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HomeMy WebLinkAboutContract 39912 (2)STATE OF TEXAS COUNTY OF TARRANT 1. Parties CITY SECREThjaRY3 CONTRACT NO,_01 WEATI3ERIZATION ASSISTANCE PROGRAM CONTRACT FOR SERVICES Between This Contract is made and entered into by and between the City of Fort Worth ("City"), acting by and through T. M. Higgins, its duly authorized Assistant City Manager, and KB Remodeling ("Contractor"), by and through its duly authorized representative. Contractor's business address is: 8003 East Melrose White Settlement, TX 76108 2. Purpose The Weatherization Assistance Program is designed to help households reduce energy costs by providing energy conservation measures to the dwelling while protecting the health and safety of the client. Eligible dwellings will be assessed and an Energy Audit conducted and/or the Priority List will be used to determine the various measures to be installed by the Contractor at the each dwelling to make it energy efficient. The basic objectives of the program are: To assist the low-income families in lowering their energy consumption, and subsequently, their energy costs' Increase comfort levels, improve health, safety & well being of clients in dwellings weatherized; and Promote energy conservation 3. Term The Term of this Contract will be for a twelve (12) month period from March 9, 2010 to March 9, 2011.This Contract may be renewed/extended for two (2) additional, twelve (12) month periods subject to the availability of grant funding, vendor performance and mutual agreement by all parties, and the approval of the City. All renewals/extensions shall be based on existing terms, conditions, and price structures set forth in original proposal award or as amended by the City. 4. Incorporated Documents The following documents are incorporated by reference as if fully reproduced herein: Request for Proposal RFP No. 09-0207, hereinafter referred to as (RFP); Contractor (s) Response to RFP; Final Negotiated Cost; *If there shall be any conflict between the terms and conditions presented uin the RFP and this Contract, this Contract shall control. CITY SECRE Aft : �� Ft, WORTH,T 1 5. Scope of Services Contractor shall perform the following services, including, without limitation as listed below under general requirements and scope of services The City and Contractor may modify the scope of work from time to time upon mutual written agreement between County and Contractor. General Requirements/Scope of Services and other Measures: The Contractor must read and understand energy audits and work orders generated by the City's Department of Housing and Economic Development ("HED"). The Contractor must applying and obtain all permits prior to installation of weatherization measures with the appropriate jurisdiction for all work performed under this Contract that requires a permit. The Contractor shall arrange for inspections with appropriate local inspectors. All permits shall be billed as pass through cost and listed as a separated line item on invoice. When applicable the Contract shall indicate charge to be paid by City for overhead costs related to obtaining any building permit required by the work items related to services being provided The Contractor must provide proper documentation with each client invoice in order to support payment of permit. Failure to provide the supporting proof documentation will result in non-payment permit expenditure. Using blower door guided air -sealing approaches the Contractor must perform blower door test before submitting the unit for payment to HED and record a final blower door reading for each unit; the Contractor shall install weather-stripping caulking and switch/outlet gaskets to reduce air exchange rates in eligible dwellings and program measures designed to preserve the integrity of the home's thermal envelope, reduce appliance energy consumption and ensure resident's health and safety include the following: Contractor shall provide all labor, material, supplies and equipment to perform the following energy conservation measures on program eligible dwellings that includes but is not be limited to the following: • Insulation of walls, attics, crawl space, switches, outlets, etc. • Blower door testing and flue gas analysis. • Air bypass sealing • Attic, basement, crawl -space, and dense -pack sidewall insulation • Caulking and weather-stripping • Window and door repair and replacement • Duct leakage sealing • Shell infiltration sealing (replaced broken windows, replace interior/exterior doors and windows, weather stripping, caulking, etc • Insulation of water heater and water heater pipes • Attic ventilation • Solar screens • Minor home repairs • Carpentry • Health and Safety measures (testing of combustion appliances, compliance with indoor air quality standards and provision of carbon monoxide detectors) • Compact fluorescent light bulbs • Smoke and Carbon Monoxide Detectors • Roofing Services (i.e repair installation, decking, removal) • Repair and/or replacement of various types of energy saving windows • Repair broken glass, remove broken and install new glass with glazing • Ducts wrapped, caulking and weather-stripping applied throughout the dwelling, and various • other items • Air diagnostic testing (i.e. blower door test and duct blaster test) • Kitchen cabinet, countertop and/or sink repair/replacement • Bathroom cabmet countertop, and/or sink repair/replacement • High/low combustion ventmg • Floor Insulation RI 1 & R19 • Foundation underpinning -vinyl • Mobile home modification energy measures (door repair and replacement, sliding, interior vents, exhaust fans, skirts, etc. • Remove & Replace burglar bars • Contractor shall repair, retrofit, and replace inefficient home heating/cooling systems, water heaters, and refrigerators. 2 • Contractor shall be able to service, clean and adjust heaters including un-vented space heaters, cook stoves, ovens, water heaters, and lower carbon —monoxide levels per specifications stated in the TDHCA Weatherization and Mechanical Field Guides and A-10CFR440. • Exterior windows and doors; replacement windows and doors shall have a window unit U-value of 0.30 or less as rated by the National Fenestration Rating Council (NFRC). U-value shall be window unit and not the center of glass U-value. Skylights shall also comply with the same or equal requirements • Storm Windows -Must meet or exceed IECC1 in combination wish the exterior window over which it is installed, for the applicable climate zone. • Materials and/or equipment purchased can be inspected by HED representative to determine conformity with the quality requirements of the call for bids. When deemed necessary HED may require documentation detailing the product specifications for the purposes of determining whether the material confoi11is, in all aspects, to the required specifications the successful bidder must remedy the deficiency or the balance of the order there for may be canceled by HED • Contractor hall be fully responsible for the removal and proper disposal of all chemical material equipment, units, appliances, and components parts associated with repair and /or replacement services. • All appliances and equipment used for retrofit, repair and/or replacement shall be energy star rated, unless otherwise noted. • All energy conservation measures will be required to comply with Depat tuuent of Energy star rated, unless otherwise noted. • Services performed shall meet or exceed the latest standards and procedures of the National • Electrical Code, American Society of Heating, Refrigerating and Air -Conditioning Engineers, Uniform Plumbing Code, International Plumbing Code and Fuel Gas Code and Depat tiiient of Energy Weatherization guidelines Any work in excess of that specified on the Weatherization Work Order and not authorized by the City will be a disallowed cost and the Contractor will receive no compensation for that work. The product of labor and skill executed and quality of materials must be in accordance with City, State and Federal building codes and regulations and according to the Weatherization Installation Standards for the State of Texas. A copy of this manual may be obtained by calling (817) 392-7332 or by writing the Weatherization Assistance Program, Housing and Economic Development Depai tinent, 908 Monroe Street, Fort Worth, Texas 76102 HED staff will inspect all completed weatherization work before payment to the Contractor is approved. The Contractor is responsible, at his own expense for the repair or replacement of all materials or product of labor and skill executed that does not meet program standards. Such return work shall be completed within five (3) days from notification by the HED staff. The Contractor will obtain and pay for any permits that may be required for the performance of any applicable weatherization work specified on the Weatherization Work Order. The Contractor shall provide all tools required to complete all work; Provide all materials required, with materials to be in accordance with specifications shown in the Weatherization Installation Standards for the State of Texas; Arrange and schedule all work with the homeowner/occupant, in accordance with City- designated order, if applicable; Provide all transportation of tools, materials and personnel to job sites; Provide adequate, trained on -site supervision of all work; Protect homeowner's property from damage or loss during work, and maintain same in as good condition as before work started; Notify the City of Fort Worth immediately of any problems with work material delivery, or homeowner; and if any special work not shown on the Weatherization Work schedule is needed; 3 Begin work within five (3) days of work assignment; work continuously on a unit after work is started, and complete each unit in a reasonable amount of time [notivally three (3) working days.] (Written time extensions may be granted if requested in writing and justified by weather, illness, accident or other unforeseen circumstances); Report only fully completed units to agency for final inspection; Take any necessary corrective action on incomplete or unsatisfactory work as determined by agency's inspection; Keep homeowners' identities and circumstances confidential; Not hire or purchase materials from any person: Who is currently an employee, agent, consultant, officer, official, or Board Member of the City of Fort Worth and who exercises or has exercised any functions or responsibilities with respect to assisted contract activities; or Who is in a position to participate in a decision- making process or gain inside information with regard to such activities, or members of their immediate families; nor shall Contractor offer or provide gratuities, or anything of monetary value to City employees, officers, or agents; Not solicit WAP Clients to perform additional work on the unit for a minimum of six months after WAP work on that unit is complete; Not bid on or perform work on unit owned or occupied by members of the Contractors' immediate family by blood or marriage relationship; The Contractor shall be courteous and considerate of residents and shall do the work with the least possible inconvenience on the part of the residents; courtesy, understanding and respect for the owner/occupant are just as much a part of the weatherization program as caulk and insulation The Contractor shall not solicit additional business from the owner/occupant while working on homes under this Contract; The Contractor shall repair, at no additional cost to the City or the owner/occupant, all surfaces damaged by the Contractor on the dwelling as a result of the weatherization work, and The Contractor shall leave the premises in at least broom clean condition. Any materials, fixtures and equipment owned by the owner/occupant, which are removed and not reinstalled shall be removed from the premises unless the owner/occupant requests that they be left. These and other materials as well as other rubbish and debris resulting from the weatherization work shall be removed from the job site immediately after completion of work. 6. Required Training In addition to the training requirements detailed in the RFP, contractors along with crew members will be required to attend a mandatory training prior to commencement of services. The training will include but not be limited to: • Lead Safe Weatherization (LSW)/Environmental-Protection Agency (EPA) requirements • Production Goals • Material Installation Standards 7. Funding and Payment There is no guarantee that a specific dollar amount will be spent or minimum purchase will be made under this Contract. 4 The City agrees to compensate Contractor for approved expenses incurred and for documented units of services performed, subject to the following limitations: Not to Exceed Amount. Contractor understands and agrees that the maximum total amount payable for the services described herein shall not exceed One Million Two Hundred Seven Thousand Two Hundred Sixty Dollars and Eight Cents ($1,207,260.80), unless a formal written amendment is executed by the parties hereto and is formally approved by the City Council. Payment to the Contractor will be made after completion of work on each house. Contractor shall submit invoices for services rendered, according to procedure outlines m the Billing Instructions, Paragraph 8 of the Standard Specifications and Conditions, and use the form in Exhibit I to submit invoices to the Housing and Economic Development Depat talent. The Director of the Depai lttient of Housing and Economic Development Depai latent his or her designee shall condition all payments upon the inspection and approval of work. Payments will be made on an individual house basis after acceptance of work by the HED staff. The Contractor is responsible for maintaining and submitting necessary documents and reports as may be required by the City on Weatherization Projects. Required documents include, but are not limited to, the following documents: Unit Completion Form (request for a final inspection); Invoice for material, labor and total charge for each home weatherized; Itemized materials invoice; Building permit, when applicable, that indicates acceptance of work by Planning and Development Depaiturent; these documents must be submitted with the invoices. Payment to the Contractor will be made within thirty (30) days after the submission of all documents according to the Billmg Instructions. The Contractor must provide the City with a written warranty that all weatherization work and materials will be free from defects for one (1) year from the date of final acceptance of the weatherization work by the Housing and Economic Development Depat talent Inspection of the City of Fort Worth. 8. Lead Safe Weatherization Additional Cost for Lead Safe Weatherization (LSW). For jobs involving LSW, contractor may charge for an additional 10% of the labor and material cost for installing the item The additional charge will cover the contractor for cost incurred in set-up for LSW practices. 9. Program Procedures The Contract is required to provide at least one valid e-mail address to which the City my send or receive the following: • Program Correspondence • Notification of Assignments • Invoices • Client Complaints • Status Reports on Unit Completion • Request for Inspection • Other Critical Documents/Memos 10. Reports and Audits; Liquidated Damages Contractor will cooperate fully with City in monitoring the Weatherization Assistance Program. In this regard Contractor agrees to keep records sufficient to document its compliance with all applicable laws, regulations and contract terms. 5 All records shall be retained for three (3) years following the date of termination of this Contract. City, TDHCA and the United States Comptroller General, or their representatives, shall have access to any books, documents records and papers relating to the operations of Contractor under this Contract for the purpose of audit, examination exception and transcription at all reasonable hours at all offices of Contractor. The City may conduct a single audit of all Contractors' operations upon demand by an independent public accountant of City s choice, in accordance with OMB Circular A-128. The types of audit documentation required from the successful Contractor(s) may include, and is not limited to: Payroll Register to verify labor charges Job costs for each property including all materials used, quantities of materials used, unit costs, names of workers who assisted in the weatherization, hourly rates, and the number of hours worked for each worker Invoices from suppliers Canceled checks to verify payments to personnel and suppliers Bank statements to trace payments for material, labor and City payments Contractor covenants and agrees that, in the event an audit is conducted by City or on behalf of the City, which audit reveals any improper expenditures by Contractor, its officers, agents, servants, employees and/or subcontractors, of the funds granted hereunder and such questioned costs are disallowed and become final under the procedures of the party by whom or on whose behalf said audit is conducted, then the amount of such disallowed cost shall constitute liquidated damages for the breach of that portion of the contract audited. In case such disallowed cost becomes final as herein set out, Contractor agrees to pay City said sum as liquidated damages for Contractor's failure to perform duties bear the liabilities and fulfill the obligations imposed upon it by this Contract, and City agrees to accept and take said cash payment as its total damages and relief hereunder in such event. The parties hereto agree that City s actual damages in the event of a default by Contractor, would be difficult to ascertain and the parties, therefore agree that such amount as shall be determined by said final disallowed cost is to each of them, reasonable as liquidated damages. 