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HomeMy WebLinkAbout6044 I BREMERTON PARKS & RECREATION DEPARTMENT 680 LEBO BLVD., BREMERTON, WA 98310 360.473.5305 MEMORANDUM May 13, 2020 TO: Mayor Wheeler FROM: Jeff Elevado Parks & Recreation Director I am requesting your approval and signature for the attached Change Order associated with Amendment 1 to the current PSA with Parametrix for Engineering Services for the Warren Ave. Playfield Renovation Project. The services associated with this amendment are for additional Engineering Services during construction. The original contract for Engineering Services did not include cost and budget associated with these "under construction" services. The Amendment and Change Order has been approved by Legal. Thank you, Jeff CITY OF BREMERTON CHANGE ORDER CONTRACT CHANGE ORDER NO: 6018-01 PROJECT NAME: Warren Avenue Playfield Renovation Project PROJECT NO: 59161 CONTRACTOR: Parametrix, Inc. ORIGINAL CONTRACT AMOUNT: 75,515.00 DAYS: 0 PREVIOUSLY APPROVED 0.00 DAYS: 0 CHANGES: THIS CHANGE: 5,003.00 DAYS: 0 REVISED CONTRACT AMOUNT: 80,518.00 DAYS: 0 This Change Order covers changes to the subject contract as described herein. The Contractor shall construct, furnish equipment and materials, and perform all work as necessary or required to complete the Change Order Items. The increase or decrease in contract price shown below includes any applicable taxes. DESCRIPTION OF CHANGES INCREASE IN (DECREASE) IN CONTRACT o CONTRACT CONTRACT TIME AMOUNT AMOUNT EXTENSION a) a) ($) ($) (DAYS:) Amendment#1 to include Engineering Service During 5,003.00 Construction NET CHANGE IN CONTRACT AMOUNT 5,003.00 INCREASE OR (DECREASE) ESTIMATED SALES TAX AT 9.0% NA TOTAL INCLUDING SALES TAX 5,003.00 Contractor acknowledges and accepts that this Change Order constitutes final settlement of all claims of any kind or nature arising from or connected with any work either covered or affected by this Change Order, including, without limitation, claims related to contract time, on-site or home office overhead, or lost profits. Nothing in this Change Order shall limit the City's right to bring a claim for past performance. The undersigned Contractor approves the foregoing Change Order as to the changes, if any, in the contract price specified for each item, including any and all supervision costs and other miscellaneous CONTRACT CHANGE ORDER NO: 6018-01 PROJECT NAME: Warren Ave. Playfield Renovation Project costs relating to the change in work, and as to the extension of time allowed, if any, for completion of the entire work due to said Change Order. This document will become a supplement of the contract and all provisions will apply hereto. It is understood that this Change Order shall be effective when approved by the City of Bremerton. The parties whose names appear below warrant that they are authorized to enter into a change order that is binding on the parties of this contract. In addition, Contractor warrants that it has or will inform the surety of this change, and shall take appropriate action to modify any bonds required under the contract to address this change. CONTRACTOR f , � 5/12/2020 Approved: .` DATE: J PROJECT MANP LER Recommended: DATE: CITY ENGINEER Council action is required as project cost will exceed approved budget. ❑ Yes RI No Council action is required as change exceeds Mayors authority per BMC 2.76.110. ❑ Yes Q No Recommended: DATE: DIRECTOR OF PARKS AND RECREATION Recommended: ra DATE: 5/tz/eau • MAYOR Approved: w DATE: S 1201202o APPROVED AS TO FORM: ATTEST: s/ Mychael Raya for: /013171zYCA -- ROGER A. LUBOVICH, Bremerton City Attorney ANGE HO VER, City Clerk R:\Legal\Legal\Forms\FORMS ON COBWEB\Change Order Rev. 10 2019.docx Page 2 of 2 Change Order Rev. 06/2018 Parametrix ENGINEERING.PLANNING.ENVIRONMENTAL SCIENCES AIMS 11111111MIIIIIIIIIIIIMIN EXHIBIT A - SCOPE OF WORK City of Bremerton Warren Avenue Playfield Amendment 1 — Engineering Services During Construction INTRODUCTION This document describes Parametrix's proposed scope of work for providing civil engineering services during construction for the project under Amendment 1 to our existing contract. A proposed schedule is included in this scope as Exhibit B and our proposed budget is attached as Exhibit C. TASK 4 — ENGINEERING SERVICES DURING CONSTRUCTION Objective Provide engineering support during the construction phase of the project. Activities The following activities are associated with this task: • Attend construction meetings as requested. • Review Contractor's submittals for compliance with the specifications. • Respond to applicable Contractor's Requests for Information (RFIs) and requests for change orders and make recommendations to the City. • Attend site walks at the request of the City. Deliverables The following deliverables are associated with this task: • Hard copies and electronic copies of responses to material submittals, cut sheets, and shop drawing review, revised design documents. Assumptions The following assumptions apply to this task: • Submittal reviews related to the Biopod will be performed under a separate contract. • Parametrix will review and respond to shop drawing submittals at an estimated 2 hours each, material submittals at an estimated 0.5 hour each, and RFIs at an estimated 1 hour each. It is assumed that a total of 4 shop drawings submittals, 12 materials submittals, and 2 RFIs will be reviewed (16 hours). City of Bremerton 233-1896-161 Warren Avenue Playfield 1 April 2020 SCOPE OF WORK (continued) • The Parametrix Project Manager and/or one lead staff will attend up to four site meetings at 2 hours each (8 hours). • Hours for support are 8 hours for the Parametrix Project Manager and 16 hours for the Design Engineer for a total of 24 engineer hours. City of Bremerton 233-1896-161 Warren Avenue Playfield 2 April 2020 SCOPE OF WORK (continued) Exhibit B- Schedule Work Element Completed By Notice to Proceed April 17, 2020 Engineering Services During Construction November 30, 2020 City of Bremerton 233-1896-161 Warren Avenue Playfield 3 April 2020 PARAMETRIX EXHIBIT C - BUDGET 4/22/2020 Project: Warren Avenue Playfield Construction Documents Client: City of Bremerton Public Works PMX# BILLING STAFF PM Eng III PC PA 233-1896-161 MULT.: D. Dinkuhn R.Fiala S. Harris L.Gilbertson TOTAL TOTAL Task Subtask 2300 3.10 Billing Rate $231.01 $137.11 $117.03 $123.23 HOURS COST 4 Engineering Services During Construction 8 16 4 4 32 $5,003 Subtotal 