RES 2023-0218 - PO to L.A. Sprinkler Inc for construction and irrigation system for cricket field at N.P. Dodge Park City Clerk Office Use Only:
) rr�; Publication Date (if applicable):
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RESOLUTION NO. 23 t-°'4c Agenda Date:
2.Department: _
Submitter: 7$
CITY OF OMAHA
LEGISLATIVE CHAMBER
Omaha, Nebraska.
WHEREAS, L.A. Sprinkler, Inc. was awarded a contract to furnish all labor, materials and equipment
necessary for the construction of the irrigation system for the cricket field at N.P. Dodge Park, located at
11005 John J Pershing Drive, Omaha, Nebraska, in the amount of$42,000.00 for the Parks, Recreation, and
Public Property Department; and,
WHEREAS, L.A. Sprinkler, Inc. 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 Resolution,
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF OMAHA:
THAT, as recommended by the Mayor, the Resolution in the total amount of $42,000.00 for L.A.
Sprinkler, Inc. to furnish all labor, materials and equipment necessary for the construction of the irrigation
system for the cricket field at N.P. Dodge Park, located at 11005 John J Pershing Drive, Omaha, Nebraska,
for Parks, Recreation, and Public Property Department, is hereby approved. The Finance Department is
authorized to pay the total amount of $42,000.00 from 2018 Parks and Recreation Fund 13357, Organization
No. 117317, Parks and Cultures Bonds, Project I.D. No. 2000P505.
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APPROVED AS TO FORM:
DEPUTY Y ATTOR DATE
sipfitt4 f
Adopted: FEB 2 8 ZO23 -1 -1)
Attest: c
City Clerk O
Approved:
Mayor
SECTION 00 50 00
AGREEMENT
This AGREEMENT, made and entered into in quadruplicate, as of this ZAe day of YLA- -C�- 7,073
A.D., 42-by and between the City of Omaha, a Municipal Corporation in Douglas County, Nebraska, party of
the first part and hereinafter called "OWNER", and L.A. Sprinkler, Inc., with principal place of business at: 14619
Grover St., Omaha, NE 68144, hereinafter called "CONTRACTOR":
WHEREAS,said Contractor did, under date of September 14,2022, submit a proposal to construct as outlined
in the proposal"Cricket Field Irrigation"for the City of Omaha,for the sum of Forty-Two Thousand Dollars and No
Cents ($42,000.00), to be constructed by the Contractor in accordance with drawings and specifications for same
prepared for Owner, which drawings and specifications have been filed with the City of Omaha.
WHEREAS, the aforesaid pro2osal of Contractor was accepted by Resolution No. 2[23O2I,,
adopted +7,brt,14 ( 2+ 2( 23 , by the City Council of the City of Omaha:
NOW, THEREFIVRE, in consideration of the following mutual agreements and covenants, it is understood and
agreed by and between the parties hereto that:
a. The above referred to plans, specifications and addenda, are expressly made a part hereof the same as
though fully set forth herein.
b. The Resolution of Owner ordering or authorizing the construction of the aforesaid "Cricket Field
Irrigation", the notice inviting contractors to bid as published, the instruction to bidders, the proposal of Contractor,
the bid bond of Contractor, the performance, payment and maintenance bond of Contractor, the general conditions
and all proceedings by the governing body of the Owner relating to said "Cricket Field Irrigation" are a part of this
Contract by reference thereto the same as though each had been fully set out and attached hereto.
c. Said construction shall be on the property owned by the City of Omaha,commonly known as,or referred
to as N.P. Dodge Park Cricket Field, 11001 John J Pershing Dr., Omaha, Nebraska, in Douglas County, Nebraska.
d. The Contractor agrees to furnish all tools, labor, mechanics for labor, equipment and materials to
construct in a good substantial and workmanlike manner, Contractor's part of said "Cricket Field Irrigation" in
accordance with the aforesaid plans,specifications and addenda, and agrees to do so for the sum of$42,000.00.
e. Owner agrees to pay Contractor said amount of$42,000.00 in accordance with the provisions of the
aforesaid specifications, addenda and proposal of the Contractor accepted by Owner.
