HomeMy WebLinkAboutContract 39912 STATE OF TEXAS
§ • cmr SECRETARY
§ CONTRACT 140.
COUNTY OF TARRANT §
WEATHERIZATION ASSISTANCE PROGRAM
CONTRACT FOR SERVICES
Between
I. Parties
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 "
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
efficient. The basic objectives of the program are: it energy
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 ,
Contract, this Contract shall control. P ted;in•tbe'Rh`A iiiiO this
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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 cabinet, countertop, and/or sink repair/replacement
• High/low combustion venting
• Floor Insulation R11 &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.
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• 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-I OCFR440.
• 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 conforms, 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 Department 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 Department 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 Department, 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;
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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 [normally 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
contract activities; or
Worth and who exercises or has exercised any functions or responsibilities with respect to assisted
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.
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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 in 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 Department.
The Director of the Department of Housing and Economic Development Department 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
Department; 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 Billing 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 Department 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.
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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 VIII of the Civil Rights Act of 1968 (42 USC 3601 et seq)
Executive Orders 11063, 11246, as amended by 11375 and as supplemented by
Department 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 Reform 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.74403,
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.
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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.C. 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 permit its officers, members, agents, employees, subcontractors or program participants to
engage in such discrimination.
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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 forms 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 harmless 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.
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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 harmless 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.
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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 Liability 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: VII 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.
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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 Department
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 terminated, 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 terms 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.
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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 perform 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 terms herein
set forth.
Department 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 Department for any money it has received from
Department.
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 Pares hereto have executed three copies of this Contract in Fort Worth,
Tarrant County,Texas, this��� day of 20 1
CITY OF FORT WORTH CONTRACT R
By: By:
T. M. Higgins lanco
Assistant City Manager it=Ier
O/O
Recommended by: Date
Jesus Chapa,Director
Department of Housing&Economic Development
Approved as to Form and Legality:
C�4 K'—
Amy J. Ra
Assistant City Attorney
ATTEST:
Al 00 0 0 0
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City Secretary 0�.$o
0,00° 0
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Authorization: o o �c ci
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O b�ObDO00b �Cy Ay
Date: � C � � v �aa
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13
EXHIBIT A
Template: FA-Special Terms and Conditions
8-20-2009 FINAL(APPROVED BY DOL)
FA-TC-0050
?r?5cript10--T u to for AR?A.Ar;-ards :rhen WAGE RATE REQUIREMENTS UtZER SECTION -06
OF THE AIMERIICAN ACT i'RECOVER'v ACT')Causes are reo_lired.
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,iinstallation(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 5ubaward.
For purposes of these Clauses, a Contract shall include subcontracts and lower-tier
subcontracts under the Contract.
(4) Controcting 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-t!er subcontractors.
(6) Recipient means any=ntq 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
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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
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)All 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 and 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 employers 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)(a)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.
(ii)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 Act, 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
maybe submitted in any form desired. Optional Form WH-347 is available for this purpose
from the Wage and Hour Division Web site at
http://www.dol.cloylesa/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
notice 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,
on 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
or 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 Subrecipient 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 Subrecipient 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 thejob 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 thejourneyman 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.
G. 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/0/7OB4872Dl6EE95A785256A26004F7EA8/$file/sfl4l3_e.pd
f. Within 14 days after issuance of a Contract or lower-tier subcontract, the Subrecipient shall
deliver to the Recipient a completed Standard Form(SF)1413, Statement and Acknowledgment,
for each Contract and lower-tier subcontract for construction within the United States,including
the Contractor and lower-tier subcontractor's signed and dated acknowledgment that this Clause
has been included in any Contract and lower-tier subcontracts. SF 1413 is available from the
Contracting Officer or at
http://contacts.gsa.gov/webforms.nsf/0/7OB4872Dl6EE95A785256A26004F7EA8/$file/sfl4l3_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 disputes 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
10
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 Rotes
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)"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.
