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RES 2022-0292 - Bid Award to Materials Packaging for Sand (Golf) - 2022 City Clerk Office Use Only: r Publication Date(if applicab e): RESOLUTION NO. �L CAI Agenda Date: _�'� L-( �-- Department: j 'I Submitter: MIEN, _S CITY OF OMAHA LEGISLATIVE CHAMBER Omaha, Nebraska RESOLVED BY THE CITY COUNCIL OF THE CITY OF OMAHA: WHEREAS, bid was received on February 9, 2022, to furnish all labor, materials, and equipment necessary for the Sand (Golf) bid, in the total amount of $24,063.35, for the Parks, Recreation and Public Property Department; and, WHEREAS, Materials Packaging submitted the best bid, within bid specifications, attached hereto and made a part hereof, in the total amount of$24,063.35; and, WHEREAS, Materials Packaging has complied with the City's Contract Compliance Ordinance No. 28885 in relation to Civil Rights - Human Relations; and, WHEREAS, the Mayor has recommended acceptance of this bid. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF OMAHA: THAT, as recommended by the Mayor, the bid in the total amount of $24,063.35 from Materials Packaging to furnish labor, materials, and equipment necessary for the Sand (Golf) bid, being the best bid received within bid specifications, attached hereto and made a part hereof, is hereby accepted. The Finance Department is authorized to pay the cost for the Sand (Golf) from the Golf Operations Fund No. 21114, and Organization Nos. 115511 — Johnny Goodman ($5,962.60), 115512 — Benson ($5,323.75), 115513 — Elmwood ($6,388.50), 115519 — Knolls ($6,388.50). APPROVED AS TO FORM: p:2925mtc 51,1(7 zz 'DEP Y CITY ATTORNEY DA Adopted: • Attest: City Clerk / Approved:,_ l/6--- Mayor BID BOND: 5% HH Douglas County Purchasing TABULATION OF BIDS ON: CITY OF OMAHA Top Dressing Sand for Golf Materials Packaging Date of Opening Department Wednesday, February 9, 2022 Parks and Recreation Quantity Unit Extended (estimated DESCRIPTION tons) Price Price B Top Dressing Sand for Golf 140 Johnny Goodman Bid/ton: $42.59 $5,962.60 150 Knolls Bid/ton: $42.59 $6,388.50 125 Benson Bid/ton: $42.59 $5,323.75 150 Elmwood Bid/ton: $42.59 $6,388.50 Top Dressing Sand (Dry) -TOTAL BID: $24,063.35 Bid Bond Received: Yes Terms: 100%/30 days Delivery: 14 calendar days/Will Call 1 of 1 HH DOUGLAS COUNTY REQUEST FOR BID AND BID SHEET ON: CITY OF OMAHA Top Dressing Sand for Golf RETURN BIDS TO: Published: January 26,2022 Page 1 CITY CLERK 1819 Farnam Street BID BOND OR CERTIFIED CHECK REQUIRED IN THE AMOUNT 5% LC-1-Omaha-Douglas Civic Center IF THE TOTAL AMOUNT FOR THE ITEM OFFERED IS$20,000 OR MORE. Omaha,NE 68183 BID BOND OR CERTIFIED CHECK SHALL BE MADE PAYABLE TO "CITY OF OMAHA" NOT AN ORDER Bid Opening Time&Date: 11:00 a.m.CT on Wednesday,February 9,2022 IMPORTANT 1. Bid must be in the office of the CITY CLERK,1819 Famam Street,LC-1, 4 Right is reserved to accept or reject any or all bids in their entirety and the bidders shall OMAHA-DOUGLAS CIVIC CENTER,Omaha,NE 68183 have the right to appeal any decision to the Omaha City Council. by the opening date and time indicated in a sealed envelope marked: 5 When submitting bid on Items listed,bidder may on a separate sheet,make BID ON:CITY OF OMAHA Top Dressing Sand for Golf suggestions covering reduction in costs wherever this is possible through 2. As evidence of good faith a bid bond or certified check must be submitted with bid. redesign,change of material or utilization of standard Items or quantity change. Bid bond or certified check shall be made payable to"City of Omaha" 6•Bid tabulation are available on the Douglas County Purchasing website: FAILURE TO DO SO IS CAUSE FOR REJECTION. www.douglascountypurchasing.org. DO NOT CALL FOR THIS INFORMATION. 3 The City of Omaha is tax exempt.Tax exempt certificates will be provided upon request Bid your lowest price,best delivery and terms,F.O.B.delivery point on the Item(s)listed below: QUANTITY DESCRIPTION UNIT PRICE EXTENSION The City of Omaha is seeking bids to furnish and deliver Top Dressing Sand (Dry)for Golf Courses per the attached specifications. Top Dressing Sand (Dry) Total Bid: $ Z 4 O t!o3' 3 S (5%Bid Bond is to be based upon this amount,if over $20,000.00) Questions regarding this bid should be sent via email to bidquestions@douglasco4inty-ne.gov. Vendor must include the bid-title in the subject line. The deadline to submit questions on this bid is 11:00 a.m.on the Thursday before the bid opening date. Answers to questions will be posted via an addendum no later than the Friday before bid opening at www.douglascountypurchasing.org. (PLEASE PRINT LEGIBLY OR TYPE) Payment Terms/d0 % 30 PAYS Firm: NAT pe4cf40,6 ivt4 ?dad In:II ej Delivery(or completion) Name: Ot- d Signature:'—ffi- I calendar days following Title: 5 LCS Phone:404 72 p-`T 373 Fax: "fez_7L 7--Q 97 award Address: 33/0 /1/- (jh -6AA S7'• c4(e4.0,v, /E gr72S VA L1-. CALL Street/P.O.Box City /� State Zip Email Address: yyy ac - OL'BV�e/5,.�.y a.(w d 14r ca - C t744 DOUGLAS COUNTY REQUEST FOR BID ON: CITY OF OMAHA-Top Dressing Sand for Golf NOT AN ORDER Page 2 QUANTITY DESCRIPTION UNIT PRICE EXTENSION (Qty.x Unit Price) (estimated tons) Top Dressing Sand (Dry) 140 Johnny Goodman Bid/ton: $ A 2. 59 $ 5;762. .0 150 Knolls Bid/ton: $ 4 z • S 1 $ (/3 88.50 125 Benson Bid/ton: $ Dr2 -S'1 $ S 3 z 3. 