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Home My WebLink AboutContract 35199Ci`�"°Y' ��f�ETARIf �;`;OR!��i�AG�' �� . ��..r�_T . CONSENT AGREEMENT FOR TEIvil'ORARY USE OF PUBLFC PROPERTY STATE OF TEXAS COIJNTY OF TARRANT T�IIS AGREFMENT is made and entered into by and between the City of Fot�t Worth, a inunicipal corporation of Tairant County, Texas, acting herein by and through its duly authorized Building Official, hereinafter re£erred to as the "City" and �j�lvf�l� %� �-}�:9 ��C�� '��' Acting by and through its duly authorized agent, ��i�� L �i=' l"��l "�u--�- � , Hereinafter referred to as "Grantee". VVTTNESSETH: For and in consideration of the payment by Grantee of charges set out below and the true and faithfirl performance of the mutual covenants herein contained, City hereby grants to Grantee permission to temporarily encroach upon, uses and occupy portion of the space under, on and/or above the streets, alleys, sidewalks or other puhlic rights-of-way as follows: �� . _/// � /L�Q �� The location and description of said encroachment is more paiticularly described in Bxhibit "B" attached hereto, incorporated hereiu and made a part hereof for all purposes. • 2. All use 1nd occupancy of p�iblic street, a[leys, sidewalks a• otlter public rights-of-way under this aareement shal[ be in strict comp(iance with the Charter, Ordinances and Codes of ehe City and in accordance with the directions of the Building Offtcial and tha Director of Transportation a�ld Pub(ic Works of City. _ 1 CONSENTArREEMENTforTemporaryus=ofpubfic raperty�aoc ^ � � �, � , ' I ,G'S I i � 1 . .� ,. ,_ !..IS��✓f:.V t �+12t ::�� =�i ?t r� J . / �` � �� F7��, c�c��':i�})�2j'':'.�%,+( � S �yj! �J�`�'; 'f,��i��l ��i'ia �. � :( B: '�� i�:�Sa 3. TJpon expiration of this agreement and the privileges gi•anted hei•eunder, there shall be no encroachment by Grantee in, under, on or above the surface of the public rights-of-�vay invol��ed. �. Grantee agrees to pay in advance an encroachinent fee for the tempocaiy privilege of eucroaching upon a portion of the public rights-of-way as descri6ed in Exhibit "B". Said fee is calculated in the manner and amounts �rescribed by tl�e Building Code of the City of Fort Woi�th for temuorarv use or occupancv of pub(ic properry. The estimated totat amoEmt of said fee is: s. Grantee, at i�o expense to City, shall make proper provision for the relocation and/or installation of any existing or future traffic control devises or other improvements affected hy such encroachment, use aitd occupaucy, including the securing of approval and consent from the appropriale agencies of the State 1nd its political subdivisions. In the event that auy installation, reinstallation, relocation or repair of any existing or firture t��affic control device or improt��ement owned or constructed by or ou beha(f of the pub(ic or af public expense is made more costly by virtue of the existence of such encroachmeut and use, Grantee shall pay to City and additional amount equal to such additional cost as determived by City. �o�� X Il = �� f 1 � 6. The term of this agreement shatl be for �_days, froiY � �� '�/."