Loading...
HomeMy WebLinkAboutContract 45645 CITY SECRETARY CITY OF FORT WORTH, TEXAS CONTRACT NO. STANDARD AGREEMENT FOR PROFESSIONAL SERVICES This AGREEMENT is between the City of Fort Worth, a Texas home-rule municipality (the "CITY"), and Miller Pipeline, LLC, authorized to do business in Texas, an independent contractor ("Consultant"), for a PROJECT generally described as: Camp Carter 60-inch Raw Water, South Holly High Service Pump Station 54-inch, 72-inch Raw Water, and Trinity Park 48-inch Raw Water Main Repairs. Article I Scope of Services (1) Consultant hereby agrees to perform as an independent contractor the services set forth in the Scope of Services attached hereto as Attachment "A". These services shall be performed in connection with Camp Carter 60-inch Raw Water, South Holly High Service Pump Station 54-inch, 72-inch Raw Water, and Trinity, Park 48-inch Raw Water Main Repairs. (2) Additional services, if any, will be requested in writing by the City. City shall not pay for any work performed by Consultant or its subconsultants, subcontractors and/or suppliers that has not been ordered in writing., It is specifically agreed that Consultant shall not be compensated for any alleged additional work resulting from oral orders of any person. Article 11 Compensation Consultant shall be compensated in accordance with the Fee Schedule shown in Attachment "B". Payment shall be considered full compensation for all labor, materials, supplies, and equipment necessary to complete the services described in Attachment "A". However the total fee paid by the City shall not exceed a total of $40,837.00 unless the City and the Consultant mutually agree upon a fee amount for additional services and amend this Agreement accordingly. The Consultant shall provide monthly invoices to the City. Payment for services rendered shall be due within thirty (30) days of the uncontested performance of the particular services so ordered and receipt by City of Consultant's invoice for payment of same. Acceptance by Consultant of said payment shall operate as and shall release the City from all claims or liabilities under this Agreement for anything related to, done, or furnished in connection with the services for which payment is made, including any act or omission of the City in connection with such services. City of Fort Worth,Texas .................... Standard Agreement for Professional Services PMO Official Release Date:1/28/2013 OFFICIAL RECORD Page 1 of 8 RECEIVED MAY 3 0 -2014 Q�TY SECRETARY FT.W 0 KTN9 TX Article III Term Unless terminated pursuant to the terms herein, this Agreement shall be for a term of 30 days, beginning upon the date of its execution, or until the completion of the subject matter contemplated herein, whichever occurs first. Article IV Independent Contractor Consultant shall operate hereunder as an independent contractor, and not as an officer, agent, servant, or employee of the City. Consultant shall have exclusive control of and the exclusive right to control the details of its work to be performed hereunder and all persons performing same, and shall be solely responsible for the acts and omissions of its officers, agents, employees, contractors and subcontractors. The doctrine of respondent superior shall not apply as between City and Consultant, its officers, agents, employees, contractors, and subcontractors, and nothing herein shall be construed as creating a partnership or joint venture between City and Consultant. Article V Professional Competence and Indemnification (1) Work performed by Consultant shall comply in all aspects with all applicable local, state and federal laws and with all applicable rules and regulations promulgated by the local, state and national boards, bureaus and agencies. Approval by the City shall not constitute or be deemed to be a release of the responsibility and liability of Consultant or its officers, agents, employees, contractors and subcontractors for the accuracy and competency of its services performed hereunder. (2) In accordance with Texas Local Government Code Section 271.904, the Consultant shall indemnify, hold harmless, and defend the City against liability for any damage caused by or resulting from an act of negligence, intentional tort, intellectual property infringement, or failure to pay a subcontractor or supplier committed by the Consultant or Consultant's agent, consultant under contract, or another entity over which the Consultant's exercises control. City of Fort Worth,Texas Standard Agreement for Professional Services PMO Official Release Date:1/28/2013 Page 2 of 8 Article VI Insurance (1) Consultant shall not commence work under this Agreement until it has obtained all insurance required under this Article and the City has approved such insurance, nor shall Consultant allow any subcontractor to commence work on its subcontract until all similar insurance of the subcontractor has been so obtained and approval given by the City; provided, however, Consultant may elect to add any subconsultant as an additional insured under its liability policies. Commercial General Liability $1,000,000 each occurrence $1,000,000 aggregate Automobile Liability $1,000,000 each accident (or reasonably equivalent limits of coverage if written on a split limits basis). Coverage shall be on any vehicle used in the course of the Project. Worker's Compensation Coverage A: statutory limits Coverage B: $100,000 each accident $500,000 disease - policy limit $100,000 disease- each employee (2) Additional Insurance Requirements a. Except for employer's liability insurance coverage under Consultant's worker's compensation insurance policy, the City, its officers, employees and servants shall be endorsed as an additional insured on Consultant's insurance policies. b. Certificates of insurance shall be delivered to the City of Fort Worth Water Department, Attention: John R. Kasavich, P.E., 1000 Throckmorton Street, Fort Worth, TX 76102, prior to commencement of work. c. Any failure on part of the City to request required insurance documentation shall not constitute a waiver of the insurance requirements specified herein. d. 