HomeMy WebLinkAboutResolution - 2010-R0067 - Contract 10-015-P-015-NJPA Talon/LPE Restroom Installation At Fiesta Plaza - 02/09/2010Resolution No. 2010-R0067
February 9, 2010
Item No. 5.11
RESOLUTION
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, job order Contract No. 10-
015-P-015-NJPA for Fiesta Plaza precast restroom installation per National Joint Powers
Alliance (NJPA), Indefinite Quality Construction Contract, by and between the City of
Lubbock and Talon/LPE of Amarillo, Texas, and related documents. Said Contract 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 City Council this 9th
ATTEST:
cc?_�R J
Rebe Garza, City Secretary
APPROVED AS TO CONTEN :
Scott Snider, Assistant City Manager
Community Development
APPROVED AS TO FORM:
"'z
Chad Weaver, Assistant City Attorney
vwxcdocs: RES.Contract-Talon LPE
January 21, 2010
day of February , 2010.
TOM MARTIN, MAYOR
Resolution No. 2010—R0067
City of Lubbock Job Order
This Job Order is governed b) all terms and conditions of the Contract referenced below which is hereby
incorporated b) reference.
O\tiner: Wesley F\erett. Director of Facilities Management for— Parks & Recreation
N.1PA Contract No.: TX04-061908-TAL. National Joint Powers Alliance (NJPA), Indefinite Quantity
Construction Contract.
Contract Job Order No.: 10-015-P-015-NJPA
Contractor: Talon/LPF-
Date of Contract: September 25. 2008
Job Order Date: January 15, 2010
ProlCct Architect for this Job Ordcr: List name, phone number and firm name of Architect contracted for this
project. N/A
Sltnlnlary and Description of Statement of' Worl< attached hereto: Fiesta Plaza Precast Restroom Installation
Talon Job Order Number: 009516.00 hereto attached.
Value ol'pre-priced xxork: S 46,513.46
Value of non -pre -priced .work: S 323.28
Insurance Requirements per Exhibit A. attached.
I oral I; iNed Price stipulated suns fir this .lob Order (".lob Order Sunl"): S 46,836.74
'tiotice to Proceed Date Ior this .lob Order: To be issued after Citv Council approval
1=xpected Completion Date for this Job Order: To be determined after City Council approval
liquidated Damages (if clif'lerent than as set forth in Agreement): $25 per day
CONTRACTOR:
'talon/1_131-
13) :
PRIN 11=D NAME: BRIDGER I 10\k/ARD
TITLE: PROJECT MANAGER
COMPLETE ADDRESS:
CITY OF LUBBOCK, TEXAS (OWNER):
By:
MAYOR
ATTEST:
City Secretary
APPROVED AS TO CONTENT:
Company Talon/LPI-
Aciclress 921 N. Bivins Street Owne
CitN. State. lip Amarillo. TX 79107
AT"FES"I :
Corporate Secretary
Cit
TO FORM:
crt purcj,;u¢Il,uj)jic \\ Oik, comr,,cmig i„i, cider Conliac1% Wesley Everett, Director of Facilities 1 262010
Resolution No. 2010—R0067
(f,IQC
Detailed Scope of Work 11� 10
To: Select a Contractor Project Manager in People From: Select a TGG Project Manager in People
Date Printed: January 15, 2010
Work Order Number: 009516.00
Work Order Title: Lubbock - Fiesta Plaza Precast RR Installation
Brief Scope: Fiesta Plaza Precast Restroom Installation
The following items detail the scope of work as discussed at the site. All requirements necessary to accomplish the
items set forth below shall be considered part of this scope of work.
Detailed Scope:
SOW:
1. Plumbing to include 925' runof PEX water system connecting to modular restroom.
2. Install approximately 30' of 4" pvc sewer line.
3. Hook up plumbing as needed for bathrooms per plans.
4. Install (1) 100 amp, single phase, 240 volt circuit from the existing panel box east of the gazebo to the new restroom
building (up to 210').
5. Proposal is based on a 100 amp service b/c a 2 pole beaker is the largest bresker the existing panel will hold as a
branch breaker. If a larger circuit is needed, additional charges will apply.
6. Proposal is based on building being prewired and plumbed by others prior to installation.
7. This proposal is based on approximately 5 loads of import sand for backfill and 5 loads of native dirt to infill the
composting reservoir. An 18" X 18" concrete footing will be installed around the perimter of the building.