� �'� Providecl, liowever, should the need for the encroachme�rts granted hereunder at any time cease, Grantee lgrees to immediately notify City of such condition; and, upon receipt of sucli notice by the Building OfCcial of the City of Fort �Vorth, tliis agreenient sl�all terminate. '7. It is expressly understood and agreed that this Cot�sent Aa�eement is for a temporary encroachrnent in, iueder, over and upon the public property as located and described in Exhibit 2 CONSFYf AGRFEI�1FNTior Tempoiary use of puWic properiy1.doc `B". This agreement shall not be construed as the granting of a permanent easenient, encroachment or license ��pon City's public streets, alleys, sidewa(ks, oi• other rights-of-way. 8. City, through its duly autliorized representatives, shall have the full and nnrestr•icted right to enter upon all public rights-of-ivay far� the purpose of ma[ciug inspections to detet�nine compliance with the terms, covei�ants and conditions herein. In the eveut that any inspectian should reveal a breach of any tezms, covenants or conditions herein, City shall give Grantee notice of such breach. Shotjld such breach not be corrected by Grantee �vithin twenty-four (24) hoiu•s of receipt of the notice, or �vithin such sl�orter period of iime as deemed uecessa�y by the Building Official for the protection of public health or safety, City may terminate and cancel this agreement. 9. Upon expiration or te►•mination of this agreement for any reason whafsoever, Grantee shall, at no eYpe�tse to City, restore the public rights-of-way and adjacent supporting structures to a condition acceptable to tl�e Director of Transportatiou and Public Works or his duly authorized representative and in accordance with then existing City specificatiais, and Grantee shall remove all barricades, equipment, supplies, materials or other propeity fi-om said location. Urantee further covenants ancl ab -ees that for a period of one (1) year after the termination of this Consent Agree�nent, Grantee will repair all conditions or damages to the sh•eets and side�val]<s or otlier rights-of-way that have resulted from Grantee's use or occupancy of the sh�eets and sidewallcs or other rights-of-way, as deterniined by the Director of Transportation and Public Works or his designee. Grantee agrees to begiu such repairs within thirty (30) days of receipt of noiice from the Director of Transpo��tation and Public Works or his designee. Al( repairs shal( be performed in an expeditious and workmanlike manner and shall comply with 111 applicable laws, codes, ordinances and City specifications. In the event ttiat Gi•antee fails to comply a��ith the covenants herein contained with respect to such removal or restoration, the City shall have the riglit to remove or dispose of any barricades, equipment, supplies, materials or other pi•aperty and repair any conditions which in the op'tnion of the City are necessary to bring the public rights-of-way to the condition prescribed llerein, and Ciry shall not be responsible for trespass or any other damage or liability ir� connection with such removal or restoration. Grantee shall reimburse City for tt�e cost and eYpense of such removal and/or repairs iinmediate(y following billing for sa�ne Uy City, 3 CONSENT AGREEMENTior Temporary use ot puhlic properiytdoc Nothing herein shall be constiued as a waiver by City to enforce penal sanctions prescribed by the Code of the City of Fort Wnrth ai�d tha laws of the State of Texas for Grantee's continued encroachment npon the public rights-of-way following termination of this Consent Agreement. 