II
(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 Subrecipient 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.
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Insui>ra ce Color COMMON POLICY DECLARATIONS -
p Policy Number L076003035
L_976002689
Renewal of Number
Item 1. Named Insured and Mailing Address:
K8 REMODELING
OSCAR BLANCO
8003 E. MELROSE ST
FT. WORTH TX 76108
Item 2. Policy Period From: 07/22/2009 To: 07/2212010 Term 365 Day(s)_
12:01 A. M. Standard Time at the address of the Named Insured as stated herein
Item 3. Business Description:
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 parts for which a premium is indicated. Where no premium is shown,
there is no coverage. This premium may be subject to adjustment.
Coverage Perna! Form No and Edition Date Premium
Commercial General Liability Coverage Part (ate' - $ 3,179-00
Property Coverage Part ?
Equipment Breakdown Covera S,> e ,. SJt '. ,�`C�t''• 41r $
Inland Marine Coverage
Terrorism Covera 0 e � $
Aft 31179.00
Fee $ 160.00
STATE TAX $ 161.94
tij9 a �S� ds SOF $ 2.00
fA
ON'S t� `L 'p0 G Total $ 3,602,94
Audit Pe4 otherwise stated:
o
vs
Item 4. For and endorsements applicable to all Coverage Parts:
See Schedule of Forms and Endorsements
Agent No.: 420076
General Agent: TKG General Agency Inc.
Address: 4661 FM 2723
Mt, Vernon TX 75457
Producer Code No.:
Producer Name: A-SUNRISE INS.
Producer Address: 3204 E. BELKNAP
FT. WORTH TX 76111
Countersigned 08103/2009 SR By
DATE COUNTERSIGNATURE
THIS COMMON POLICY DECLARATIONS AND THE SUPPLEMENTAL DECLARATIONS,TOGETHER WITH THE COMMON POLICY CONDITIONS,
COVERAGE EORM(S)AND ENDORSEMENTS COMPLETE THE ABOVE NUMBER POLICY.
IN WITNESS WHEREOF,this Company has CWN!d the Pdky to be jWod by its Prq*hRtt and ih SCMgwy and wwwsign d by■duty Out-f-d-p-wntaKim
U)Aov� A . -7x42A4(CzJt4kA'
President Secretary
ACD 04-07 INSURED
n
CENTRAL
VDUR ndeppendeit'
Insurance�/1GENT
SEOYES YOU EIOST
AGENCY, INC. �®
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,
Rene Ransom
Account Representative
(512)451-6551 Ext#139
rransom@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
AmCOMP Assurance Corp o�lc Number ; Pbltcy Period
p FFR 0 �® y Fror1:: To
P.O.Box 164347
Austin,TX 78716-4347 ®� WCV 4217944 01/22/2009 01/22/2010
(8:38)339-1771 InsureA.M.stated her in at the address of the
ransaction:
POLICY DECLARATION
1 Named In tired and Address =Agent.
OSCAR BLANCO DBA KB REMODELING CENTRAL INSURANCE AGENCY, INC. 4219611
8003 E. MELROSE ST. 6000 N. LAMAR BLVD. , #100
FORT WORTH TX 76108 P.O. BOX 15427
AUSTIN, TX 78761
Telephone:
Customer# Carrier# FEIN# Risk ID# Entity of Insured
36870 364625734 000000000 INDIVIDUAL
Additional Locations:
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.