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. City of Fort Worth,Texas Standard Agreement for Professional Services PMO Official Release Date:1/28/2013 Page 3 of 8 e. 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. f. 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. g. Workers' compensation insurance policy(s) covering employees employed on the Project shall be endorsed with a waiver of subrogation providing rights of recovery in favor of the City. h. City shall not be responsible for the direct payment of insurance premium costs for Consultant's insurance. L Consultant'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. j. In the course oft Agreement, Consultant shall report, in a timely manner, to City's officially designated contract administrator any known loss occurrence which could give rise to a liability claim or lawsuit or which could result in a property loss. k. Consultant's liability shall not be limited to the specified amounts of insurance required herein. 1. Upon the request of City, Consultant shall provide complete copies of all insurance policies required by these Agreement documents. Article VII Transfer or Assignment City and Consultant each bind themselves, and their lawful successors and assigns, to this Agreement. Consultant, its lawful successors and assigns, shall not assign, sublet or transfer any interest in this Agreement without prior written consent of the City. Article Vill Termination of Contract (1) City may terminate this Agreement for its convenience on 30 days' written notice. Either the City or the Consultant for cause may terminate this Agreement if either Party fails substantially to perform through no fault of the other and does not City of Fort Worth,Texas Standard Agreement for Professional Services P Official Release Date:1/28/2013 Page 4 of 8 ................. commence correction of such nonperformance with 5 days of written notice and diligently complete the correction thereafter (2) If City chooses to terminate this Agreement under Article 8, upon receipt of notice of termination, Consultant shall discontinue services rendered up to the date of such termination and City shall compensate Consultant based upon calculations in Article 2 of this Agreement and Exhibit "B" attached hereto and incorporated herein, (3) All reports, whether partial or complete, prepared under this Agreement, including any original drawings or documents, whether furnished by the City, its officers, agents, employees, consultants, or contractors, or prepared by Consultant, shall be or become the property of the City, and shall be furnished to the City prior to or at the time such services are completed, or upon termination or expiration of this Agreement. Article IX Right to Audit (1) Consultant agrees that the City shall, until the expiration of three (3) years after final payment under this Agreement, have access to and the right to examine any directly pertinent books, documents, papers and records of Consultant involving transactions relating to this Agreement. Consultant agrees that the City shall have access during normal working hours to all necessary facilities and shall be provided adequate and appropriate workspace in order to conduct audits in compliance with the provisions of this section. City shall give Consultant reasonable advance notice of intended audits. (2) Consultant further agrees to include in all its subcontracts hereunder, a provision to the effect that the subcontracting consultant agrees that the City shall, until the expiration of three (3) years after final payment under the subcontract, have access to and the right to examine any directly pertinent books, documents, papers and records of such sub-consultant, involving transactions to the subcontract, and further, that City shall have access during normal working hours to all sub- consultant facilities, and shall be provided adequate and appropriate work space in order to conduct audits in compliance with the provisions of this article. City shall give Consultant and any sub-consultant reasonable advance notice of intended audit. (3) Consultant and sub-consultants agree to photocopy such documents as may be requested by the City. The City agrees to reimburse Consultant for the cost of copies at the rate published in the Texas Administrative Code in effect as of the time copying is performed., City of Fort Worth,Texas Standard Agreement for Professional Services P Official Release Date:1128/2013 Page 5 of 5 Article X Minority Business and Small Business Enterprise (MBE)(SBE) Participation In accordance with the Ci 's Business Diversity Enterprise Ordinance No. 20020-12-2011, as amended, the City has goals for the participation of minority business enterprises and/or small business enterprises in City contracts, Consultant acknowledges the MBE and SBE goals established for this Agreement and its accepted written commitment to MBE and SBE participation. Any misrepresentation of facts (other than a negligent misrepresentation) and/or the commission of fraud by the Consultant may result in the termination of this Agreement and debarment from participating in City contracts for a period of time of not less than three (3) years. Article XI Observe and Comply Consultant shall at all times observe and comply with all federal, state, and local laws and regulations and