4 4 $5,003 PROJECT TOTAL $5,003 Prepared By: David Dinkuhn, P.E. Reviewed By: Dwight Miller, P.E. (Project Manager) (Division Manager) Amend 1 Warren Ave Budget 042220.xlsx Page 1 PURCHASE ORDER CHANGE REQUEST PO Number 19239 Date April 23, 2020 Vendor Parametrix, Inc. Vendor# 1489 Contract No./Job Description 6018 PSA for A&E Services-Warren Ave. Renovation Council Action Required ❑YES (Attach Agenda Bill) [] NO Original Contract Amount $ 75,515.00 Previous Change Orders $ - Amount of Current Change Add $ 5,003.00 Deduct Adjusted Contract Amount $ 80,518.00 Reason for Change: Amendment 1 to include Engineering Service During Construction Exhibit A - Scope of Work attached. CHANGE ORDER INSTRUCTIONS BASUB ELE OBJ PROJECT AMOUNT 594.76590 54110 59161 5,003.00 TOTAL $ 5,003.00 CERTIFICATION: I, the undersigned, do hereby certify that the authority levels and approvals of BMC 2.76 have been follow d. X e---Ort<7 C CHANGE ORDE APPROVAL CHANG ORDER PREPARER PURCHASING DIVISION USE ONLY Received/Update: Purchasing initials date Rev 5/14/14 PROFESSIONAL SERVICES AGREEMENT Warren Avenue Playfield Biopod The City of Bremerton("City") and Parametrix ("Consultant"), referred to collectively as the"Parties," enter into the following Agreement for professional services: I. Scope: The Consultant agrees to perform the services more specifically described in the Scope of Work, dated November 14th, 2019, including any attachments thereto, attached hereto as Exhibit A, which is incorporated by reference herein. The Scope of Work may be modified only pursuant to Section VII.H of this Agreement. If the Scope of Work provides for unspecified additional services such services shall only be performed upon the express written request of the City. Consultant further represents that the services furnished under this Agreement will be performed in accordance with generally accepted professional practices in effect at the time such services are performed. II. Term: The City and the Consultant agree that work will begin on the tasks described in Exhibit A immediately upon execution of this Agreement. The parties agree that the work described in Exhibit A is to be completed as provided for in the work schedule attached hereto as Exhibit B;provided however,that additional time shall be granted by the City for excusable delays or extra work as provided for in Section IX.A of this agreement. III. Compensation: In consideration of the services provided pursuant to this Agreement,the City shall pay Consultant in an amount not to exceed$7,000. Consultant's charges and bills shall conform to the fee schedule attached hereto as Exhibit C and incorporated herein by this reference. The Consultant shall submit regular billing statements detailing work performed and amount charged on each task or portion thereof. The descriptions shall conform to and fall within the categories set out in the Scope of Work and/or Fee Schedule. Upon receipt of a conforming billing statement, the City shall promptly process payment. PROVIDED, HOWEVER, the City reserves the right to prioritize scoped work and accelerate and/or delay work tasks under the time frame set forth in Section II herein. The Consultant's labor rates and billing fees shall be as delineated in Exhibit C. Consultant shall not perform work beyond the Scope of Work, nor shall be compensated for such work, unless the Scope of Work or amount of compensation is modified pursuant to this Agreement. Consultant shall only be compensated for additional services if requested pursuant to Section I and, if not otherwise provided, such compensation shall be in accordance with Exhibit C. If a billing statement does not conform to this Agreement,the City may withhold payment until the statement is brought into compliance. Such withholding does not relieve Consultant of its obligations under this Agreement. IV. Relationship of Parties: Consultant represents that it is skilled in the matters addressed in the Scope of Work and is performing independent functions and responsibilities within its field Page 1 of 7 Bremerton/jConsultantl f Proj ect Name'. Rev. 10/2019 of expertise. Consultant and its personnel are independent Consultants and not employees of the City. Consultant and its personnel have no authority to bind the City or to control the City's employees and other Consultants. None of the benefits provided by the City to its employees, including,but not limited to,compensation, insurance, and unemployment insurance are available from the City to the employees, agents, representatives, or sub-consultants of the Consultant. Consultant will be solely and entirely responsible for its acts and for the acts of Consultant's agents, employees, representatives and sub-consultants during the performance of this Agreement. The City may, during the term of this Agreement, engage other independent Consultants to perform the same or similar work. As an independent Consultant, Consultant is responsible for its own management. The City's administration and enforcement of this Agreement shall not be deemed an exercise of managerial control over Consultant or its personnel. As an independent Consultant, Consultant is responsible for payment of all taxes and licensing fees necessary to perform its obligations under this Agreement. These taxes and fees include but are not limited to State industrial insurance,Business&Occupation, State professional licensing, and City business licensing. If any taxes or fees due the City have been declared delinquent,the City may withhold the delinquent amount,plus any additional charges arising from the delinquency, from any payments due Consultant. V. Indemnification: A. Consultant shall defend, indemnify and hold the City, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits, including all legal costs and attorney fees, arising out of or in connection with the performance of this Agreement except for that portion of the injuries and damages caused by the City's sole negligence,unless Consultant is conducting work pursuant to Subsection B below. The City's review or acceptance of any of the work when completed shall not be grounds to avoid any of these covenants of indemnification. B. Architects, Engineers and Any Other Professional Listed In and Performing Services Defined in RCW 4.24.115. Should a court of competent jurisdiction determine that Consultant's services provided pursuant to this Agreement is subject to RCW 4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent negligence of the Consultant and the City, its officers, officials, employees, agents and volunteers, the Consultant's liability hereunder shall be only to the extent of the Consultant's negligence. IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE CONSULTANT'S WAIVER OF IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER. Page 2 of 7 Bremerton/[Consultantl JProject Name} Rev. 10/2019 The provisions of this section shall survive the expiration or termination of this Agreement. VI. Insurance: The Consultant shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which may arise from or in connection with the performance of the work hereunder by the Consultant, its agents, representatives, employees, sub-consultants or sub-contractors. Before beginning work on the project described in this Agreement, the Consultant shall provide a Certificate of Insurance evidencing: 1. Automobile Liability insurance with limits no less than $1,000,000 combined single limit per accident for bodily injury and property damage; and 2. Commercial General Liability insurance written on an occurrence basis with limits no less than $1,000,000 combined single limit per occurrence and general aggregate for personal injury, bodily injury and property damage. Coverage shall include but not be limited to: blanket contractual; products/completed operations/broad form property damage; explosion, collapse and underground (XCU) if applicable; and 3. Excess Liability insurance with limits not less than $1,000,000 limit per occurrence and aggregate; and 4. Professional Liability insurance with limits no less than $1,000,000 limit per occurrence/claim; and 5. Workers Compensation insurance as statutorily required by the Industrial Insurance Act of the State of Washington, Title 51, Revised Code of Washington and employer's liability with limits not less than$1,000,000. Any payment of deductible or self-insured retention shall be the sole responsibility of the Consultant. All required policies shall be provided on an "occurrence" basis except professional liability insurance(if required),which may be provided on a"claims-made"basis. The City shall be named as an additional insured on the Commercial General Liability insurance policy, as respects work performed by or on behalf of the Consultant and a copy of an endorsement that is acceptable to the City, which names the City as an additional insured shall be attached to the Certificate of Insurance. The City reserves the right to receive a certified copy of all the required insurance policies and endorsements. The City further reserves the right to reject any unacceptable policies and/or endorsements. The Consultant's Commercial General Liability insurance shall contain a clause stating that coverage shall apply separately to each insured against whom claim is made or suit is brought, except with respects to the limits of the insurer's liability. The Consultant's insurance shall be primary and non-contributory insurance as respects the City and shall contain a waiver of subrogation against the City for claims arising out of any operations, liabilities and obligations to which coverage applies. It shall be an affirmative Page 3 of 7 Bremerton/[Consultantl [Project Name.' Rev. 10/2019 obligation upon Consultant to advise the City's Risk Manager by fax at (360) 473-5161, or by certified mail, return receipt requested to City of Bremerton, Attn: Risk Management, 345 6th Street, Suite 100, Bremerton, WA 98337 within two days of the cancellation, suspension or substantive change of any insurance policy set out herein, and failure to do so shall be construed to be a breach of this Agreement. The City also reserves its unqualified right to require at any time and for any reason,proof of coverage in the form of a duplicate of the insurance policy with all endorsements as evidence of coverage. VII. General Conditions: A. Reports and Information: When requested by the City, Consultant shall furnish periodic reports and documents on matters covered by this Agreement. The reports and documents shall be furnished in the time and form requested. Consultant shall maintain accounting records in accordance with Generally Accepted Accounting Principles("GAAP")to substantiate all billed amounts. B. Ownership and Use of Records and Documents: Original documents, drawings, designs and reports, including those in electronic format, developed under this Agreement are the property of the City. All written information submitted by the City to the Consultant in connection with the services performed by the Consultant under this Agreement will be safeguarded by the Consultant to at least the same extent as the Consultant safeguards like information relating to its own business. If such information is publicly available or is already in Consultant's possession or known to it,or is rightfully obtained by the Consultant from third parties,Consultant shall bear no responsibility for its disclosure, inadvertent or otherwise. All data, documents and files created by Consultant under this Agreement may be stored at Consultant's office in Bremerton, Washington. Consultant shall make such data, documents, and files available to the City upon its request at all reasonable times for the purpose of editing, modifying and updating as necessary until such time as the City is capable of storing such information in the City's offices. Duplicate copies of this information shall be provided to the City upon its request, and at reasonable cost. All documents, including all reports, drawings, specifications, computer software or other items prepared or furnished by Consultant pursuant to this Agreement, are instruments of service with respect to the project and are the property of the City. Any reuse by the City for other than the specific purpose intended will be at City's sole risk. C. Use of Photographs and Images. Consultant shall not use or distribute photographs or images depicting City officials, personnel, property, or equipment whether prepared by Consultant or provided by City without prior written consent of the City. The City will not unreasonably withhold its consent. D. Work Performed at Consultant's Risk: Consultant shall take all precautions necessary and shall be responsible for the safety of its employees, agents, and sub-consultants in Page 4 of 7 Bremerton/[Consultantl [Project Namel Rev. 10/2019 the performance of the work hereunder and shall utilize