10. It is fiu�ther unde►•stood and agreed between the parties l�ereto that City holds the city streets, alleys, sidewalks and other pubIic rights-of-way, including the portians of such streets ��sed and encroached upon as described herein, as trustee for �he public; that City exercises such powers over the streets as liave been delegated to it by the Constitution of the State of Texas or by the LegisJature; az�d tlie City cannot contract away its duty and its legislative power to control the sti�ets for tl�e use and benefit of the public. It is accordingly ag,��eed that if the gove��ning body of City, to wit, its CI[j/ COIp1ClI, shall at any time dm•ing tha terrn heeeof deteimine in its sole discretion to use or cause or pertnii to be used for any public purpose tl�e said encroached portion ofthe streets, then this agreemenl shall be automaticl(ly cancelecl and terminated. 11. Grantee agrees to co�nply fully with all applicable federal, stata and local laws, statutes, ordinances, codes or regulations iu connection with the consh�uction, operation and mai��tenance of said encroachments 1nd uses. 12. Grantee agrees to pay promptly when due all fees, taxes or rentals provided for by this agreement or by any federal, state or local stahie, la�v or regulation. 13. Grautee covenants and agrees that it shall e�eccise all rigl�ts and privileges granted hereunder as an independent contractor, and not as an officer, agent, setva[lt or employee of City; that Grantee shall have exctnsive control of �nd the exclusive right to control the details of its operations and activities on said ciescribed public propei-ty and all persons performing same, and shall be solely i•esponsible fof• the acts and omissions of its officers, agents, servants, e�nployees, contractors, subcontractors, licensees and invitees; that the doctrine of respondeat snperior shall not apply as bet�veen City and Grantee, its off'icers, agents, servants, employees; contractors and subcontractors, and nothing herein shall be construed as creating a partnership or joint enterprise between City and Grantee.. 4 CONSENT AGREEMENTfer Temporery use of puNic prooeriyl.doc 14. GRANTEE COVEi+I�1Ai3'� AND AGREES T� Il�IDEt��'Y, AND DOES HEREBI' iI+1DEIV�"i', I�OLD 1�IARMLESS AND DEFEIVD CITY, I'TS OFFICERS, AGEI+IT�, �ERVANT� AND EyIPLOYEE�, FROM AIVD AGAI�ST ANY EiND ALL CLAIiiYIS OR SUITS FOR PROPERTY DAI�AGE OR LOSS A�iD/�R PERSOAtAL T`�i iNRY, CNCI�UDING DEATH, TO A1VY AND ALL PERS�N�, OF V4'HATSOEV�R KIIVD OR CHARACTER, WH�TIIER REAL OR A�SERTED, ARISIlVG OUT OF OR IN CONNECTIOlai WITH, DIl�ECT�LY OR Ili�DIl2ECTLY, TH� I�IAIt�TENAI�TCE, OCCUPAI�iCY, IJSE, EXIST�NCE OR LOCATIOId� OF SAID El�CROACIINIENT A1�TD USES GItA1�1TED HEREUlVDER, WHETHER OR oTOT CAUSE, I�T �VI�OLE OR P4RT, BY ALLEGED loTEGLIGE1�tCE �F OFI+IC�RS, AG�IVT�, SERVAI�T�, �1VIPLOY��S, CONTRAC�ORS, SUBCONTRACTORS, LICENSEES OR IImiVITEES OF CITI'; AND GRA.NTE� F3�R�BY ASSU�IE� ALL LIABILITY A1e1D R�SPONSIBILITY OF CITY, ITS OFFIC�RS, AGEI�ITS, SERVANTS AND El�'LOYE�S, POR SUCH CLAIM� �R SUITS. GRAI+ITEE SHALL I,IKEWISE A��Ulb1E ALL LiA131I.17CY A1�Ill It�SPONSIl3ILITY AP+tD S�IALL INDEIVINIFY CITY FOR ANY AND �I.L 1NJURY �R DAMAGE �'O CITY PROPERTY, ARISING OUT OT OR I1�I CONNECTIOl� WITH ANY �ND ALL ACT� OR OMI�SION� OF GRAliTT�E, IiS OI'FIC�R�, AGENTS, SIGRVANTS, �NiPLOY��S, CONTRACTORS, SUBCOIVTRACTORS, LICESNE�S, INVITE�S OR TRICSPASSER�. 