7c 150 Elmwood Bid/ton: $ 40-S 4368.50 1 $ Top Dressing Sand (Dry) -Total bid: $ DO. 33-- (enter this amount on Page 1) SIGN ALL COPIES Firm /krAy A.,AL S (u4.7 By friAQ-c - GO- c/E-11- ra G/4 Title PO-6S CONTINUATION SHEET BIDS TRANSMITTED BY CIT(CLERK OPENED BY COMMITTEE FEB 0.9 2022 AS PER ORD#37061 Referred to Purchasing Agent DOUGLAS COUNTY REQUEST FOR BID ON: CITY OF OMAHA-Top Dressing Sand for Golf NOT AN ORDER Page 3 BID CLAUSES-TERMS AND CONDITIONS Requirement for Bid Bond: The surety company issuing the bid bond should be licensed by the State of Nebraska and listed on the current edition of Circular 570 of the United States.Department of the Treasury. A certified check,an official bank check, or cashier's checks drawn on a national bank or a bank chartered under the laws of the state, payable to the City of Omaha, or lawful money of the United States,or a United States Government Bond(negotiable)are acceptable substitutes for bond requirements. LETTERS OF CREDIT AND COMPANY CHECKS ARE NOT ACCEPTABLE SUBSTITUTES FOR A BID BOND AND WOULD BE CAUSE FOR REJECTION OF BID. If a bidder submits more than one bid,only one bid bond is required. Conflict of Interest: Pursuant to all state and local rules,CONTRACTOR assures the City of Omaha(CITY)that no elected Official or any officer or CITY employee shall have a financial interest,direct or indirect, in any CITY agreement. In the performance of this agreement, CONTRACTOR will avoid all conflicts of interests or appearances of conflict of interest. CONTRACTOR will report any conflict of interest immediately to the CITY. CONTRACTOR did not and will not provide any money or other benefit of any kind to any CITY employee in the procuring of,facilitation of,and execution of or during the duration of this Agreement. Communication with Staff: From the date this bid is issued until a contract is awarded,communication regarding this solicitation between potential vendors and individuals employed by the City of Omaha is prohibited. Only written communication via email to bidquestions@douglasCity-ne.gov is permitted. Once an award is made the vendor will be permitted to speak with person(s)participating in contract negotiations. Violation of these conditions may be considered sufficient cause to reject a vendor's bid and/or selection irrespective of any other condition. The following exceptions to these restrictions are permitted: (1)Contacts made pursuant to any pre-existing contracts or obligations; (2)City staff and/or vendor staff present at a Pre- Proposal Conference, if scheduled,when recognized by the City as staff facilitating the meeting for the purpose of addressing questions; and (3)Presentations, key personnel interviews,clarification sessions or discussions to finalize a contract, as requested by the City. Unavailability of Funding: Due to possible future reductions including but not limited the City of Omaha(CITY),State and/or Federal appropriations,the CITY cannot guarantee the continued availability of funding for this Agreement,notwithstanding the consideration stated in this Agreement. In the event funds to finance this Agreement become unavailable either in full or in part due to such reduction In appropriations,the CITY,may terminate the Agreement or reduce the consideration upon notice in writing to Contractor. The notice shall be delivered by certified mail, return receipt requested,or in person with proof of delivery. The CITY shall be the final authority as to the availability of funds. The effective date of such Agreement termination or reduction in consideration shall be specified in the notice as the date of service of the notice or the actual effective date of the CITY, State and/or Federal funding reduction,whichever is later. Provided,that reduction shall not apply to payments made for services satisfactorily completed prior to the effective date. In the event of a reduction of consideration, Contractor may cancel this Agreement as of the effective date of the proposed reduction upon the provision of advance written notice to CITY. Assignment and Delegation: This Agreement is exclusive to the Parties and rights may not be assigned nor duties delegated by either Party except on prior written consent of the other. Any attempted assignment or delegation without such approval shall be void and shall constitute a material breach of contract. Any and all additional fees,charges,costs or expenses,which result from an approved assignment or delegation, shall be paid by the assigning/delegating Party. Termination: The City of Omaha may terminate the awarded contract at any time if the vendor fails to carry out the terms or fails to make substantial progress toward the fulfillment of the contract obligations. In such event, the City shall provide the vendor with thirty(30)days written notice of conditions which endanger contract performance. If after such notice the vendor fails to remedy these conditions,the City may send a certified letter to the vendor for immediate cancellation of the contract. In such event,the City would receive a pro-rated portion of the value of the performance bond depending on the value of the remaining portion of the contract. The City will give the vendor sixty(60)days'notice of termination of contract if appropriations cease.The City of Omaha may also terminate the agreement for any reason upon 30 days notice. Payment Terms:Net 30 payment terms shall apply to all invoices