f. All provisions of aforesaid plans,specifications and addenda shall be strictly complied with and conformed
to by Contractor, the same as if re-written herein, and no substitution or change in said plans, specifications and
addenda shall be made except upon written consent or written direction (the form of either of which shall be a written
"Change Order")of Owner and Owner's Architect John Williams, PLA,ASLA, Landscape Architect/Park Planning
Division —City of Omaha Parks, Recreation and Public Property Department; 1819 Farnam Street, Suite 701,
Omaha, NE 68183-0701. Office: 402.444.4915; Direct: 402.444.5943; Fax: 402.444.4921; email:
john.williams@cityofomaha.org and any such substitution or change shall in no manner be construed to release
either party from any specified or implied obligation of the aforesaid plans, specifications and addenda except as
specifically provided for in the Change Order.
g. This Contract is entered into subject to the following conditions:
Park Planning Division Cricket Field Irrigation Date
Omaha Parks&Recreation Dept. Agreement December 14,2022
005000-1
g-1. Contractor does hereby state, warrant and covenant that it has not retained or employed any company,
or person,other than bona fide employees working for said Contractor,to solicit or secure this Contract,and that it has
not paid or agreed to pay any company or person, other than bona fide employees working solely for the Contractor,
any fee, commission, percentage, brokerage fee, gifts, or any other consideration, contingent upon or resulting from
the award or making of this Contract. For breach of violation of this statement, warrant, and covenant, the City of
Omaha shall have the right to annul this contract without liability.
g-2. Contractor shall comply with all Municipal Ordinances and State and Federal Laws relating to, or
applicable to, this work.
g-3. Contractor shall furnish Performance, Payment and Maintenance Bond in an amount at least equal to
one hundred percent(100%)of the Contract price, and shall maintain during the life of the Contract, Fire, Workmen's
Compensation, Public Liability and Property Damage insurance, all as required in the aforesaid specifications and
addenda.
g-4. Owner, its employees and representatives, and the Owner's Representative shall have access to the
work wherever it is in preparation or progress, and the Contractor shall provide proper facilities for such access and
inspection by them.
g-5. The Contractor shall indemnify and save harmless the City of Omaha, its officers,employees,and agents
from all claims, suits or actions of every kind and character made upon or brought against the said City of Omaha, its
officers, employees and agents, for or on account of any injuries or damages received or sustained by any party or
parties by or from the acts of the said Contractor or its servants, agents and subcontractors in doing the work herein
contracted for, or by or in consequence of any negligence in guarding the same or any improper material used in its
construction,or by or on account of any act or omission of said Contractor or its servants, agents,and subcontractors;
and also from all claims of damage or infringement of any patent in fulfilling this Contract.
g-6. Contractor shall pay to the Unemployment Compensation Fund of the State of Nebraska unemployment
contributions and interest due under the laws of the State of Nebraska on wages paid to individuals employed in the
performance of this Contract, and shall submit to the City of Omaha a written clearance from the Commissioner of
Labor of the State of Nebraska ("Certification of Contribution Status" - form "NEBRUI Form 16") certifying that all
payments due of contributions or interest which may have arisen under this Contract have been paid by the Contractor,
or his subcontractor, to the State of Nebraska Unemployment Compensation Fund. Payment of the final ten percent
(10%)of the total amount of this Contract shall be withheld until this provision has been complied with.
g-7. The Contractor shall not discriminate against any employee or applicant for employment because of race,
religion, color, sex, age, sexual orientation, gender identity, disability or national origin as defined by the Americans
with Disabilities Act of 1990 and Omaha Municipal Code Sec 13-82. The Contractor shall take affirmative action to
ensure that applicants are employed and that employees are treated during employment without regard to their race,
religion, color, sex, age, sexual orientation, gender identity, disability or national origin. The Contractor shall take all
actions necessary to comply with the Americans with Disabilities Act of 1990 and Omaha Municipal Code, (Chapter
13) including, but not limited to, reasonable accommodation. As used herein, the word "treated" shall mean and
include,without limitation,the following: Recruited,whether advertising or by other means;compensated;selected for
training, including apprenticeship; promoted; upgraded; demoted; downgraded; transferred; laid off; and terminated.