11. Applicable Laws Federal Contractor agrees to comply with the following laws and the regulations issued there under as they are currently written or are hereafter amended during the performance of this Contract: Title VI of the Civil Rights Act of 1964 (42 USC 2000d et seq) Title VI I of the Civil Rights Act of 1968 (42 USC 3601 et seq) Executive Orders 11063, 11246, as amended by 11375 and as supplemented by Depai liuent of Labor regulations (41 CFR, Part 60) The Age Discrimination in Employment Act of 1975 (42 USC 6101 et seq) Section 504 of the Rehabilitation Act of 1973 (29 USC 794) Immigration Refoini and Control Act of 1986 (Pub. L. 99-603, 100 Stat. 3359, as amended) specifically including the provisions requiring employer verification of the legal worker status of its employees The Davis -Bacon Act (sec. 1-7, 46 Stat. 1949, as amended; Pub L 74-403, 40 U.S.C. 276a-276a-7) Copeland Act (40 U.S.C. 276c) The Contract Work Hours and Safety Standards Act (40 U.S.C. 327-332) National Housing Act (sec. 212 added to c. 847, 48 Stat. 1246, by sec. 14 53 Stat. 807, 12 U.S.C. 1715c and repeatedly amended) Housing Act of 1950 (college housing) (amended by Housing Act of 1959 to add labor provisions, 73 Stat 681; 12 U.S C. 1749a(f)) Housing Act of 1959 (sec 401(f) of the Housing Act of 1950 as amended by Pub L 86-372, 73 Stat. 681; 12 U.S.C. 1701q(c)(3)). The Americans with Disabilities Act of 1990 (42 USC 12101 et seq) Contractor, in the operation of its program, will also comply with Office of Management and Budget Circular A087 and attachments and revision thereto; regarding principles for determining costs for TDHCA- funded programs. 6 Clean Air Act (42 USC 1857 [h]), Sec. 306 Clean Water Act (33 USC 1368), Sec. 508 Executive Order 11738, and Environmental Protection Agency Regulations (40 CFR, Part 15). These Sections prohibit the use of facilities included on the EPA List of Violation Facilities in the Performance of the contract, or if a facility has been convicted of violation of either the Clean Air Act or Clean Water Act Contractor shall report any violations to City. Energy Policy and Conservation Act (PL 94-163, as amended). Contractor shall recognize mandatory standards and policies relating to energy efficiency contained in the State of Texas Energy Conservation Plan issued in compliance with the Act. 12. Davis Bacon Act The Contractor is required to adhere to the general provision so set forth in the Davis Bacon Act CLAUSE XX DAVIS BACON ACT REQUIREMENTS as defined in Exhibit A. Contactor is required to adhere to the wage determinations as set forth in the approved DOL Wage Determination as defined in see Exhibit B. All rulings and interpretations of the Davis -Bacon and Related Acts contained in 29 CFR parts 1, 3, and 5 are hereby incorporated by reference in the Award, Subaward, or Contract 13. Copeland "Anti -Kickback" Act (18 USC 874), as supplemented by Department of Labor Regulations (29 CFR Part 3) This Act provides that each Contractor shall be prohibited from inducing by any means, and person employed in the Construction, completion, or repair of public work, to give up any part of the compensation to which he is otherwise entitled. 14. Environmental Act The National Historic Preservation Act of 1966 (16 U.S.C. 470 et seq.), particularly sections 106 (16 U.S.0 470 and 470h-2) will be considered for all properties receiving services under this Contract. 15. Other Laws Contractor and covenants agrees that its officers, members, agents, employees, or subcontractors, shall abide by and comply with all other laws, federal state and local, relevant to the performance of this Contract, including all ordinances, rules and regulation of the City of Fort Worth Contractor further promises and agrees that it has read, and is familiar with, terms and conditions of the TDHCA Grant under which funds are granted and that it will fully comply with same. It is agreed and understood that if City calls the attention of Contractor to any such violations on the part of Contractor or any of its officers, members, agents, employees or subcontractors, then Contractor shall immediately desist from and cease such violation. Contractor agrees to use its best efforts to giving women -owned business concerns, small and disadvantaged business concerns and labor surplus area business concerns the maximum practicable opportunity to participate in subcontracts it awards, to the fullest extent consistent with the efficient performance of its contract. 16. Prohibition against Discrimination Generally Contractor in the execution performance or attempted performance of this Contract, will not discriminate against any person or persons because of sex race, religion, color or national origin, nor will Contractor peunit its officers, members, agents, employees, subcontractors or program participants to engage in such discrimination. 7 Employment During the performance of this Contract, Contractor agrees, and will require all of its subcontractors to agree, as follows: Contractor will not discriminate against any employee or applicant for employment because of race, color, religion sex or national origin. Contractor will take affirmative action to ensure that applicants are employed and that employees are treated during employment without regard to their race, color, religion, sex or national origin Such action shall include, but not limited to, the following: employment upgrading, demotion or transfer; recruitment or recruitment advertising layoff or termination rates of pay or other foims of compensation; and selection for training, including apprenticeship Contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices setting forth the provisions of this nondiscrimination clause. Contractor will, in all solicitations or advertisements for employees placed by or on behalf of Contractor, state that all qualified applicants will receive consideration for employment without regard to race color, religion, sex or national origin. Age In accordance with the policy of the Executive Branch of the federal government, Contractor covenants that neither it nor any of its officers members, agents, employees, program participants or subcontractors, while engaged in performing this Contract, shall, in connection with the employment, advancement or discharge of employees or in connection with the terms conditions or privileges of their employment discriminate against persons because of their age except on the basis of a bona fide occupational qualification, retirement plan or statutory requirement. Contractor further covenants that neither it nor its officers, members, agents, employees, subcontractors, program participants, or persons acting on their behalf, shall specify in solicitations or advertisements for employees to work on this Contract, a maximum age limit for such employment unless the specified maximum age limit is based upon a bona fide occupational qualification, retirement plan or statutory requirement. Disability In accordance with provision of the Americans With Disabilities Act of 1990 (` ADA"), Contract warrants that it and any and all of its subcontractors will not unlawfully discriminate on the basis of disability in the provision of services to the general public nor in the availability terms and/or employees of Contractor or any of its subcontractors. Contractor warrants it will fully comply with ADA's provision and any other applicable federal, state and local laws concerning disability and will defend, indemnify and hold City hariuless against any claims or allegations asserted by third parties or subcontractors against City arising out of Contractor's and/or its subcontractors alleged failure to comply with the above -referenced laws concerning disability discrimination in the performance of this Contract. 17. Prohibition against Interest No member, officer or employee of City or its designees or agents; no member of the governing body of the locality in which the program is situated; and no other public official of such locality or localities, who exercises any functions or responsibilities with respect to the program funded hereunder during his tenure or for one year thereafter, shall have any interest, direct or indirect, in any contract or subcontract, or the proceeds thereof for work to be performed hereunder. Contractor shall incorporate, or cause to be incorporated, like language prohibiting such interest in all contracts and subcontracts hereunder. No office, employee, member or program participant of Contractor or its subcontractors shall have a financial interest direct or indirect in this Contract or the monies transferred hereunder or be financially interested, directly or indirectly, in the sale to Contractor of any land, materials, supplies or services purchased with any funds transferred hereunder, except on behalf of Contractor as an officer, employee member or program participant. Any willful violation of this paragraph with the knowledge, expressed or implied, of Contractor or its subcontractors shall render this Contract voidable by the City of Fort Worth. 8 18. Subcontracting and Non -Assignment Contractor will not assign or subcontract any or all of its rights or responsibilities under this Contract without the prior written approval of the City. Any purported assignment without such approval will be a breach of this Contract and void in all respects. The Contractor shall not subcontract more than Fifty percent (50%) of the work to be performed pursuant to this Contract without the prior written approval of the City 19. Independent Contractor Contractor shall operate hereunder as an independent Contractor and not as an officer, agent, servant or employee of City Contractor shall have exclusive control of, and the exclusive right to control, the details of the work and services performed hereunder, and all persons performing same, and shall be solely responsible for the acts and omissions of its officers, members, agents, servants, employees, subcontractors, program participants, licensees or invitees The doctrine of respondent superior shall not apply as between City and Contractor, its officers, members, agents, servants, employees subcontractors program participants, licensees or invitees, and nothing herein shall be construed as creating a partnership or joint enterprise between City and Contractor. It is expressly understood and agreed that no officer, member, agents, employee, subcontractor, licensee or invitee of the Contractor, nor any program participant hereunder is in the paid service of City and that City odes not have the legal right to control the details of the tasks performed hereunder by Contractor, its officers members agents, employees subcontractors, program participants licensees or invitees. City shall in no way nor under any circumstance be responsible for any property belonging to Contractor its officers, members, agents, employees, subcontractors, program participants, licensees or invitees, which may be lost, stolen, destroyed or in any way damaged; and Contractor hereby indemnified and holds hainiless City and its officers, agents, and employees from and against any and all claims or suits. 20. Indemnity Contractor covenants and agrees to indemnify, hold harmless and defend, at its own expense, City and its officers, agents, servants and employees from and against any and all claims or suits for property loss or damage and/or personal injury, including death, to any and all persons, of whatsoever kind of character, whether real or asserted, arising out of or in connection with the execution, performance, attempted performance or non performance of this Contract and/or the operations, activities and services of the programs described herein, whether or not caused, in whole or in part, by alleged negligence of officers, agents, servants, employees, Contractors or subcontractors of City; and Contractor hereby assumes all liability and responsibility of City and its officers, agents, servants and employees for any and all claims or suits for property loss or damage and/or personal injury, including death, to any and all persons, of whatsoever kind of character, whether real or asserted, arising out of or in connection with the execution, performance, attempted performance or nonperformance of this Contract and/or the operations, activities and services of the programs described herein, whether or not caused in whole or in part, by alleged negligence of officers, agents, servants, employees, Contractors or subcontractors of City. Contractor likewise covenants and agrees to and does hereby indemnify and hold harmless City from and against any and all injury, damage or destruction of property of City, arising out of or in connection with all acts or omissions of Contractor, its officers, members, agents, employees, subcontractors, invitees, licensees, or program participants, or caused, in whole or in part, by alleged negligence of officers, agents, servants, employees, Contractors or subcontractors of City. 21. Waiver of Immunity If Contractor, as a charitable or nonprofit organization, has or claims an immunity or exemption (statutory or otherwise) from and against liability for damages or injury, including death, to persons or property, Contractor hereby expressly waives its rights to plead defensively such immunity or exemption as against City. This section shall not be construed to affect a governmental entity's immunities under constitutional, statutory or common law. 9 22. Public Liability Insurance Contractor shall furnish a certificate of insurance as proof that it has secured and paid for policies of public liability and automobile liability insurance covering all risks incident to or in connection with the execution, performance, attempted performance or nonperformance of this Contract in the following amounts: INSURANCE a) The Contractor(s) shall assume all risk and liability for accidents and damages that may occur to persons or property during the prosecution of the work. The Contractor(s) shall file with the Department of Housing and Economic Development, Weatherization Assistance Program of the City of Fort Worth, before the commencement of services, a certificate of insurance documenting the following required insurance. i) Statutory Workers' Compensation Insurance and Employer's Liability Insurance at the following limits • $100,000 Each Accident • $500,000 Disease — Policy limit • $100,000 Disease — Each Employee ii) Commercial General Liabihty Insurance including Explosion, Collapse, and Underground Coverage shall be provided as follows: • $1,000,000 Each Occurrence • $2,000,000 Annual Aggregate iii) Auto Liability Insurance shall be provided as follows: • $250,000 Bodily Injury Per Person Each Accident • $250,000 Property Damage; or • $500,000 Combined Single Limit Each Accident iv) Pollution Insurance • $1,000,000 Each Occurrence ADDITIONAL INSURANCE INFORMATION i) The City, its officers, employees and servants shall be endorsed as an additional insured on Contractor(s) insurance policies excepting employer's liability insurance coverage under Contractor(s) workers' compensation insurance policy. ii) Any failure on part of the City to request required insurance documentation shall not constitute a waiver of the insurance requirements specified herein. iii) Each insurance policy shall be endorsed to provide the City a minimum thirty days notice of cancellation, non -renewal, and/or material change in policy terms or coverage A ten days notice shall be acceptable in the event of non-payment of premium. iv) Insurers must be authorized to do business in the State of Texas and have a current A.M. Best rating of A: VIE or equivalent measure of financial strength and solvency. v) Deductible limits, or self -funded retention limits, on each policy must not exceed $10,000.00 per occurrence unless otherwise approved by the City. vi) Other than worker's compensation insurance, in lieu of traditional insurance, City may consider alternative coverage or risk treatment measures through insurance pools or risk retention groups The City must approve in writing any alternative coverage. vii) Workers compensation insurance policy(s) covering employees of the Contractor(s) shall be endorsed with a waiver of subrogation providing rights of recovery in favor of the City. Contractor agrees to require its subcontractors to carry adequate Workers' Compensation Insurance in the amounts required by State law viii) City shall not be responsible for the direct payment of insurance premium costs for Contractor(s) insurance. 