15. Grantee agrees to fiu•nish City with a Certificate of Insurance, naming City as certificate holder, as proof that it has secured and paid for a policy of public (iability insnrance covering all public risks related to the proposed use and occupancy of public property as located and described in Bxhibit "B". The amotmts of sach insurance shal( be not less that the following: Property damage, per occurrence $100,000.00 � Bodily injury, per persou S250,000.00 f Bodily injury or death, per occurrence �500,000.00 With the understanding of and agreement by Grantee that such insut�ancc amounts sh111 be revised ( up�vard at City's option and tl�at Grantee shall so revise such amount immediately following notice to Grantee of such requirement. Sucl� insurance policy shall provide that it cannot be ca�lceled or arnended �vitfiout at least tliirty (30) days' prior written notice to the Bui(ditzg Official 5 CONSENT AGREE'dENT(or Temporary use of public properh�t.dnr. of the City of Fort Wo►-�h. A copy of such Certificate of Insurance is attached as Exhibit "A". Grantee agrees to submit a similar Certificate nf Insurance aunually to City on the anniversary date ofthe e:cecution of this agreement. Grantee, agrees, binds and obligates itself, it successois and assigns, to maintain and keep in force such public lia6ility insurance at all times during the term of this agreement and until the removal of afl encroachments and the cleaning and restoration of the city streets. A(1 insurance coverage reqttired herein shall include coverage of all Grantee's contr•actors. I6. Grantee covenants and agrees that it will not assigr► all or any of its rigl�ts, privileges or duties under this contract without prior written approval of City, and any atieit�pted assignment �vithout stich prior written approval shall he void. 17. This a�•eement shall be binding upon the parties hereto, their successors and assigvs. 14. Sl�ould �ny action, whether real or asserted, at la�v or in equity, arise out oE the terms aud conditions of this agreernent or out of tl�e use and occupaucy of City property �►s permitted hereunder, venue for said action shall be in Tarrant County, Texas. ]9. In any action bcoug0t by City for tlie enforcement of the obligations of Grantee, City shalt be entitled to recover interest and reasonable attorneys' fees. EXECUTED thisZlsi day of � h�'i� GRANTOR: CITY OF FORT WORTH � / "�� , -��/�� „l /./% , i % /i : / , � �;,- Buildilig Officiai ` �� 200� GRANTEE: , �//%��I/%� � ��/��l` /� , /� �' / �c-c �� Title 6 CONSENT AGREEMENTfor Temocrar/ use of public properlyt.dac APPROVE�"TO FOR1�I AND LEGALiTY: �,.f-��-/�" � Assistant ity Attorney Date � ' � � / --��--� �� t _��.(} =^�� City Secretar Date � �r IV� ��_�h��A�J�I��T�� .�_,�___� __,__�_-_• � CONSENT AGREEMENTfor Temporary use of F hc gropeqyt coc � ��, �_ ;�� r,1:� 1.�� L 1,��'��:�:; � ,_ i �S �r y�!t��'�i I 'v � L e V��.� 1. S�l'.,� ,�( !; � 7 � � �^ �� I U '� r`,` `ii;:;,^�: i� � i `J ! o �'ri'1.�r6� �54�.: STATE OF TEXAS COUNTY OF TARRANT BEFORE ME, tlae u�a�lef�signed aaitlaof�ity� !l NOtlll��P1[IJZZC lll CIIlCI Fof� tlae State of Tex�rs, oi: tlzis day pef•so�tally appeared l"'%/��i' l ,��'�r�t�i�i�� '�" ,linown to nte to be tlre pet�so�a wlzose ii�nte is sacbscribed to tlae fos�egoa�zg instr�ccnze�zt, a�td acliizofvledge�f to me tlr�at li�e/slae execa�ted tli�e sanie for� tlie pirfposes a�r�d co�isi�leratio�a� tlr�es�ein expresse�l, as tlie act a�zd �leerl of �7==�,,' ,� •'� < �-r . �r=r-�C �'/�L_ , aiid in tlae capacit�� tlaef•ei�r. state�l / 'i,.. GI, V, E`N UNDER MYHAND A1VD SEAL OF OFFICE tlris � dt�y o f '!�f/�j't l 20 �'� %. -; /' % -i% �� /(/ �� . Affia rt '' ;; �-` , � r , �l� , � Title ' �� ,. _ ` Notafy Public in �r�i�l for Tlr�e State o Texc�s �-,,;;;�,�,,,-,_� -. - =`_== .