SEE EXTENSION OF INFORMATION PAGE
Minimum Premium $ 250 Expense Constant $ 140
Premium Discount $ -200
Assessments and Taxes $ Total Estimated AnnualPremium $ 7,358
❑ This is a Three Year Fixed Rate Policy
Premium Adjustment Period: ® Annual; ❑ Semiannual; ❑ Qua erly; ❑ Monthly
r
Countersigned this Day of r
Issued Date: 01/30/09 F Authorized Rs6resentative
Issuing Office AmCOMP Assurance Corp
INSURED
WC990634 (5/98 Ed. )
Workers Compensation and Employers Liability
< Insurance Policy
Policy Number: WCV 42.17944
AmCOMP Assurance Corp Named Insured: OSCAR BLANCO DBA KB REMODELING
P„O.Box 164347 Agent: CENTRAL INSURANCE AGENCY, INC. 4219611
Austin,TX 78716-4347
EXTENSION OF INFORMATION PAGE
CLASSIFICATION OF OPERATIONS
Premium Basis Rate Per Estimated Policy
St Loc Code Classification Description Total Estimated $100 of Term Premium
No. 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
0063 PREMIUM DISCOUNT 0.02700 $ -200
0900 EXPENSE CONSTANT $ 140
9740 TERRORISM 0,02000 $ 20
SUBTOTAL $ 1,578
TOTAL FOR STATE $ 7,358
TOTAL FOR POLICY $ 7,358
Issued Date: 01/3 0/0 9
INSURED
WC990630 (5/98 Ed. )
Workers Compensation and Employers Liability
+ a Insurance Policy
Policy Number: WCV 4217944
AmCOMP Assurance Corp Named Insured: OSCAR BLANCO DBA KB REMODELING
P.P.Box 164347 Agent: CENTRAL INSURANCE AGENCY,INC. 4219611
Austin,TX 78716-4347
NAMED INSURED SCHEDULE
Loc Loc
Nbr Name &Address Nbr Name &Address
00001 OSCAR BLANCO DBA KB REMODELING
8003 E. MELROSE ST.
FORT WORTH TX 76108
Issued Date: 01/30/09
wcpnisa INSURED
WC990632 I lean �A
Workers Compensation and Employers Liability
Insurance Policy
Policy Number: WCV 4217944
AmCOMP Assurance Corp Named Insured: OSCAR BLANCO DBA KB REMODELING
P,).Box 164347 - Agent: CENTRAL INSURANCE AGENCY,INC. 4219611
Austin,TX 78716-4347
ENDORSEMENT SCHEDULE
Loc Number Description
00 WCOOOOOOA WORKERS COMP / EMPLOYERS LIAB
42 WC000406 PREMIUM DISCOUNT ENDORSEMENT
42 WC420301F TX AMENDATORY ENDORSEMENT
42 WC420308 TX PRTNRS,OFFCRS,OTHRS EXCLUS
42 WC420402A TX ANNIVERSARY RATING DATE
42 WC420407 TX-AUDIT PREMIUM & RETRO PREM
42 WC990694 TX-TERRORISM RISK INS PROGRAM
42 WC990695 TX-TERRORISM PREMIUM ENDT
Issued Date: 01/30/09
INSURED
WC990633 (5/98 Ed. )
Aftcomv
• WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
Beginning on page
INFORMATIONPAGE . ........................................................................................................ 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 Will 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 .................. ....................................................................................
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 ....::.................
C. Remuneration ....................................................................................................................... 5
D. Premium Payments ............................................................................................................... 5
E. Final Premium ....................................................................................................................... 5
F. Records .......................................................... ................................. ................. 5
....................
G. Audits .................................................................................................................................... 5
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
(Ed. 4-92)
is paid. If any insurance or self-insurance is 1. As between an injured worker and us, we have
exhausted, the shares of all remaining insurance will notice of the injury when you have notice.
be equal until the loss is paid. 2. Your default or the bankruptcy or insolvency of
F. Payments You Must Make you or your estate will not relieve us of our
You are responsible for any payments in excess of duties under this insurance after an injury
the benefits regularly provided by the workers occurs.
compensation law including those required because: 3. We are directly and primarily liable to any person
1. of your serious and willful misconduct; entitled to the benefits payable by this
insurance. Those persons may enforce our
2, you knowingly employ an employee in violation
of law; duties; so may an agency authorized by law.