with all City ordinances and regulations which in any way affect this Agreement and the work hereunder, and shall observe and comply with all orders, laws ordinances and regulations which may exist or may be enacted later by governing bodies having jurisdiction or authority for such enactment. No plea of misunderstanding or ignorance thereof shall be considered. Consultant agrees to defend, indemnify and hold harmless City and all of its officers, agents and employees from and against all claims or liability arising out of the violation of any such order, law, ordinance, or regulation, whether it be by itself or its employees. Article X11 Venue and Jurisdiction If any action, whether real or asserted, at law or in equity, arises on the basis of any provision of this Agreement, 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 Agreement shall be construed in accordance with the laws of the State of Texas. Article X111 Contract Construction The Parties acknowledge that each party and, if it so chooses, its counsel have reviewed and revised this Agreement 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 City of Fort Worth,Texas Standard Agreement for Professional Services P Official Release Date:1128/2013 Page 6 of 6 interpretation of this Agreement or any amendments or exhibits hereto. Article XIV Severability The provisions of this Agreement are severable, and if any word, phrase, clause, sentence, paragraph, section or other part of this Agreement 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 Agreement and the application of such word, phrase, clause, sentence, paragraph, section, or other part of this Agreement to other persons or circumstances shall not be affected thereby and this Agreement shall be construed as if such invalid or unconstitutional portion had never been contained therein. Article XV Notices Notices to be provided hereunder shall be sufficient if forwarded to the other Party by hand-delivery or via U.S. Postal Service certified mail return receipt requested, postage prepaid, to the address of the other Party shown below: City of Fort Worth Attn: Water Department 1000 Throckmorton Street Fort Worth, Texas 76102 Consultant: Miller Pipeline, LLC Attn: Terry Bell 8850 Crawfordsville Road Indianapolis, IN 46234 Article XVI Headings The headings contained herein are for the convenience in reference and are not intended to define or limit the scope of any provision of this Agreement City of Fort Worth,Texas Standard Agreement for Professional Services PMO Official Release Date: 1/28/2013 Page 7 of 8 Article XVII Counterparts This Agreement may be executed in one or more counterparts and each counterpart shall, for all purposes, be deemed an original, but all such counterparts shall together constitute but one and the same instrument. Executed and effective this the 3 day of May, 2014. BY: BY: CITY OF FORT WORTH ENGINEER Miller Pipeline, LLC A 06.............. Fernando Costa Kevi Miller Assistant City Manager President Date: 452-� Date-, APPROVAL RECOMMENDED: By: S. Frank Crumb, P.E. Director, Water Department APPROVED AS TO FORM AND LEGALITY M&C No.: N/A By: MC Date: N/A —6-0-lug-las W. Black Assistant City Attorney F qi? ATTEST: 00 *coo 0 Jo Mary J. Ka y s 0.0""o 00 City ecreta AS. .......... City of Fort Worth,Texas Standard Agreement for Professional Services PMO Official Release Date:1/28/2013 OFFICIA1.,RECORD Page 8 of 8 CITY SECRETARY 1:11 WORT1141 17 ATTACHMENT A SERVICES FOR CAMP CARTER 60-INCH RAW WATER,SOUTH HOLLY HIGH SERVICE PUMP STATION 54-INCH®72-INCH RAW WATER, AND TRINrrY PARK 48-INCH RAW WATER MAIN REPAIRS CITY PROJECT NO.:PE45-539120-0607007 ATTACHMENT A Scope for Engineering Dg§sigin Related Services for Water and/or Sanitary Sewer Improvements SERVICES FOR CAMP CARTER 60-INCH RAW WATER, SOUTH HOLLY HIGH SERVICE PUMP STATION 54-INCH, 72-INCH RAW WATER, AND TRINITY PARK 48-INCH RAW WATER MAIN REPAIRS CITY PROJECT NO.: PE45-539120.0607007 The scope set forth herein defines the work to be performed by the CONSULTANT in completing the project. WORK TO BE PERFORMED Task 1. Management Task 2. Scope of Work Task 3. Methods TASK 1. MANAGEMENT. CONSULTANT shall ensure efficient and effective use of CONSULTANT's and CI 's time and resources. CONSULTANT shall manage change, ■ Communicate effectively, ■ Coordinate internally and externally as needed, and ■ Proactively address issues with the CITY's Project Manager and others as necessary to make progress on the work. . . Communications and Reporting • Prepare and submit monthly invoices in the format requested by the CITY. DELIVERABLES A. Monthly invoices TASK 2. SCOPE OF WORK During a pipeline inspection of the 60-inch raw water at Camp Carter and the 54- inch raw water and 72-inch raw water mains at South Holly High Service Pump Station, Water Field Operations and Water Production determined that several pipeline joints needed repair. Also, the existing 48-inch raw water main was found leaking inside Trinity Park, located south of W. 7th St., just west of the Trinity River. The scope of work includes installation of internal joint seals at each of these locations. A total of 12 .