�4 - ;sJ,, :'�ry.,�,, f;. �. ��l�2EZ _. re ,:'�- Notary Public, State of Texas - �.�:5; My Cammission Expires ��'�;'F�F�E;�'�� Septembar 10, 20�9 ,,,��,�� 8 .5`�'ATE �F TE�A,S' C`�UNTY OF TARRAN7' BEFOREME, the untle�signerl aufhot•ity, allot�rsyPcsblic in asz�! For tlae State of Texas, on s day personrrlly appeare�l �uF�- �''=i1�Z� ,Icnaw�z to fne to be t/ie peYson iU{tose nrcfne is suGscPibe�l to tlie fof�egoing itzst�umerat, c�nd acknowlerlge�l to rne i�tat lae/slze executed trie sr�me for tlze pcct�ose,s, ayirt cnr�sideyatin�e tlie��eiyt expresserl, as tlte act anrl �leed of >� �fJ�.� � �ifad in tfie crcpucity ilief•ein ,st�rted. GIVFN I,11iTDER [lIYHAND 1) SEAL OF OFFIC`E tl:is � I-`3 �� r�uy of �M � �1- zo� �. �� a zt � . �tle �-K� �t1� 9 iry b[ic in ur�rl for Stafe Texrrs John L. Lambert ►�' Commission E�irea July 28, 2007 < �d s �-�. �0�� ,It�� ;Y 0� �'UE3LIC:; l'(�0 ��I � �Y� i �r, ! FS� Contractors Name�`�""'I ��i�hrt �i Point of Contact: �f.Ji '►zi� �. �� Phone Number: �11- � l — � Building Permi.t Number. �� ' � � +,r Purpose for Closure:_�_3u� -� YZ � Begin Date: �� rJ: End Date: � S Type of Taper according to posted spe�d limit; Tapers @ 30 MPH l Oft Offset 30ft ininimwn Tapers Q 35 MPH 1Oft Offset 35ft minimum Tapers @ 40 MPH 10$ Offset 40ft minim� � - � r.� n�.v� ., � J �� UAYS =- � � �� Q� - �,�,. ; �—��'�"-_ _� - DqYS _ r � , , 4 .� � — ;;�RFFT � �-� �r��lv_--��_I `--_ � _ _ - --- - 1 `�,' _ � __ __ _ _ _ - sc .".�c - —�. � -.. —._ -: _ -_.: _ — __�..-�—i ��`� � c� .. V__ �.-�� c�� i I� �Q � � � �1 �� Cc C�z-> S �( �� c�, �-�-� e -� (n � X t �� = Ca��o S,��F,�- . G,�,�ir� ,.,�.r._ � �,� ,-�t �� s .�;;�� s- ..., � �� c?BS ��`"�� . lV y �,r, tTv�.�FG�I'3.C► �'Y$i�'�� ;, � �'�, :�1.�{KIBRS v q , /N� i� �� ,, � ._ , ��; 04/03/2007 6�:25 8172442898 BRUCEI�HITE PAGE 62 �om,zxxercial Certi�cate o� �nsux`ance Agenc-y . }�ruce White Ageney Narne . gOt)S C'amp BmN[e W#� 12 �+ � F'ort Worch, Tex�s 76116 Addre.� • Sr. 3 S Insured N�me & �C](jxNS� bist, 1� __. Agenl 31 a , pFinzay Dehart Yainting � 6f 13 Gen�ox [to�d • Fort Wortb, Texas iCt { 16 riYi�%;4 /� )i1:!:��.�, � � /� � �n:; � ��-i _, _�:�- . xssue 1�ate (MM/i)D/YY) � 7'his cea'tif#cate is is4ue.d as a matter n( informakioo only and confers no ri�hks upott the certlficdte holder. '1'hi,e cer[i�i�ate dces nvt amend, extend or alter the roverage afforded by the pali�}rs shown be�lpw. Companic� �roviding Gaveta� Com�pa�y P1 Ttuck Ir,nurancc E;xchao,Ge t.�� company g F<utxters I�surance Excharige tNt�r cwvpany C Mfd-CFntury Insuc�nce Gompany � cr�er Cuntpany d Scottsciale ins Coxx�panY IRttCT ' GaVerages 'fhis ix to crrti�y rhat rhe nnHcies oFinnt��tn' )isttd he�loµ' hxve been Lmi� to the Insurccl namecl aboti�e for the p4ltcy (>C�iod ictdECatetl. i`1c�twithstat�dir�� any ret�trlrnmPnf. trrm or ronditlon of any r,nntrart nr nther da:ument wlth rpsper,t to which this certificate may be Issued or may pertain, the i�uuranr,e afforrirci hy t��' �511r1� dPsrrit�ed hrre�n is sah}ec:t tn all the tPrms, exclusiqn5 and mnditio�ts of s��;h pc�tletes. Llmtts sho�+'n may f�:�vC bpe� re<tuced hy Dald claims. _ _ --- ��' Type� af Inxur�nc'e �-lr. D Ge+ieral �iabiliry c,on�m�,r�i�� ceneral LiAbilit.y • QCCIJITP.(1CP. �/PTY�f/ll Contrartt�?! - ftxldental C)nly (7Wt1PfS � � �)flrYxf'i()IS 13i�i)i. AuXo+nobik' �i�bility (� AII �WIIM.� CP1'C1tY]CY'C,'i�I Autta� S<:heciulwt /1ut��c Hired A��tcx Nan-Owr�rcl Airt�� C'>arage (,fabllltY Policy Numher C�.S.] ]26724 Ub934S332 f'oli ,ry Effeclive Policy Fx�iratlan palicy LiXnits Date (MMrt�nnxl Date chs�mDrm p4- I 7-20�6 Ofi-(14-2006 u�tbre�la �iAni�ity _ WorkP�s' Compensation � �5�� 06-�9U20Ub �I� —�Emplayers' Ljabihty I NAF3C� Ln4fi39 _._�,.,,_.._.