billed to the City of Omaha. Payment of invoice amount will occur within 30 days following receipt of invoice or receipt of goods/services,whichever is later. Drug Free Policy: CONTRACTOR assures the City of Omaha that CONTRACTOR has established and maintains a drug free workplace policy. SIGN ALL COPIES Firm A, I v/LIAL S F .GVA 4/N 4 By /fAA.K- G`eu -1 A Title SAL,c 5 DOUGLAS COUNTY REQUEST FOR BID ON: CITY OF OMAHA-Top Dressing Sand for Golf NOT AN ORDER Page 4 BID CLAUSES-TERMS AND CONDITIONS FEDERAL DEBARMENT OR SUSPENSION: Has bidder or its prince als been debarred or suspended from Federal contracts? YES NO (failure to provide a response may be cause for rejection of bid) Bidder certifies by submission of this bid that neither it nor its principals are presently debarred or suspended from participation in Federal contracts. If during the term of the agreement the awarded bidder or any person engaged in performing this agreement becomes debarred or suspended such Party shall notify the City of Omaha immediately. Form CC-1: All bidders awarded a City contract in the amount of$10,000 or more must comply with the Contract Compliance Ordinance by having a current Contract Compliance Report(Form CC-1)on file with the Human Rights&Relations Department. This report shall be in effect for 24 months from the date received by the Human Rights&Relations Department. Any questions regarding the Contract Compliance Ordinance should be directed to the Human Rights&Relations Department at(402)444-5055. Bidders are encouraged to use the following weblink to determine if they have a current Form CC-1 on file (search by company name): https://humanrights.cityofomaha.org/cc-1-search. Equal Employment Opportunity: In accordance with the Nebraska Fair Employment Practice Act, Neb. Rev.Stat.§48-1122, the Contractor agrees that neither it nor any of its subcontractors shall discriminate against any employee,or applicant for employment to be employed in the performance of this Agreement,with respect to hire,tenure,terms,conditions,or privileges of employment because of the race,color,religion,sex,disability,or national origin of the employee or applicant. Non-Discrimination: Both Parties agree that in accordance with 42 USCS 12101 et seq.,the Nebraska Fair Employment Practice Act-Neb.Rev.Stat.§48-1122,and Omaha Municipal code 13-89,they will not discriminate against any employee or applicant for employment,to be employed in the performance of this Agreement,with respect to hire,tenure,terms,conditions, or privileges of employment because of the age,race,color,religion,sex,disability,or national origin of the employee or applicant. None of the Parties shall,in the performance of this Agreement,discriminate or permit discrimination in violation of federal or state laws or local ordinances. E-Verify: New Employee Work Eligibility Status(Neb.Rev.Stat.§4-108-114): The Contractor is required and hereby agrees to use a federal immigration verification system to determine the work eligibility status of new employees physically performing services within the state of Nebraska. A federal immigration verification system means the electronic verification of the work authorization program authorized by the Illegal Immigration Reform and Immigrant Responsibility Act of 1996,8 U.S.C. 1324a, known as the E-Verify Program,or an equivalent federal program designated by the United States Department of Homeland Security or other federal agency authorized to verify the work eligibility status of a newly hired employee. If the Contractor is an individual or sole proprietorship,the following applies: 1. The Contractor must complete the United States Citizenship Attestation Form,available on the Department of Administrative Services website at www.das.state.ne.us. 2. If the Contractor indicates on such attestation form that he or she is a qualified alien,the Contractor agrees to provide the US Citizenship and Immigration Services documentation required to verify the Contractor's lawful presence in the United States using the Systematic Alien Verification for Entitlements(SAVE)Program. 3. The Contractor understands and agrees that lawful presence in the United States is required and the Contractor may be disqualified or the contract terminated If such lawful presence cannot be verified as required by Neb. Rev.Stat.§4-108. Joint Governmental Purchases:The City of Omaha has been authorized to join with other public corporations or units of government within the State of Nebraska in the cooperative procurement of materials,equipment,work,or services. With the consent of the successful bidder the City may use the public competitive bid secured herein for the procurement of future materials,equipment,work,or services under the same terms,conditions,and prices offered by the bidder herein. Bidders are requested to indicate below if they are willing to extend the pricing,terms,and conditions of this bid to other City of Omaha departments, Douglas County departments,or other government agencies,if the bidder is the successful bidder. If the successful bidder replies Yes to this provision,other City of Omaha departments, Douglas County departments,and other government agencies may enter into a contract with the successful bidder for the purchase of the goods and/or services described herein based on the terms,conditions, and prices offered by the successful bidder to the City of Omaha. YES NO 'SIDS TRANSMITTED lir Cl f/CLERK ,1J SIGN ALL COPIES OPENED BY COMMITTEE Firm j41tk't-E.41 AL.'S {•4 C.