINE Bottled Water and Water Treatment * terr*Annual 21$-02/BM S ptonber 26, 2002,1.00 P.M. Pricing CST PREBID DATi~ TIMEAND LOCATION: September 20, 2002, 9:00 A.M. CST, SV8M1TTALSAWZVSD AMMA80VE Municipal Building, Planning Conference Room 107, 162513s' Street, Lubbock, DATEAND 77MEMI VOTBE Texas 79401 GONSDB�ID RESPONDENT NAME lUmf ' ) fC 11, cl, IF RETURNING ASA "NO BID", PLFAgCOMPLEi SAND RETURN THESrATB 4ENT OF°NO BID". MAILING ADDREM CITY — A — ZIP. By my signature I certify that this offer is made without prior understanding, agreement, or connection with any corporation, firm, business entity, or person submitting an offer for the same TBJ3DHONENO: q 0 materials, supplies, equipment, or servioe(s), and is in all respects fair and without ootlusion or fraud. I further agree that if the offer is FAX NO: I accepted, theofferorwiil convey, sell, amign, ortransferto the City 9 9 . eZ 3 b of Lubbock all right, title, and interest in and to all causes of action it may now or hereafter acquire under the Anti-trust lawsof the E4�AIL 1erdW ,�. United Sates and to Sate of Texas for price fixing relating to the particular commodity(s) or services) purchased or acquired by the City of Lubbock. At the Oty'sdiscretion, such assignment shall be Fl�StiAt TAX ID NO. OR SOCIAL S�URJTY N0. rl J - 0 14 13 made and become effective at the time the City tenders final ZED omment to the vendor. THE CITY OF LUBBOCK REBWE'STHE RIGHT TO ACCi37T OR REECT ANY AND ALL SIDSIN WHOLE OR IN PART AND WAIVE ANY INFORMALITY IN THE COMPETITIVE BID PROCESB RJRTHE� THE CITY REMVBS THE RIGHT TO ENTER INTO ANY CONTRACTDEEMEi TO REIN THEBESf INTt MI OFTHECITY. THEIIDD014810911ACKNOOFAND AGRE 13ITSIND ISBASSD ON THEFOLLOWING ADDENDA: 8 3 #4 #6- (Please iritial) The City of Lubbock Charter states that no officer or employee of the City can benefit from any contract, job, work or service for the municipality or be interested in the sale to the City of any supplies, equipment, material or articles purchased. Will P�nny officer or employee of the City, or member of their immediate family, benefit from the award of this bid to the above firm? YM_�L NO IN COMPLIANCE WITH THIS SOLICITATION, THE UNDERSIGNED BIDDER HAVING IXAMINE D THE INVITATION TO BID AND SPECIFICATION$ AND BEING FAMILIAR WITH THE CONDITIONS TO BE MET, HEREBY SUBMITS THE FOLLOWING BID FOR FURNISHING THEMATERAL, MUIPMfN T, LABORAND l?OtWTHING NECESSARY THEITEMSLISTM ON THE ATTACHED BID FORM AND AGREESTO DEJVERSAID ITEMSATTHE LOCATiONSAND FORTHEPRICBSE`TFORTti ON THEBID FORM. AN INDIVIDUAL AUTHORIZED TO BIND THECOMPANY MUST SIGN THEFOLLOWING SIMMON. FAILURETO EXECUTE THISPORTION MAY LT IN BID E�t70N. f7f,Jn� Authorized Slpvtisre Title Print/Type Nam Date THISFORM MUST BECOMPLOW AND RETURN® WITH YOURREiPONSE r; B #215-C21BM ITB # 215-02/13M, Addendum #1 BID FORM Bottled Water and Water Treatment Systems- Annual Pricing CITY OF LUBBOCK, TEXAS . ITB # 215-02/13M In compliance with the Invitation to Bid # 215-02/BM, the undersigned Bidder having examined the Invitation to Bid and Specifications, and being familiar with the conditions to be met, hereby submits the following Bid for furnishing the material, equipment, labor and everything necessary for providing the items listed below and agrees to deliver said items at the locations and for the prices set forth on this form. The Invitation to Bid # 215-02/BM is by reference incorporated in this contract. UNIT OF UNIT PRICE* Extended Delivery ITEM QTY MEASURE DESCRIPTION BID Cost Days ARO** 1. 