�,._. ...........V..-�. --------- - Description of Ot�c'i�ations/Vehicles/k�c'strictiar►s/Spe�fa1 itezr��: C;Untrr�r.tor-Pxinti�R C��1'HtiOnS 04-17-2UU7 Ufi,(19-2007 06-(19-2007 Cenerai Agg�rega[c Produns-C�c�mp/UP5 Aggtegate Per9on�l &. Advertlsing in}ury EACfI aCClllT'CIICe Fire Damage (Any <H-ie ti�*) Medital Expense (Any one jx'�on) Combinecf Sxngle z.�m;t Budily ln ury (Per Frerson� Budily ]njury (Per ac;cident) Pro}�erty Damage (;arage AggrCgate Limit Statutory �,ac h Accident D1.tP.�rtSP - Fach F.mpby� �Iscasr - PoNcy I�imft � 2,OQf1,000.U0 3 2,OC1(),000.00 � 1,OQO,U00.00 � 1.000,0�0.00 S 1 U0,000.00 g S,Od0.d0 � �.00O,W0.00 $ g 5 S $ � �D0,000.00 � 500,000.00 S 500,000.00 Certificate Nalder�. ...�_,.---�---._�__. Cattcellatian ,'j'�� (."�ty of Ft Wortlz, I� U�cers � Should any of the above descr�flx'd po��Cles tm r�tir.eqed before [he e�iration date NamP . rmployees Named as an ndditional therenf. the iauing �ompany will rndeavor to mall 30 days wrirtet� notlr;e tn the r,Prtiflr,�tr, holder n�med co the left. fiut Fall��r to rnall such noUce shall impase no 8r � in5ure<i .�1i�dress: 5treet Maita�em�-nt ��hIIRa liabUiky of any ki d iaJxm the cnmpany. its agents or re�resentative�. Addrrsti ' Section, .31 I W 1(ltb 5t, ft Worth, Tx 76l t � �+� � n 04/03/2007 00:25 8172442898 BRUCEWHITE car��aaN Paucv ��c�RnT�ows RENEWALOF �� S,,,r,�'�'$�A�.� INS�C_TnAhTC� GUIVIPA�.�'�g �i.,s i 12 6_7 z a H ame �ffice: ' r �� dn6 �atidnwidb P1sza � ColUmbus, Qhio A3215 AdministratNe �fHce: g877 Narth Galney Ce 1te��3�767G5��H'�' A�Yon� 85258 q STOCK COMPANY IT�M 1. N�med In�u d auln Address . --.�_---� --� `�" Dann� D�Hart Painting 661� Genoa Road F��t Wor�h� Texas '7'6116 Agent Name and Address L.�. �i 8 & W Ineuran�� Group, 2?07. EAST �.'��76046 ARLINGTON � 'Z'X .— ITEM 2_.Pollcx,p�►�� - STH �'LOOR p�gent No.: 42o n - 04/17/2q06 Tp: b4/17/2007 -rom: 1�:d1 A.M., 8t�ntlnrd Tirrrn ac aur ma41ln edcire■9. PAGE �3 Poll�y Numb�r C�51245A�93 Progr�m Na.: __. KJ Tarm� 365 DAYS�^ BuslnesB da�c�ptfon: P.AIN�'�Rs with you ta provide the �11 we agrea In r�turn fbr the �ayme�t t� �h� Premtum, and $uble�t to all the terms af this p �s �r whlch a prem(um is fndicat�d. In�urance as siated fn this pdfcY. Thls pc�licy �nsists of the foliowing � s�� to ad}ustment. Wh�re no premlum is shbwn, there �s no coverage. Thls pr�mlum maY � Premfum Gpverege Part(s) �prnmercfal General Uablltry Cover�ge PaK Commerclal Praperty Goverage P�r� Gommerclal C►ime Cdverags Pat� Cammc�rcfal Inland Mgrine Cov�rage Part Cotnmercial Autb (Business Auta or Tru�kBrs) Cc�vere�9e Pa� Comm�rclei Garage Cov9reqe Pert Frofessi�nal Li�blllty �oveta9e P�rt 4,504 �� DTOT C�VERED � r7QT COVERE(7 � � �10T C�'�EREp � N�T C�"VERED � � T1pT CQVERED � $� NGT covER�.n_�...— $ —_ — �----- � _ _� 7otat Paifcy Premlum: $ 9 504 . 00 ppZ,TCY FEE � 250.00 _ $ — �- . SURFI:,US LII3BS x"AX �� 230.57 �— STA.Z'�I�ZNG FEE $ _ 4 ' � �-� `I'OTAL $ 4 �9 B 9. 3 Z $ _.., ---� � Forrn�S) and ErKiorsemant(s) marie a pa� of thls pdicy at time of Issue� SEE 9CMEDUL� QF Ff�AtM8 ANd ENQOR$EMENT Bw�rxz-srs/raA oq/2o/aoos AUTN012�ZED R�PRE9EN'TATIV� DON CAR50N ��r TH1S COMMON POLICY DECLARATION AND 7ME SUPP�EMENTAI.. D�C�F�,4710N(S), TpGETHER WITH TWF COMNS�N POLICY CONQITIqNS, COQ� �E��S��Q�E�MBER p�p� � a FORMS AND ENDORS�MENTS, I� ANY, opsdlh.fap �PS-[7-1 (12-Op)