all protection necessary for that purpose. All work shall be done at Consultant's own risk, and Consultant shall be responsible for any loss of or damage to materials,tools,or other articles used or held for use in connection with the work. E. Place of Work: The Consultant shall perform the work authorized under this Agreement at its offices in Bremerton, Washington. Meetings with the City staff as described in Exhibit A, Scope of Work, shall take place at the City's offices, or at locations mutually agreed upon by the parties. F. Entire Agreement: This Agreement and its Exhibits constitutes the entire agreement between the Parties, and the Parties acknowledge that there are no other agreements, written or oral, that have not been set forth in the text of this Agreement. G. Severability: Should any part of this Agreement be found void, the balance of the Agreement shall remain in full force and effect. H. Modification: This Agreement may only be modified by written instrument signed by both Parties. I. Written Notices: All communications regarding this Agreement shall be sent to the parties at the addresses listed below by registered or 1st class mail, or by personal service, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may be hereafter specified in writing. Notices to be sent to: Notices to be sent to: CITY: CONSULTANT: Attn: Chance Berthiaume Attn: David Dinkuhn, P.E. City of Bremerton 60 Washington Ave 345 6t'Street, Suite 100 Bremerton, WA 98337 Bremerton, WA 98337-1891 J. Waiver: Failure to enforce any provision of this Agreement shall not be deemed a waiver of that provision. Waiver of any right or power arising out of this Agreement shall not be deemed waiver of any other right or power. K. Non-Waiver of Breach: The failure of the City to insist upon strict performance of any of the covenants and agreements contained herein, or to exercise any option herein conferred in one or more instances shall not be construed to be a waiver or relinquishment of said covenants, agreements or options, and the same shall be and remain in full force and effect. L. Compliance with Laws: Consultant shall comply with all applicable Federal,State, and local laws in performing its obligations under this Agreement. Page 5 of 7 Bremerton/[Consultantl [Project Name] Rev. 10/2019 M. Choice of Law and Venue: This Agreement shall be interpreted according to the laws of the State of Washington. Any judicial action to resolve disputes arising out of this Agreement shall be brought in Kitsap County Superior Court. N. Attorneys' Fees: In the event of litigation to enforce any of the terms or provisions herein, each party shall pay all its own costs and attorney's fees. O. Assignment: Any assignment of this agreement by the Contractor without the written consent of the City shall be void. VIII. Nondiscrimination: Consultant shall not discriminate in employment or services to the public on the basis of race, color, national origin, sex, religion, age, marital status, disability, or sexual orientation except for employment actions based on bona fide occupational qualification. IX. Termination: This Agreement shall remain in force until completion and acceptance of the services, terminated by written instrument upon mutual consent, or by the City of Bremerton for convenience. This Agreement may be immediately terminated for cause by a Party if the other Party substantially fails to perform through no fault of the terminating Party, and the non- performing Party does not commence correction of the failure of performance within thirty (30) days of the terminating Party's sending notice to the non-performing Party. Any Notice by Consultant shall include a report showing the status of all items listed in the Scope of Work current through the termination date. If the City receives reimbursement by any federal, state,or other source for work described in Section I herein, and that funding is withdrawn,reduced or limited in any way, or the project is cancelled or substantially reduced after the execution date of this Agreement and prior to the completion of the work,the City may summarily terminate this Agreement. A. Excusable Delays: The right of Consultant to proceed shall not be terminated nor shall Consultant be charged with liquidated damages for any delays in the completion of the work due to: 1)any acts of the federal government in controlling,restricting,or requisitioning materials, equipment,tools, or labor by reason of war, national defense, or other national emergency; 2)any acts of the City, its consultants, or other public agencies causing such delay; and 3) causes not reasonably foreseeable by the parties at the time of the execution of the Agreement that are beyond the control and without the fault or negligence of the Consultant, including, but not restricted to, acts of God, fires, floods, strikes, or weather of unusual severity. PROVIDED, HOWEVER, that the Consultant must promptly notify the City within ten(10)calendar days in writing of the cause of the delay. If, on the basis of the facts and the terms of this Agreement, the delay is properly excusable, the City shall, in writing, extend the time for completing the work for a period of time commensurate with the period of excusable delay. B. Rights Upon Termination: In the event of termination, the City shall pay for all services performed by the Consultant to the effective date of termination, as described on a final invoice submitted to the City. After termination, the City may take possession of all records and data within the Consultant's possession pertaining to this project which may be used by the City Page 6 of 7 Bremerton/[Consultant] [Project Namel Rev. 10/2019 without restriction. Any such use not related to the project which Consultant was contracted to perform shall be without liability or legal exposure to the Consultant. 1 X. Suspension & Debarment. For contracts involving Federal funding, Consultant hereby certifies, by signing this agreement, that neither it nor its principals are presently debarred, suspended,proposed for debarment,declared ineligible,or voluntarily excluded from participation in this transaction by any Federal department or agency. Consultant shall provide immediate written notice to the City if at any time it learns that it is or has become ineligible for certification. Should Consultant enter into a covered transaction with another firm,Consultant agrees by signing this agreement that it will verify that the firm with whom it intends to do business is not debarred, suspended, ineligible, excluded or disqualified. IN WITNESS WHEREOF,the parties below have executed this Agreement. CITY: CONSULTANT: CITY OF BREMERTON Parametrix Inc. By: By:afr - i Print Name:Thomas Knuckey PrinVame: mi/l� Y Its: Public Works.