60 EA Initial installation of each water -dispensing unit for five- bottle, herein. (Cooler type dispensers N O (More gallon as specified $ $ or less) are not acceptable) 5 Initial installation of each water -dispensing unit for two and .2. (More EA one-half gallon bottle, as specified herein. (Cooler type d.e j or less) dispensers are not acce table) :5. i 60 Monthly rental fee for five -gallon wa dispensing unit, as O She, 3. (More EA specified herein. (Cooler type dispensers are not acceptable) �" or less) -t, calf A ' 5 Monthly rental fee for two and one-half gallon water I v IY 4. (More EA dispensing unit, as specified herein. (C oler type dispensers or less) are not acceptable) S 250 Monthly purchase and delivery of46ottled water in five- 5. (More EA gallon containers. Unit Price represents price per 5-gallon or less) container, asspecified herein. . 570 6,1 d4ji'j 80 Monthly purchase and delivery of bottled water in two and • f S awL t 6. (More re EA one-half gallon containers. Unit Price represents price per 2- Jr p or less) 1/2 allon container, asspecified herein. 01 1 -{�jtij 40 Monthly purchase and delivery of bottled water in one- r S �N 7. (More EA gallon containers. Unit Price represents price per 1-gallon I� dJ or less) container, asspecified herein. dow tI Installation charge for water purification systems at various 8. 3 EA locations (to be provided to successful bidder), as specified herein. Monthly rental fee for water purification systems. Cost must 9. 3 EA include all associated fees such as maintenance, maintenance kits, filters, etc. All maintenance to be performed by the successful bidder, asspecified herein. *PRICE: F.O.B. City of Lubbock **Days After Receipt of Order (ARO) PAYMENT TERMS AND DISCOUNTS - Bidder offers a prompt payment discount off,, net _ calendar days. Discounts will not be considered in determining low bid. Unless otherwise indicated on the Bid Form, payment terms will be NET THIRTY DAYS. The City will pay the successful bidder within thirty days after the receipt of a correct invoice or after the date of acceptance, whichever event occurs later. Discounts for prompt payment requiring payment by the City within a stipulated number of days will be interpreted as applying within the stipulated number of calendar days after the date of receipt by the City of a correct invoice or after the date of acceptance that meets contract requirements, whichever event occurs later. Discounts for payment in less than ten days will not be considered. INTERLOCAL PURCHASING (optional): The City desires to make available to other local government entities of the State of Texas, by mutual agreement with the successful bidder, and properly authorized interlocal purchasing agreements as provided for by the Interlocal Cooperation Act (Chapter 791, Government Code), the right to purchase the same services, at the prices quoted, for the period of this contract. Each bidder shall indicate on the Bid Form in the space provided below if he/she will honor Political Subdivision orders in accordance with contract terms and conditions, in addition to orders from the City of Lubbock. M`�YeS ❑ No THIS BID IS SUBMITTED BY a corporation organized under the laws of the State of or a partnership consisting of of the Cityof t_--LA b kCC.JL Address: x ;-- I a Z ` CL A l) e • S+"e- • P - 19 ITB # 215-02/13M Ad 1 ITB # 215-021BM, Addendum #1 City: l D �L State:_ zip 9 M/WBE Firm: Woman Black American Native American --� Hisoanic American I Asian Pacific American I Other (Soecifv) B Date: % a Authorized Representative - must sign by-hh nli - Officer Name and Title: f�,06by i (� Ct �OCk- QI-z f -t"ir -7(LV"i Piease Print Business Telephone Number t0 5a FAX: (O -r7 r7 ' D-4 3 a FOR CITY USE ONLY Bid Form Item Number(s) Awarded to Above Named FirmAndividual: Date of Award by City Council (for bids over $25,000): Date P.OJContract Issued: ITB # 215-02/13M Ad.1 FROM : CLeAP. WATEP. COMPANY FAX NO. : 9067712439 Oct. 09 2002 02:23PM P2 Resolution No. 2002-RO470 Clear Water Company 8212 Ithaca Ave. Ste. E-18 Lubbock, TX 79423 806-797-7052 or 1-800-79CL -AR City of Lubbock Attu: Brace MacNair 775-2164 clear Water can provide 2 and 1/2 gallons at the same price of the 3 gallons with no deposit required. These do not require bottle dispensers. If you have further questions please do not htsitate to contact our office_ n # 215.021BM. Bottled Water and Water Treatment Systems-Arnual Pricing City Of Lubbock Resolution No. 2002—R0470 Consideration of Location of Bidder's Principal Place of Business Affidavit of Eligibility Pursuant to Texas Local Government Code 271.905(b), in purchasing real property or personal property that is not affixed to real property, if the City receives one or more bids from a bidder whose principal place of business is in the City of Lubbock and whose bid is within three percent (3%) of the lowest bid price received by the City from a bidder who is not a resident of the City of Lubbock, the City may enter into a contract with. (1) the lowest bidder; or (2) the bidder whose principal place of business is in the City of Lubbock if the City Council determines, in writing, that the local bidder offers the City the best combination of contract price and additional economic development opportunities for the City of Lubbock created by the contract award, including the employment of residents of the City of Lubbock and increased tax revenues to the City of Lubbock. In order to receive consideration, bidders must submit this affidavit to: . Victor Ki;man, Purchasing Manager City of Lubbock 1625 131 Street Lubbock, TX 79401 Complete all areas below. incomplete affidavits may be rejected. Local Business Name: be within the City limits): .`ice- ---a qP,3 1. is the above address the principal place of business for the business named above? S 2. How many residents of the City of Lubbock are employed at the above business location? 19____ 3. Year your business was established in the City of Lubbock: lj 4. For transactions that require sales tax., provide the following Reseller information: Reseller Permit Number: Company Name and Address (as it appears on permit). 5. Does your business have more than one office in the State of Texas? _ Yes �No If Yes, identify the office location considered as the point -of sale credit for sales tax purposes: 6. Was the local business required to pay business and/or real property tax for the most recent tax year? �es No If Yes, did the local business pay any of this tax to the City of Lubbock? ��Yes No Under penalty of perjury, the undersigned states at the foregoing statements are true and correct. It is further acknowledged that any person, firm, corporation or entity intentionally s bmitting false information to the City in an attempt to qualify for eligibility shall be prohibited from bidding on Cit of Lubbock p acts and services for a period of one (1) year. i Authorized Signature: t '+'�-'�--r_ Dater Z Printed Name and Title: =&C1U_ 1 (?