10 ix) Contractor(s) insurance policies shall each be endorsed to provide that such insurance is primary protection and any self -funded or commercial coverage maintained by City shall not be called upon to contribute to loss recovery. x) While the Contract is in effect, Contractor shall report, in a timely manner, to the Depat twent of Housing and Economic Development any known loss occurrence that could give rise to a liability claim or lawsuit or which could result in a property loss. xi) Contractor(s) liability shall not be limited to the specified amounts of insurance required herein. xii) Upon the request of City, Contractor shall provide complete copies of all insurance policies required by these contract documents. 23. Termination City may terminate this Contract whenever such termination is determined to be in the best interest of City, in event of Contractor's default inability, or failure to perform or to comply with any of the terms herein, or for other good cause, including substandard work. Substandard work shall be defined as material or workmanship deviating from or falling short of standard as prescribed by Appendix A- Standards for Weatherization Materials, published in Title 16, Code of Federal Regulation, or the State of Texas Weatherization Standards Manual. Termination may occur if the quality and quantity of work is determined to be substandard Once this determination has been made, Contractor will be notified and will be given thirty (30) days in which to improve its performance, after which time this Contract may be either continued or teiiuinated, at the sole discretion of City. Termination will be effected by written notice to Contractor, specifying the portions of the contract affected and the effective date of termination. Upon Contractor's receipt of such termination notice Contractor will: Stop work under the contract on the date and to the extent specified by City; Cease expenditures of TDHCA monies, except as necessary for completion of portions of the contract not terminated: and Terminate all orders and contracts to the extent that they relate to terminated portions of the contract. Contractor will return to City any unused monies previously distributed under this Contract within thirty (30) days of the effective date of contract termination. 24. Changes and Amendments to Law; Automatic Incorporation Any change in the terms of this Contract which is required by a change in state or federal law or regulation is automatically incorporated herein effective on the date designated by such law or regulation Except as otherwise specifically provided herein any other change in the tends of this Contract shall be by amendment hereto in writing and executed by both parties to this Contract. 25. Political Activity and Lobbying No funds provided under this Contract may be used to attempt to influence in any manner a member of Congress to favor or oppose any legislation or appropriation by Congress, nor to lobby state or local elected officials. No federal appropriated funds may be paid, by or on behalf of Contractor to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal loan, the entering into any cooperative agreement, and the extension, continuation, renewal, amendment or modification of any federal contract, grant, loan, or cooperative agreement. 11 26. Legal Authority Contractor represents that it possesses the practical ability and the legal authority, to enter into this Contract, receive and manage the funds authorized by this Contract, and to perform the services Contractor has obligated itself to perfoini under this Contract. The person signing this Contract on behalf of Contractor hereby warrants that he/she has been authorized by Contractor to execute this Contract on behalf of Contractor and to bind Contractor to all tetxns herein set forth. Depai linent shall have the right to suspend or terminate this Contract if there is a dispute as to the legal authority of either Contractor or the person signing this Contract to enter into this Contract or to render performances hereunder. Contractor is liable to Depai liuent for any money it has received from Depth tinent. If any action, whether real or asserted, at law or in equity, arises on the basis of any provision of this Contract, venue for such action shall lie in state courts located in Tarrant County, Texas or the United States District Court for the Northern District of Texas — Fort Worth Division. This written instrument and the exhibits attached hereto, which are incorporated by reference and made a part of this Contract for all purposes, constitute the entire agreement between the parties hereto concerning the work and services to be performed hereunder, and any prior or contemporaneous, oral or written agreement which purports to vary from the terms hereto shall be void. Any amendments to the terms of this Contract must be in writing and must be approved by City. 27. Contract Construction The Parties acknowledge that each party and, if it so chooses its counsel have reviewed and revised this Contract and that the normal rule of construction to the effect that any ambiguities are to be resolved against the drafting party must not be employed in the interpretation of this Contract or any amendments or exhibits hereto. 28. Severability The provisions of this Contract are severable, and if any word, phrase clause, sentence, paragraph, section or other part of this Contract or the application thereof to any person or circumstance shall ever be held by any court of competent jurisdiction to be invalid or unconstitutional for any reason, the remainder of this Contract and the application of such word, phrase clause, sentence paragraph, section, or other part of this Contract to other persons or circumstances shall not be affected thereby and this Contract shall be construed as if such invalid or unconstitutional portion had never been contained therein. [SIGNATURES APPEAR ON FOLLOWING PAGE] 12 IN WITNESS WHEREOF, the Parties hereto have executed three copies of this Contract in Fort Worth, Tarrant County, Texas, this ,r' day of , 20 /- CITY OF FORT WORTH • By: T. M. Higgins Assistant City Manager Recommended by: Jesus Chapa, Director Department of Housing & Economic Development Approved as to Form and Legality: Amy J. Ra Assistant City Attorney ATTEST: MI* City SecretaXrn4e4J ry Authorization: C--- -1 I 3 ra- Date: 3 lq i 0 • moo' eci "Ion st.4 f(3)* Q ith�00000 .31aner By: Date 0° 0 ocAYA °,;(40,4 o ri o 13 EXHIBIT A Template: FA -Special Terms and Conditions 8-20-2009 FINAL (APPROVED BY DOL) FA-TC-0050 Prescription: inc.,de for ARRA Awards when WAGE RATE REQUIREMENTS UNDER SECTION 1606 OF THE AMERICAN RECOVERY AND REINVESTMENT ACT (RECOVEERv ACT) Clauses are required. CLAUSE XX. DAVIS BACON ACT REQUIREMENTS A. Definitions. For purposes of this Clause, Clause XX, Contract Work Hours and Safety Standards Act and Clause XX, Recipient Functions, the following definitions are applicable: (1) Award means the Award by the Department of Energy (DOE) to a Recipient that includes a requirement to comply with the labor standards clauses and wage rate requirements of the Davis -Bacon Act (DBA) for work performed by all laborers and mechanics employed by Subrecipients Contractors and subcontractors on projects funded by or assisted in whole or in part by and through the Federal Government pursuant to the Recovery Act. (2) "Construction, alteration or repair" means all types of work done by laborers and mechanics employed by the Subrecipient, construction contractor or construction subcontractor on a particular building or work at the site thereof, including without limitation — (a) Altering, remodeling,,instaliation (if appropriate) on the site of the work of items fabricated off -site; (b) Painting and decorating; or (c) Manufacturing or furnishing of materials, articles, supplies, or equipment on the site of the building or work. (3) Contract means a written procurement contract executed by a Subrecipient for the acquisition of property and services for construction, alteration, and repair under a Subaward. For purposes of these Clauses, a Contract shall include subcontracts and lower- tier subcontracts under the Contract. (4) Contracting Officer means the DOE official authorized to execute awards on behalf of DOE and who is responsible for the business management and non -program aspects of the financial assistance process_ (5) Contractor means an entity that enters into a Contract. For purposes of these Clauses, Contractor shall include subcontractors and lower -tier subcontractors. (6) Recipient means any entity other than an individual that receives Recovery Act funds in the form of a grant directly from the Federal Government. The term includes the State that 1 receives an Award from DOE and is financially accountable for the use of any DOE funds or property, and is legally responsible for carrying out the terms and conditions of the program and,Award. (7) "Site of the work" — (a) Means-- (i) The physical place or places where the construction called for in the Award, Subaward, or Contract will remain when work on it is completed; and (ii) Any other site where a significant portion of the building or work is constructed, provided that such site is established specifically for the performance of the project (b) Except as provided in paragraph (c) of this definition, the site of the work includes any fabrication plants, mobile factories batch plants, borrow pits, job headquarters, tool yards, etc., provided— (1) They are dedicated exclusively, or nearly so, to performance of the project; and (2) They are adjacent or virtually adjacent to the site of the work as defined in paragraphs (7)(a)(i) or (7)(a)(ii) of this definition; and (c) Does not include permanent home offices, branch plant establishments, fabrication plants, or tool yards of a Contractor or subcontractor whose locations and continuance in operation are determined wholly without regard to a particular contract or Federal Award or project. In addition, fabrication plants, batch plants borrow pits, job headquarters, yards, etc., of a commercial or material supplier which are established by a supplier of materials for the project before opening of bids and not on the project site as defined in paragraphs (7)(a)(i) or (7)(a)(ii) of this definition, are not included in the 'site of the work." Such permanent, previously established facilities are not a part of the "site of the work" even if the operations for a period of time may be dedicated exclusively or nearly so, to the performance of an Award, Subaward, or Contract. (8) Subaward means an award of financial assistance in the form of money, or property in lieu of money, made under an award by a Recipient to an eligible Subrecipient or by a Subrecipient to a lower- tier subrecipient. The term includes financial assistance when provided by any legal agreement, even if the agreement is called a contract, but does not include the Recipient s procurement of goods and services to carry out the program nor does it include any form of assistance which is excluded from the definition of "Award" above. (9) Subrecipient means a non -Federal entity that expends Federal awards received from a pass -through entity [Recipient] to carry out a Federal program, but does not include an individual that is a beneficiary of such a program The term includes a Community Action Agency (CAA), local agency, or other entity to which a Subaward under the Award is made by a Recipient that includes a requirement to comply with the labor standards clauses and wage rate requirements of the DBA work performed by all laborers and mechanics employed by 2 contractors and subcontractors on projects funded by or assisted in whole or in part by and through the Federal Government pursuant of the Recovery Act. B. Davis -Bacon Act (1)(a) Ail laborers and mechanics employed or working upon the site of the work will be paid unconditionally and not less often than once a week and without subsequent deduction or rebate on any account (except such payroll deductions as are permitted by regulations issued by the Secretary of Labor under the Copeland Act (29 CFR Part 3)), the full amount of wages and bona fide fringe benefits (or cash equivalents thereof) due at time of payment computed at rates not less than those contained in the wage determination of the Secretary of Labor which is attached to the Subaward or Contract and made a part hereof, regardless of any contractual relationship which may be alleged to exist between the Recipient, a Subrecipient, or Contractor and such laborers and mechanics (i) Applicable to Recipient Only: Prior to the issuance of the Subaward or Contract, the Recipient shall notify the Contracting Officer of the site of the work in order for the appropriate wage determination to be obtained by the Contracting Officer from the Secretary of Labor. (ii) If the Subaward or Contract is or has been issued without a wage determination, the Recipient shall notify the Contracting Officer immediately of the • site of the work under the Subaward or Contract in order for the appropriate wage determination to be obtained by the Contracting Officer from the Secretary of Labor. (b) Contributions made or costs reasonably anticipated for bona fide fringe benefits under section 1(b)(2) of the DBA on behalf of laborers or mechanics are considered wages paid to such laborers and mechanics, subject to the provisions of paragraph B(4) below; also regular contributions made or costs incurred for more than a weekly period (but not less often than quarterly) under plans, funds, or programs which cover the particular weekly period, are deemed to be constructively made or incurred during such period. (c) Such laborers and mechanics shall be paid not less than the appropriate wage rate and fringe benefits in the wage determination for the classification of work actually performed, without regard to skill, except as provided in the paragraph entitled Apprentices arid Trainees. Laborers or mechanics performing worK in more than one classification may be compensated at the rate specified for each classification for the time actually worked therein; provided that the employer's payroll records accurately set forth the time spent in each classification in which work is performed. (d) The wage determination (including any additional classifications and wage rates conformed under paragraph B(2) of this Clause) and the Davis -Bacon poster (WH-1321) shall be posted at all times by the Subrecipient and Contractor at the site of the work in a prominent and accessible place where it can be easily seen by the workers. (2)(aj The Contracting Officer shall require that any class of laborers or mechanics which is not listed in the wage determination and which is to be employed under the Subaward or 3 Contract shall be classified in conformance with the wage determination. The Contracting Officer shall approve an additional classification and wage rate and fringe benefits therefore only when all the following criteria have been met. (i) The work to be performed by. the classification requested is not performed by a classification in the wage determination. (il) The classification is utilized in the area by the construction industry, (iii) The proposed wage rate, including any bona fide fringe benefits, bears a reasonable relationship to the wage rates contained in the wage determination. (b) If the Subrecipient (and Contractor, when applicable) and the laborers and mechanics to be employed in the classification (if known), or their representatives agree on the classification and wage rate (including the amount designated for fringe benefits, where appropriate), the Subrecipient shall notify the Recipient. The Recipient shall notify the Contracting Officer of this agreement. If the Contracting Officer agrees with the classification and wage rate (including the amount designated for fringe benefits, where appropriate), a report of the action taken shall be sent by the Contracting Officer to the Administrator of the: Wage and Hour Division Employment Standards Administration U.S Department of Labor Washington, DC 20210 The Administrator or an authorized representative will approve, modify, or disapprove every additional classification action within 30 days of receipt and so advise the Contracting Officer or will notify the Contracting Officer within the 30-day period that additional time is necessary. (c) In the event the Subrecipient (and Contractor, when applicable), and the laborers or mechanics to be employed in the classification, or their representatives, do not agree on the proposed classification and wage rate (including the amount designated for fringe benefits, where appropriate), the Subrecipient shall notify the Recipient. The Recipient shall notify the Contracting Officer of the disagreement. The Contracting Officer shall refer the questions, including the views of all interested parties and the recommendation of the Contracting Officer, to the Administrator of the Wage and Hour Division for determination. The Administrator, or an authorized representative, will issue a determination within 30 days of receipt and so advise the Contracting Officer or will notify the Contracting Officer within the 30-day period that additional time is necessary. (d) The wage rate (including fringe benefits, where appropriate) determined pursuant to subparagraphs B(2)(b) or B(2)(c) of this Clause shall be paid to all workers performing work in the classification under the Award, Subaward, or Contract from the first day on which work is performed in the classification. 