&Utilities Director Its: Cr— Date: rDate: I/127 0 Date: ®A? APPROVED AS TO FORM: ATTEST: By: r c v— By: Roger . Lubovich, Bremerton City-Attorney Angela Hoov City Clerk R:\Legal\Legal\Forms1 FORMS ON COBWEB\Professional Services Agreement Rev. 10 2019.docx Page 7 of 7 Bremerton/f Consultantl fProject Namel Rev. 10/2019 Parametrix ENGINEERING_PLANNING ENVIRONMENTAL SCIENCES EXHIBIT A SCOPE OF WORK City of Bremerton Warren Avenue Playfield Biopod INTRODUCTION This exhibit presents Parametrix's proposed scope of work(SOW)for preparation of construction plans, specifications, and engineers estimate (PS&E)for the addition of a stormwater treatment device to the City's Warren Avenue Playfield Construction Documents project.The work includes installation of a Biopod treatment vault to treat stormwater runoff from the project's new parking lot.A proposed schedule for the work is provided in Exhibit B and our proposed budget is attached as Exhibit C. The following tasks are associated with this SOW. Task 1 — Engineering Design and Construction Support Objective To incorporate a stormwater treatment device into the project to treat runoff from the new parking lot. Activities The following activities will be performed as part of this task: • Perform streamlined hydrologic modelling effort to determine runoff flow rates. • Coordinate with the Biopod vendor(Oldcastle)to select the appropriate size of vault to treat 91%of the parking lot runoff as required by the Ecology stormwater manual. • Add a catch basin, conveyance piping, and Biopod vault to the project's 90%complete and final PS&Es. Construction costs for the work will be placed in a separate bid schedule so that they can be tracked separately. Deliverables The following deliverables will be prepared: • Draft and final hydrologic model results technical memorandum • 90%and final plan sheets (1 plan sheet and 1 detail sheet, 2 total) • 90%and final specifications and cost estimates. • Review response to Biopod shop drawing submittal during construction City of Bremerton 233-1896-8BB Warren Avenue Playfield Biopod 1 November 2019 SCOPE OF WORK (continued) Assumptions The following assumptions apply to this task: • The Biopod vault will be placed in the new 6-foot-wide planter adjacent to the parking lot. • The Biopod will be planted with a drought tolerant shrub. Irrigation will not be provided.A watering bag will be provided for the shrub. • AutoCAD and PDF files of all drawings and documents will be provided on CD. City of Bremerton 233-1896-8BB Warren Avenue Playfield Biopod 2 November 2019 SCOPE OF WORK (continued) EXHIBIT B — SCHEDULE Work Element Completed By Notice to Proceed November 21, 2019 Hydrology TM (3 weeks) December 12, 2019 90% PS&E(3 weeks) December 12, 2019 Final PS&E (4 weeks) January 8, 2020 Construction NOTE:The assumed turnaround time for City review of deliverables is 1 week. City of Bremerton 233-1896-8BB Warren Avenue Playfield Biopod 3 November 2019 EXHIBIT C Client:City of Bremerton Project:Warren Avenue Playfield Biopod Project No:P23318968BB rE C fa s u y p u fa Y _, an a1 2 c J 0 m 0] — C C J CO 0 0 -0 C Q C N > a N Ln 0 Q Y J_C CO COO cc 2O C a a, .> fa N al C fl_ p O n U c U c fa c _ Q _ O — v v v u c u C a, a1 o — ca c p U 3 H d Cl N at 0 In W Burdened Rates: $116.65 $231.19 $109.88 $106.76 $122.83 $136.67 Task Description Labor Dollars Labor Hours 01 Engineering Design and Construction Support $5,891.49 38 4 11 1 6 4 12 Labor Totals: $5,891.49 38 4 11 1 6 4 12 Totals: $5,891.49 $466.60 $2,543.09 $109.88 $640.56 $491.32 $1,640.04 Project Total $5,891.49 11/15/2019 WarrenAveBiopod_BudgetReport_P23318968BBv11-1.xlsx A ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 11/21/2019 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 Dealey, Renton&Associates PHONE FAX P. O. Box 12675 (wc.No.Ext)• 510-465-3090 (A/c,No):510-452-2193 Oakland, CA 94604-2675 ADDRESS: certificates@dealeyrenton.com License#0020739 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Fire Insurance Co of Hartford 20478 INSURED PARAINC-01 INSURER B:Continental Insurance Company 35289 Parametrix, Inc. 1019 39th Ave. SE Suite 100 INSURER c:American Casualty Company of Reading PA 20427 Puyallup,WA 98374 INSURER D:XL Specialty Insurance Co. 37885 (253)604-6600 INSURER E:Valley Forge Insurance Company 20508 INSURER F: COVERAGES CERTIFICATE NUMBER:1617630199 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY Y Y 6050531366 11/1/2019 11/1/2020 EACH OCCURRENCE $1,000,000 DAMAGE RETED CLAIMS-MADE X OCCUR PREM SESO(Ea occurrence) $1,000,000 X Contractual Liab MED EXP(Any one person) $10,000 X XCU Included PERSONAL&ADV INJURY $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JERCOT LOC PRODUCTS-COMP/OPAGG $2,000,000_ X OTHER: WA Stop Gap/EL WA Stop Gap $1,000,000 E AUTOMOBILE LIABILITY Y Y 6050531352 11/1/2019 11/1/2020 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS x HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ B X UMBRELLA LIAB X OCCUR 6050531433 11/1/2019 11/1/2020 EACH OCCURRENCE $15,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $15,000,000 DED X RETENTION$n $ C WORKERS COMPENSATION Y 6050531383 11/1/2019 11/1/2020 X STATUTE EORH WA STOP GAP C AND EMPLOYERS'LIABILITY Y/N 6050531402 11/1/2019 11/1/2020 ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Professional Liability DPR9932956 11/1/2019 11/1/2020 Per Claim $1,000,000 Claims Made Annual Aggregate $1,000,000 Pollution Liability Included Retroactive Date: 01/01/1969 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Umbrella Liability policy is a follow-form to underlying General Liability/Auto Liability/Employers Liability. RE:Project No.233-1896-BBJ-Warren Avenue Playfield Biopod City of Bremerton is named as an additional insured as respects general and auto liability as required per written contract or agreement.General and Auto Liability are Primary/Non-Contributory per policy form wording.Insurance coverage includes waiver of subrogation per the attached endorsement(s). CERTIFICATE HOLDER CANCELLATION 30 Days Notice of Cancellation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Bremerton ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Chance W. Berthiaume 345 6th Street, Suite 100 AUTHORIZED REPRESENTATIVE Bremerton WA 98337 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CNA CNA PARAMOUNT Blanket Additional Insured - Owners, Lessees or Contractors - with Products-Completed Operations Coverage Endorsement This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART It is understood and agreed as follows: I. The WHO IS AN INSURED section is amended to add as an Insured any person or organization whom the Named Insured is required by written contract to add as an additional insured on this coverage part, including any such person or organization, if any, specifically set forth on the Schedule attachment to this endorsement. However, such person or organization is an Insured only with respect to such person or organization's liability for: A. unless paragraph B. below applies, 1. bodily injury, property damage, or personal and advertising injury caused in whole or in part by the acts or omissions by or on behalf of the Named Insured and in the performance of such Named Insured's ongoing operations as specified in such written contract; or 2. bodily injury or property damage caused in whole or in part by your work and included in the products- completed operations hazard, and only if a. the written contract requires the Named Insured to provide the additional insured such coverage; and b. this coverage part provides such coverage. B. bodily injury, property damage, or personal and advertising injury arising out of your work described in such written contract, but only if: 1. this coverage part provides coverage for bodily injury or property damage included within the products completed operations hazard; and 2. the written contract specifically requires the Named Insured to provide additional insured coverage under the 11-85 or 10-01 edition of CG2010 or the 10-01 edition of CG2037. II. Subject always to the terms and conditions of this policy, including the limits of insurance, the Insurer will not provide such additional insured with: A. coverage broader than required by the written contract;or B. a higher limit of insurance than required by the written contract. III. The insurance granted by this endorsement to the additional insured does not apply to bodily injury, property damage, or personal and advertising injury arising out of: A. the rendering of, or the failure to render, any professional architectural, engineering, or surveying services, including: 1. the preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and 2. supervisory, inspection, architectural or engineering activities; or B. any premises or work for which the additional insured is specifically listed as an additional insured on another endorsement attached to this coverage part. IV. Notwithstanding anything to the contrary in the section entitled COMMERCIAL GENERAL LIABILITY CONDITIONS, the Condition entitled Other Insurance, this insurance is excess of all other insurance available to the additional insured whether on a primary, excess, contingent or any other basis. However, if this insurance is required by written CNA75079XX(1-15) Policy No: 6050531366 Page 1 of 2 Endorsement No: 5 Nat'1 Fire Ins Co of Hartford Insured Name: PARAMETRIX, INC. Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office,Inc.,with its permission. CNA CNA PARAMOUNT Blanket Additional Insured - Owners, Lessees or Contractors - with Products-Completed Operations Coverage Endorsement contract to be primary and non-contributory, this insurance will be primary and non-contributory relative solely to insurance on which the additional insured is a named insured. V. Solely with respect to the insurance granted by this endorsement, the section entitled COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: The Condition entitled Duties In The Event of Occurrence, Offense, Claim or Suit is amended with the addition of the following: Any additional insured pursuant to this endorsement will as soon as practicable: 1. give the Insurer written notice of any claim, or any occurrence or offense which may result in a claim; 2. except as provided in Paragraph IV. of this endorsement, agree to make available any other insurance the additional insured has for any loss covered under this coverage part; 3. send the Insurer copies of all legal papers received, and otherwise cooperate with the Insurer in the investigation, defense, or settlement of the claim; and 4. tender the defense and indemnity of any claim to any other insurer or self insurer whose policy or program applies to a loss that the Insurer covers under this coverage part. However, if the written contract requires this insurance to be primary and non-contributory, this paragraph (4) does not apply to insurance on which the additional insured is a named insured. The Insurer has no duty to defend or indemnify an additional insured under this endorsement until the Insurer receives written notice of a claim from the additional insured. VI. Solely with respect to the insurance granted by this endorsement, the section entitled DEFINITIONS is amended to add the following definition: Written contract means a written contract or written agreement that requires the Named Insured to make a person or organization an additional insured on this coverage part, provided the contract or agreement: A. is currently in effect or becomes effective during the term of this policy; and B. was executed prior to: 1. the bodily injury or property damage; or 2. the offense that caused the personal and advertising injury for which the additional insured seeks coverage. Any coverage granted by this endorsement shall apply solely to the extent permissible by law. All other terms and conditions of the Policy remain unchanged. This endorsement,which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy. CNA75079XX(1-15) Policy No: 6050531366 Page 2 of 2 Endorsement No: 5 Nat'l Fire Ins Co of Hartford Insured Name: PARAMETRIX, INC. Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office,Inc.,with its permission. CNA CNA PARAMOUNT Waiver of Transfer of Rights of Recovery Against Others to the Insurer Endorsement This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: ANY PERSON OR ORGANIZATION WHOM THE NAMED INSURED HAS AGREED IN WRITING IN A CONTRACT OR AGREEMENT TO WAIVE SUCH RIGHTS OF RECOVERY, BUT ONLY IF SUCH CONTRACT OR AGREEMENT: 1. IS IN EFFECT OR BECOMES EFFECTIVE DURING THE TERM OF THIS COVERAGE PART; AND 2. WAS EXECUTED PRIOR TO THE BODILY INJURY, PROPERTY DAMAGE OR PERSONAL AND ADVERTISING INJURY GIVING RISE TO THE CLAIM. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. It is understood and agreed that the condition entitled Transfer Of Rights Of Recovery Against Others To The Insurer is amended by the addition of the following: Solely with respect to the person or organization shown in the Schedule above, the Insurer waives any right of recovery the Insurer may have against such person or organization because of payments the Insurer makes for injury or damage arising out of the Named Insured's ongoing operations or your work done under a contract with that person or organization and included in the products-completed operations hazard. All other terms and conditions of the Policy remain unchanged. E, This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy. CNA75008XX(1-15) Policy No: 6050531366 Page 1 of 1 Endorsement No: 7 Nat'l Fire Ins Co of Hartford Insured Name: PARAMETRIX, INC. Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Business Auto Policy Y Policy Endorsement CONTRACTORS EXTENDED COVERAGE ENDORSEMENT - BUSINESS AUTO PLUS THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM I. LIABILITY COVERAGE A. Who Is An Insured The following is added to Section II, Paragraph A.1., Who Is An Insured: 1. a. Any incorporated entity of which the Named Insured owns a majority of the voting stock on the date of inception of this Coverage Form; provided that, b. The insurance afforded by this provision A.1. does not apply to any such entity that is an insured under any other liability "policy" providing auto coverage. 2. Any organization you newly acquire or form, other than a limited liability company, partnership or joint venture, and over which you maintain majority ownership interest. The insurance afforded by this provision A.2.: a. Is effective on the acquisition or formation date, and is afforded only until the end of the policy period of this Coverage Form, or the next anniversary of its inception date, whichever is earlier. b. Does not apply to: (1) Bodily injury or property damage caused by an accident that occurred before you acquired or formed the organization; or (2) Any such organization that is an insured under any other liability "policy" providing auto coverage. 3. Any person or organization that you are required by a written contract to name as an additional insured is an insured but only with respect to their legal liability for acts or omissions of a person, who qualifies as an insured under SECTION II — WHO IS AN INSURED and for whom Liability Coverage is afforded under this policy. If required by written contract, this insurance will be primary and non-contributory to insurance on which the additional insured is a Named Insured. 4. An employee of yours is an insured while operating an auto hired or rented under a contract or agreement in that employee's name, with your permission, while performing duties related to the conduct of your business. "Policy", as used in this provision A. Who Is An Insured, includes those policies that were in force on the inception date of this Coverage Form but: 1. Which are no longer in force; or 2. Whose limits have been exhausted. B. Bail Bonds and Loss of Earnings Section II, Paragraphs A.2. (2) and A.2. (4) are revised as follows: 1. In a.(2), the limit for the cost of bail bonds is changed from $2,000 to $5,000; and 2. In a.(4), the limit for the loss of earnings is changed from $250 to $500 a day. Form No: CNA63359XX(04-2012) Policy No: 6050531352 Page: 1 of 4 Policy Effective Date: 11/01/2019 Underwriting Company: The Continental Insurance Company, 151 N Franklin St, Chicago, IL 60606 °Copyright CNA All Rights Reserved. Includes copyrighted material of the Insurance Services Office, Inc., used with its permission. CNA Business Auto Policy Policy Endorsement C. Fellow Employee Section II, Paragraph B.5 does not apply. Such coverage as is afforded by this provision C. is excess over any other collectible insurance. II. PHYSICAL DAMAGE COVERAGE A. Glass Breakage - Hitting A Bird Or Animal - Falling Objects Or Missiles The following is added to Section III, Paragraph A.3.: With respect to any covered auto, any deductible shown in the Declarations will not apply to glass breakage if such glass is repaired, in a manner acceptable to us, rather than replaced. B. Transportation Expenses Section III, Paragraph A.4.a. is revised, with respect to transportation expense incurred by you, to provide: a. $60 per day, in lieu of $20; subject to b. $1,800 maximum, in lieu of $600. C. Loss of Use Expenses Section III, Paragraph A.4.b. is revised, with respect to loss of use expenses incurred by you, to provide: a. $1,000 maximum, in lieu of $600. D. Hired "Autos" The following is added to Section III. Paragraph A.: 5. Hired "Autos" If Physical Damage coverage is provided under this policy, and such coverage does not extend to Hired Autos, then Physical Damage coverage is extended to: a. Any covered auto you lease, hire, rent or borrow without a driver; and b. Any covered auto hired or rented by your employee without a driver, under a contract in that individual employee's name, with your permission, while performing duties related to the conduct of your business. c. The most we will pay for any one accident or loss is the actual cash value, cost of repair, cost of replacement or $75,000, whichever is less, minus a $500 deductible for each covered auto. No deductible applies to loss caused by fire or lightning. d. The physical damage coverage as is provided by this provision is equal to the physical damage coverage(s) provided on your owned autos. e. Such physical damage coverage for hired autos will: (1) Include loss of use, provided it is the consequence of an accident for which the Named Insured is legally liable, and as a result of which a monetary loss is sustained by the leasing or rental concern. (2) Such coverage as is provided by this provision will be subject to a limit of $750 per accident. E. Airbag Coverage The following is added to Section III, Paragraph B.3.: The accidental discharge of an airbag shall not be considered mechanical breakdown. Form No: CNA63359XX (04-2012) Policy No: 6050531352 Page: 2 of 4 Policy Effective Date: 11/01/2019 Underwriting Company: The Continental Insurance Company, 151 N Franklin St, Chicago, IL 60606 ©Copyright CNA All Rights Reserved. Includes copyrighted