Enforcement may be against us or against you
3. you fail to comply with a health or safety law or and us.
regulation; or 4. Jurisdiction over you is jurisdiction over us for
4. you discharge, coerce or otherwise discriminate purposes of the workers compensation law. We
against any employee in violation of the workers are bound by decisions against you under that
compensation law. law, subject to the provisions of this policy that
If we make any payments in excess of the benefits are not in conflict with that law.
regularly provided by the workers compensation 5. This insurance conforms to the parts of the
law on your behalf, you will reimburse us promptly. workers compensation law that apply to:
G. Recovery From Others a. benefits payable by this insurance; or
We have your rights, and the rights of persons b. special taxes, payments into security or
entitled to the benefits of this insurance, to recover other special funds, and assessments
our payments from anyone liable for the injury. You payable by us under that law.
will do everything necessary to protect those rights 6. Terms of this insurance that conflict with the
for us and to help us enforce them. workers compensation law are changed by this
H. Statutory Provisions statement to conform to that law.
These statements apply where they are required by Nothing in these paragraphs relieves you of your
law. duties under this policy.
PART TWO - EMPLOYERS LIABILITY INSURANCE
A. How This Insurance Applies 5. If you are sued, the original suit and any related
This employers liability insurance applies to bodily legal actions for damages for bodily injury by
injury by accident or bodily injury by disease. Bodily accident or by disease must be brought in the
injury includes resulting death. United States of America, its territories or
1. The bodily injury must arise out of and in the possessions, or Canada.
course of the injured employee's employment by B. We Will Pay
you. We will pay all sums you legally must pay as
2. The employment must be necessary or incidental damages because of bodily injury to your
to your work in a state or territory listed in Item employees, provided the bodily injury is covered by
3.A. of the Information Page. this Employers Liability Insurance.
3. Bodily injury by accident must occur during the The damages we will pay, where recovery is
policy period. permitted by law, include damages:
4. Bodily injury by disease must be caused or 1 . for which you are liable to a third party by
aggravated by the conditions of your reason of a claim or suit against you by that
employment. The employee's last day of last third party to recover the damages claimed
exposure to the conditions causing or against such third party as a result of injury to
aggravating such bodily injury by disease must your employee;
occur during the policy period. 2. for care and loss of services; and
WC 00 00 00 A 2
(Ed. 4-92) Copyright 1991 National Council on Compensation Insurance.
(Ed. 4-92)
G. Limits of Liability 3. We will not pay any claims for damages after we
Our liability to pay for damages is limited. Our limits have paid the applicable limit of our liability
of liability are shown in Item 3.B. of the Information under this insurance.
Page. They apply as explained below. H. Recovery From Others
1. Bodily Injury by Accident. The limit shown for We have your rights to recover our payment from
"bodily injury by accident - each accident" is the anyone liable for an injury covered by this insurance.
most we will pay for all damages covered by You will do everything necessary to protect those
this insurance because of bodily injury to one or rights for us and to help us enforce them.
more employees in any one accident. I. Actions Against Us
A disease is not bodily injury by accident unless There will be no right of action against us under this
it results directly from bodily injury by accident. insurance unless:
2. Bodily Injury by Disease. The limit shown for 1. You have complied with all the terms of this
"bodily injury by disease - policy limit" is the
policy; and
most we will
pay for all damages covered by
this insurance and arising out of bodily injury by 2. The amount you owe has been determined with
disease, regardless of the number of employees our consent or by actual trial and final judgment.
who sustain bodily injury by disease. The limit This insurance does not give anyone the right to add
shown_ for "bodily injury by disease - each us as a defendant in an action against you to deter
employee" is the most we will pay for all mine your liability. The bankruptcy or insolvency of
damages because of bodily injury by disease to you or your estate will not relieve us of our obliga
any one employee. tions under this Part.