4 (3) Whenever the minimum wage rate prescribed. in the Award, Subaward, or Contract for a class of laborers or mechanics includes a fringe benefit which is not expressed as an hourly rate, the Subrecipient and Contractor shall either pay the benefit as stated in the wage determination or shall pay another bona fide fringe benefit or an hourly cash equivalent thereof (4) If the Subrecipient or Contractor does not make payments to a trustee or other third person, the Subrecipient or Contractor may consider as part of the wages of any laborer or mechanic the amount of any costs reasonably anticipated in providing bona fide fringe benefits under a plan or program, provided, that the Secretary of Labor has found, upon the written request of the Subrecipient or Contractor that the applicable standards of the Davis - Bacon Act have been met. The Secretary of Labor may require the Subrecipient or Contractor to set aside in a separate account assets for the meeting of obligations under the plan or program. C. Rates of Wages (1) The minimum wages to be paid laborers and mechanics under the Subaward or Contract involved in performance of work at the project site, as determined by the Secretary of Labor to be prevailing for the corresponding classes of laborers and mechanics employed on projects of a character similar to the contract work in the pertinent locality, are included as an attachment to the Award, Subaward, or Contract. (2) If the Subaward or Contract has been issued without a wage determination, the Recipient shall notify the Contracting Officer immediately of the site of the work under the Subaward or Contract in order for the appropriate wage determination to be obtained by the Contracting Officer from the Secretary of Labor. D. Payrolls and Basic Records (1) Payrolls and basic records relating thereto shall be maintained by the Recipient, Subrecipient and Contractor during the course of the work and preserved for a period of 3 years thereafter for all laborers and mechanics working at the site of the work. Such records shall contain the name address, and social security number of each such worker, his or her correct classification, hourly rates of wages paid (including rates of contributions or costs anticipated for bona fide fringe benefits or cash equivalents thereof of the types described in section 1(b)(2)(B) of the Davis -Bacon Act), daily and weekly number of hours worked, deductions made, and actual wages paid. Whenever the Secretary of Labor has found, under paragraph (4) of the provision entitled Davis -Bacon Act, that the wages of any laborer or mechanic include the amount of any costs reasonably anticipated in providing benefits under a plan or program described in section 1(b)(2)(B) of the Davis -Bacon Aa, the Subrecipient or Contractor shall maintain records which show that the commitment to provide such benefits is enforceable, that the plan or program is financially responsible, and that the plan or program has been communicated in writing to the laborers or mechanics affected, and records which show the costs anticipated or the actual cost incurred in providing such benefits. The Subrecipient or Contractor employing apprentices or trainees under approved programs shall maintain written evidence of the registration of apprenticeship programs and 5 certification of trainee programs, the registration of the apprentices and trainees, and the ratios and wage rates prescribed in the applicable programs. (2)(a) The Contractor shall submit weekly for each week in which any Contract work is performed a copy of all payrolls to the Subrecipient. The Subrecipient shall submit weekly for each week in which any Subaward or Contract work is performed a copy of all payrolls to the Recipient The Recipient shall submit weekly for each week in which any Subaward or Contract work is performed a copy of all payrolls to the Contracting Officer. The payrolls submitted shall set out accurately and completely all of the information required to be maintained under paragraph D(1) of this Clause, except that the full social security numbers and home addresses shall not be included on weekly transmittals. Instead, the payrolls shall only need to include an individually identifying number for each employee (e.g. the last four digits of the employee's social security number). The required weekly payroll information may be submitted in any form desired. Optional Form WH-347 is available for this purpose from the Wage and Hour Division Web site at httpi/www.dol.gov/esa/whd/forms/wh347instr.htm or its successor site. (b) The Recipient is responsible for the ensuring that all Subrecipients and Contractors submit copies of payrolls and basic records as required by paragraph D, Payrolls and Basic.. Records, of this Clause. The Subrecipient is responsible for ensuring all Contractors, including lower tier subcontractors submit copies of payrolls and basic records as required by paragraph D, Payrolls and Basic Records, of this clause. Subrecipients and Contractors shall maintain the full social security number and current address of each covered worker, and shall provide them upon request for transmission to the Contracting Officer, the Recipient, or the Wage and Hour Division of the Department of Labor for purposes of an investigation or audit of compliance with prevailing wage requirements. The Recipient shall also obtain and provide the full social security number and current address of each covered worker upon request by the Contracting Officer or the Wage and Hour Division of the Department of Labor for purposes of an investigation or audit of compliance with prevailing wage requirements. It is not a violation of this section for a Recipient to require a Subrecipient or Contractor to provide addresses and social security numbers to the Recipient for its own records, without weekly submission to the Contracting Officer. (c) Each payroll submitted shall be accompanied by a "Statement of Compliance," signed by the Recipient, Subrecipient or Contractor or his or her agent who pays or supervises the payment of the persons employed under the Subaward or Contract and shall certify -- (i) That the payroll for the payroll period contains the information required to be maintained under paragraph D(2)(a) of this Clause, the appropriate information is being maintained under paragraph D(1) of this Clause, and that such information is correct and complete; (ii) That each laborer or mechanic (including each helper, apprentice, and trainee) employed on the Subaward or Contract during the payroll period has been paid the full weekly wages earned, without rebate, either directly or indirectly, and that no deductions have been made either directly or indirectly from the full wages earned, other than permissible deductions as set forth in the Regulations, 29 CFR Part 3; and 6 (iii) That each laborer or mechanic has been paid not less than the applicable wage rates and fringe benefits or cash equivalents for the classification of work performed, as specified in the applicable wage determination incorporated into the Subaward or Contract. (d) The weekly submission of a properly executed certification set forth on the reverse side of Optional Form WH-347 shall satisfy the requirement for submission of the "Statement of Compliance" required by paragraph D(2)(c) of this Clause. (e) The falsification of any of the certifications in Paragraph D, Payrolls and Basic Records, of this Clause may subject the Recipient, Subrecipient or Contractor to civil or criminal prosecution under Section 1001 of Title 18 and Section 3729 of Title 31 of the United States Code. (3) The Recipient, Subrecipient, or Contractor shall make the records required under paragraph D(1) of this Clause available for inspection, copying, or transcription by the Contracting Officer authorized representatives of the Contracting Officer, or the Department of Labor. The Subrecipient or Contractor shall permit the Contracting Officer, authorized representatives of the Contracting Officer or the Department of Labor to interview employees during working hours on the job. If the Recipient, Subrecipient or Contractor fails to submit the required records or to make them available, the Contracting Officer may, after written n otice to the Recipient, Subrecipient, or Contractor take such action as may be necessary to cause the suspension of any further payment, advance, or guarantee of funds. Furthermore, failure to submit the required records upon request or to make such records available may be grounds for debarment action pursuant to 29 CFR 5.12. E. Withholding of Funds (1) The DOE Contracting Officer shall, upon his or her or its own action or upon written request of an authorized representative of the Department of Labor, withhold or cause to be withheld from the Recipient or any other contract or Federal Award with the same Recipient, o n this or any other federally assisted Award subject to Davis -Bacon prevailing wage requirements, which is held by the same Recipient so much of the accrued payments or advances as may be considered necessary to pay laborers and mechanics, including apprentices, trainees, and helpers, employed by the Subrecipient or a Contractor the full amount of wages required by the Award or Subaward or a Contract. In the event of failure to pay any laborer or mechanic, including any apprentice, trainee, or helper employed or working on the site of the work, all or part of the wages required by the Award or Subaward o r a Contract, the Contracting Officer may, after written notice to the Recipient take such action as may be necessary to cause the suspension of any further payment, advance, or guarantee of funds until such violations have ceased. (2) The Recipient shall, upon its own action or upon written request of the DOE Contracting Officer or an authorized representative of the Department of Labor, withhold or cause to be withheld from any Subrecipient or Contractor so much of the accrued payments or advances as may be considered necessary to pay laborers and mechanics including apprentices, trainees and helpers, employed by the Subrecipient or Contractor the full amount of wages required by the Subaward or Contract. In the event of failure to pay any laborer or mechanic, 7 including any apprentice, trainee, or helper, employed or working on the site of the work, .all or part of the wages required by the Subaward or Contract, the Recipient may, after written notice to the Subreciptent or Contractor, take such action as may be necessary to cause the suspension of any further payment, advance, or guarantee of funds until such violations have ceased or the Government may cause the suspension of any further payment under any other contract or Federal award with the same Subrecipient or Contractor, on any other federally assisted Award subject to Davis -Bacon prevailing wage requirements, which is held by the same Subreciptent or Contractor. F. Apprentices and Trainees (1) Apprentices. (a) An apprentice will be permitted to work at less than the predetermined rate for the work they performed when they are employed— (i) Pursuant to and individually registered in a bona fide apprenticeship program registered with the U.S. Department of Labor, Employment and Training Administration, Office of Apprenticeship and Training, Employer and Labor Services (OATELS) or with a State Apprenticeship Agency recognized by the OATELS; or (ii) In the first 90 days of probationary employment as an apprentice in such an apprenticeship program, even though not individually registered in the program, if certified by the OATELS or a State Apprenticeship Agency (where appropriate) to be eligible for probationary employment as an apprentice. (b) The allowable ratio of apprentices to journeymen on the job site in any craft classification shall not be greater than the ratio permitted to the Subrecipient or Contractor as to the entire work force under the registered program. (c) Any worker listed on a payroll at an apprentice wage rate, who is not registered or otherwise employed as stated in paragraph F(1) of this Clause, shall be paid not less than the applicable wage determination for the classification of work actually performed. In addition, any apprentice performing work on the job site in excess of the ratio permitted under the registered program shall be paid not less than the applicable wage rate on the wage determination for the work actually performed. (d) Where a Subrecipient or Contractor is performing construction on a project in a locality other than that in which its program is registered, the ratios and wage rates (expressed in percentages of the journeyman s hourly rate) specified in the Subrecipient's or Contractor's registered program shall be observed. Every apprentice must be paid at not less than the rate specified in the registered program for the apprentice s level of progress, expressed as a percentage of the journeyman hourly rate specified in the applicable wage determination. (e) Apprentices shall be paid fringe benefits in accordance with the provisions of the apprenticeship program If the apprenticeship program does not specify fringe benefits, 8 apprentices must be paid the full amount of fringe benefits listed on the wage determination for the applicable classification. If the Administrator determines that a different practice prevails for the applicable apprentice classification, fringes shall be paid in accordance with that determination. (f) In the event OATELS, or a State Apprenticeship Agency recognized by OATELS, withdraws approval of an apprenticeship program, the Subrecipient or Contractor will no longer be permitted to utilize apprentices at less than the applicable predetermined rate for the work performed until an acceptable program is approved. (2) Trainees. (a) Except as provided in 29 CFR 5.16, trainees will not be permitted to work at less than the predetermined rate for the work performed unless they are employed pursuant to and individually registered in a program which has received prior approval evidenced by formal certification by (OATELS). The ratio of trainees to journeymen on the job site shall not be greater than permitted under the plan approved by OATELS. (b) Every trainee must be paid at not less than the rate specified in the approved program for the trainee's level of progress, expressed as a percentage of the journeyman hourly rate specified in the applicable wage determination. Trainees shall be paid fringe benefits in accordance with the provisions of the trainee program. If the trainee program does not mention fringe benefits, trainees shall be paid the full amount of fringe benefits listed in the wage determination unless the Administrator of the Wage and Hour Division determines that there is an apprenticeship/training program associated with the corresponding journeyman wage rate in the wage determination which provides for less than full fringe benefits for apprentices. Any employee listed on the payroll at a trainee rate who is not registered and participating in a training plan approved by the OATELS shall be paid not less than the applicable wage rate in the wage determination for the classification of work actually performed. In addition, any trainee performing work on the job site in excess of the ratio permitted under the registered program shall be paid not less than the applicable wage rate in the wage determination for the work actually performed. (c) In the event OATELS withdraws approval of a training program, the Subrecipient or Contractor will no longer be permitted to utilize trainees at less than the applicable predetermined rate for the work performed until an acceptable program is approved. (3) Equal employment opportunity. The utilization of apprentices, trainees, and journeymen under this Clause shall be in conformity with the equal employment opportunity requirements of Executive Order 11246, as amended, and 29 CFR Part 30. 