- 48--inch, 1 ® 54-inch, 4 - 60-inch, and 2 - 72-inch Extra-Wide WEKO Seals are included for the repairs for this project. City of Fort Worth,Texas Attachment A FWWTR Release Date:02.02.2010 Page 1 of 3 ATTACHMENT A SERVICES FOR CAMP CARTER 60-INCH RAW WATER,SOUTH HOLLY HIGH SERVICE PUMP STATION 54-INCH,72-INCH RAW WATER, AND TRINITY PARK 48-INCH RAW WATER MAIN REPAIRS CITY PROJECT NO.:PE45.539120.0607007 Also includes costs for mobilization/demobilization of crews, equipment, and materials. DELIVERABLES Contractor will provide, upon completion, a report detailing locations of repairs, other leaking joints, potential leak locations, and future repair locations. TASK 3. METHODS This project requires man-entry of the pipeline, thru an existing access manhole. Confined space entry equipment and other safety procedures will be required. Following inspection of the pipeline, the pipe joints are cleaned. Joint gaps will be filled with hydraulic cement behind the WEKO-SEALs. WEKO-SEAL is a flexible rubber leak clamp that ensures a non-corrodible seal around a pipe joint. A total of 12 — 48-inch, 1 — 54-inch, 4 — 60-inch, 2 — 72-inch Extra Wide WEKO-SEALs will be installed with Type 304 Stainless Steel Retaining Bands, for the high priority leaking joints. All components are NSF 61 drinking water approved. Once installed, pressure and leakage tests will be performed. ADDITIONAL SERVICES NOT INCLUDED IN THE EXISTING SCOPE OF SERVICES Additional Services not included in the existing Scope of Services — CITY and CONSULTANT agree that the following services are beyond the Scope of Services described in the tasks above. However, CONSULTANT can provide these services, if needed, upon the CITY's written request. Any additional amounts paid to the CONSULTANT as a result of any material change to the Scope of the Project shall be agreed upon in writing by both parties before the services are performed. These additional services include the following: • Negotiation of easements or property acquisition including temporary right-of- entries. • Services related to development of the CITY's project financing and/or budget. • Services related to disputes over pre-qualification, bid protests, bid rejection and re-bidding of the contract for construction. • Construction management and inspection services • Periodic site visits during construction phase • Design phase public meetings • Performance of materials testing or specialty testing services. • Services necessary due to the default of the Contractor. • Services related to damages caused by fire, flood, earthquake or other acts of God. City of Fork Worth,Texas Attachment A PMO Release Date:06.19.2010 Page 2 of 3 ATTACHMENT A SERVICES FOR CAMP CARTER 60-INCH RAW WATER,SOUTH HOLLY HIGH SERVICE PUMP STATION 54-INCH,72-INCH RAW WATER, AND TRINITY PARK 48-INCH RAW WATER MAIN REPAIRS CITY PROJECT NO.:PE45-539120-0607007 • Services related to warranty claims, enforcement and inspection after final completion. • Services related to submitting for permits (ie.TxDOT, railroad, etc...) • Services related to Subsurface Utility Engineering Levels A, B, C or D • Services related to Survey Construction Staking • Services related to acquiring real property including but not limited to easements, right-of-way, and/or temporary right-of-entries. • Services to support, prepare, document, bring, defend, or assist in litigation undertaken or defended by the CITY. • Construction Shop drawing review, samples and other submittals submitted by the contractor. • Performance of miscellaneous and supplemental services related to the project as requested by the CITY. City of Fort Worth,Texas Attachment A PMO Release Date:06.19.2010 Page 3 of 3 ATTACHMENT B COMPENSATION Services for Camp Carter 60-inch Raw Water, South Holly High Service Pump Station 54-inch, 72-inch Raw Water, and Trinity Park 48-inch Raw Water Main Repairs City Project No. PE45-539120-0607007 Lump Sum Project I. Compensation A. The CONSULTANT shall be compensated a total lump sum fee of $40,837 as summarized in Exhibit B-1 — Consultant Invoice and Section IV — Summary of Total Project Fees. The total lump sum fee shall be considered full compensation for the services described in Attachment A, including all labor materials, supplies, and equipment necessary to deliver the services. B. The CONSULTANT shall be paid monthly payments as described in Section 11 - Method of Payment. II. Method of Payment A. Partial payment shall be made to the CONSULTANT monthly upon City's approval of an invoice prepared and submitted by the CONSULTANT in the format and including content as presented in Exhibit B-1, Progress Reports as required in item III. of this Attachment B, and Schedule as required in Attachment D to this Agreement. B. The estimated current physical percent complete as required on the invoice shall be calculated from the progress schedule as required in Attachment D to this Standard Agreement and according to the current version of the City of Fort Worth's Schedule Guidance Document. C. The cumulative sum of such monthly partial fee payments shall not exceed the total current project budget including all approved Amendments. D. Each invoice shall be verified as to its accuracy and compliance with the terms of this Agreement by an officer of the CONSULTANT. 111. Progress Reports A. The CONSULTANT shall prepare and submit to the designated representative of the Water Department monthly progress reports and schedules in the format required by the City. City of Fort Worth,Texas Attachment B PMO Official Release Date:5.19.2010 Page 1 of 3 B-1 ATTACHMENT B COMPENSATION IV. Summary of Total Project Fees ... ........ .......- ........... ..........- .