�� )-Cc - a"7 roar Ia*-� tTB #215.02/BM 20 CERTIFICATE ®F-'LIAERL1':(.lt4,Ij!► DATE(MMADM'j E 2%27/20C1.- PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE � JOE SCHOENIG AGENCY 102 UNIVERSITY AVE .--JBBOCK, TX 79423 (806)745-7777 FAX (806) 748-1469 ND OR ALTER THE OVERAGE AFFCERTIFICATEORDED BBYTTAHEEPOLICIEE3 BELOW. COMPANIES AFFORDING COVERAGE COMPANY ; A MID-CENTURY INSURANCE COMPANY INSURED COMPANY —{ BOBBY TADLOCK B TRUCK INSURANCE EXCHANGE I DBA CLEAR WATER COMPANY COMPANY 8212 ITHACA, SUITE 17 C TEXAS COUNTY MUTUAL i LUBBOCK, TX 79423 COMPANY t D FARMERS INSURANCE EXCHANGE CCWERAm... THIS IS TO CERTIFY THAT THE FOLICIES 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 i CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, i EXCLUSION$ AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. `CO TYPEOPNSURANCE PO =NUMBER MlpplM D FIMMJDDMf} L GENERAL LIABLftY GENERAL AGGREGATE X PRODUCTS - COMPJOP AGG s�_0 0-0 000 COMMERCIAL GENERAL UABILITY CLAIMS ❑X OCCUR PERSONAL & ADV INJURY _ $1., 000 000 A OWNER'SACONTRACTOR'SPROT 60244 51 42 0.1-01-02 01-01-03 EACH OCCURRENCE slf 000 000 S 50 00 ;_1 FIRE DAMAGE V"on.**) MED EXP (Any one pan=) s 5 f } �a AUTOMOBLE LIABLITY ANY AUTO COMBINED SWGLE LIMIT i 11000, 00cr BODILY INJURY Ipw PSI i ALL OWNED AUTOS SCHEDULED AUTOS X C HIREDAUTOS NOWOWNEDAUTOS 60244 51 43. 01-01-02 01-01-03 X BODILY INJURY (Pffumoeq i X -� X Leased vehicle PROPERTY DAMAGE S X DEDS. 500/500 GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT 3 AGGREGATE s EXCESS L"LITY EACH OCCURRENCE s 1, O 0 O 0 0 0—: AGGREGATE B x UMBRELLA FORM OTHER THAN UMBRELLA FORM 60244 51 45 01-01-02 01-01-03 $1, 000, 0"jo ! WORKERS COMPENSATION AND TRY UMfTS X ER {e " EL EACH ACCIDENT s 50 0 0 0 n s 500,0(�(OH It 5 0 O Q D EM PLOYERS' LIABUTY THE PROPRIETOR u.CL OFFICERSRSARE:PARTNEIMTIVE Px, cACL N2307 71 99 I 01-01-02 01-01-03 ELDISEAs=-poLscvLwuT EL MEAN - EA EMPLOYEE OTHER DESCRIPTION OF OPERATIONSILOCATIONLwr ICLESBPECIALITEM S. - CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED AND LOSS PAYEE FOR ALL VEHICLES LEASED, RENTED OR SUPPLIED AS A SUBSTITUTE TO THE NAMED INSURED BY THE CERTIFICATE HOLDER CER'tiHCATE HOLDER '--' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE VFRATION DATE THEREOF, THE .SSUNG COMPANY WILL ENDEAVOR TO MAL ,I_ DAYS WRITTEN NOTICE TO THE CERTFWATE HOLDER NAMED TO THE LEFT, BUT FALURE TO MAL SUCH NOTICE SHALL IMPOSE NO OBLIGATON OR LWOW" iR RlPR!lENTAT7VE4 i ACORD CARf7GRl4%lONae . rexAa ELWSINESt AUTO RENEWAL FARMERS TEXAS COUNTY MUTUAL INSURANCE COMPANY CERTIFICATE MEMBERS OF FARMERS INSURANCE GROUP OF COMPANIES HOME OFFICE: 4680 WILSHIRE BLVD., LOS ANGELES, CALIFORNIA 90010 VVaaluable- Attach this i RegionalOffices: FM 1 25, Austin Interregional 28 y.' Austin, Texas 787(i41 ca o your po cy ITEM ONE NAMED BOBBY TADLOCK INSURED DBA CLEAR WATER COMPANY MAILING 8212 ITHACA SUITE 17 ADDRESS LUBBOCK TX 79423 XE98601 Monthly Pay Plan No. _3s-77-31-S- _ 602144-S1-4:4 Agent Policy Number RENEWS Form of Business: ® Individual Partnership NO: BOTTLED WATER QCorporation Other Policy Period from 01 i 01 i 0 2 to O 1101 i 0 3 12:01 AM Standard Time at your mailing .address shown above. In consideration of the payment of the premium stated, this policy is renewed from the inception date to the expiration date stated. Insurance is only with respect to coverage for which an auto symbol, limits of insurance and premium charge is stated, subject to all off the terms of this police_ any attached forms and endorsements. ITEM TWO SCHEDULE OF COVERAGES AND COVERED AUTOS This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those aL.