6. Compliance with Copeland Act Requirements The Recipient, Subrecipient or Contractor shall comply with the requirements of 29 CFR Part 3 which are hereby incorporated by reference in the Award, Subaward or Contract. H. Subawards and Contracts 9 (1) The Recipient, the Subrecipient and Contractor shall insert in the Subaward or any Contracts this Clause entitled "Davis Bacon Act Requirements" and such other clauses as the Contracting Officer may require. The Recipient shall be responsible for ensuring compliance by any Subrecipient or Contractor with all of the requirements contained in this Clause The Subrecipient shall be responsible for the compliance by Contractor with all of the requirements contained in this Clause (2) Within 14 days after issuance of a Subaward, the Recipient shall deliver to the Contracting Officer a completed Standard Form (SF) 1413, Statement and Acknowledgment, for each Subaward and Contract for construction within the United States, including the Subrecipient's and Contractor's signed and dated acknowledgment that this Clause) has been included in the Subaward and any Contracts. The SF 1413 is available from the Contracting Officer or at http://contacts.gsa.gov/webforms.nsf/0/7084872 D16EE95A785256A26004F7EA8/$file/sf1413_e.pd f . Within 14 days after issuance of a Contract or lower- tier subcontract, the Subrecipient shall deliver to the Recipient a completed Standard Form (SF) 1413, Statement and Acknowledgment, for each Contract and lower -tier subcontract for construction within the United States, including the Contractor and lower- tier subcontractor's signed and dated acknowledgment that this Clause has been included in any Contract and lower- tier subcontracts. SF 1413 is available from the Contracting Officer or at http://contacts gsa.gov/webforms.nsf/0/70B4872D16EE95A785256A26004F7EA8/$file/sf1413_e.pd f. The Recipient shall immediately provide to the DOE Contracting Officer the completed Standard Forms (SF) 1413. L Contract Termination -- Debarment A breach of these provisions may be grounds for termination of the Award, Subaward, or Contract and for debarment as a Contractor or subcontractor as provided in 29 CFR 5.12. J. Compliance with Davis -Bacon and Related Act Regulations All rulings and interpretations of the Davis -Bacon and Related Acts contained in 29 CFR Parts 1, 3, and 5 are hereby incorporated by reference in the Award Subaward or Contract. K. Disputes Concerning Labor Standards The United States Department of. Labor has set forth in 29 CFR Parts 5, 6 and 7 procedures for resolving aisputes concerning labor standards requirements Such disputes shall be resolved in accordance with those procedures and shall not be subject to any other dispute provision that may be contained in the Award, Subaward, and Contract. Disputes within the meaning of this Clause include disputes between the Recipient, Subrecipient (including any Contractor) and the Department of Energy, the U.S. Department of Labor, or the employees or their representatives. L. Certification of Eligibility. (1) By entering into this Award, Subaward, or Contract (as applicable), the Recipient, Subrecipient, or Contractor, respectively certifies that neither it (nor he or she) nor any person or firm who has an interest in the Recipient, Subrecipient, or Contractor s firm, is a person, entity, or firm ineligible I0 to be awarded Government contracts or Government awards by virtue of section 3(a) of the Davis -Bacon Act or 29 CFR 5.12(a)(1). (2) No part of this Award, Subaward or Contract shall be subcontracted to any person or firm ineligible for award of a Government contract or Government award by virtue of section 3(a) of the Davis -Bacon Act or 29 CFR 5.12(a)(1). (3) The penalty for making false statements is prescribed in the U.S. Criminal Code, 18 U.S.C. 1001. M. Approval of Wage Rates All straight time wage rates, and overtime rates based thereon, for laborers and mechanics engaged in work under an Award, Subaward or Contract must be submitted for approval in writing by the head of the federal contracting activity or a representative expressly designated for this purpose, if the straight time wages exceed the rates for corresponding classifications contained in the applicable Davis -Bacon Act minimum wage determination included in the Award, Subaward or Contract. Any amount paid by the Subrecipient or Contractor to any laborer or mechanic in excess of the agency approved wage rate shall be at the expense of the Subrecipient or Contractor and shall not be reimbursed by the Recipient or Subrecipient. If the Government refuses to authorize the use of the overtime, the Subrecipient or Contractor is not released from the obligation to pay employees at the required overtime rates for any overtime actually worked. Clause XXX. Contract Work Hours and Safety Standards Act This Clause entitled "Contract Work Hours and Safety Standards Act (CWHSSA)1 shall apply to any Subaward or Contract in an amount in excess of $100,000. As used in this CWHSSA Clause, the terms laborers and mechanics include watchmen and guards. A. Overtime requirements. No Subrecipient or Contractor contracting for any part of the Subaward work which may require or involve the employment of laborers or mechanics shall require or permit any such laborer or mechanic in any workweek in which he or she is employed on such work to work in excess of forty hours in such workweek unless such laborer or mechanic receives compensation at a rate not less than one and one-half times the basic rate of pay for all hours worked in excess of forty hours in such workweek. B. Violation; liability for unpaid wages; liquidated damages. In the event of any violation of the clause set forth in paragraph B herein, the Subrecipient or Contractor responsible therefor shall be liable for the unpaid wages. In addition, such Subrecipient or Contractor shall be liable to the United States (in the case of work done under a Subaward or Contract for the District of Columbia or a territory, to such District or to such territory), for liquidated damages. Such liquidated damages shall be computed with respect to each individual laborer or mechanic, including watchmen and guards, employed in violation of the provision set forth in CWSSHA paragraph A, in the sum of $10 for each calendar day on which such individual was required or permitted to work in excess of the standard workweek of forty hours without payment of the overtime wages required by the clause set forth in paragraph (A) of this section. C. Withholding for unpaid wages and liquidated damages. (1) The DOE Contracting Officer shall upon its own action or upon written request of an authorized representative of the Department of Labor withhold or cause to be withheld, from any moneys payable on account of work performed by the Recipient on this or any other Federal Award or Federal contract with the same Recipient on any other federally -assisted Award or contract subject to the CWHSSA, which is held by the same Recipient such sums as may be determined to be necessary to satisfy any liabilities of such Recipient for unpaid wages and liquidated damages as provided in the clause set forth in CWHSSA, paragraph B of this Clause (2) The Recipient shall, upon its own action or upon written request of the DOE Contracting Officer or an authorized representative of the Department of Labor, withhold or cause from any moneys payable on account of work performed by the Subrecipient or Contractor on this or any other federally assisted subaward or contract subject to the CWHSSA, which is held by the same Subrecipient or Contractor such sums as may be determined to be necessary to satisfy any liabilities of such Subrecipient or Contractor for unpaid wages and liquidated damages as provided in clause set forth in CWHSSA paragraph B of this Clause D. Subcontracts. The Subrecipient shall insert in a Contract and a Contractor shall insert in any lower tier subcontracts, the clauses set forth in these CWHSSA paragraphs (A) through (D) and also a provision requiring the Contractors to include this CWHSSA Clause in any lower tier subcontracts. The Recipient shall be responsible for compliance by any Subrecipient or Contractor, with the CWHSSA paragraphs A through D. The Subrecipient shall be responsible for compliance by any Contractor (including lower- tier subcontractors). E. The Subrecipient or Contractor shall maintain payrolls and basic payrolls in accordance with Clause XX Davis- Bacon Act Requirements, for all laborers and mechanics, including guards and watchmen working on the Subaward or Contracts. These records are subject to the requirements set forth in Clause XX, Davis Bacon Requirements. Clause XXXX. RECIPIENT FUNCTIONS (1) On behalf of the Department of Energy (DOE), Recipient shall perform the Following functions: (a) Obtain maintain, and monitor all DBA certified payroll records submitted by the Subrecipients and Contractors at any tier under this Award; (b) Review all DBA certified payroll records for compliance with DBA requirements, including applicable DOL wage determinations; (c) Notify DOE of any non-compliance with DBA requirements by Subrecipients or Contractors at any tier, including any non -compliances identified as the result of reviews performed pursuant to paragraph (b) above; 12 (d) Address any Subreciprent and any Contractor DBA non-compliance issues; if DBA non-compliance issues cannot be resolved in a timely manner, forward complaints, summary of investigations and all relevant information to DOE; (e) Provide DOE with detailed information regarding the resolution of any DBA non- compliance issues; (f) Perform services in support of DOE investigations of complaints filed regarding noncompliance by Subrecipients and Contractors with DBA requirements; (g) Perform audit services as necessary to ensure compliance by Subrecipients and Contractors with DBA requirements and as requested by the Contracting Officer; and (h) Provide copies of all records upon request by DOE or DOL in a timely manner. (2) All records maintained on behalf of the DOE in accordance with paragraph (1) above are federal government (DOE) owned records. DOE or an authorized representative shall be granted access to the records at all times. (3) In the event of, and in response to any Freedom of Information Act 5 U S.C. 552, requests submitted to DOE, Recipient shall provide such records to DOE within 5 business days of receipt of a request from DOE. 13 S 2009-TX-001 Issue Date: 12/ 11 /2009 Exp. Date: 03/05/2010 EXHIBIT B TEXAS RESIDENTIAL WEATIIERIZATION WAGE DETERMINATION 'This project wage determination is issued in response to a request from the Department of Energy (DOE) for prevailing wage rates specific to weatherization of residential structures as those structures are defined in the All Agency Memorandum 130 and 131.. This wage determination has application only to weatherization construction projects on existing residential structures as described in the SF 308 submitted by DOE. -The primary purpose of the project for which this wage determination is being issued is weatherization and is not for the renovation, repair, or new construction of residential structures. All other types of residential construction projects are subject to the published general residential wage determinations for the State of Texas found on www.wdol.gov. General weatherization work for purposes of this wage determination is defined as minor repairs, batt insulation, blown insulation, window and door repair, and weather stripping, solar film installation, air sealing, caulking, minor or incidental structural repairs, duct sealing. air sealing, installation of light bulbs, and installation of smoke detectors. In Texas, the Department's recent survey determined as a matter of prevailing practice that these duties are performed by a weatherization worker classification. Additionally, specialty weatherization work is defined as the (1) replacement of doors and windows, (2) installation and repair of furnace/cooling (HVAC) systems and all associated work involved with the installation of the HVAC system including electrical, pipe, and duct work. In Texas, the Department's recent survey determined that the duties described by (1) above are performed by a Window and Door Replacement Worker, and by (2) above arc performed by an HVAC worker. Wage payment data submitted for the State of Texas included wage data information for a weatherization crew chief classification. This classification of worker is essentially a working foreman who performs the same tasks as the weatherization worker, but who is responsible for supervision, job oversight, forms completion, work assignments, and quality assurance. The additional duties are not "laborer or mechanic" work as defined by the Davis -Bacon and related Acts regulations, but are more supervisory in nature. The Department issues various classifications of workers when the duties are defined and distinct from all other classifications of workers on the wage determination. The "laborer or mechanic" duties of the crew chief are not sufficiently distinct to warrant the issuance of a separate classification on the wage determination. Moreover, the Department does not issue separate wage determinations based on a worker's skill, experience or individual training. Therefore, the weatherization crew chief is not listed as a separate classification of worker. The weatherization crew chief must be classified as a weatherization worker and paid at least the applicable wage determination rate of the weatherization worker when performing weatherization work. There is no restriction however to paying the weatherization crew chief more than the weatherization worker wage rate listed on the wage determination. The rates listed on this wage determination are the minimum rates that may be paid the listed classification for the work performed. Wage rates are based strictly on work performed and are not based on the employee's level of experience, seniority, ability, etc. There are no levels of rates for this work. Workers performing the work described are due at least the minimum rates listed. 1 S2009-TX-001 Issue Date: 12/11/2009 Exp. Date: 03/05/2010 The following is a key to the chart below. Each county in the state is listed in alphabetical order on the far left side of the chart. There are two main columns separated by a bold line with the left column labeled Weatherization Survey Waae Determination and the right column labeled Existing Residential Ware Determination. The three classifications listed under the Weatherization Survey Wage Determination column are the classifications and rates determined to be prevailing for weatherization work and are based on wage data submitted in response to the weatherization survey. Weatherization work, as well as the specific duties that may be performed by these three classifications, is defined on this project decision. The rate information under each classification is the basic hourly rate and fringe benefit (if fringe benefits were found to be prevailing). If there is no wage rate or fringe benefit listed under the classification column, usually the I-IVAC Worker, then there was no data or insufficient data from which to establish a rate and/or fringe benefit for that classification. If the work performed by that classification is needed for the project, then an additional classification request (conformance) must be made. NOTE: Classifications and rates listed under the Existing Residential Wage Determination Column may not be used for unlisted classifications/work in the Weatherization Survey Wage Determination column, See below for the procedure for requesting additional classifications and the form to request these classifications. The classifications listed under the Existing Residential Wage Determination column are those classifications and rates currently published as prevailing on the residential general wage determinations. These wage determinations may be found at www.wdo]...gov. The classifications and rates listed under the Existing Residential Wage Determination column may be used on weatherization projects only in those situations where the work is different than that described for the three classifications listed under the Weatherization Survey Column. For example, when an electrician is needed to perform electrical work not associated with the installation, repair, or overhaul of furnace or cooling equipment, then the existing electrician classification and rate listed under this column may be used for that work. The rate information under each classification is the baste hourly rate and a fringe benefit (if fringe benefits were found to be prevailing). If there is no wage rate or fringe benefit listed under the classification column, then there was no data or insufficient data from which to establish a rate and/or fringe benefit for that classification. If that unlisted classification is needed for the project, then a request for an additional classification (conformance) should be made. See below for the procedure for requesting additional classifications and the form to request these classifications. Any unlisted classifications and rates (conformances) needed for work not listed on the chart below may be added after award only as provided in the labor standards contract clauses (29CFR 5.5 (a) (1) (ii)). The procedure for requesting approval of an unlisted classification and rate (conformance) as well as a "pdf' copy of the form (SF Form 1444) may be found at http://www.dol.gov/esa/whd/recovery1. The SF Form 1444 may be sent to the Department electronically, by facsimile. or by mail. Electronic submissions should be sent to 09WeatherizatlonSurvevrdgl.gov. Facsimile submissions should be sent to (202) 693-1432. Mailed forms should be sent to the address listed in $lock 1 of the SF Form 1441. Any SF Form 1444 submitted for weatherization projects should be marked as being for weatherization projects and the project decision being used for the project should also be submitted with the SF Form 1444. 