(Gill 6. ((t By 141A & . CI—CV E.Q.(t CaA FEB 00 2022 Title S,4 LE5 AS PER ORD#37061 CONTINUATION SHEET Referred to Purchasing Agent DOUGLAS COUNTY REQUEST FOR BID ON: CITY OF OMAHA-Top Dressing Sand for Golf NOT AN ORDER Page 5 BID CLAUSES-TERMS AND CONDITIONS INSURANCE: Each bidder must provide a Certificate of Insurance with their bid documents which details their current levels of coverage. FOLLOWING AWARD OF CONTRACT: For City projects where the scope of work will be less than$200,000.00,it is required that the awarded contractor provide a Certificate of Insurance meeting or exceeding the following levels of insurance:(1) adequate workers'compensation(statutory); (2)commercial general liability in an amount not less than$250,000 for any person for any number of claims arising out of a single occurrence and not less than$500,000 for all claims arising out of a single occurrence;and(3)property damage insurance in an amount not less than$500,000;and naming CITY OF OMAHA as an additional insured,except for Workers'Compensation policies/certificates,for the term of the agreement. Certificates of Insurance are required before service begins. FOLLOWING AWARD OF CONTRACT: For City projects where the scope of work will exceed$200,000.00,it is required that the awarded contractor provide a Certificate of Insurance meeting or exceeding the following levels of insurance:(1)adequate workers'compensation(statutory);(2)commercial general liability in an amount not less than$1,000,000 for any person for any number of claims arising out of a single occurrence and not less than$5,000,000 for all claims arising out of a single occurrence;and(3)property damage insurance in an amount not less than$500,000;and naming CITY OF OMAHA as an additional insured,except for Workers'Compensation policies/certificates,for the term of the agreement. Certificates of Insurance are required before service begins. Liquidated damages shall be assessed at a rate of 1%of the total purchase order amount per calendar day that satisfactory performance is not fully complete. Satisfactory performance shall occur on or before the date agreed to at the time of the bid or purchase award between the City and the awarded bidder. Satisfactory performance shall also be deemed to include product or purchase compliance with all specifications set forth in the bid award. The amount of liquidated damages shall be deducted from any monies due the awarded bidder by the City. if applicable,when the monies due to the awarded bidder are not sufficient to satisfy the City's liquidated damages,the awarded bidder shall submit payment to the City the amount to satisfy any outstanding liquidated damages owed within 10 days of the date of non-performance. The City may,at its sole discretion,allow"excusable delays"when assessing if liquidated damages are applicable. An excusable delay is defined as.a delay that causes disruption to the installation schedule but which is beyond the awarded bidder's control. Excusable delay may include delays caused by weather,strikes,or natural disasters. Any determination of • excusable delay by the City shall be limited in time and scope and shall not be a guarantee or promise of future determinations of excusable delay by the City. Independent Contractor: Both parties understand and agree that(CONTRACTOR)is an independent contractor under the provisions of this Agreement and not employed by or otherwise affiliated with Douglas County(COUNTY)or the City of Omaha (CITY). Employees of CONTRACTOR(if any)are not employees of COUNTY/CITY. Each Party shall pay all wages,salaries and other amounts due its employees and shall be responsible for all reports, obligations,and payments pertaining to social security taxation, income tax withholding,workers'compensation,unemployment compensation,group insurance coverage, collective bargaining agreements or any other such similar matters. Both parties understand and agree that CONTRACTOR is solely responsible for acquiring and maintaining,for the term of this Agreement,adequate general and special liability insurance,including but not limited to workers' compensation insurance,sufficient to protect CONTRACTOR'ability to complete performance under this Agreement. Neither Party shall have any authority to bind the other by or with any contract or agreement,nor to impose any liability upon the other.All acts and contracts of each shall be in its own name and not in the name of the other. SIGN ALL COPIES Firm 44TZi4'-s By /OAL GLFrf/c i K.Cs Title 5Ac^C,$ CONTINUATION SHEET DOUGLAS COUNTY REQUEST FOR BID ON: CITY OF OMAHA-Top Dressing Sand for Golf NOT AN ORDER Page 6 BID CLAUSES-TERMS AND CONDITIONS EXTRAORDINARY EVENTS: In the event of a pandemic, natural disaster,terroristic attack,or closure of a facility due to construction, remodeling or sale or any other extraordinary event which results in one,some or all of the listed facilities in this Agreement being closed for two weeks or more,the City may discontinue services upon immediate notice. Quantities are estimated. Depending on bid pricing and budget,the City may purchase more or less than the quantities listed. Unit Pricing: If unit pricing is requested but a bidder only provides a total