< shown as covered autos. Autos are shown as covered autos for a particular coverage by the entry of. one or mare of the symbols from the COVERED At-' Section of the Business Auto Coverage Form next to the name of the coverage. (Entry of one or more of the symbols from the COVERED THE MOST WE WILL PAY FOR PREMi COVERAGES AUTOS Section of the BE ANY ONE ACCIDENT OR LOSS Auto Coverage Form shows which autos are covered autos) (LIMITS SHOWN IN THOUSANDSI , each person; $ each accident 1 7,116 .:, SEE END. J $ SEE SCHEDULE j 1 ?-1 SEE END. 1,301.0 s each person$ each accident PHYSICAL DAMAGE Actual Cash Value or Cost of Repair, whichever is COMPREHENSIVE COVERAGE 7 8 less minus $ SEE SCHEDULE Ded. for Each Covered 1, 37': Auto. But no Deductible Applies to Loss Caused by Fire or Li htnin . See Item Four for hired or borrowed autos. STATED AMOUNT $ PHYSICAL DAMAGE SPECIFIED Actual Cash Value or Cost of Repair, whichever is CAUSES OF LOSS COVERAGE 7 8 Less Minus $25 Ded. for Each Covered Auto for logs 16. Q" Caused by Mischief or Vandalism. See Item Four for hired or borrowed Autos. STATED AMOUNT PHYSICAL DAMAGE Actual Cash Value or Cost of Repair whichever is COLLISION COVERAGE 7 8 less minus $ SEE SCHEDULE Ded. for Each Covered Auto. 3, 23t, . $ for each disablement of a private Premium Shown is payable $ at inception. F7ARME RS' ,�lYRAIFCt LNCUP t'l W5233 2N0 EDITION 6.00 D3233E2 666233-ED2 page I of 4 60244-51-43 TEXAS BUSINESS AUTO RENEWAL CERTIFICATE(CONTINUED)POLICY NUiiABER - ENDORSEMENTS ATTACHED TO THIS POLICY: IL 00 21-Broad Form Nuclear Exclusion I 00 10498 S1929- 1 TE 04 0 TE 0 09D TE 99 170 99 60A TE 0010 9 COUNTERSIGNED By Year, Model, Trade Name, Body Type Serial Number (S) Vehicle Identification Number (VIN) Town & State where Covered Auto will be principally garaged Original Actual Cost & Covered Auto No. Cost New New (N -USED 2 97 25MOVEA3715 ICKUP 25400 LUBBOCK TX 3 UCK 62745 LUBBOCK TX '4' 98 TCH101X.103538 AILER 3000 LUBBOCXL TX 5 77 02 ILER 2000 LUBBOCK TX CLASSIFICATION Except for towing, all physical Radius of Business use Size GVW Age Primary Secondary Code Operation s - service GCW or Veh. Group Rating Rating loss is payable to you and the los.. r - retail Seating Factor Factor payee named below as interest Liab. Pto veredd Covered c - commercial Capacity may appear at the time of the lose No.,Phhryn 8111 1. 0 1:k4 : SEE S1929 . 2202 COVERAGES -PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any column below means that the , :� 1 .0 78.00 AND DEDUCTIBLES, (Absence of a deductible or limit entry in any column below means • YJul: 3 1.00 573. COVERAGES -PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any column below means !hat the or deductible entry In the com3sp2ndina ITEM TWO column applies instead SPECIFIED CAUSES OF LOSS COLLISION TOWING AND LABOR Limit stated In ITEM Premium Limit stated in Premium Limit Per Premium Covered TWO ITEM TWO minus Disablement Auto