Bodily injury by disease does not include disease
that results directly from a bodily injury by
accident.
PART THREE - OTHER STATES INSURANCE
A. How This Insurance Applies we are not permitted to pay the benefits directly
1. This other states insurance applies only if one or to persons entitled to them.
more states are shown in Item 3.C. of the 4. If you have work on the effective date of this
information Page. _ policy in any state not listed in Item 3.A. of the
2. If you begin work in any one of those states Information Page, coverage will not be afforded
after the effective date of this policy and are not for that state unless we are notified within thirty
insured or are not self-insured for such work, all days.
provisions of the policy will apply as though that B. Notice
state were listed in Item 3.A. of the Information Tell us at once if you begin work in any state listed
Page. in Item 3.C, of the Information Page.
3. We will reimburse you for the benefits required
by the workers compensation law of that state if
PART FOUR - YOUR DUTIES IF INJURY OCCURS
Tell us at once if injury occurs that may be covered 4. Cooperate with us and assist us, as we may
by this policy. Your other duties are listed here. request, in the investigation, settlement or
1. Provide for immediate medical and other services defense of any claim, proceeding or suit.
required by the workers compensation law. 5. Do nothing after an injury occurs that would
2. Give us or our agent the names and addresses interfere with our right to recover from others.
of the injured persons and of witnesses, and 6. Do not voluntarily make payments, assume
other information we may need. obligations or incur expenses, except at your
3. Promptly give us all notices, demands and legal own cost.
papers related to the injury, claim, proceeding or
suit.
WC 00 00 00 A 4
(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 2. We may cancel this policy. We must mail or
have under this provision. deliver to you not less than ten days advance
B. Long Term Policy written notice stating when the cancellation is to
If the policy eriod is longer than one year and take effect. Mailing that notice to you at your
y g y mailing address shown in Item 1 of the
sixteen days, all provisions of this policy will apply Information Page will be sufficient to prove
as though a new policy were issued on each annual notice.
anniversary that this policy is in force.
C. Transfer of Your Rights and Duties 3. The policy period will end on the day and hour
g stated in the cancellation notice.
Your rights or duties under this policy may not be 4. Any of these provisions that conflict with a law
transferred without our written consent. that controls the cancellation of the insurance in
If you die and we receive notice within thirty days this policy is changed by this statement to
after your death, we will cover your legal comply with the law.
representative as insured. E. Sole Representative
D. Cancellation The insured first named in Item 1 of the Information
1. You may cancel this policy. You must mail or Page will act on behalf of all insureds to change this
deliver advance written notice to us stating policy, receive return premium, and give or receive
when the cancellation is to take effect. 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.
Schedule
1. State 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
Sections 2 and 3 are amended to add:
This exclusion does not apply unless the violation of law caused or contributed to the bodily injury.
Section 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
Number 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.
1
WC 42 03 01 F Hart Fo,ms&Services
Reorder No. 14-AO54
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 without our 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. Notice of cancellation or nonrenewal must 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.
2
Hart Forms &Services
WC 42 03 01 F Reorder No. 14-AO54
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
3
WC 42 03 01 F
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 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
Persons 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-AO57
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 definitions 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 resulted in 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 Forms TM
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 94
(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 I<B REMODELING
Insurance Company: AmCOMP Assurance Corp
WC 99 06 94 Page 2 of 2
(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 I<B REMODELING
Insurance Company: AmCOMP Assurance Corp
WC 99 06 95 Page 1 of 1
(Ed. 1-08) Wolters Kluwer Financial Services I Uniform FormSTM
990695
Incorporated • Assurance Corporation Preferred Insurance Company
Y
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 11
costs.
Please report claims as soon as possible. Do not wait for doctor's reports or billings to report
claims. We recommend reporting claims as soon as the injured employee leaves your
operations for treatment by your local medical provider.