price(extension),then it may be cause for rejection of the bid.In the event of a calculating error, unit price(s)in the submitted bid document prevails. Bidder shall not be allowed to change their unit price(s)due to a calculating error. CONSUMER PRICE INDEX CLAUSE: Following the initial contract term,the awarded bidder may propose price increases for any contract extensions offered by the City. Price increases must be requested 30 days prior to proposed increase and must be justified with documentation(e.g.reports, manufacturer statements, invoices,etc.). Proposed price increases will be reviewed by the City,who at their sole discretion will either approve or reject the proposed increase. SIGN ALL COPIES Firm /I/l A-1-621AtS PA GVA-L41N By 1441-K- GJ EA,.trs4.A Title 4A.LE $ CONTINUATION SHEET BIDS TRANSMITTED BY CIT(CLERK OPENED BY COMMITTEE FEB 00 2022 AS PER ORD#37061 Referred to Purchasing Agent Responsible Contractor Compliance Form RC-1 0 ahHA,i . s� v kr f-- r 1. Regulation: og � 44D FGa0r". A.Article N,Division I of Chapter 10 of the Omaha Municipal Code thereon require: 1.That all contractors who submit a bid to City of Omaha shall designate a representative who on behalf of the Contractor,shall fill out completely a Responsible Contractor Compliance Form (RC-1). An incomplete or unsigned RC-1 form will make your bid null and void. 2. Filing this Report(please initial in the boxes below): Contractor agrees that Contractor will not knowingly employ or hire an employee not lawfully authorized to perform employment in the United States and that the Contractor and all sub- contractors shall use E-Verify to determine work eligibility. Contractor agrees that Contractor will not knowingly violate Nebraska's Misclassification of Employee law(Neb.Rev.Stat.Section 48-2901 et seq.). Contractor agrees that Contractor will not knowingly violate Nebraska's Fair Labor Standards I Law(Neb.Rev.Stat.Section 73-104 et seq.). 1-711 Contractor has not been convicted of any tax violations(local,State and Federal)within the last three years from the date this bid is submitted. Contractor has not,upon final determination by the Occupational Safety and Health Administration,been convicted of a criminal,repeat,or willful violation of the Occupational Safety and Health Act(OSHA)or been convicted of 3(three)separate"serious"OSHA violations within the past three(3)years. Contractor agrees to make a good faith effort to ensure all subcontractors employed on this project ��I ��- !!! comply with the rovisions of the Responsible Contractor Compliance Form RC-1. /76I-3/- 2Z Sigma a Date By signing,I verify on behalf of the Contractor that the information above is true and correct. Filing false information carries a penalty of up to a$500 fine or six months in jail. In addition,the contractor and sub- contractors can be subject to immediate disqualification and prohibited from any future City of Omaha contract for a period of 10 years. EMPLOYEE CLASSIFICATION ACT: Each contractor who performs construction or delivery service pursuant to this contract shall submit with their bid submission an affidavit attesting that (1) each individual performing services for such contractor is properly classified under the Nebraska Employee Classification Act, 2010 LB 563 ("the Act"); (2)such contractor has completed a Federal I-9 Immigration form and has such form on file for each employee performing services; (3) such contractor has complied with Neb. Rev. Stat. Section 4-114 (Federal Immigration Verification System--E- Verify); (4) such contractor has no reasonable basis to believe that any individual performing services for such contractor is an undocumented worker; and (5) as of the time of the contract, such contractor is not barred from contracting with the state or any political subdivision pursuant to the Act. The contractor shall follow the provisions of the Act. A violation of the Act by a contractor is grounds for rescission of the contract by City of Omaha/Douglas County. CONTRACTOR shall follow the provisions of the Employee Classification Act (Act). A violation of the Act will be a material breach and, in addition to any other remedies, be grounds for immediate contract rescission. If CONTRACTOR is performing construction or providing delivery service, CONTRACTOR shall submit an affidavit that complies with the Act. CONTRACTOR will also ensure that all subcontractors performing services for Contractor will also complete affidavits that comply with the Act. Contractor may submit the affidavit(s) with their bid submission. In all circumstances, Contractor shall provide the affidavits before work or services are undertaken pursuant to this Agreement. Following award, if CONTRACTOR changes or adds additional subcontractors, CONTRACTOR shall ensure that the subcontractor provides an Employee Classification Act affidavit to Douglas County Purchasing Department before that subcontractor begins work or services. All Employee Classification Act affidavits shall be sent to: Douglas County Purchasing Agent, 1819 Farnam Street,Room 902,Omaha NE 68183. FAIR LABOR STANDARDS: CONTRACTOR agrees to maintain FAIR LABOR STANDARDS as defined in Neb. Rev Stat§ 73-104. CONTRACTOR has filed with Douglas County (City/County Purchasing) a statement that it is complying with and will continue to comply with, fair labor standards as provided in Neb. Rev. Stat. §§73-102 & 73-104. In addition, CONTRACTOR assures County that it will continue to comply with statutory fair labor standards throughout its performance under this contract. BIDS TRANSMITTED BY CIT(CLERK 13IED B l,tEflK OPENED BY COMMITTEE OPENED DSTRANSMTIT BY.C)MYMMil`(1F. FEB Og 2022 FEB O Q 2022 AS PER ORD#37061 AS PER ORE)#:Ii (.1 Referred to Purchasing Agent dteferred to Purcheau:;.4 l;<it..A AFFIDAVIT FOR EMPLOYEE CLASSIFICATION ACT&FAIR LABOR STANDARDS I, /i l ids,. CL 0veA t n 4A , being first duly sworn under oath, state and depose as follows: 1. I am competent to testify to, and have personal knowledge of,the matters stated in this affidavit. 