2 S2009-TX-001 issue Date: 12/11/2009 Exp. Date 03/05/2010 Counties Weatherization Survey Wage Determination (S2009-TX-001) Weatherization Worker Doors & Windows Replacement Worker HVAC, Furnace, Heating & Cooling Repair, Installation, Replacement Worker Existing Residential Wage Determination (www.wdol.gov) Carpenter (Excludes Door & Window Replacement, and work listed as performed by weatherization worksri Electrician (Excludes electrical work associated with HVAC installation, overhaul, and work listed as performed by weatherization worker) Plumber (Excludes work associated with HVAC installation, repair or overhaul and work listed as performed by weatherization worker) 3 Weatherization Survey Wage Determination (S2009-TX.O01) Existing Residential Wage Determination (www.wdolgov) Electrician (Description of Work, Page 3) Plumber (Description of Work, Page 3) Counties Weatherizatlon Worker Doors & Windows Replacement Worker HVAC, Furnace, Heating & Cooling Repair, Installation, Replacement Worker Carpenter (Description of Work, Page 3) Schackieford $12.00+.46 $12.00+0.46 $12.00 $11.26 $15.99 $20.00 Schleicher $12.00+.46 $12.00+0.46 $12.00 $11.26 $15.99 $20,00 Scurry $10.00 $11.00 $12.00 $11.26 $15.99 $20.00 Shelby $12.00+.46 812.00+0.46 $12.00 $11.26 $15.99 $20.00 Sherman $15.63 $15.63 $18.75 $11.26 $15.99 $20.00 Smith $12,50 $12.50 $15.00+.29 $12.92 $15.99 $20.00 Somervell $12,00+.46 $12.00+0.46 $12.00 $8.25 $15.99 $20.00 Starr $8.84+.54 $10.00 $10.50 $8.00 $8.50 $7.875 Stephens $11.09+.31 $10,75 $13.00+0.25 $10.86 $15.99 $20.00 Sterling_ $12.00+.46 $12.00+0.46 $12.00 $11.26 $15.99 $20.00 Stonewall $10.00 $10.00 $13,00+0.25 $11.26 $15.99 $20.00 Sutton $10.00 $11.00 $10.50 $11.26 $15.99 $20.00 Swisher $15.63 $15.63 $18.75 $11.26 $15.99 $20.00 Tarrant $14.31 $14.31 $13.00 $8.25 $15.99 $20.00 18 200-11-13 •20 insurrante Cori WY L076002689 Renewal' of Number » 87720171 P 2/2 COOKYECLAONMMON aLDECLARATIONS Policy Number L076003035 Item 1. Named Insured and Mailing Addre s: KB REMODELING OSCAR BLANCO 8003 E. MELROSE ST FT. WORTH Item 2, Policy Period From. 07/22/2009 TX 76108 • To: 07/22/2010 Term 365 Day(s) 12 01 A. M. Standard Time at the address of the Named Insured as stated herein Item 3. Business Descnption: REMODELING In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. • This policy consists of the following coverage darts for which a premium is indicated. Where no premium is shown, there is no coverage. This premium may be subject to adjustment Coverage Part(s1 ect0 Form No and Edition Date Premium Commercial General Liability Coverage Part ''� PO`' s- 'L $ 3,179.00 Property Coverage tiYGtr Part ? dc g\\ , ' C"� _ Equipment Breakdown Covers`;. u`, • 5� .• .ttt,' e Inland Marine Coverage P • Terrorism Covers �e rO' � % ram . <0 Wit` 3� *P‘ $ 3,178,00 �t�,tad ‘ ' '\• •' t ' Y J Fee 4 180.00 Q %`STATE `��; ti'�� ✓s :� TAX $ 161.94 �t,k� �; ' r,\_$ t2 '/N°. de+ t '. SOF .. $ 2.00 C„s�5°. ��� Ci i $ Cep C sE o ....,N-aeP mu *` ...`i.'i a. GQ ' ITotal $ 3,502,94 Audit Peng074r urea otherwise stated* • \tar Ire Item 4. Forms and endorsements applicable to all Coverage Parts: See Schedule of Forms and Endorsements Agent No.: 420075 General Agent: TKG General Agency Inc. Address: 4661 FM 2723 Mt, Vernon Producer Code No.: - Producer Name: A -SUNRISE INS. Producer Address: 3204 E BELKNAP FT. WORTH TX 76111 Countersigned 08/03/2009 SR DATE TX 75457 (?;:::a) By COUNTERSIGNATURE THIS COMMON POLICY DECLARATIONS AND THE sVPPLEMENTAL DECLARATIONS, TOGETHER WITH THE COMMON POLICY. CONDITIONS, COVERAGE FORMS) AND ENDORSEMENTS COMPLETE THE ABOVE NUMBER POLICY. IN WITNESS WHEREOF, this Company hos gpused the Policy to be signed by ha Prasldml! and its S rctery dad countonigned bye duly authorized rePiezer tatiYe, �.," , President teZ&4A. - Secretary ACD 04-07 INSURED AGENCY, INC. 7Pe ite eentizaa es ittearat...4earatA eentreae a ea YOUR ndependeiif Insurance /i9OENT SERVES YOU FIRST 2/9/2009 KB Remodeling Oscar Blanco dba 8003 E Melrose St Ft. Worth, TX 76108 RE• Insurance - Workers Compensation Policy #WCV4217944 Effective 01/22/2009 to 01/22/2010 Dear Insured, Thank you for the opportunity to assist you in your financial protection Your Workers Compensation policy insured through AmComp Assurance Corp. is enclosed. Please take a moment to review your policy. If you have any questions or changes, please contact our office as soon as possible. Please feel free to call regarding any matter of insurance advice or information. We appreciate the opportunity to handle this portion of your insurance needs. Sincerely, avekson, Rene Ransom Account Representative (512)451-6551 Ext #139 Transom c(�centralins.com 6000 N. LAMAR .• P.O. BOX 15427 • AUSTIN, TEXAS 78761-5427 • 512-451-6551 • FAX 512-454 0183 www.centralins.com Workers Compensation and Employers Liability Insurance Policy mCOMP Assurance Corp P.O. Box 164347 Austin, TX (a38)339-1771 78716-4347 PER 0 6 2009 Policy WCV 4217944 01/22/2009 01/22/2010 12:01 A.M. Standard Time at the address of the Insured as stated herein POLICY DECLARATION .................................................................. OSCAR BLANCO DBA KB REMODELING 8003 E. MELROSE ST. FORT WORTH TX 76108 ;4gent:s` ::::::`::: CENTRAL INSURANCE AGENCY, INC. 6000 N. LAMAR BLVD., #100 P.O. BOX 15427 AUSTIN, TX 78761 Telephone: 4219611 Customer # Carner # 3 687 0 FEIN # 364625734 Risk ID # 000000000 Entity of Insured INDIVIDUAL Addlt,onal Locat one: 2. The Policy Period is from 01/22/2009 to 01/22/2010 12:01 a.m. Standard Time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: Texas B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 100 000 each accident Bodily Injury by Disease $ 500 000 policy limit Bodily Injury by Disease $ 100 , 000 each employee C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: AL,AZ,DC,FL,GA,IL,IN,KS,KY,MD,MO,MS,NM,NC,.OK,SC,TN,TX,VA,WI 4 D. This policy includes these endorsements and schedules: See attached schedule. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. Minimum Premium $ 250 Assessments and Taxes $ SEE EXTENSION OF INFORMATION PAGE Expense Constant Premium Discount Total Estimated AnnualPremium This is a Three Year Fixed Rate Policy Premium Adjustment Period: Fl Annual; (l Semiannual; Countersigned this Day of Issued Date: 01/30/09 Issuing Office AmCOMP Assurance Corp Qua erly; ❑ Monthly itialLma Authorized R $ 140 resentative -200 7,358 INSURED WC990634 (5/98 Ed.) • Workers Compensation and Employers Liability Insurance Policy AmCOMP Assurance Corp P„n. Box 164347 Austin, TX 78716-4347 P olicy Number: WCV 4217944 N amed Insured: OSCAR BLANCO DBA KB REMODELING Agent: CENTRAL INSURANCE AGENCY, INC. 4219611 EXTENSION OF INFORMATION PAGE St Loc Code Classification Description No. CLASSIFICATION OF OPERATIONS Premtum Basis Rate Per Estimated Policy Total Estimated $100 of Term Premium Annual Remuneration Remuneration TX 0001 5437 CARP-INST OF CAB WK / INT TRIM $ 100,000 5.78000 $ 5,780 TOTAL FOR UNIT $ 5,780 9889 TX -SCHEDULE DEBIT 0.28000 $ 1,618 O 063 PREMIUM DISCOUNT 0.02700 $ -200 O 900 EXPENSE CONSTANT $ 140 9740 TERRORISM 0.02000 $ -20 SUBTOTAL $ 1,578 TOTAL FOR STATE $ 7,358 TOTAL FOR POLICY - $ 7,358 Issued Date: 0 1/3 0/0 9 INSURED WC990630 (5/98 Ed.) Workers Compensation and Employers Liability Insurance Policy Policy Number: wcv 4217944 AmCOMP Assurance Corp P.C.Box 164347 Austin, TX _ 78716-4347 Named Insured: OSCAR BLANCO DBA KB REMODELING Agent: CENTRAL INSURANCE AGENCY, INC. 4219611 NAMED INSURED SCHEDULE Loc Loc Nbr Name & Address Nbr 00001 OSCAR BLANCO DBA KB REMODELING 8003 E. MELROSE ST. FORT WORTH TX 76108 Name & Address Issued Date: 01/30/09 wcpnisa WC990632 (G/QR F'A INSURED Workers Compensation and Employers Liability Insurance Policy AmCOMP Assurance Corp P.J. Box 164347 - Austan, TX 78716-4347 Loc 00 42 42 42 42 42 42 42 Number WC000000A WC000406 WC420301F WC420308 WC420402A WC420407 WC990694 WC990695 Policy Number WCV 4217944 Named Insured: OSCAR BLANCO DBA KB REMODELING Agent: CENTRAL INSURANCE AGENCY, INC. 4219611 ENDORSEMENT SCHEDULE Description WORKERS COMP / EMPLOYERS LIAR PREMIUM DISCOUNT ENDORSEMENT TX AMENDATORY ENDORSEMENT TX PRTNRS,OFFCRS,OTHRS EXCLUS TX ANNIVERSARY RATING DATE TX —AUDIT PREMIUM & RETRO PREM TX —TERRORISM RISK INS PROGRAM TX —TERRORISM PREMIUM ENDT Issued Date: 01/30/09 ThT!'QQ(1F2-2 /F /QQ ?;a \ INSURED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Beginning on page INFORMATION PAGE . 1 GENERAL SECTION A. The Policy 1 B Who Is Insured 1 C Workers Compensation Law 1 D. State 1 E Locations 1 PART ONE - WORKERS COMPENSATION INSURANCE A. How This Insurance Applies 1 B. We Will Pay 1 C. We Will Defend 1 D. We Will Also Pay 1 E. Other Insurance 1 F. Payments You Must Make 2 G.Recovery From Others 2 H. Statutory Provisions 2 PART TWO - EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies 2 B. We Will Pay 2= C. Exclusions 3 D. We WiII Defend 3 E. We Will Also Pay 3 F. Other Insurance 4 G Limit tts of Liability 4 H. Recovery From Others 4 I. Actions Against Us 4 PART THREE - OTHER STATES INSURANCE A. How This Insurance Applies 4 B. Notice 4 PART FOUR - YOUR DUTIES IF INJURY OCCURS 4 PART FIVE - PREMIUM A. Our Manuals 5 B. Classifications 5 C. Remuneration 5 D. Premium Payments 5 E. Final Premium F. Records G. Audits PART SIX - CONDITIONS A. Inspection 6 B. Long Term Policy 6 C. Transfer of Your Rights and Duties 6 D. Cancellation 6 E. Sole Representative 6 PIKERS CONII'ENSATION A1VD EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A (Ed: 4-92) is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments In excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons e ntitled to the benefits of this insurance, to recover o ur payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have n otice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury o ccurs. 3. We are directly and primarily liable to any person e ntitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of -this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: benefits payable by this insurance; or special taxes payments into security or other special funds, and assessments payable by us under that law 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary o'r incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your e mployment. The employee's last day of last e xposure to the conditions causing or aggravating such bodily injury by disease must o ccur during the policy period. WC 00 00 00 A 2 B. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought -in the United States of America, its territories or possessions, or Canada. We Will Pay We will pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. for which you are liable to a third party by reason of a claim or suit against you by that third party torecover the damages claimed against such third party as a result of injury to your employee; 2.. for care and loss of services; and (Ed. 4 92) Copyright 1991 National Council on Compensation Insurance. WuKiCtKS UUlvlrtivmM lwjN AIVU tIVIPLUYLKS LIABILITY INSURANCE POLICY WC 00 00 00 A (Ed. 4-92) G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page They apply as explained below. 1. Bodily. Injury by Accident. The limit shown for 'bodily injury by accident - each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for 'bodily injury by disease - policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease - each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodilyinjury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to deter mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obliga tions under this Part. PART THREE - OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self -insured for such work, all provisions of the policy will apply as though that state were listed in Item 3 A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded for that state unless we are notified within thirty days. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1 Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. WC 00 00 00 A 4 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. (Ed. 4 92) Copyright 1991 National Council on Compensation Insurance. WORKERS COMPENSATION AND .EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A (Ed. 4-92) rate service organizations have the same rights we have under this provision. Long Term Policy If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. D. Cancellation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancellation notice 4. Any of these provisions that conflict with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with the law. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancellation. WC 00 00 00 A 6 (Ed. 4 92) Copyright 1991 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 06 (Ed. 8 84) PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. 1. State Schedule Estimated Eligible Premium First Next Next $5 000 $95,000 $400 000 Balance 0 % 8.4% 10.5% 11.0% 2. Average percentage discount: 3. Other policies: 4. If there are no entries in Items 1 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number: This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. WCV4217944 Insured OSCAR BLANCO DBA KB REMODELING Insurance Company AmCOMP Assurance Corp Countersigned by WC 00 04 06 - Texas (Ed. 8 84) Copyright 1983 National Council on Compensation Insurance, Inc. 000406A4 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 03 01 F Effective January 1, 2000 TEXAS AMENDATORY ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of the Information Page. GENERAL SECTION B. Who is Insured is amended to read: You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership or joint venture, and if you are one of its partners or members, you are insured, but only in your capacity as an employer of the partnership's or joint venture's employees. D. State is amended to read: State means any state or territory of the United States of America, and the District of Columbia. PART ONE - WORKERS' COMPENSATION INSURANCE E. Other Insurance is amended by adding this sentence: This Section only applies if you have other insurance or are self -insured for the same loss. F. Payments You Must Make This Section is amended by deleting the words "workers compensation" from number 4. H. Statutory Provisions This Section is amended by deleting the words "after an injury occurs" from number 2. PART TWO - EMPLOYERS' LIABILITY INSURANCE C. Exclusions S ections 2 and 3 are amended to add: This exclusion does not apply unless the violation of law caused or contributed to the bodily injury. S ection 6 is amended to read. 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America, Mexico or Canada who is temporarily outside these countries. D. We Will Defend This section is amended by deleting the last sentence. PART FOUR - YOUR DUTIES IF INJURY OCCURS N umber 6 of this part is amended to read: 6. Texas law allows you to make weekly payments to an injured employee in certain instances. Unless authorized by law, do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. WC 42 03 01 F Hart Forms & Services Reorder No. 14-A054 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 03 01 F PART FIVE - PREMIUM A. Our Manuals is amended by adding the sentence: In this part, "our manuals" means manuals approved or prescribed by the Texas Department of Insurance. C. Remuneration Number 2 is amended to read: 2. All other persons engaged in work that would make us liable under Part One (Workers' Compensation Insurance) of this policy. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured workers' compensation insurance. E. Final Premium Number 2 is amended to read: 2. .If you cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. PART SIX - CONDITIONS A. Inspection is amended by adding this sentence: Your failure to comply with the safety recommendations made as a result of an inspection may cause the policy to be cancelled by us: C. Transfer of Your Rights and Duties is amended to read: Your rights and duties under this policy may not be transferred withoutour written consent. If you die, coverage will be provided for your surviving spouse or your legal representative. This applies only with respect to their acting in the capacity as an employer and only for the workplaces listed in Items 1 and 4 on the Information Page. - D. Cancellation is amended to read: 1. You may cancel this policy. You must mail or deliver advance notice to us stating when the cancellation is to take effect. 2. .We may cancel this policy. We may also decline to renew it. We must give you written notice of cancellation or nonrenewal. That notice will be sent certified mail or delivered to you in person. A copy of the written notice will be sent to the Texas Workers' Compensation Commission. 