8. The existing building will be demolished and hauled offsite to a disposal facility.
Detailed Scope of Work Page 1 of 1
EZ/QC - Southwest 1/15/2010
Resolution No. 2010-R0067
Page 1 of 7 of Proposal - CSI -.i, —1 to% r ' 1
Contractor's Price Proposal Summary - CSI
Print Date: January 15, zu1u
Contract Number: TX04-061908-TAL
Work Order Number: 009516.00
Work Order Title: Lubbock - Fiesta Plaza Precast RR Installation
Contractor: Talon/LPE
Proposal Value: $ 46,836.74
Proposal Name: Lubbock - Fiesta Plaza Precast RR Installation
Subtotal for Section -01:
$18,037.79
Subtotal for Section -02:
$6,907.64
Subtotal for Section -03:
$2,739.06
Subtotal for Section -05:
$32.79
Subtotal for Section -15:
$14,531.13
Subtotal for Section -16:
$4,588.33
Proposal Total $46,836.74
This proposal total represents the correct total for the proposal. Any discrepancy between line totals,
sub -totals and the proposal total is due to rounding of the line totals and sub -totals.
The Percentage of NPP on this Proposal: 0.6902%
Price Proposal Summary - CSI Paqe 1 of 7
EZIQC - Southwest 1/15/2010
Page 2 of 7 of Proposal - CSI JQCjC:('
Contractor's Price Proposal Detail - CSI
Print Date:
January 15, 2010
Contract Number:
TX04-061908-TAL
Work Order Numbe 009516.00
Work Order Title:
Lubbock - Fiesta Plaza Precast RR Installation
Contractor:
Talon/LPE
Proposal Value:
$ 46,836.74
Proposal Name:
Lubbock - Fiesta Plaza Precast RR Installation
Record Section - Item ModiufierUOM Description
Line Total
Section -01
1 01352-0023
HR Plumber,Note: Line items in the CTC include appropriate costs to cover labor.
$11,258.41
These items will be requested specifically by the owner for miscellaneous work not
covered in the CTC.
Quantity Unit Price Factor
Total
Installation 240.00 x $36.28 x 1.2930 =
$11,258.41
2 01352-0029
HR Sprinkler Installer,Note: Line items in the CTC include appropriate costs to cover
$1,176.11
labor. These items will be requested specifically by the owner for miscellaneous
work not covered in the CTC.
Quantity Unit Price Factor
Total
Installation 20.00 x $45.48 x 1.2930 =
$1,176.11
3 01590-0213
WK 60" Wide, 1/3 CY Bobcat, With Full -Time Operator
$3,539.59
Quantity Unit Price Factor
Total
Installation 2.00 x $1,368.75 x 1.2930 =
$3,539.59
4 01590-0297
WK 1/2 To 5/8 CY, 65 HP, Loader -Backhoe, With Full -Time Operator
$2,063.68
Quantity Unit Price Factor
Total
Installation 1.00 x $1,596.04 x 1.2930 =
$2,063.68
Subtotal for Section -01:
$18,037.79
Section -02
5 02201-0002
EA Bobcat Delivery/Mob/DemobNote: Use for bobcat or similar sized equipment.
$130.44
Includes delivery fee, delivery, set-up and return.
Quantity Unit Price Factor
Total
Installation 1.00 x $100.88 x 1.2930 =
$130.44
6 02201-0003
EA Backhoe, Dozer Or Roller Up To 250 HP Delivery/Mob/DemobNote: Use for
$433.35
backhoe, dozer, roller, loader, excavator or similar sized equipment Includes
delivery fee, delivery, set-up and return.
Quantity Unit Price Factor
Total
Installation 1.00 x $335.15 x 1.2930 =
$433.35
7 02213-0003
CY Sand, Washed
$2,592.14
Quantity Unit Price Factor
Total
Installation 75.00 x $26.73 x 1.2930 =
$2,592.14
8 02215-0003
CY Over 12" Wide, Excavation for Trenching by Machine in Soil
$0.00
Quantity Unit Price Factor
Total
Installation 0.00 x $2.87 x 1.2930 =
$0.00
9 02215-0010
CY Backfilling or Placing Subbase for Trenches with Imported or Stockpiled Materials
$115.40
by Machine
Quantity Unit Price Factor
Total
Installation 75.00 x $1.19 x 1.2930 =
$115.40
Price Proposal Detail - CSI
Paqe 2 of 7
EZ/QC - Southwest
1/15/2010
Page 3 of 7 of Proposal - CSIIQCJI!