The Contractor agrees to and shall post in conspicuous places,available to employees and applicants for employment,
notices to be provided by the contracting officers setting forth the provisions of this nondiscrimination clause.
g-8. The Contractor shall, in all solicitations or advertisements for employees placed by or on behalf of the
Contractor,state that all qualified applicants will receive consideration for employment without regard to race, religion,
Park Planning Division Cricket Field Irrigation Date
Omaha Parks&Recreation Dept. Agreement December 14,2022
005000-2
color, sex,age,sexual orientation, gender identity,disability or national origin as recognized under 42 USCS 12101 et
seq.
g-9. The Contractor shall send to each labor union or representative of workers with which they have a
collective bargaining agreement or other contract or understanding a notice advising the labor union or worker's
representative of the Contractor's commitments under the Equal Employment Opportunity Clause of the City and shall
post copies of the notice in conspicuous places available to employees and applicants for employment.
g-10. The Contractor shall furnish to the Contract Compliance Officer all Federal forms containing the
information and reports required by the Federal government for Federal contracts under Federal rules and regulations,
and including the information required by Sections 10-192 to 10-194, inclusive, and shall permit reasonable access to
his records. Records accessible to the Contract Compliance Officer shall be those which are related to Paragraphs
(7) through (13) of this subsection and only after reasonable notice is given the Contractor. The purpose for this
provision is to provide for investigation to ascertain compliance with the program provided for herein.
g-11. The Contractor shall take such actions with respect to any subcontractor as the City may direct as a
means of enforcing the provisions of Paragraphs (7) through (13) herein, including penalties and sanctions for
noncompliance; however, in the event the Contractor becomes involved in or is threatened with litigation as the result
of such directions by the City,the City will enter into such litigation as necessary to protect the interests of the City and
to effectuate the provisions of this division; and in the case of contracts receiving Federal assistance, the Contractor
or the City may request the United States to enter into such litigation to protect the interest of the United States.
g-12. The Contractor shall file and shall cause their subcontractors, if any, to file compliance reports with the
Contractor in the same form and to the same extent as required by the Federal government for Federal contracts under
Federal rules and regulations. Such compliance reports shall be filed with the Contract Compliance Officer.
Compliance reports filed at such times as directed shall contain information as to the employment practices, policies,
programs and statistics of the Contractor and their subcontractors.
g-13. The Contractor shall include the provisions of Paragraphs (7) through (13) of this Section, "Equal
Employment Opportunity Clause", and Section 10-193 in every subcontract or purchase order so that such provisions
will be binding upon each subcontractor or vendor(refer to Specification Section 00205 for more detail).
g-14. Contractor shall pay all just claims due for the payment of all employees and mechanics for labor that
shall be performed, for the payment of all material and equipment furnished, and for the payment of material and
equipment rental which is actually used or rented in the performance of the Contract.
g-15. Contractor agrees to commence work on the date specified in the notice from the Park Planning Division
of the Omaha Department of Parks, Recreation and Public Property, and to substantially complete all the work by
May 15,2023.
g-16. The Contractor shall guarantee their work for material and workmanship for a period of two(2)years after
the date of"substantial completion" of his Contract, and should any defect be discovered in any of the work included
in this Contract within the period of two (2) years from the"substantial completion"of this Contract, the repair of such
defect and the cost of such repairs shall be borne by the Contractor under their Contract.
a. Substantial Completion: Substantial Completion shall mean that in general,the Work,excluding
minor punch list items and appropriate paperwork to closeout the project is one hundred percent(100%)complete and
ready for use by the Owner.
g-17. Contractor shall maintain fair labor standards in accordance with any valid laws of the State of Nebraska
in the execution of this Contract.