2. I am (a contractor) or (the authorized agent of the contractor) for A i Eo...(f�LS I,4G.1404 4 i N 17 Company, (hereinafter "Contractor"). I attest to the following: (a) each individual performing services for Contractor is properly classified under the Nebraska Employee Classification Act, ("the Act"), (b)Contractor has completed a federal I- 9 immigration form and has such form on file for each employee performing services, (c) Contractor has complied with Neb. Rev. Stat. §4-114 (use of federal immigration verification system), (d) Contractor has no reasonable basis to believe that any individual performing services for Contractor is an undocumented worker, (e) as of the time of the contract, Contractor is not barred from contracting with the state or any political subdivision pursuant to the Act, and (f) Contractor is complying with and will continue to comply with, fair labor standards as provided in Neb.Rev.Stat. §§73-102 & 73-104, as applicable and as amended hereinafter. Contractor will also ensure that all subcontractors execute affidavits in compliance with the Act. FURTHER AFFIANT SAYETH NAUGHT. Affiant(Contracto fi SUBSCRIBED AND SWORN TO before me this v 1 5day of J Q..Il1 . , 20 g, jNERALNOIARvtateofNebraska / � CATHY J.SNiTILY (� _ f ,�%�✓�C My Comm.Exp.May 31,2023 Notary Public Top Dressing Sand Material bid must contain less than 4% silt and clay. All materials must be delivered dry. Sieve Retain #4 0% #8 0% #16 4% #30 20% -70% #50 70% - 97% #100 97% -99% #200 100% DELIVERY LOCATION Johnny Goodman 6112 S 99th St, 68127 Knolls 11650 Sahler, 68164 Benson 6910 Ames Ave, 68134 Elmwood 707 S. 62nd St, 68106 Quantities are estimates. (BIDS TRANSMITTED BY CIT(CLERK OPENED BY COMMITTEE FEB 0.9 2022 AS PER ORD#37061 Deferred to Purchasing Agent E ACCORD CERTIFICATE OF LIABILITY INSURANCE DAT2/2/LO22»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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER Liberty Mutual Insurance Co.National Insurance East NAMT"C'T Valerie Reece 2000 Westwood Dr. PHONE WC.No.Extt: 513-867-3822 , A/C,No): Wausau,WI 54401 E.MAIL ADDRESS: Old castle.certs@ LibertyMutual.co m INSURER(S)AFFORDING COVERAGE NAIC# www.LlbertyMutual.com INSURER A: Liberty Mutual Fire Insurance Company 23035 INSURED INSURER B: Liberty Insurance Corporation 42404 Ash Grove Admin APG (APAP1310) (NSURERC: 315 Phillips Road North Little Rock AR 72211 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 66587846 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POUCY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYYI A / COMMERCIAL GENERAL LIABILITY ✓ TB2-C81-004095-111 9/1/2021 9/1/2022 EACH OCCURRENCE $2,000,000 CLAIMS-MADE ✓ OCCUR DAMAGE REM PREMISES(Ea(Ea occurrence) $300,000 XCU Coverage Included I Primary/Non-Contributory MED EXP(Any one person) $50,000 ✓ Separation of Insured PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 RPOLICY ✓ PECT I I LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY ✓ AS2-C81-004095-121 9/1/2021 9/1/2022 (EsaBcolidentsINGLELIMIT $2,000,000 ANY AUTO BODILY INJURY(Per person) $ A ✓ OWNED SCHEDULED AS2-C81-054502-521 9/1/2021 9/1/2022 BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS Physical Damage only: HIRED AUTOS ONLY _ AUTOS NLYY Comprehensive Ded$10,000 (Per aacidTnDAMAGB $ Collision Ded$10,000 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _$ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WA7-C8D-004095-021 9/1/2021 9/1/2022 ,/ PEAfUTE ERR- AND EMPLOYERS'LIABILITY Y/N All except OH,ND,WA,WY ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED4 El /A B (Mandatory In NH) WC7-C81-004095-011 9/1/2021 9/1/2022 E.L.DISEASE-EA EMPLOYEE $1.000.000 If yes,describe under DESCRIPTION OF OPERATIONS below WI,MN E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) RE:City of Omaha-Top Dressing Sand for Golf. Douglas County/City of Omaha and Hero Rentals are listed as additional insured with regards to the general liability and automobile liability policies,on a primary and non-contributory basis,where required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Douglas County/City of Omaha THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 1819 Farnam St LC-1 Omaha Douglas Civic Center AUTHORIZED REPRESENTATIVE Omaha NE 68183 _I L �'•Zed-e. I Valerie Reece 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD -_._ . _.- .. . -- -. -- -- _. ...-, n n ..-.