3. Noticeofcancellation ornonrenewalmust be sent to you not later than the 30th day before the date on which the cancellation or nonrenewal becomes effective, except that we may send the notice not later than the 10th day before the date on which the cancellation or nonrenewal becomes effective if we cancel or do not renew because of: a. Fraud in obtaining coverage; b. Misrepresentation of the amount of payroll for purposes of premium calculation: c. Failure to pay a premium when payment was due; d. An increase in the hazard for which you seek coverage that results from an action or omission and that would produce an increase in the rate, including an increase because of failure to comply with reasonable recommendations for loss control or to comply within a reasonable period with recommendations designed to reduce a hazard that is under your control; e. A determination by the Commissioner of Insurance that the continuation of the policy would place us in violation of the law, or would be hazardous to the interests of subscribers, creditors, or the general public. WC 42 03 01 F 2 Hart Forms & Services Reorder No. 14-A054 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 03 01 F 4. If another insurance company notifies the Texas Worker's Compensation Commission that it is insuring you as an employer, such notice shall be a cancellation of this policy effective when the other policy starts. PART SEVEN - OUR DUTY TO YOU FOR CLAIM NOTIFICATION A. Claims Notification We are required to notify you of any claim that is filed against your policy. Thereafter, we shall notify you of any proposal to settle a claim or, on receipt of a written request from you of any administrative or judicial proceeding relating to the resolution of a claim, including a benefit review conference conducted by the Texas Workers'Compensation Commission. You may, in writing elect to waive this notification requirement. We shall, on the written request from you, provide you with a list of claims charged against your policy, payments made and reserves established on each claim, and a statement explaining the effect of claims on your premium rates. We must furnish the requested information to you in writing no later than the 30th day after the date we receive your request. The information is considered to be provided on the date the information is received by the United States Postal Service or is personally delivered. COMPLAINT NOTICE: SHOULD ANY DISPUTE ARISE ABOUT YOUR PREMIUM OR ABOUT A CLAIM THAT YOU HAVE FILED CONTACT THE AGENT OR WRITE TO THE COMPANY THAT ISSUED THE POLICY. IF THE PROBLEM IS NOT RESOLVED, YOU MAY ALSO WRITE THE TEXAS DEPARTMENT OF INSURANCE P.O. BOX 149091 AUSTIN, TEXAS 78714-9091, FAX # (512) 475-1771. THIS NOTICE OF COMPLAINT PROCEDURE IS FOR INFORMATION ONLY AND DOES NOT BECOME A PART OR CONDITION OF THIS POLICY. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. WCV4217944 Endorsement No. Insured OSCAR BLANCO DBA KB REMODELING Premium $ Insurance Company AmCOMP Assurance Corp WC 42 03 01 F 3 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY we 42 03 08 (Ed. 1-97) TEXAS PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT The policy does not cover bodily injury to any person described in the Schedule. The premium basis for the policy does not include the remuneration of such persons. You will reimburse us for any payment we must make because of bodily injury to such persons. Schedule Parsons State Sole .Proprietor: OSCAR BLANCO This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Effective Policy No.: WCV4217944 Endorsement No.: Premium . Insured : OSCAR BLANCO DBA KB REMODELING Insurance Company: AmCOMP Assurance Corp Countersigned by: WC 42 03 08 (Ed. 1-97) 410308a.fap WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 04 02 A (Ed. 3-97) TEXAS ANNIVERSARY RATING DATE ENDORSEMENT The premium for this policy and the experience rating modification factor, if any, may change on your anniversary rating date shown in the Schedule. Schedule Anniversary Rating Date 01/22/2009 (Day) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective. Policy No. WCV4217944 Endorsement No. Insured OSCAR BLANCO DBA KB REMODELING Premium $ Insurance Company AmCOMP Assurance Corp WC 42 04 02 A (Ed. 3-97) Hart Forms & Services Reorder No. 14-A057 TEXAS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY MANUAL WC 420407 Effective March 23, 2002 TEXAS - AUDIT PREMIUM AND RETROSPECTIVE PREMIUM ENDORSEMENT Selection D of Part Five of the policy is replaced by the following provision: PART FIVE - PREMIUM D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers' compensation law is not valid. The billing statement or invoice for audit additional premium and/or retrospective additional premium establishes the date that the premium is due. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. WCV4217944 Insured OSCAR BLANCO DBA KB REMODELING - Insurance Company AmCOMP Assurance Corp WC 42 04 07 Hart Forms & Services Reorder No. 14-4854 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 94 (Ed. 1-08) TEXAS TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2007. Definitions The definition's provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2007. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resultedin damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means, any loss resulting from an act of terrorism (including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty Insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2008, and ending on December 31, 2014, an amount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applicable Program Year. "Program Year" refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a Program Year and if we have met our Insurer Deductible. we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100 000,000,000; and for aggregate Insured Losses up to • $100,000,000 000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceeds $100,000,000 in a Program Year, the United States Government would pay 85% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000 000. 3. The premium charged for the coverage for Insured Losses under this policy is included in the amounts shown in Item 4 of the .Information Page or in the Schedule in the Texas Terrorism Premium Endorsement. (WC 99 06 02), attached to this policy. WC 99 06 94 .. Page 1 of 2 (Ed. 1-08) Wolters Kluwer Financial Services I Uniform FormsTM WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC990694 (Ed. 1-08) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy No.: WCV 4217944 00 Insured: OSCAR BLANCO DBA KB REMODELING Insurance Company: AmCOMP Assurance Corp WC990694 Page2of2 (Ed. 1-08) Wolters Kluwer Financial Services I Uniform FormsTM 990694 . WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 95 (Ed. 1-08) TEXAS TERRORISM PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium for losses that may occur in the event of an act of terrorism. Your policy provides coverage for workers compensation losses caused by acts of terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. For purposes of this endorsement, an "act of terrorism" is defined as: a. Any act that is violent or: dangerous to human life, property or infrastructure; and b. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. The premium charge for the coverage your policy provides for workers compensation losses caused by an act of terrorism is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate per $100 of payroll SEE EXTENSION OF INFORMATION PAGE This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy No.: WCV 4217944 00 Insured: OSCAR BLANCO DBA KB REMODELING Insurance Company: AmCOMP Assurance Corp WC 99 06 95 (Ed. 1-08) 990695 Page 1 of 1 Wolters Kluwer Financial Services I Uniform FormsrM OMF • Incorporated • Assurance Corporation • Preferred Insurance Company Telephonic Claims Reporting Instructions To report a workers' compensation claim. 1. Prior to reporting a claim, please review your records to ensure that the following information is available: • • • • • • • Injured employee's name, social security number, address, telephone number, date of hire, and salary information. Your policy number (see #4 below). Date and location of the incident that led to the injury Type of injury or illness and the body part that was injured. Brief description of the incident. Information on whether the injured employee has returned to work_ Name of doctor or medical provider that treated the injured employee. 2. Call AmCOMP at 1-800-749-1898. 3. You will hear an automated operator that will instruct you to, "Dial 5 to report a claim." 4. After dialing five, an operator will take your call. Please give them your company's name and your policy number. Your policy number is WCV4217944 5. The person you speak with will ask you a series of questions about the injured employee and the events leading to the incident that caused the injury or illness. Many of these questions will refer to the information described in #1 above. 6. You will receive a First Report of Injury form for your records after you report the claim. Prompt reporting of claims is essential in controlling workers' compensation insurance costs. Please report claims as soon as possible. DV not wait for LLVct Vr' J reports of billings to report claims. We recommend reporting claims as soon as the injured employee leaves your operations for treatment by your local medical provider. OMF • Incorporated • Assurance Corporation • Preferred Insurance Company Steps for Employees to Follow When Injured on the Job 1. Get immediate medical attention if a life -threatening injury has occurred. • Call 911, or your local emergency number, in a life -threatening emergency. 2. Report your injury to your supervisor immediately. • Failure to promptly report your injury may affect your workers' compensation insurance benefits. 3. See a medical provider for treatment of your injuries. 4. Provide all paperwork or any notes provided by the doctor to your employer. 5. Follow the doctor's orders on treatments and follow-up appointments. • Failure to follow the doctor's orders or missing scheduled follow-up appointments may affect your workers' compensation insurance benefits. OAF • Incorporated • Assurance Corporation • Preferred Insurance Company Safety Review Guide Employee's Name Today's Date Job Title Regular Dept. Date of Incident Time of Incident Location of Incident (Specific address or plant or department) Description of Incident Did employee seek outside treatment? [ ] Yes [ ] No medical Did employee return to work? [ ] Yes [ ] No Did employee return to regular duties [ ] Yes [ ] No Were there any witnesses [ ] Yes [ ] No If yes, who? Part of body injured* Type of Incident [ ] [ ] Struck Struck by against [ ] [ ] Slip/Fall Caught in [ ] [ ] Burn/Cold Cumulative Trauma [ ] Lifting/Overexertion [ ] Inhalation [ ] Other In your opinion, what was the root cause of the incident? In your opinion, what could be done to prevent the incident from reoccurring? Signed Date Management/Safety Committee Review Has this type of incident happened before? [ ] Yes [ ] No Is employee consultation needed? [ ] Yes [ ] No What can be done to prevent reoccurrence Project Leader Completion Target Signed Date This is not the Notice of Injury Form. This form is to be used for your safety committee review. State Mandator MC Program VoluntaryMC Progra Employee SelPhys Physician Treating Employer SelPhys ct May caning Filing of Notice of Injury (2) Penalty for offenses, Late Reporting (petty Alabama X 5 days X Alaska X (1.) 10 days X Arizona X 10 days X Arkansas X X 10 days X California X X (3.) 5 days - X Colorado X X 10 days X Connecticut X X (4.) 7 days X Delaware X 10 clays X District of Columbia X 10 days X Florida X X X 7 days X Georgia X X 10 days X Hawaii X 7 days X Idaho X 10 days Illinois X X X Indiana X 7 days X Iowa 4 days X Kansas X 28 days X Kentucky X X X 7 days X I' Lv oiusiana - X 10 days X Maine X (10 days) 7 days X Maryland X 10 days X Massachusetts X X (5.) 7 days X Michigan X (limited to 10 days) X Minnesota X X 10 days X Mississippi X 10 days X Missouri X X 5 days X Montana X X X X Nebraska X X 7 days X Nevada X X'(6] 6 days X New Hampshire X X (7.) 5 days X New Jersey X X 7 days X New Mexico X (limited to 60 days) 10 days X New York X (8.) (9.) X 10 days X North Carolina X X 5 days X North Dakota X X X Ohio X (10.) X 7 days X (admission of compensability) Oklahoma X X 10 days X Oregon X X 5 days X (employer responsible pensation due to employee for 25% of com if insured) Pennsylvania X(11.) immediately X Rhode Island X X 10 days X South Carolina X PPO's (HMO allowed) o and 10 days Y X South Dakota X X 10 days X X X (12.) 10 days hrs. to (within MC plan) 24 X Tennessee Texas X 14 days X Utah X X (13.) 8 days X Vermont X X (for the only) first visit 7 da s y X Virginia X (from employee physicians) a panel of 3 selected - 72 hours X Washington X "at once" X West Virginia X 5 days X Wisconsin X Determined Department by . _... X Wyoming X X 10 days X 1. However the employer can insist on examination of the injured worker by a physician chosen by the employer within 14 days of the injury and every 60 days there after. 2. Research has consistently shown that prompt reporting of injuries greatly reduces overall claim costs In all states. 3. If the employee has a personal physician and has notified the employer of this in writing prior to the injury, the employee has the right to be treated by the personal physician. Otherwise, the employer selects the physician for the first 30 days following the injury, after which time the employee may choose the physician within a reasonable geographic area (4600). Employees of employers whose insurer contracts with at least two HMOs to provide services to injured employees (in accordance with requirements stipulated in the Act), are to be treated in accordance with the contract, except that injured employees who have designated a personal physician prior to injury are to be treated by the personal physician. The same applies to employees of self -insured employers who contract with at least two HMOs. Employees are to be given opportunity to designate a personal physician or health care organization at the time of employment and annually thereafter (4600.3 (a.1)). 4. Employer selection is limited to employers with approved managed care plans. 5. Limited to the initial visit. After the initial visit, the employee may choose their physician. 6. Employee selects from a certified MCO panel. 7. In a managed care plan, the employee selects from a network physician. 8. Employee may opt out of the managed care network after 30 days. 9. Employees may seek out of network treatment. 10. Employees may treat outside the network, but may be responsible for co -payments. 11. For the first 90 days the employee must choose from a list of six providers designated by his employer, after 90 days they may seek treatment outside the panel. If no panel is provided the employee may seek care elsewhere. 