'CA(
Record Section - Item ModiufierUOM Description
Line Total
Section -02
10 02224-0051
LF Directional Boring For 3" (76 mm) Diameter Pipe, Horizontal, Underground
$1,501.82
Quantity Unit Price Factor
Total
Installation 50.00 x $23.23 x 1.2930 =
$1,501.82
11 02224-0068
LF 3" (76 mm) Steel Pipe Pull In Place By Boring Machine, Includes Pipe Welding
$476.47
Quantity Unit Price Factor
Total
Installation 50.00 x $7.37 x 1.2930 =
$476.47
12 02951-0003
EA Initial Set Up For Video Camera Inspection, Up To 12" Diameter Pipe Or Culvert
$346.92
Quantity Unit Price Factor
Total
Installation 1.00 x $268.31 x 1.2930 =
$346.92
13 02951-0010
LF 4" To 6" Diameter Pipe Inspection, Planning/Analysis PhaseNote: CCN inspection
$527.54
of pipe interior.
Quantity Unit Price Factor
Total
Installation 600.00 x $0.68 x 1.2930 =
$527.54
14 02951-0019
LF 4" To 6" Diameter Pipe Inspection, Pre -Rehabilitation PhaseNote: CCN inspection
$783.56
of pipe interior.
Quantity Unit Price Factor
Total
Installation 600.00 x $1.01 x 1.2930 =
$783.56
Subtotal for Section -02:
$6,907.64
Section -03
15 03210-0006
TON Grade 60 Reinforcing Steel, Footings And Slabs, #346
$745.00
Quantity Unit Price Factor
Total
Installation 0.40 x $1,440.45 x 1.2930 =
$745.00
16 03311-0009
CY Pour Continuous Footings, Direct Chute, 3000 PSI Concrete
$1,994.06
Quantity Unit Price Factor
Total
Installation 20.00 x $77.11 x 1.2930 =
$1,994.06
Subtotal for Section -03:
$2,739.06
Section -05
17 05506-0002
LF Unistrut Channel 1-5/8" Wide x 1-5/8" High, 12 Gauge
$32.79
Quantity Unit Price Factor
Total
Installation 4.00 x $6.34 x 1.2930 =
$32.79
Subtotal for Section -05:
$32.79
Section -15
18 15063-0391
LF 1/2" Inside Diameter (12 mm) Copper Pipe/Tubing Type L, Prices Include All
$230.41
Hangers And Couplings, Elbow, Tee, Reducer Fittings. All Hangers Are Complete
Assemblies
Quantity Unit Price Factor
_
Total
Installation 20.00 x $8.91 x 1.2930 =
$230.41
19 15063-0392
LF 3/4" Inside Diameter (20 mm) Copper Pipe/Tubing Type L, Prices Include All
$277.22
Hangers And Couplings, Elbow, Tee, Reducer Fittings. All Hangers Are Complete
Assemblies
Quantity Unit Price Factor
f Total
Installation 20,00 x $10.72 x 1.2930 =
$277.22
Price Proposal Detail - CSI Pape 3 of 7
EZ/QC - Southwest 1/15/2010
Page 4 of 7 of Proposal - CSI 1QC'
CIA(:1
Record Section - Item ModiufierUOM Description Line Total
Section -15
20 15063-0395 LF 1-1/2" Inside Diameter (40 mm) Copper Pipe/Tubing Type L, Prices Include All $415.05
Hangers And Couplings, Elbow, Tee, Reducer Fittings. All Hangers Are Complete
Assemblies
Quantity Unit Price t Factor Total
Installation 20.00 x $16.05 x 1.2930 = $415.05
21 15063-0396 LF 2" Inside Diameter (50 mm) Copper Pipe/Tubing Type L, Prices Include All $561.42
Hangers And Couplings, Elbow, Tee, Reducer Fittings. All Hangers Are Complete
Assemblies
Quantity Unit Price Factor Total
Installation 20.00 x $21.71 x 1.2930 = $561.42
22 15064-0340 LF 2" Pipe Schedule 40 PVC Socket Weld $84.30
Quantity Unit Price Factor Total
Installation 20.00 x $3.26 x 1.2930 = $84.30
23 15064-0343 LF 4" Pipe Schedule 40 PVC Socket Weld $196.79
Quantity Unit Price Factor Total
Installation 20.00 x $7.61 x 1.2930 = $196.79
24 15064-0366 EA 2" 45 Degree Elbow, PVC Schedule 40 Socket Weld $534.16
Quantity Unit Price Factor Total
Installation 20.00 x $19.43 x 1.2930 = $502.46
Demolition 2.00 x $12.26 x 1.2930 = $31.70
25 15064-0368 EA 3" 45 Degree Elbow, PVC Schedule 40 Socket Weld $155.63
Quantity Unit Price Factor Total
Installation 3.00 x $40.12 x 1.2930 = $155.63