Park Planning Division Cricket Field Irrigation Date
Omaha Parks&Recreation Dept. Agreement December 14,2022
005000-3
h. Upon receipt of written notice by Owner and its Architect that the construction is ready for final inspection
and acceptance, the Architect shall promptly make such inspection and, when he finds the construction acceptable
under the Contract and the Contract fully performed, he shall promptly issue a final certificate, over his own signature,
stating that the construction provided for in this Contract has been completed and is accepted by him under the terms
and conditions thereof, and that the entire balance found to be due the Contractor, and noted in said final certificate, is
due and payable. Before issuance of final certificate,the Contractor shall submit evidence satisfactory to the Architect
that all payrolls, material bills, and other indebtedness connected with the work have been paid. If, after the work has
been substantially completed, full completion thereof is materially delayed through no fault of the Contractor, and the
Architect so certifies, the Owner shall, upon certificate of the Architect and without terminating the Contract, make
payment of the balance due for that portion of the work fully completed and accepted. Such payment shall be made
under the terms and conditions governing final payment, except that it shall not constitute a waiver of claims.
i. The Contractor shall procure a policy, or policies, of insurance which shall guarantee payment of
compensation according to the Workmen's Compensation laws of Nebraska for all workmen injured in the scope of
employment, and further agrees to keep said policy, or policies in full force and effect throughout the term of this
Contract. In addition, all other forms of insurance referred to in the specifications shall be procured by the Contractor
and kept in force and effect by it throughout the term of this Contract, and certificate or certificates of insurance shall
be filed by Contractor with the City of Omaha.
j. Pursuant to Section 8.05 of the Home Rule Charter of the City of Omaha, no elected official or any officer
or employee of the City shall have a financial interest, direct or indirect, in any City Contract. Any violation of this
section shall render the Contract voidable by the Mayor or City Council.
k. Any subsequent agreement between the parties hereto or any matter whatsoever shall be in writing and
executed by an authorized officer.
I. The parties hereto acknowledge that, as of the date of the execution of this agreement, Section 10-142
of the Omaha Municipal Code provides as follows: Any amendment to contracts or purchases which taken alone
increases the original bid price as awarded (a) by ten percent, if the original bid price is one hundred fifty thousand
dollars ($150,000) or more, or(b) by seventy-five thousand dollars ($75,000) or more, shall be approved by the City
Council in advance of the acceptance of any purchase in excess of such limits or the authorization of any additional
work in excess of such limits. However, neither contract nor purchase amendments will be split to avoid advance
approval of the City Council.
The originally approved scope and primary features of a contract or purchase will not be significantly
revised as a result of amendments not approved in advance by the City Council. The provisions of this Section will be
quoted in all future City contracts. Nothing in this Section is intended to alter the authority of the Mayor under Section
5.16 of the City charter to approve immediate purchases.
Park Planning Division Cricket Field Irrigation Date
Omaha Parks&Recreation Dept. Agreement December 14,2022
005000-4
IN WITNESS WHEREOF, we the contracting parties, by our respective duly authorized agents, hereto affix our
signatures and seals at Omaha, Nebraska;
L.A. SPRINKLER, INC. CITY OF OMAHA
I
Executed this __day of , 20 Executed this Z� day of AA ew rG G1 , 20 Z.
By:
(Authorize Signature) Jean Stothert, Mayor
ATTEST:
(Printed Name&Title)
City Clerk
Witness Signature
APPROVED AS TO FORM:
-turf,'y City At i -y
5i4*
END OF SECTION
Park Planning Division Cricket Field Irrigation Date
Omaha Parks&Recreation Dept. Agreement December 14,2022
005000-5
Form III-9 Request for Taxpayer
G(Rev.October2018) Identification Number and Certification requueste stem to r.Do the
the
Department of the Treasury reqot
Internal Revenue Service ►Go to www.irs.gov/FormW9 for instructions and the latest information. Send to the IRS.
1 Name as shown on your income tax return).Name is required on this line;do not leave this line blank.
LA, $/ ,vi-G ,.ANC
2 Business name/disregarded entity name,if different from above
m3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 ExemptionsI
following seven boxes. (codes apply y only to
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certain entities,not individuals;see
instructions on page 3):
g 0 Individual/sole proprietor or ❑ C Corporation S Corporation ❑ Partners
roe single-member LLC Partnership 0 Trust/estate
° Exempt payee code(if any)
,L.a,t ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)►
o Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
a c LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that code(if any)
,. is disregarded from the owner should check the appropriate box for the tax classification of its owner.