12. The employee may select from a list of at least three providers designated by the employer. If no list is provided the employee may go wherever they wish. 13. The insurance carrier or employer has the right to designate a preferred medical provider for the first visit and any hospital care. After the first visit the employee has free choice of physician. ( P • Incorporated • Assurance Corporation • Preferred Insurance Company Notice To Policyholders DEDUCTIBLE PROGRAMS For information on deductible programs, please contact your agent. SAFETY CONSULTATION In an effort to assist our policyholders in reducing the frequency and severity of accidents in the workplace, we would like to inform you of the availability of safety consultations If you would like more information on our safety consultation services, please contact (800) OVERTIME You do not need to pay workers' compensation premium on gross overtime pay. One-third (1/3) of the gross overtime paid is not used when calculating workers' compensation premium Example: If you pay $150 in gross overtime pay one-third or $50 will be excluded from determining your premium. AUDIT PROCEDURES You will be contacted by AmCOMP or their designee to schedule an appointment for completing a year-end audit The auditor will need to examine and audit the following records as applicable to individual policyholders: • Payroll records (indicating any overtime, commissions, bonuses, tips, and any other forms of compensation) • Internal Revenue forms (W-3, W-2s, 1096, 1099s, 941s, 940) • General ledgers and subsidiary journals • Unemployment Compensation Reports • Checking accounts and other cash disbursement accounts • Accounts payable and disbursement journals • Certificates of Insurance • Payroll information regarding salary reduction, retirement, or cafeteria plans Wrap -Up Agreement information Certificates of Election to be exempt from Workers' Compensation Law • Any other records necessary to determine premium calculation Once audit has been completed, a final audit statement will be produced. You will have 20 days from the date the audit results were mailed to file a written dispute No revisions will be made to the final audit statement except experience modification changes unless written notice has been received by AInCOMP Interim audits may be required during the policy period and will be handled in the same manner. SUB -CONTRACTORS I INDEPENDENT CONTRACTORS You will be charged workers' compensation premium for Sub -contractors who have not provided you with a valid Certificate of Insurance evidencing workers' compensation coverage during the audit period. If you are utilizing Independent Contractors, in order to avoid paying premiums on these individuals, you must secure a copy of their Certificate of ' Exemption. OMF • Incorporated • Assurance Corporation • Preferred Insurance Company Basics of a Good Safety Program Management Commitment Management must create a culture that does not allow for unsafe conditions or behaviors to exist. This message must start at the top. Define Responsibilities and Expectations Responsibilities and expectations must be developed for top management, supervisory and hourly employees. All must be held accountable for meeting the expectations. Basic Safety Rules and Procedures Basic safety rules and procedures must be developed and communicated to employees in order for the program to have direction. New Employee Orientation A new employee orientation program must be developed to provide new employees with information about the work environment and their job safety responsibilities. Employee Involvement Employees should be involved in the establishment of safety rules and procedures. It is vital to the success of the program that employees participate on the safety committee. Continual Education Ongoing training is a must for any program to work successfully Injury Investigation A procedure to investigate all injuries should be developed to determine the cause of the injury or injuries. Documentation All training activities and inspection reports must be documented. Records must be maintained in accordance with OSHA guidelines. Measurement. System A system to measure the programs' effectiveness must be developed. It should also measure the employee's safety performance. AmCOMP would like to provide your company with more instructional and detailed lnfoiunation. We look forward to assisting you in developing a good safety program. To get started, contact your Loss Control Consultant today. .j OMF • Incorporated • Assurance Corporation • Preferred Insurance Company Ways to Reduce Your Workers' Compensation Costs Employers having the ability to control or influence many of the factors that contribute to worker's satisfaction levels, return -to -work outcomes, and claims costs. Studies have shown that the following factors impact the cost and outcome of workers' compensation claims and the overall costs of insurance. Ongoing pre -injury employee education that addresses how to prevent injuries, and what to do when experiencing a work -related injury. The results of educating employees are improved employee satisfaction, and reduced attorney involvement when a claim occurs. Education should be offered during new employee orientation, and at least annually thereafter (group health enrollment sessions are a good time to present workers' compensation benefits to employees). • Identification of a provider and establishing a relationship with a provider pre -injury facilitates the physicians understanding of employee job duties, and transitional job opportunities. • When an injury occurs, referral of the injured employee to a provider is viewed positively by most injured workers. • Employers who make sure that injured workers are escorted to treatment and maintain compassionate contact during the recovery period (by sending cards/flowers, visiting and/or contacting the injured worker by phone) have more satisfied workers, and less legal involvement in claims. • After an injury occurs, workers who have ongoing communication with their employers concerning the workers' compensation process are less likely to seek legal counsel, and are more satisfied with their care • Providing transitional modified jobs (light duty) until full recovery, is viewed positively by injured workers and reduces costs and lengths of disability. AmCOMPSM AmCOMP Preferred Insurance Company AmCOMP Assurance Corporation P O Box 164347 Austin, TX (512)330-1777 (888)339-1771 Fax: (888)339-1772 Your Workers' Compensation and Employers Liability Insurance Coverage afforded by this policy is provided by the Company named on the Policy Information Page. IN WITNESS WHEREOF THE CORPORATION HAS CAUSED THIS POLICY TO BE EXECUTED , A1`1 ES'1ED AND COUNTERSIGNED BY A DULY AUTHORIZED REPRESENTATIVE OF THE COMPANY SECRETARY WC 99 06 93 (01- 2008) PRIVACY STATEMENT This Privacy Statement is provided by AmCOMP Incorporated and its subsidiary companies, AmCOMP Preferred Insurance Company; AmCOMP Assurance Corporation; Pinnacle Administrative Company; Pinnacle Benefits, Inc. and AmSERV, Inc. (collectively called "AmCOMP"). You are receiving this Privacy Statement because you are an AmCOMP customer. Your Privacy is Important to Us As your workers' compensation insurance carrier, AmCOMP recognizes our obligation to protect your private personal information and we are committed to keeping this information secure and confidential. Most of the information we use in evaluating your application and servicing your policy comes to us directly from you. In addition, we may collect nonpublic personal information from your application such as, name, address, social security numbers, and from any of your transactions such as, policy coverage, premiums and payment history with AmCOMP We may also collect information about you from third parties in order to carry out our responsibilities provided for in your policy and as required by law. AmCOMP does not disclose any nonpublic personal information about our customers to anyone, except as permitted by law. Information about you is shared with AmCOMP employees who need the information in order to provide you with products, benefits or services. We maintain physical, electronic and procedural safeguards to protect your personal information from being accessed by unauthorized persons. AmCOMP obtains medical information only in connection with servicing claims of injured workers. We will not use or share personally identifiable information for any purpose other than the underwriting or administration of your policy, claim or account. You have the right to obtain access to certain- information and the right to request the correction of information you feel is inaccurate. To change or access information, a written request must be made to: AmCOMP Incorporated Regulatory and Compliance - Privacy P.O Box 88806 North Palm Beach, Florida 33408 • AmCOMP Privacy Notice 9-2002 INFORMATIONAL BULLETIN INTRODUCTION In the wake of the tragic events of September 11, 2001, the United States Government intensified its efforts to detect and prevent acts of terrorism within its borders and to seize or obstruct the financial assets supporting terrorism and other threats to national security. As part of those efforts, President Bush issued Executive Order 13224 to be effective September 24, 2001. The Order requires that property and interests in property of persons and entities listed in the Annex to the Order located in the United States or coming into the United States, be blocked. The Order also prohibits transactions by US persons with respect to the blocked interests and provides a mechanism for identifying additional persons or entities that are subject to the Order. AUTHORITY The United States Department of the Treasury, Office of Foreign Assets Control (OFAC) which administers and enforces economic and trade sanctions against targeted foreign countries, terrorists, international narcotics traffickers, and. those engaged in activities related to the proliferation of weapons of mass destruction, maintains a list of Specialty Designated Nationals (SDNs) and Blocked Persons and certain countries with whom transactions and relationships are restricted OFAC has provided the following instructions with regard to identifying SDNs, Blocked Persons and restricted countries. "U.S. underwriters, brokers, agents, primary insurers, and reinsurers and U.S. citizen employees of foreign firms in the insurance industry are prohibited from engaging in transactions not licensed by OFAC that in any way involve: • Individuals, entities, or vessels appearing on OFAC's Specially • Designated Nationals and Blocked Persons list • Governmental entities and officials of Libya, Iraq, Sudan, or Cuba; • Companies located in Cuba; • Companies, wherever located, organized in or controlled from Cuba; • Individuals, regardless of citizenship, currently residing in Cuba; • Cuban citizens, wherever located (except those legally residing in the United States, or unblocked by OFAC license)." If a U.S. citizen or entity discovers that it is considering a transaction with or involving an individual, entity or _country on the SDN List, the citizen or entity must not complete that transaction. Identification of property, interests or transactions that should be blocked are required to be reported to OFAC and other appropriate federal authorities. If a U.S. citizen or entity discovers that it has already entered into such a transaction, OFAC will likely require the citizen or entity to cease further performance of that contract and freeze any assets in its possession or control belonging to the blocked individual or entity at issue Violations of these requirements can result in substantial civil and criminal penalties and/or incarceration, which currently can include corporate and personalfinesup to $10 million and incarceration up to.30.years. NIT FXC_1 I ISIVF TC) 1NSIJIRANfF C IMPANIFS The requirements set forth by OFAC are not exclusive to insurance companies Every individual and company doing business in the United States has a responsibility to verify that they are not doing business with or employing someone on the SDN list. AmCOMPs EFFORTS We want you to know AmCOMP has completed significant research and development of processes and procedures to comply with the requirements of Executive Order 13224 and we have implemented detailed systems to compare our company data with the OFAC-SDN lists: We believe our agents and insureds also have a legal obligation to identify any transactions involving those individuals and entities appearing on the SDN lists. For additional information relating to Executive Order 13224 or the OFAC SDN Lists, we encourage you to review the information on the U.S Department of the Treasury website at www.treas.gov/ofac. We also recommend you contact a knowledgeable attorney for advice regarding your compliance obligations. NOTICE TO ALL TEXAS POLICYHOLDERS "AmCOMP is required by law to provide its policyholders with certain accident prevention services as required by the Texas Labor Code 411.066, at no additional charge and return -to -work coordination services as required by Texas Labor Code 413.021. If you would like more information, call AmCOMP's loss control division at 1-888-339-1771 for accident prevention services or for return -to -work coordination services. If you have questions about this requirement, call the Texas Department of Insurance Division of Workers' Compensation at 1(800) 687-7080." Texas 166.4 Accident Prevention Service 09.01 .2005 IMPORTANT NOTICE To obtain information or make a complaint: You may contact your agent at You may call AmCOMP Incorporated's toll -free telephone number for information or to make a complaint at: 1-888-339-1771 or 1-800-226-1898 You may contact the Texas Department of Insurance to obtain information on companies, coverage, rights or complaints at: 1-800-252-3439 or 1-512-463-6500 You may write the Texas Department of Insurance at: P.O. Box 149104 Austin, TX 78714-9104 FAX # (512) 475-1771 PREMIUM OR CLAIM DISPUTES:Should you have a dispute concerning your premium or about a claim, you should contact the agent or the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document. AVISO IMPORTANTE Para obtener informacion o para someter una queja: Puede comunicarse con su agente al: Usted puede Ilamar al numero de telefono gratis de AmCOMP Incorporated para informacion o para someter una queja al : 1-888-339-1771 or 1-800-226-1898 Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion de companias, coberturas, derechos o quejas al 1-800-252-3439 or 1-512-463-6500 Peude escnbir al Departamento de Seguros de Texas al : P.O Box 149104 Austin, TX 78714-9104 FAX # (512) 475-1771 DISPUTAS SOBRE PRIMAS 0 RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, dede comunicarse con el agente o la compania prirnero. Si no resuelve la disputa, puede entonces comunicarse con el departamento (TDI) UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de informacion y no se convierte en parte o condicuion del documento adjunto. Texas2 M&C Review Page 1 of 2 CITY COUNCIL AGENDA DATE: 3/9/2010 REFERENCE NO.: CODE: C SUBJECT: TYPE: C-24132 NON - CONSENT LOG NAME: PUBLIC HEARING: Official site of the City of Fort Worth, Texas FoRT WORTH 17WAP DOE ARRA VENDOR CONTRACT NO Authorize Contracts with Multiple Vendors for the Weatherization Assistance Program Grant Funds from the American Recovery and Reinvestment Act of 2009 RECOMMENDATION: It is recommended that the City Council: 1) Authorize the City Manager or his designee to execute one year contracts with multiple vendors for Weatherization Assistance Program. 2) Authorize the City Manager or his designee to extend or renew the contracts for two additional one terms contingent upon receipt of funding from the Texas Department of Housing and Community Affa and 3) Authorize the City Manager or his designee to amend the contracts if necessary to acheive project provided that the amendment is within the scope of the project and in compliance with City policies an applicable laws and regulations governing the use of federal funds. DISCUSSION: The Weatherization Assistance Program provides for the weatherization of households to benefit the elderly, disabled and low-income citizens in the Tarrant County service area. Typical weatherization measures include attic, wall and floor insulation, weather-stnpping, caulking, repairs to faulty doors an windows and performing tune-ups and repairs to heating and cooling units. The maximum allowable weatherization benefit under this grant is $6,500.00 per household The City was notified that it was awarded a total of $12,072,608.00 in Weatherization Assistance Prog grant funds for program services for a two year period to serve 1,500 households. These grant funds provided under the American Recovery and Reinvestment Act of 2009 through the Texas Department Housing and Community Affairs (TDHCA) In order to spend these dollars in a timely manner, the City issued an Request For Proposals (RFP) to solicit contractors to perform weathenzation services The RFP was advertised in the Fort Worth Star - Telegram on October 14, 2009 and October 21, 2009. One hundred fifty-three vendors were solicited the purchasing database system Nineteen responses were received and the panel selected ten vend' Staff recommends entering into a Weatherization Services Contract with the following vendors: Atlas Star Energy/A Cooler House Efficient Attic Systems d/b/a Weatherization Management Group E3 Solutions, LLC Diversified Building Contractors Glenn's A/C & Heating GTO Construction Integrity Texas Construction Inc. KB Remodeling Standard Renewable Energy, LP Mills Efficient Home, Inc. http://apps.cfwnet.org/council_packet/mc_review.asp?ID=13203 &councildate=3/9/20 1 0 03/10/2010 M&C Review Page 2 of 2 Work will be assigned on a rotation basis to each vendor. At this time the total amount of the contraca be limited to $6,036,304 00 due to the partial funding of the grant. The remaining contract amounts wil available contingent upon subsequent TDHCA funding. RENEWAL OPTIONS - These contracts may be renewed for up to two additional one-year terms at th City's option. This action does not require specific City Council approval M/WBE- All 10 selected vendors are in compliance with the City's M/WBE Ordinance by committing to percent D/MWBE participation The City's goal for this program is 20 percent. Three of the 10 selecte vendors, Glenn's A/C & Heating GTO Construction and Integnty Texas Construction Inc , are certified D/M/WBEs The program is available in ALL COUNCIL DISTRICTS. FISCAL INFORMATION/CERTIFICATION: The Financial Management Services Director certifies that funds are available in the current operating budget, as appropriated, of the Grants fund. TO Fund/Account/Centers FROM Fund/Account/Centers GR76 53910 017200384020 $3,545,833 GR76 539120 017200384020 $2,490,471 Submitted for City Manager's Office by: Thomas Higgins (6192) Originating Department Head: Jay Chapa (5804) Additional Information Contact: Joe Cordova (7332) ATTACHMENTS http://apps.cfwnet.org/council_packet/mc_review.asp?ID=13203&councildate=3/9/2010 03/10/2010