__-- ncu i n_-- _ ...._-b_ i nlolo000 ].nn.19 fl ll•CT, I Dane , of „ Policy Number: AS2-C81-004095-121, AS2-C81-054502-521 Issued by: Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED-NONCONTRIBUTING This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIERS COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(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. Schedule Name of Person(s)or Organizations(s): Any person or organization where the Named Insured has agreed by written contract to include such person or organization Regarding Designated Contract or Project: Any Each person or organization shown in the Schedule of this endorsement is an "insured"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 II of the Coverage Form. The following is added to the Other Insurance Condition: If you have agreed in a written agreement that this policy will be primary and without right of contribution from any insurance in force for an Additional Insured for liability arising out of your operations, and the agreement was executed prior to the "bodily injury" or "property damage", then this insurance will be primary and we will not seek contribution from such insurance. I3IDS TRANSMITTED BY CIT f CLERK OPENED BY COMMITTEE FEB 0'9 2022 AS PER ORD#37061 Referred to Purchasing Agent AC 84 23 08 11 ©2010, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 36587846 I LM 44 109.21-09.22 Standard 2-2 Excess S5M I Connie Mvszka 12/2/2022 3:04:17 PM (CST1 I Pace 2 of 11 POLICY NUMBER: AS2-C81-004095-121, AS2-C81-054502-521 COMMERCIAL AUTO CA04441013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless modified by the endorsement. SCHEDULE Name(s)Of Person(s) Or Organization(s): Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring. Premium: $ INCL Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. • CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 .ec o�onc i rw. AA I no 91-no 19 cranriard 9-9 Rvnnaa SW I Cnnnie Mva,ka 12/2/2022 3:04:17 PM (CST) I Page 3 of 11 Policy Number: AS2-C81-004095-121, AS2-C81-054502-521, TB2-C81-004095-111 Issued By: Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Other Person(s)I Email Address or mailing Number • Organization(s): address: Days Notice: Where required by written contract Where required by written contract 90 BIDS TRANRMIITED BY Cir(CLERK OPENED BY:COM VIITTEE FEB ® 2022 AS PER ORD#3748i Referred to Purchasing Agent A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 ©2011, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. ;6587846 I LM 44 109.21-09.22 Standard 2-2 Excess S5M I Connie Mvszka 12/2/2022 3:04:17 PM (CST) I Pane 4 of 11 POLICY NUMBER:TB2-C81-004095-111 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to 1. All work, including materials, parts or include as an additional insured the person(s) or equipment furnished in connection with such organization(s) shown in the Schedule, but only with work, on the project (other than service, respect to liability for "bodily injury", "property maintenance or repairs) to be performed by or damage" or "personal and advertising injury" on behalf of the additional insured(s) at the caused, in whole or in part, by: location of the covered operations has been 1. Your acts or omissions;or completed;or 2. The acts or omissions of those acting on your 2. That portion of "your work" out of which the behalf; injury or damage arises has been put to its in the performance of your ongoing operations for intended use by any person or organization the additional insured(s) at the location(s) other than another contractor or subcontractor designated above. engaged in performing operations for a principal as a part of the same project. However: C. With respect to the insurance afforded to these 1. The insurance afforded to such additional additional insureds, the following is added to insured only applies to the extent permitted by Section III—Limits Of Insurance: law; and If coverage provided to the additional insured is 2. If coverage provided to the additional insured is required by a contract or agreement, the most we required by a contract or agreement, the will pay on behalf of the additional insured is the insurance afforded to such additional insured will amount of insurance: not be broader than that which you are required 1. Required by the contract or agreement; or by the contract or agreement to provide for such additional insured. 2. Available under the applicable Limits of B. With respect to the insurance afforded to these Insurance shown in the Declarations; additional insureds, the following additional whichever is less. exclusions apply: This endorsement shall not increase the This insurance does not apply to "bodily injury" or applicable Limits of Insurance shown in the "property damage"occurring after: Declarations. SCHEDULE Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Organization(s): Any owner,lessee,or contractor for whom you have Any location listed in such agreement agreed in writing prior to a loss to provide liability insurance Information required to complete this Schedule, if not shown above,will be shown in the Declarations. CG 2010 0413 ©Insurance Services Office, Inc.,2012 Page 1 of 1 eenno.e . .0 A.. I no ol_no 'fo e«....4e.-.i o_'1 o CSM I lnnn:n M..00La 1 '3/1/7f19' 1.f1,1.17 PM ![AT1 I Pana 5 of 11 POLICY NUMBER: TB2-C81-004095-111 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Any owner, lessee, or contractor for whom you have Any location listed in such agreement agreed in writing prior to a loss to provided liability insurance Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage"caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the "products-completed operations 1. Required by the contract or agreement; or hazard". 