- Firm Primary Res po n s i b I I i t y Fee Am ou n t Prime Consultant Miller Pipeline Pipeline Inspection and Repair $40,837 100 Corporation Proposed MfWBE Sub-Consultants none Non-MfWBE Consultants none TOTAL $40,837 100% C4 of Fort Worth,Texas Attachment B PMO Official Release Date:&19.2010 Page 2 of 3 B-2 EXHIBIT "B-1" ENGINEER INVOICE (Supplement to Attachment B) Insert required invoice format following this page, including negotiated total budget and allocations of budgets across work types and work phases. City of Fort L"dorth,Texas Attachment B PMO Official Release Date:5.19.2010 Page 3 of 3 B-3 ATTACHMENT "C" CHANGES AND AMENDMENTS TO STANDARD AGREEMENT Services for Camp Carter 60-inch Raw Water, South Holly High Service Pump Station 54-inch, 72- inch Raw Water, and Trinity Park 48-inch Raw Water Main Repairs City Project No. PE45-539120-0607007 No changes to Standard Agreement City of Fort Worth,Texas Attachment C PMO Release Date:05.19.2010 Page 1 of 1 Consulting Contract Schedule Specifications FORT WORTH City of Fort Worth Capital Improvement Program Attachment D-Project Schedule The scope of this project will take 30 days to complete the inspection and repairs for the 48- inch, 54-inch, 60-inch, and 72-inch raw water mains; therefore no detailed schedule is required. City of Fort Worth,Texas Attachment D PMO Release Date:02.15.2011 Page 1 of 1 Miller Pipeline Invoice-WATER/SEWER ............. ......... 8850 Crawfordsville Rd Proj.Invoice No. Indianapolis,IN 46234 Invoice date: Tei., 317-293-0278 Period (From-To) _MII ntInvolce Number Fax., 317-295-6410 DOE No. NIA L ............ Gmaik terMbetWifferpiaellne.corn Water Proj No. PE46-5391.20-0607007 Sewer Proj No. NIA City Secy.Cont.No. .............................................................................. COPW Project Manager I"R.Kasalyvich P,!�. .......................... ConSUManrS Pron"t Manager Ta Sall ............. Maim of Project: Camp Cl!!eEtio-lflsh t!A0!kHIQkSeM�re.,E!!m S4tionU-Inch 7k-i chjIqd1qqAP1ft1k- Water llfi Pack,-Inch � atn Irs _p Work Phase Check stage of project _--WATER SEWER Revised Amts.Ind, Revised Arms.Ind, 2q2.Amounts Amendments Amounts Amandments 83 Water Main Inspection and Joint Repairs A P $ -L 49—AER-Pq $- $ El CONTRACTAMOUTS _L�40837.00_L$_ TOTAL CONTRACT AMOUNT TOTAL CONTRACT AMOUNT TO DATE(Ind.Amendments) $ --40 837'.00 WATER 10_,14,40 Work Phase TOTAL CONTRACT AMT. TOTAL PREVIOUS CONTRACT AMT. No. DESCRIPTION OF WORK THIS INVOICE PREVIOUS REMAINING THIS INVOICE INVOICES REMAINING INVOICES 83 See Itemized Breakdown attached $ $ 40 A37.00 $ $ $ $ $ $ $ $ TOTALS $ $ $ 40,837.00 $ $ $ List all amendments to data (Do not invoice for additional work until the related amendment has been executed!!I the city) Amendment Contract No. Date Executed Water Sewer Description Total Amount Work Phases 31,32, No. for the. by City Wrk.Phase 61 Work Phases 31,32,33 Wrk.Phase 5l 33 $ ...— $ $ $ A-- 2 $ $ $ $ $ 3 $ A-- I-- $ 41 $ A $ $ $ 5 $ $ $ $ $ 7 $ $ $ $ $ $ A--------------- A-- $ 9 $ $ $ 10 $ $ $ $ $ TOTALS $ $ $ $ $ TOTAL WA TOTAL SEWER . .................. TOTAL THIS INVOICE $0.00 Make all checks paystito to:: Company Name Address submitted by: project Accountant Informalion ^ Miller Pipeline [mW City of Fort Worth Date. 4(151*1-41 Project:Camp Carter 604nch Raw Water,South Holly High Service Pump Station$44nch,724neh Raw Water,and Trinity Prepared By: Teny Ball Par,k 484rich Raw Water Main Repairs pc-,,;F" L3 True: Supplemental Invoice inforrTnatl n Sheet: 2 of3 WATER SEWER TOTAL CONT CONTRACT TOTAL CONTRACT THIS INVOICE PREVIOUS RACT CONTRACT Inspection and Construction AMOUNT AMT. THIS INVOICE PREVIOUS AMT. INVOICES REMAINING INVOICES AMOUNT REMAINING —3 FURNISH AND INSTALL 1-54-INCH EXTRA WIDE SEALS _$I 687 _$1 681 $0 $0 4 FURNISH AND INSTALL 4-60-INCH EXTRA WIDE SEALS $ $5,400 $5,400 $0 —so 5 FURNISH AND INSTALL 2-72-INCH EXTRA WIDE SEALS $0—__IQI_$3 150 "J50L.— $0 $0 6 CREW T&M RATE AS APPLICABLE FOR 4 PERSON CRE' $0 $01 $01 1 $0 $0 LEE $0 $0 $0 $0 11 $0. WATER SEWER TOTAL CONTRACT TOTAL CONTRACT THIS INVOICE PREVIOUS CONTRACT CONTRACT GENERAL ADDITIONAL SERVICES AMOUNT AMT. THIS INVOICE PREVIOUS AMOUNT AMT. so sol $0 SUBTOIAL $0 so WATER SEWER TOTAL CONTRACT TOTAL CONTRACT CONTRACT THIS I VOICE CONTRACT AMT. THIS INVOICE PREVIOUS AMT. PREVIOUS AMOUNT AMOUNT Water Department Additional Services: INVOICES REMAINING INVOICES REMAINING Miller Pipeline Client: City of Fort Worth Date: N16020114 Port jell Carter a:d.CLZ6 Project.,Camp Wrich Raw Water,South Holly High Service Pump Station"Inch,72-Inch Raw Water,and Trinity Prepared By. Terry Bell Pro Park 48-Inch Raw Water Main Repairs P 91 0 C ft PE4&.6391204-0607007 TIOa: Su 1i Invoice Information Sheet: WATER SEWER TOTAL CONTRACT TOTAL CONTRACT THIS INVOICE PREVIOUS AMOUNT AMT. THIS INVOICE PREVIOUS CONTRACT Inseection and Construction INVOICE REMAINING INVOICES � AMOUNT MT. -6 UNT REMAINING I MOBILIZATION/DEMOBILIZATION $0_$15 300_$15 300 $o— $0 2 FURNISH AND INSTALL 12-48-INCH EXTRA WIDE SEALS _$15 300_$15 300 3 FURNISH AND INSTALL 1-54-INCH EXTRA WIDE SEALS $0 _$I 687_$1 687 $0 4 FURNISH AND INSTALL 4-60-INCH EXTRA WIDE SEALS $0 _$5 400_$5 400 $0 $0 5 FURNISH AND INSTALL 2-72-INCH EXTRA WIDE SEALS $0 $0..................$3150_$3150 $0 $0 6 CREW T&M RATE AS APPLICABLE FOR 4 PERSON CRF $0—$o $0 $0 $0 $o $o $o $0 $6 so—s,--so— $0 —$o $0 $0 $0 $01 $0 1 $0 $0 $0 $0 $0 $0 10 $0 $0 $0 $0 $0 $01 $0 $011 $0 $0 so $0 $0 $01 $0 $09 TOTAL L $0 $0 $40837 40 937 s0 $0 WATER SEWER TOTAL CONTRACT CONTRACT TOTAL CONTRACT CONTRACT THIS INVOICE PREVIOUS AMOUNT AMT. THIS INVOICEI PREVIOUS AMOUNT AMT. GENERAL ADDITIONAL SERVICES INVOICES 1SEMAINING INVOICES REMAINING --.so $0 $0 $0 $0 $0 $0 $0 $o— $0 $0 $o so $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 0 — 06 $0 $0 $0 $0 ==$ $o # $0 $o— $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 SUBTOTAL WATER SEWER TOTAL CONTRACT CONTRACT TOTAL CONTRACT CONTRACT THIS INVOICE PREVIOUS AMT. THIS INVOICE PREVIOUS AMT. Water Department Additional Services: INVOICES AMOUNT REMAINING INVQ ICE S AMOUNT REMAINING $0 $o $o $0 $o $o ===$() $0 ---Mo $0 $0 $0 0 $0 $0 $0 $0 $0 SUBTOTAL so so so $0 ITOTAL THIS INVOICE to $0 Miller Pipeline Client: City of Fort Worth Date: 4/15/2014 Project: Camp Carter 60-inch Raw Water,South Holly High Service Pump Station 54-Inch,72-Inch Raw Water,and Trinity Park Terry Bell 48-inch Raw Water Main Repairs CitV Project No.: PE45-639120-0607007 Check-,'Fzy- Water Breakdown Sheet: 3 OF 3 THIS INVOICE WORK PHASE WORK PHASE BUDGETS CONST TASK 83 83 1 $0 $0 $0 $15,300 2 $0 $0 $0 $15300 $0 3 $0 $0 $0 $1,687 $0 4 $0 $0 $0 $5,400 $o $o 5 $0 $0 $0 $3,150 $0 $0 6 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $-o -$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 To--$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ISUBTOTAL $o $0 $0 $0 $40,837 $0 $0 $0 TOTAL THIS CE u---- _0 ITOTAL WATER BUDGET= U$40837 AC"R FDATE(MMIDDfYYYYI mow. CERTIFICATE OF LIABILITY INSURANCE Page 1 of 5/15/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willie of Minnesota, Inc„ PHONE_. _ � c/o 26 Century Blvd, eto,:EdLZyw_ 877-945-73 _..I 888-4.67®2378 P. CJ. Box 305191 E-MAIL c e f iems i� . n Nashville, 37230-5191 ..... . .... ...._._.