No. ded. shown below 0 Total Premium 7.00 1 1,636.00 •(LIMITS SHOWN IN THOUSANDS) 66-563 2ND EDITION 840 DD293Ez 568*ED2 wa• 2 of 4 FLEET SCHEDULE - LIABILITY AND PHYSICAL DAMAGE This endorsement modifies insurance provided under the following: 2ND Ec: ,• BUSINESS AUTO COVERAGE FORM TE TRUCKERS COVERAGE FORM GARAGE COVERAGE FORM This endorsement changes the Policy effective on the inception date of the policy unless another date is indicated below: Endorsement Effective 01/01/02 1Policy Number 60244-51-43 wnwu nwuwu i7Vaai iAYLVVA --- �� Countersigned b SCHEDULE OF COVERED AUTOS YOU OWN (Authorized Representai; DESCRIPTION TERRITORY PURCHASED Year, Model, Trade Name, Body Type Serial Number (S) Vehicle Identification Number (VIN) Original Actual Cost & Town& State where the Covt--m- Auto will be principallyga aGL. Covered Cost New (N) Auto No. USE D U 20L2XEA48491 T' 7 8 L NN AA 4341 TRACTOR 01FTRUCK 92ITCB!1622YI044775 38000 61000 LUBBOCK TX i LUBBOCK 9 ALjNJA;872 872fRUCK TX F250 0120F91E- 24000 LUBBOCK TX 10 00 TRAILER 3000 LUBBOCK TX CLASSIFICATION ' Radius of Business use Siae GVW, Age Primary Secondary Code Except for towing, ail physicsi dam. Operation s - service GCW or Veh Group Rating Rating lass is payable to you and the lass r - retail Seating Factor Factor payee named below as intere,`. Covered c - commercial Capacity Liab. Phy. may appear at the time cf ;:.e Auto No. Dam. :11,110 SEE S1929 1 9 COVERAGES -PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any column below means that the L`' —� or deductible entry in the corresponding ITEM TWO column of the Declarations applies instead LIABILITY PERSONAL INJURY PROTECTION AUTO MED PAY 'Limit Premium Limit stated in Premium 'Limit Premium each PIP End. Covered Auto No. 16.00 2, ttyy1,01 1 COVERAGES -PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any column below means that tee !" or deductible entry in the correspondinq ITEM TWO column of the Declarations applies instead UNINSURED/UNDERINSURED MOTORISTS COMPREHENSIVE 'Limit Premium Limit (Actual Cash Deductible Premium Covered Value or stated Amt.) Auto No. 11110 : 1 COVERAGES -PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any column below means that th,� I or deductible entryin the corres ndin ITEM TWO column of the Declarations applies instead)_ SPECIFIED CAUSES OF LOSS COLLISION TOWING AND LABOR Limit (Actual Cash Premium Limit (Actual Cash Deductible Premium Limit Per Premium Covered Value or stated Amt) Value or stated Amt.) Disablement Auto No. pp 00p � gg 1 9.001 30 0 FORM TE 99 76 B - FLEET SCHEDULE • LIABILITY AND PHYSICAL DAMAGE ' (LIMITS SHOWN IN THOUSAND' Texas Standard Automobile Endorsement, Prescribed March 19,1922. 90.1908 2ND EDITION 9.92 ERAS BUSINESS AUTO RENEWAL CERTIFICATE (CONTINUED) 'EM FOUR :HEOULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AN 60244-51-43 Policy Number TX — 23.00 TOTAL PREMIUM 23.00 Cost of hire means the total amount you incur for the hire of autos you don't own (not including autos you borrow or rent from your employees orzzneir members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. PHYSICAL MMARE COVERAGE LIMIT OF INSURANCE COVERAGES THE MOST WE WILL PAY RATE PREMIUM DEDUCTIBLE ACTUAL CASH VALUE, COST OF REPAIRS OR $ 30000WHICHEVER IS LESS MINUS COMPREHENSIVE $ 1000DED. FOR EACH COVERED AUTO. 7.00 BUT NO DEDUCTIBLE APPLIES TO LOSS CAUSED BY FIRE OR LIGHTNING.. ACTUAL CASH VALUE