material of the Insurance Services Office, Inc., used with its permission. CNA Business Auto Policy Policy Endorsement F. Electronic Equipment Section III, Paragraphs B.4.c and B.4.d. are deleted and replaced by the following: c. Physical Damage Coverage on a covered auto also applies to loss to any permanently installed electronic equipment including its antennas and other accessories d. A $100 per occurrence deductible applies to the coverage provided by this provision. G. Diminution In Value The following is added to Section III, Paragraph B.6.: Subject to the following, the diminution in value exclusion does not apply to: a. Any covered auto of the private passenger type you lease, hire, rent or borrow, without a driver for a period of 30 days or less, while performing duties related to the conduct of your business; and b. Any covered auto of the private passenger type hired or rented by your employee without a driver for a period of 30 days or less, under a contract in that individual employee's name, with your permission, while performing duties related to the conduct of your business. c. Such coverage as is provided by this provision is limited to a diminution in value loss arising directly out of accidental damage and not as a result of the failure to make repairs; faulty or incomplete maintenance or repairs; or the installation of substandard parts. d. The most we will pay for loss to a covered auto in any one accident is the lesser of: (1) $5,000; or (2) 20% of the auto's actual cash value (ACV). III. Drive Other Car Coverage — Executive Officers The following is added to Sections II and III: 1. Any auto you don't own, hire or borrow is a covered auto for Liability Coverage while being used by, and for Physical Damage Coverage while in the care, custody or control of, any of your "executive officers", except: a. An auto owned by that "executive officer" or a member of that person's household; or b. An auto used by that "executive officer" while working in a business of selling, servicing, repairing or parking autos. Such Liability and/or Physical Damage Coverage as is afforded by this provision. (1) Equal to the greatest of those coverages afforded any covered auto; and (2) Excess over any other collectible insurance. 2. For purposes of this provision, "executive officer" means a person holding any of the officer positions created by your charter, constitution, by-laws or any other similar governing document, and, while a resident of the same household, includes that person's spouse. Such "executive officers" are insureds while using a covered auto described in this provision. IV. BUSINESS AUTO CONDITIONS A. Duties In The Event Of Accident, Claim, Suit Or Loss The following is added to Section IV, Paragraph A.2.a.: Form No: CNA63359XX (04-2012) Policy No:6050531352 Page: 3 of 4 Policy Effective Date: 11/01/2019 Underwriting Company: The Continental Insurance Company, 151 N Franklin St, Chicago, IL 60606 ©Copyright CNA All Rights Reserved. Includes copyrighted material of the Insurance Services Office, Inc., used with its permission. CNA Business Auto Policy Policy Endorsement (4) Your employees may know of an accident or loss. This will not mean that you have such knowledge, unless such accident or loss is known to you or if you are not an individual, to any of your executive officers or partners or your insurance manager. The following is added to Section IV, Paragraph A.2.b.: (6) Your employees may know of documents received concerning a claim or suit. This will not mean that you have such knowledge, unless receipt of such documents is known to you or if you are not an individual, to any of your executive officers or partners or your insurance manager. B. Transfer Of Rights Of Recovery Against Others To Us The following is added to Section IV, Paragraph A.5. Transfer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have, because of payments we make for injury or damage, against any person or organization for whom or which you are required by written contract or agreement to obtain this waiver from us. This injury or damage must arise out of your activities under a contract with that person or organization. You must agree to that requirement prior to an accident or loss. C. Concealment, Misrepresentation or Fraud The following is added to Section IV, Paragraph B.2.: Your failure to disclose all hazards existing on the date of inception of this Coverage Form shall not prejudice you with respect to the coverage afforded provided such failure or omission is not intentional. D. Other Insurance The following is added to Section IV, Paragraph B.5.: Regardless of the provisions of Paragraphs 5.a. and 5.d. above, the coverage provided by this policy shall be on a primary non-contributory basis. This provision is applicable only when required by a written contract. That written contract must have been entered into prior to Accident or Loss. E. Policy Period, Coverage Territory Section IV, Paragraph B. 7.(5).(a). is revised to provide: a. 45 days of coverage in lieu of 30 days. V. DEFINITIONS Section V. paragraph C. is deleted and replaced by the following: Bodily injury means bodily injury, sickness or disease sustained by a person, including mental anguish, mental injury or death resulting from any of these. Form No: CNA63359XX (04-2012) Policy No: 6050531352 Page:4 of 4 Policy Effective Date: 11/01/2019 Underwriting Company: The Continental Insurance Company, 151 N Franklin St, Chicago, IL 60606 ©Copyright CNA All Rights Reserved. Includes copyrighted material of the Insurance Services Office, Inc., used with its permission. CNA Workers Compensation And Employers Liability Insurance Policy Endorsement WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT I 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 shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Any Person or Organization on whose behalf you are required to obtain this waiver of our right to recover from under a written contract or agreement. The premium charge for the endorsement is reflected in the Schedule of Operations. All other terms and conditions of the policy remain unchanged. This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below. Form No: WC 00 03 13 104-19841 Policy No:6 50531402 Endorsement No: 3; Page: 1 of 1 Underwriting Company: American Casualty Company of Reading, Pennsylvania, 333 S Wabash Ave, Chicago, IL 60604 Copyright 1983 National Council on Compensation Insurance.