4ftff OM11
• 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.
v ,k of'ii
• Incorporated • Assurance Corporation • Preferred Insurance Company
Safety Review Guide
Employee's Name Today's Date
Job Title Regular Dept.
Time of Incident
Date of Incident
Location of Incident(Specific address or plant or department)
Description of Incident
Did employee seek outside medical treatment? [ ] Yes [ ] No
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 by [ ] Slip/Fall [ ] Burn/Cold
[ ] Struck against [ ] Caught in [ ] Cumulative Trauma
[ ] Lifting/Overexertion [ ] Inhalation [ ] Other:
In your opinion,what was the root cause of the incident?
In your o inion,what could be done to prevent the incident from reoccurring?
Signed Date
Management/Safety 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.
Mandatory Voluntary MC Employee Employer May Filing of Notice Penalty for Late Reporting (petty
State MC Program Program SelPhys Physician Treating Select Treating of Injury(2.1 ofines,eand/ordim misdemeanors, civil
Alabama v
X 5 days X
Alaska X 1. 10 days X
Arizona X 10 days X
kansas X X 10 days X
' California X X 3. 5 days X
Colorado X X 10 days X
Connecticut X X4. 7das X
Delaware X 10 days 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 da s X
Kansas X 28 da s X
Kentuckv X X X 7 days X
Eniiisiana X 10 day X
Maine X 10 days) 7 days X
MArvinnd X 10 days X
ssachusetts X X 5. 7 days X
X limited to 10 days) X
Minnesota X X 10 da s X
Mississmoom 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 Hamnsh"re 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 da s X
North Dakota X X X
Ohio X 10. X 7 days X admission of com ensabilR
Oklahoma X X 10 days X
X(employer responsible for 25%of com
Oregon X X 5 days ensation due to employee if insured
Pennsylvania X 11. immediately X
Rhode Island X X 10 days X
South Carolina X(HMO's and 10 days X
PPO's allowed Y
South Dakota X X 10 days X
Tennessee X X(12.) 10 days(within 24 X
hrs.to MC Ian
Texas X 14 days X
Utah X X 13. 8 days X
Vermont X X(for the first visit 7 da
only) s X Y
X(from a panel of 3
Virginia employee selected 72 hours X
physicians)
Washinaton X "at once" X
West Viroinia X 5 da s X
Wisconsin X Determined by X
De artment
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. It 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.
AtICOMP� • 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)
OVERTBIE
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, 941 s, 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 AmCOMP. 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.
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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
information. We look forward to assisting you in developing a good safety program. To
get started, contact your Loss Control Consultant today.
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Incorporated Assurance Corporation Preferred Insurance Company
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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.
S. AmCOMP"
1 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,
ATTESTED AND COUNTERSIGNED BY A DULY AUTHORIZED REPRESENTATIVE OF THE
COMPANY
RESI ENT SECRETARY
WC 99 06 93 (01 2008)
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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
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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 personal fines up to $10 million and incarceration up to 30 years.
NOT EXCLUSIVE ISIVE TO INSURANCE COMPANIES
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.
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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 acerca de companias, - - -
coberturas, derechos o quejas al
1-800-252-3439 or 1-512-463-6500
Peude escribir al Departamento de Seguros de Texas al
P.O. Box 149104
Austin, TX 78714-9104
FAX# (512) 475-1771
DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, dede
comunicarse con el agente o la compania primero. 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
y M&C Review Page 1 of 2
Official site of the City of Fort Worth,Texas
CITY COUNCIL AGENDA FQ_ ;TH
DATE: 3/9/2010 REFERENCE C-24132 LOG NAME: 17WAP DOE ARRA
NO.: VENDOR CONTRACT
CODE: C TYPE: NON- PUBLIC NO
CONSENT HEARING:
SUBJECT: 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 foll
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-stripping, 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 weatherization 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 vends
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=3/9/2010 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 contras
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 Integrity 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=13 203&councildate=3/9/201 0 03/10/2010