COST OF REPAIRS OR SPECIFIED $ WHICHEVER IS LESS MINUS CAUSES OF LOSS $25 DED. FOR EACH COVERED AUTO FOR LOSS CAUSED BY MISCHIEF OR VANDALISM. ACTUAL CASH VALUE, COST OF REPAIRS OR _ COLLISION g 10fl00EDFORIEACH AUTO 18.00 COVERE01 TOTAL PREMIUM PHYSICAL DAMAGE COVERAGE for covered autos you nlre or borrow is excess unless indicated below by'UX - [� If this box is checked, PHYSICAL DAMAGE COVERAGE applies on a direct primary basis and for purposes of the condition entitled OTHER INSURANCE, any covered auto you hire or borrow is deemed to be a covered auto you own. ITEM FIVE SCHEDULE FOR NON -OWNERSHIP LIABILITY NAMED INSURED'S BUSINESS RATING BASIS NUMBER I PREMIUM Other then a Number of Employees 10 $ 35.00 Social Service Agency Number of Partners is *{aItUULC ruK I3KU" KCVGrIG VR MILC NIC UPWIG • LIADILII i %-WVKMWC • rVQLIH xV IV VA 16CMIMU INCnIAL im"UMAO RATES Estimated 0 Per $100 of Gross Receipts PREMIUMS Yearly [] Per Mile [� Gross Receipts LIABILITY AUTO MEDICAL P.I.P. LIABILITY COVERAGE AUTO MEDICAL P.I.P: Mileage SM233 2NO EDITION 6-W D UIR osa• 3 of 4 WORKERS COMPENSATION INFORMATION PAGE ❑ Assigned Risk 1. Named - BOBBY TADLOCK Insured • DBA : CLEAR WATER Mailing - 8212 ITHACA, STE Address • LUBBOCK FARMERS INSURANCE EXCHANGE 17744 (An inter -Insurance Exchange hereinafter Sometimes Referred To As Company) Members of the Farmers insurance Group of Companies Nome Office: 4680 Wilshire Blvd., Los Angeles, California 90010 2002 N2307-71-99 02 Policy Year Poii No. of Co.. TEXAS N2�307-71-99 00 issuing office ReneWal 61 Policy a o . SW1 7904 17 Issuing Office Telephone Number T35-77-315 X 79423 Agent No. FVsk Identification No. Legal Entity: ®Individual Gl Pattnership D Co Idenufication Na nemploymentAccount o. � rporation 752907423 ❑ Other Federal Identification No. Federal Ident ficatlon No. Other workplaces not shown above: SEE ENDORSEMENT 2. Policy Period: From 01 /01 /02 to 01 /01 /03 12:01 a.m. Standard Time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the. states listed here. T% B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of liability under Part TWO are: Bodily Injury by Accident $ 500,000 each accident Bodily injury by Disease $ 500,000 each employee Bodily Injury by Disease $ SOO, 000 policy Omit Other States Insurance. Part Three of the policy applies to the states, If any, listed here: "All states except No. Dakota, Ohio, C. Washington, West Virginia, Wyoming, states designated In item 3A of the information Page and 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. The Information - required below is subject to verification and change by audit $ 0.00 Total Deposit Premium $ SEE INVOICE Cash Received $ SEE INVOICE Other Credits $ SEE INVOICE BALANCE DUE Classification of Operations Code No. Premium Basis Rates Estimated Estimated Per $100 Annual Total Annual of Remu- Premium. Remuneration neration SEE CLASSIFICATION OF OPERATIONS SCHEDULE THt$1$ NOT N INVOICE Minimum Total Estimated Annual Premium Premium $ 250.00 Expense Constant If indicated, interim adjustments of premium shall be made: 0 Monthly $ 19,894.00 $ . 200.00 Phis policy includes these endorsements and schedules: NC4203308 25-2361 WC420301F 56-5284ED2 25-2541 WCOOOOOOA E5028-ED3 E5357-ED1 Countersigned , Authorized Represotive lWC 00 00 01 A ED. e-asi FARMERS + ��hHSURAACE 41:ULv R R • . . ,._..__„ -- h.-,— C^wrieht 107. us" with its osrmtn oft. C:192501 PACs