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the applicable by law; and Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is required by a contract or agreement, the IOS f�NgMf((EO BY CIf f CLERK insurance afforded to such additional insured OpENEia 6Y COMMITTEE will not be broader than that which you are required by the contract or agreement to FEB p'9 2022 provide for such additional insured. B AS PER ORD#370 A ent deferred to puraha$ing A CG 20 37 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 i 6587846 I LM 44 109.21-09.22 Standard 2-2 Excess $5M I Connie Mvszka 12/2/2022 3:04:17 PM (CST) I Paae 6 of 11 Policy Number TB2-C81-004095-111 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY . THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT—SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Person(s)or Organization(s): Any person or organization for which such coverage is required by written contract prior to a loss If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person(s) or organization(s) shown in the Schedule of this endorsement that qualifies as an additional insured on this Policy, this Policy will apply solely on the basis required by such written agreement and Paragraph 4. Other Insurance of Section IV — Conditions will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of Section IV — Conditions will apply. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured for the same "occurrence", claim or"suit". LC 24 2011 18 ©2018 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. POLICY NUMBER:TB2-C81-004095-111 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule below because of payments we make for injury or damage arising out of your ongoing operations or "your work"done under a contract with that person or organization and included in the"products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule below. SCHEDULE Name Of Person Or Organization: As required by written contract or agreement entered into prior to loss. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. 1 1DSTRANSMITTED BY CI'I'Ct..S3t " OPENED BY QOMMITTf..E FEB 0 0 2022 AS PER ORD 4',,,-^r.t :Referred to Purc;hasirl4 A;t;iit CG 24 04 05 09 ©Insurance Services Office, Inc.,2008 Page 1 of 1 :4SG7g1 I TM d4 I no .,1-AO 99 9-9 Pvra,- S9M I Cnnnio Mva,kn 19/2/2022 1:04:17 PM IC8PI I Pane 8 of 11 NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below.We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Schedule Name of Other Person(s)/ Email Address or mailing address: Number Days Notice: Organization(s): Schedule on file with the Schedule on file with the 90 Company Company All other terms and conditions of this policy remain unchanged. Issued by Liberty Insurance Corporation 21814 For attachment to Policy No. WA7-C8D-004095-021 Effective Date Premium$ Issued to CRH Americas, Inc. WC 99 20 75 ©2016 Liberty Mutual Insurance Page 1 of 1 Ed. 12/01/2016 ;4441444 I r.M 44 I nq.21-n9.22 Standard 2-2 Euress SSM I Connie Mvszka 12/2/2022 3:04:17 PM (CST1 I Paae 9 of 11 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Not applicable in Alaska, Kentucky, New Hampshire, New Jersey Schedule Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri,this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others(subrogation)rule in our manual. Where required by contract or written agreement prior to loss and allowed by law. In the states of Connecticut, Florida, Iowa, Maryland, Nebraska and Oregon, the premium charge is 1% of the total manual premium, subject to a minimum premium of$250 per policy. In the states of Alabama,Arizona,Arkansas, Colorado, Delaware, District of Columbia, Georgia, Idaho, Illinois, Indiana, Kansas, Maine, Michigan, Mississippi, Missouri, Montana, Nevada, New Mexico, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Vermont and West Virginia,the premium charge is 2% of the total manual premium, subject to a minimum premium of$100 per policy. In the states of New York and Tennessee,the premium charge is 2% of the total manual premium, subject to a minimum premium of$250 per policy. In the state of Virginia, the premium charge is 5%of the total manual premium, subject to a minimum premium of$250 per policy. In the state of Hawaii,the premium charge is$250 and determined as follows: The premium charge for this endorsement is 1%of the total manual premium, subject to a minimum premium of$250 per policy. SIDS TRANSMITTED BY CIT CLERK OPENED BY COMMITTEE. In the state of Louisiana, the premium charge is 2%of the total standard premium, subject to a minimum premium of$250 per policy. FEB 0.9 2022 In the state of Massachusetts, the premium charge is 1% of the total AS PER ORD 437061 Referred to Purchasing Agent WC 00 03 13 ©1983 National Council on Compensation Insurance. Page 1 of 2 Ed.04/01/1984 56587846 I LM 44 109.21-09.22 Standard 2-2 Excess $5M I Connie Mvszka 12/2/2022 3:04:17 PM (CST) I Paae 10 of 11 manual premium. Issued by Liberty Insurance Corporation 21814 For attachment to Policy No. WA7-C8D-004095-021 Effective Date Premium$ Issued to CRH Americas, Inc. Endorsement No. WC 00 03 13 ©1983 National Council on Compensation Insurance. Page 2 of 2 Ed.04/01/1984 56587846 I LM 44 109.21-09.22 Standard 2-2 Excess S5M I Connie Mvszka 12/2/2022 3:04:17 PM (CST) I Pace 11 of 11