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2 ❑ Other(see instructions)►
5 Address(number,street,and apt.or suite no.)See instructions. (Mares to accounts ional)nedoutside the U.S.)
m /�` iq / �.l /� Requester's name and address(optional)
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6 City,state,and ZIP code
7 List account number(s)here(optional)
Part I Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid 1 Social security number
backup withholding.For individuals,this is generally your social security number(SSN).However,for a
resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later.For other I I — I I —I
I I
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entities,it is your employer identification number(EIN).If you do not have a number,see How to get a I TIN,later.
or
Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and I Employer identification number
Number To Give the Requester for guidelines on whose number to enter. it- — f
Part II Certification 4 �I� �I�I�IZ'
Under penalties of perjury,I certify that:
1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2.I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3.I am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,
acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments
other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part II,later.
Sign Signature of
Here U.S.person►
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General Instructions •Form 1099-DIV(dividends,inse from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise
noted. •Form 1099-MISC(various types of income,prizes,awards,or gross
proceeds)
Future developments.For the latest information about developments
related to Form W-9 and its instructions,such as legislation enacted •Form 1099-B(stock or mutual fund sales and certain other
after they were published,go to www.irs.gov/FormW9. transactions by brokers)
Purpose of Form •Form 1099-S(proceeds from real estate transactions)
•Form 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T(tuition)
identification number(TIN)which may be your social security number
(SSN),individual taxpayer identification number(ITIN),adoption •Form 1099-C(canceled debt)
taxpayer identification number(ATIN),or employer identification number •Form 1099-A(acquisition or abandonment of secured property)
(EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident
amount reportable on an information return.Examples of information alien),to provide your correct TIN.
returns include,but are not limited to,the following.
•Form includ 1099-INT(interest earned or paid) If you do not return Form W-9 to the requester with a TIN,you might
be subject to backup withholding.See What is backup withholding,
later.
Cat.No.10231X Form W-9(Rev.10-2018)
A CERTIFICATE OF LIABILITY INSURANCE DATE
rn 12/29/2022
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(ies)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
Tom Demory, ChFC,Agent NAME: Tom Demory
PHONE FAX
State Farm Insurance (A/C.No.Eat):402-571-5700 (A/C,No):402-571-6765
9925 Maple St Ste B ADDRESS:tom@tomdemory.com
.£ Omaha, NE 68134 INSURER(S)AFFORDING COVERAGE NA #
ILINSURER A:State Farm Fire and Casualty Company 25143
INSURED L A Sprinklers INC INSURER B:State Farm Mutual Automobile Insurance Company 25178
14619 Grover Street INSURER C:
Omaha, Nebraska 68144-5477 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 POLICY EFF POLICY EXP W (M LIMITS
LTRINSR VD POLICY NUMBER M/DD/YYYY) (MMIDD/YYYY)
A GENERAL LIABILITY Y Y 97-BY-H546-5 12/12/2022 12/12/2023 EACH OCCURRENCE $ 500,000
X COMMERCIAL GENERAL LIABILITY PR RENTED
PREEMMI ESESS l(Ea occurrence) $ 300,000
CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 500,000
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000
—1 POLICY PRO- LOC $
JECT
B AUTOMOBILE LIABILITY 033 5009-A30-27D 12/12/2022 12/12/2023 COMBINED SINGLE LIMIT
(Ea accident)
X ANY AUTO BODILY INJURY(Per person) $ 500,000
ALL OWNED SCHEDULED BODILY INJURY(Per accident) 500,000
AUTOS AUTOS $
X HIRED AUTOS X NON
OS-OWNED PROPERTY DAMAGE
(Per accident) $ 100,000
AUT
B X UMBRELLA LIAB X OCCUR 97-B9-0840-2 12/12/2022 12/12/2023 EACH OCCURRENCE $ 1,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000
DED RETENTION$ $
A A DRKERS COMPENSATION EMPLOYERS'LIABILITY Y/N 97-BY-H544-0 12/12/2022 12/12/2023 X ORY LIMITSOER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000
OFFICE/MEMBER EXCLUDED? N N/A Y
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required)
CERTIFICATE HOLDER CANCELLATION
City of Omaha SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Omaha-Douglas Civic Center ACCORDANCE WITH THE POLICY PROVISIONS.
1819 Farnam Street
Omaha, Ne. 68183 AUTHORIZED REPRESENTATIVE li
1--C1 .142 -- it a a
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1001486 132849.6 11-15-2010