__-- --_..._ INSURER(S)AFFORDING COVERAGE NAICM _ ._.._.__.........._ ----........._._.__.- _._._...........--_........---... _ INSURERA: Zurich American Insurance Company 16535-000 ,,,. ...._._.,_ ........ Miller Pipeline, ILC INSIIRERB° is Surplus Insurance Company 26620-002 ...._. _.. __ _ .. ._..—,.._ _....__, _. Miller Pipeline Corp. INSURF..'RC:American Zurich Insurance Company 40142-001 8950 Crawfordsville Rd. _....-----__,_.._...__� ----__...._....m......__— _........ �..._..___. ---_..._......_....m_. .....__._ __.:...... Indianapolis, IN 46234-1559 INSURER D: ONSURER E: ENSURER F:: COVERAGES CERTIFICATE NUMBER"21610079 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAPPED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TIME TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPEOFINSUF§ANCE DD' SUB POLICYNUKABER POLICY EFF POLICY EXP LIMITS qw; • GENERAL LIABILITY Y GLO9242201-02 /1/2014 4/1/2015 EACH OCCURRENCE._.. ...........$ 1 OQ_.O Q.aa_ I)WiAGE TdRENTED X COM1MiEROAL GENERAL..UABILITM �REMISES E a occurelbrc*�,_. $ . ........ _._. �CLAIMS-M1ADEFX-10C:CUR MIELDEXP(Any one person) $ la 040 X t, actual....Liab lit�/.....,.._ PERSONAL&AD'VINJURY O00_.,_... GENERAIIAAGGREGATE $ 2�0oa,.00Q_ GEN'L AGGREGATE UMBIT APPLIES PER: PRODUCTS COMPIOPAGG $ ��QaQ Boa PC3LICY PRI LT.DC $ • AUTOMOBILE LIABILITY y BAP9242202-02 4/1/2014 4/1/2015 COMBINED SINGLE URAIT 4 a act aer,,"1_._................._.........................$„, .2,000,000 ANYAUTO 80 DR..Y INJ URY(Per person) $ ALL..OWNED SCHEDULED - LY—_ �.. AJTO'S 1—: AUTOS CDBUDOLYVIUJURh(Pwraa¢flderdt,p $ X HIREDALUTOS ,..NON-OWNE',D PROP E .. _„..AUTOS (Per,acci dent) $ $1QCt Com�i _...._...,,. ....... ...,. ....... ._._ ...... _..._........ X Hired auto x'10 1-& $ B UMBRELLA LIAB X OCCUR EAU758748/01/2014 4/1./2014 4/1/2015 I:AL.H OCCURRENCE— $ X EXCESS LIAR °41AIDE AGC RCGAT'i .............................._.__ DED RE'/c'.N'f'GC7N$ $ C WORKERS COMPENSATION WC9242205 02 /1/2014 4/;,fl./2015 X �rc:s AIU C I,d. AND EMPLOYERS'LIABILITY _ I DRY k,9hRI _ „tt .— .... A14YPROPRIE”GO F41PADTTNE.rFPJEDEkCLD°rVVEI-k NIA E.A.EACHACCIDENT $ 1,,000,,000 rDF ndaloryInNH)Ri.Xa LUDi�II:::D� ..... .._..... GMarudater I�NH) u�i RISE asL I A F�LIPLG SEE $ 1,000,000.. V/ e^'o,uSesoru aaarwPe:r �. _ _.. __.... _ D SC NP1I0NI0F0PERA1iONS Inelraaw H,!',"fl I7Y S::AS .B fU IC k .IIuII'I $ 1,000,000 i DESCRIPTION OF OPERATIONS/LOCATIONS F VEHICLES(Attach Acord 101,Ardditonal Remarks Schedule,II more space is required) Employers Liability for the Monopolistic States of ND, OFir WA & WY is provided in the Workers, compensation policy. Statutory coverage is not included. `:E'he City of Fort Worth, its officers, eMployee^sa and servants is additional insured with respect to the General Liability and Automobile Liability coverages when required by written contract executed prior to loss. The workers Com ensatioTn olio isacludes a Waiver of sub.co atioxT vwhcn re aired b cozatract CERTIFICATE HOLDER ..... CANCELLATION SIHOUli..D AI'gY OF'fl"II°IE AIf OVE.I:DESCRIBED POL.ICWES II:.bE.CANCEL.I,.EE:D BEFORI::I. TITP::". EXPIRATION DATE: THEREOF, NOTICE,�,.V�IBLL„w1�3�..,C7F �V �,m AL','ICOREDANCE WWlIITll°I TIflG-'POL..IICY PROVlISa O S SECRETARY City' of Fort Worth Water Dept. AUTHOR➢ZIEDREPRESEN'TATIVE 000YWOrth� TX on St.cla, P.B. laaa °Y°fllr&3 f'DR]P1Y,Tr t4YII1 fit. r"`1 „may., CITY 02 ATIO I if TX e � a �: OR �.AI h _ ed. Cro11..m44166�5 "iC 1n17898:z C"erLw 7.610079 X1988-° 010AC0 GO Pte„ ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: ACC>R" ADDITIONAL REMARKS SCHEDULE Page .2 of _2............... AGENCY NAMED INSURED Miller Pipeline, LLC Willis of Minnesota, Inc. Miller Pipeline Corp. ..............---—----............................. .................................................................................. POLICY NUMBER 8850 Crawfordsville Rd. Indianapolis, IN 462341559 See First Page —-------------------- CARRIER NAIL CODE See First Pa a EFFECTIVE DATE: See First Pa e ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE ------- executed prior to loss, as permitted by law. Such insurance as is afforded to additional insured with regard to the General Liabilit p shall be primary and non-contributory with any other insurance available to additional Tnsolreicyif required y contract and executed prior to loss, except where prohibited by law. ............. ACORD 101 (2008101) Coll:4416655 rpl:1789853 Cert:21610079 @2008 ACORD CORPORATION,All rights reserved. The ACORD name and Ilogo are registered marks of ACORD Additional Insured —Automatic — Owners, Lessees Or ZURICH Contractors Policy, No. Eff. Date of Pogo Exp. Date of PoL Eff. Date ol End. Producer No. Addl Preen Return Prern, .............. GL09242201-02 04/01/2014 04/01/2015 34937000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured- Miller Pipeline, LLC MN Limited, LLC Address (including ZIP Code): 8850 Crawfordsville Rd, Indianapolis, IN 46234-1559 This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. Section 11—Who Is An Insured is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract or written agreement. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property darnage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, in the performance of your ongoing operations or "your work" as included in the ""products-completed operations hazard", which is the subject of the written contract or written agreement. However, the insurance afforded to such additional insured: i. Only applies to the extent permitted by lawn and 2. Will not be broader than that which you are required by the written contract or written agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds,, the following additional exclusion applies: This insurance does not apply to, "Bodily injury", "property damage"" or"personal and advertising injUry" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services including: a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications-, or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege r)egligence or other wrongdoing in the Supervision, hiring, einpioyment, training or monitoring of others lby that insured, if the "occurrence" which caused the "bodily injury" or "property damage"', or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering 011"SUirveying services. U GL-1'1'75-11:::!CW(04/13) Page I of 2 ft-idludes copyilgihted material of InSUrance Services Office,hc,,with its permission, . ............................ C. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV — Commercial General Liability Conditions: The additional insured must see to it that: 1. We are notified as soon as practicable of an "occurrence"or offense that may result in a claim; 2. We receive written notice of a claim or"suit"as soon as practicable; and 3. A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on is the additional insured is a Named Insured if the written contract or written agreement requires that this coverage be primary and non-contributory. D. For the purposes of the coverage provided by this endorsement* 1. The following is added to the Other Insurance Condition of Section IV — Commercial General Liability Conditions: Primary and Noncontributory insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured provided that: a. The additional insured is a Named Insured under such other insuranceu and b. You are required by written contract or written agreement that this insurance be primary and not seek contribution from any other insurance available to the additional insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV—Commercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or"suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by a written contract or written agreement to provide coverage to the additional insured on a primary and non- contributory basis. E. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. F. With respect to the insurance afforded to the additional insureds under this endorsement, the following is added to Section III—Limits Of Insurance.-- The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the written contract or written agreement referenced in Paragraph A. of this endorsement; or 2. Available under the applicable Limits of Insurance shown in the Declarations, whichever is less. This endorsernent shall not increase the applicable Limits of Insurance shown in the Declarations. All other terms and conditions of this policy remain unchanged. U-GLA 175.T CW(0411 3) Igage 2 of 2 Indudes coppighted matehall of hnsurance Services Offi ce,kic-Wth its jpwmissioin, I............. POLICY NUMBER:: BAP9242202-02 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by this endorsement, This endorsement identifies person(s) or organ ization(s)who are "insureds"under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: Countersigned-By.- 4/1/2014 Named Insured- Miller Pipeline, LLC (Authorized Representative) SCHEDULE Name of Person(s) or Organ ization(s): Any person or organization to who or to which you are required to provide additional insured status or additional insured status on a primary, non-contributory basis, in a written contract or written agreement executed prior to loss, except where such contract or agreement is prohibited by law. (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "inSLjred"for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section 11 of the Coverage Form, Copyright, I lawaii Insurance Bureau, Inc., 1999 lVICILides copyrighted rnaterial of the Insurance Services Office, Mc,,with its permission CA 1028 (2-99) CA 20 48 02 9 9 Copyrigtnt, Insurance Services Office, Inc., 1999 Page 1 of 1 a Blanket Notification r II i n ZURICH Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. AWL Prem Return Prem. GL09242201-02 4/1/2014 411/2015 34937000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. If we cancel this Coverage Part by written notice to the first Named Insured for any reason other than nonpayment of premium, we will deliver electronic notification that such Coverage Part has been cancelled to each person or organization shown in a Schedule provided to us by the First Named Insured. Such Schedule: 1. Must be initially provided to us within 15 days: a. After the beginning of the policy period shown in the Declarations; or b. After this endorsement has been added to policy; 2. Must contain the names and e-mail addresses of only the persons or organizations requiring notification that such Coverage Part has been cancelled; 3. Must be in an electronic format that is acceptable to us; and 4. Must be accurate. Such Schedule may be updated and provided to us by the First Named Insured during the policy period. Such updated Schedule must comply with Paragraphs 2. 