26 15064-0379 EA 2" Tee, PVC Schedule 40 Socket Weld $217.30
Quantity Unit Price Factor Total
Installation 6.00 x $28.01 x 1.2930 = $217.30
27 15064-0449 EA 2" Coupling, PVC Schedule 40 Socket Weld $727.70
Quantity Unit Price Factor Total
Installation 30.00 x $18.76 x 1.2930 = $727.70
28 15064-0451 EA 3" Coupling, PVC Schedule 40 Socket Weld $3,364.26
Quantity Unit Price Factor Total
Installation 70.00 x $37.17 x 1.2930 = $3,364.26
29 15064-0452 EA 4" Coupling, PVC Schedule 40 Socket Weld $115.13
Quantity Unit Price Factor Total
Installation 2.00 x $44.52 x 1.2930 = $115.13
30 15064-1042 LF 1" Cross -Linked Polyethylene Tubing $7,271.83
Quantity Unit Price Factor Total
Installation 1,850.00 x $3.04 x 1.2930 = $7,271.83
Cross Link Tubing will be 2", 2" line item not available
31 15104-0022 EA 2" Ball Valve, PVC, Socket Weld, 150# $120.61
Quantity Unit Price Factor Total
Installation 2.00 x $46.64 x 1.2930 = $120.61
32 15104-0024 EA 3" Ball Valve, PVC, Socket Weld, 150# $259.32
Quantity Unit Price Factor Total
Installation 2.00 x $100.28 x 1.2930 = $259.32
Subtotal for Section -15: $14,531.13
Price Proposal Detail - CSI Paqe 4 of 7
EZ/QC - Southwest 1/15/2010
Page 5 of 7 of Proposal - CSI
Record Section - Item ModiufierUOM Description
( IQ
'A C (C
Line Total
33
16027
Time Clock Allowance
$323.25
Quantity Unit Price Factor
Total
NPP Task
Installation 1.00 x $250.00 x 1.2930 a
$323.25
34
16120-0114
MLF #6 AWG Cable - Type THHN-THWN, Underground Feeder And Branch Circuit
$368.50
Quantity Unit Price Factor
Total
Installation 0.22 x $1,295.43 x 1.2930 =
$368.50
35
16120-0117
MLF #1 AWG Cable - Type THHN-THWN, Underground Feeder And Branch Circuit
$2,977.90
Quantity Unit Price Factor
Total
Installation 0.66 x $3,489.53 x 1.2930 =
$2,977.90
36
16131-0868
LF 1-1/4" EMT Conduit, Mounted Exposed On Flat Wall
$21.98
Quantity Unit Price Factor
Total
Installation 5.00 x $3.40 x 1.2930 =
$21.98
37
16131-0934
EA 1-1/4" EMT Box Connector, Compression
$24.59
Quantity Unit Price Factor
Total
Installation 2.00 x $9.51 x 1.2930 =
$24.59
38
16131-1121
EA 1-1/4" IMC Coupling, Mounted Exposed On Flat Wall
$27.28
Quantity Unit Price Factor
Total
Installation 2.00 x $10.55 x 1.2930 =
$27.28
39
16131-1137
LF 1-1/4" PVC Schedule 40 Conduit With Coupling, Direct Burial, Glued Coupling
$621.80
Quantity Unit Price Factor
Total
Installation 210,00 x $2.29 x 1.2930 =
$621.80
40
16131-1150
EA 1-1/4" PVC Schedule 40 Elbow 90 Degree Direct Burial, Glued Coupling
$30.70
Quantity Unit Price Factor
Total
Installation 2.00 x $11.87 x 1.2930 =
$30.70
41
16131-1163
EA 1-1/4" PVC Schedule 40 Adapter, Direct Burial, Glued Coupling
$17.79
Quantity Unit Price Factor
Total
Installation 2.00 x $6.88 x 1.2930 =
$17.79
42
16131-1541
LF 1-1/4" Liquid Tight Flex Conduit
$16.71
Quantity Unit Price Factor
Total T
Installation 4.00 x $3.23 x 1.2930 =
$16.71
43
16131-1594
EA 1-1/4" Flexible Straight Connectors, Plain
$19.50
Quantity Unit Price Factor
Total
Installation 2.00 x $7.54 x 1.2930 =
$19.50
44
16190-0332
EA PVC Coated One Hole MI Conduit Strap, 1-1/4"
$20.71
Quantity Unit Price Factor
Total
Installation 2.00 x $8.01 x 1.2930 =
$20.71
45
16923-0060
EA 60 A / 2 Pole - 100 A / 2 Pole Bolt -On Branch Circuit Breaker
$117.62
Quantity Unit Price Factor
Total
Installation 1.00 x $90.97 x 1.2930 =
$117.62
Subtotal for Section -16:
$4,588.33
Proposal Total
$46,836.74
This proposal total represents the correct total for the proposal. Any discrepancy between line totals,
sub -totals and the proposal total is due to rounding of the line totals and sub -totals.