3. and 4. above. B. Our delivery of the electronic notification as described in Paragraph A. of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured. Delivery of the notification as described in Paragraph A. of this endorsement will be completed as soon as practicable after the effective date of cancellation to the first Named Insured. C. Proof of emailing the electronic notification will be sufficient proof that we have complied with Paragraphs A. and B. of this endorsement. D. Our delivery of electronic notification described in Paragraphs A. and B. of this endorsement is intended as a courtesy only. Our failure to provide such delivery of electronic notification will not: 1. Extend the Coverage Part cancellation date; 2. Negate the cancellation; or 3. Provide any additional insurance that would not have been provided in the absence of this endorsement. E. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the Schedule provided to us as described in Paragraphs A. and B. of this endorsement. All other terms and conditions of this policy remain unchanged. U-GL-1114-A CW(10-02) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. Blanket Notification r ll io IC Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add'I. Prem Return Prem. 13AP9242202-02 4/1/2014 4/1/2015 34937000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Commercial Auto Coverage Part A. If we cancel this Coverage Part by written notice to the first Named Insured for any reason other than nonpayment of premium, we will deliver electronic notification that such Coverage Part has been cancelled to each person or organization shown in a Schedule provided to us by the First Named Insured. Such Schedule: 1. Must be initially provided to us within 15 days: a. After the beginning of the policy period shown in the Declarations; or b. After this endorsement has been added to policy; 2. Must contain the names and e-mail addresses of only the persons or organizations requiring notification that such Coverage Part has been cancelled; 3. Must be in an electronic format that is acceptable to us; and 4. Must be accurate. Such Schedule may be updated and provided to us by the First Named Insured during the policy period. Such updated Schedule must comply with Paragraphs 2. 3. and 4. above. B. Our delivery of the electronic notification as described in Paragraph A. of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured. Delivery of the notification as described in Paragraph A. of this endorsement will be completed as soon as practicable after the effective date of cancellation to the first Named Insured. C. Proof of emailing the electronic notification will be sufficient proof that we have complied with Paragraphs A. and B. of this endorsement. D. Our delivery of electronic notification described in Paragraphs A. and B. of this endorsement is intended as a courtesy only. Our failure to provide such delivery of electronic notification will not: 1. Extend the Coverage Part cancellation date; 2. Negate the cancellation; or 3. Provide any additional insurance that would not have been provided in the absence of this endorsement. E. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the Schedule provided to us as described in Paragraphs A. and B. of this endorsement. All other terms and conditions of this policy remain unchanged. U-CA-388-A Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY U-WC-332-A NOTIFICATION TO OTHERS OF CANCELLATION ENDORSEMENT This endorsement is used to add the following to Part Six of the policy. PART SIX—CONDITIONS F. Notification To Others Of Cancellation 1. If we cancel this policy by written notice to you for any reason other than nonpayment of premium, we will deliver electronic notification to each person or organization shown in a Schedule provided to us by you. Such Schedule: a. Must be initially provided to us within 15 days: After the beginning of the policy period shown in the Declarations; or After this endorsement has been added to policy; b. Must contain the names and e-mail addresses of only the persons or organizations requiring notification that this policy has been cancelled; c. Must be in an electronic format that is acceptable to us; and d. Must be accurate. Such Schedule may be updated and provided to us by you during the policy period. Such updated Schedule must comply with Paragraphs b. c. and d. above. 2. Our delivery of the electronic notification as described in Paragraph 1. of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to you. Delivery of the notification as described in Paragraph 1. of this endorsement will be completed as soon as practicable after the effective date of cancellation to you. 3. Proof of emailing the electronic notification will be sufficient proof that we have complied with Paragraphs 1. and 2. of this endorsement. 4. Our delivery of electronic notification described in Paragraphs 1. and 2. of this endorsement is intended as a courtesy only. Our failure to provide such delivery of electronic notification will not: a. Extend the policy cancellation date; b. Negate the cancellation; or c. Provide any additional insurance that would not have been provided in the absence of this endorsement. 5. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the Schedule provided to us as described in Paragraphs 1. and 2. of this endorsement. All other terms and conditions of this policy remain unchanged. 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 4/1/2014 Policy No. WC9242205-02 Endorsement No. Miller Pipeline, LLC Premium $ American Zurich Insurance Company U-W C-332-A (Ed. 01-11) Includes copyrighted material of National Council on Compensation Insurance, Inc. used with its permission.