Price Proposal Detail - CSI Paqe 5 of 7
EZ/QC - Southwest 1/15/2010
Page 6 of 7 of Proposal - CSI IQCr
The Percent of NPP on this Proposal: 0.69016%
Price Proposal Detail - CSI Paqe 6 of 7
EZ/QC - Southwest 1/15/2010
Page 7 of 7 of Proposal - CSI
Subcontractor Listing
Date Printed: 1/15/2010
Work Order Number: 009516.00
Work Order Title: Lubbock - Fiesta Plaza Precast RR Installation
Amount: $ 46,836.74
IQC.
CIA(
Name of Contractor
Duties
Amount
No Subcontractors have been
$0.00
0.00
selected for this Work Order
Signature
Title
Firm or Corporate Name Talon/LPE
Address 921 N Bivins Street, , Amarillo TX 79107
Telephone Number
Date of Signing 15 -January -2010
Subcontractor Listing Pape 7 of 7
EZ/QC - Southwest 1/15/2010
Res. No. 2010—R0067
ACORD- CERTIFICATE
OF LIABILITY INSURANCE
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NISR
LTR
12123109(MM/DDIYYW
PRODUCER
POLICY NUMBER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Willis of Texas, Inc.
LIMITS
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1800 Washington, Suite 400
9
GENERAL LIABILITY
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P O Box 1149
12/31/10
EACH OCCURRENCE $1,000,000
Amarillo, TX 79105-1149
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Ironshore Specialty Ins. 25445
Talon/LPE, Ltd.
INSURER B: Ironshore Specialty Ins. 124
921 N. Bivins Street
INSURER c: Texas Mutual Insurance Company 22945
Amarillo, TX 79107
MED EXP (Any one person) S25,000
INSURERD: America First Insurance 12696
INSURER E:
CAVFRAnFC
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NISR
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DTE MMIDD
POLICY EXPIRATION
DATE M
LIMITS
A
GENERAL LIABILITY
000065300
12/31/09
12/31/10
EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED $300,000
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 51OCCUR
MED EXP (Any one person) S25,000
PERSONAL & ADV INJURY $1,000,000
X PD Ded:10,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/012 AGG $2,000,000
POLICY PRCT LOC
D
AUTOMOBILE LIABILITY
BA8369955
12/31/09
12/31/10
COMBINED SINGLE LIMIT
51,000,000
X ANY AUTO
(Eeaccident)
BODILY INJURY $
ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person)
BODILY INJURY $
X HIRED AUTOS
X NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG S
B
EXCESSIUMBRELLA LIABILITY
000065500
12/31/09
12/31/10
EACH OCCURRENCE S9 000 000
X OCCUR F1 CLAIMS MADE
AGGREGATE $9,000,000
S
$
DEDUCTIBLE
$
X RETENTION $10000
C
WORKERS COMPENSATION AND
TSF0001155583
12/31/09
12/31/10
X TORY WC LIMITATT OTH-
C
EMPLOYERS' LIABILITY
I -.L EACH ACCIDENT $1,000,000
ANY PROPRIETORIPARTNERJEXECUTIVE
E.L. DISEASE - EA EMPLOYEE $1,000,000
OFFICERIMEMBEREXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT $1,000,000
A
OTHER
000065300
12/31/09
12/31/10
$1,000,000 Occurrence
Professional Llab
$1,000,000 Aggregate
Pollution Liab
Claims Made
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 15PEGIAL PROVISIONS
It is hereby understood and agreed that the certificate holder is an
additional Insured on the general liability and the general liability is
primary. A waiver of subrogation applies on the general liability,
automobile and workers compensation coverage. The general liability does
(See Attached Descriptions)
TE
City of Lubbock
162513th Street
Lubbock, TX 79414
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL IQ_ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVE
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
DESCRIPTIONS (Continued from Page 1)
not exclude XCU Coverage.
aMc,2r, i mniinm 'A of a 11M799ao