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Home My WebLink AboutRES 13-248 RESOLUTION NO. 13-248 BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF BEAUMONT: THAT the City Council hereby approves the award of a contract, with an option to renew on an annual basis, to Triangle Stagecraft, Inc., of Port Neches, Texas, in the estimated annual amount of$230,000 for the furnishing of skilled temporary workers to load, unload, set up and take down equipment needed for a variety of events and performances that the Event Facilities Department holds at multiple City venues. The contract is substantially in the form attached hereto as Exhibit "A" and made a part hereof for all purposes; and, BE IT FURTHER RESOLVED THAT the City Manager be and he is hereby authorized to execute a Letter of Understanding with Triangle Stagecraft, Inc., of Port Neches, Texas, for the purposes described herein. PASSED BY THE CITY COUNCIL of the City of Beaumont this the 29th day of October, 2013. Xr� (>l1 n M yor Becky Ames - LETTER OF UNDERSTANDING BETWEEN TRIANGLE STAGECRAFT, INC. AND CITY OF BEAUMONT This Letter of Understanding is made this day of 2013, by and between Triangle Stagecraft,Inc. (Triangle Stagecraft) and City of Beaumont,Beaumont,Texas (City). Triangle Stagecraft is to provide temporary workers for the following services on an as-needed basis for the City of Beaumont. The terms and conditions of this letter of Understanding are as follows: L PAYMENT"FOR WORKERS All temporary workers provided by Triangle riangle Stagecraft will be billed/paid at the hourly rate included in this Letter of Understanding. There will be an additional charge of one and one- half times(x 1.5)the applicable straight time rate for hours worked between 12:00 Midnight and 8:00 A,M,and/or after eight(8)consecutive hours. For pay purposes,any portion of an hour constitutes one(1)hour billed/paid. The load in,any rehearsal,the show and load out are considered separate from each other and overtime accumulation. 2. ADMINISTRATIVE CHARGE A Triangle Stagecraft administrative charge of twenty-two percent(22/0)will be added to each Triangle Stagecraft bill in order to help cover workers' compensation insurance,and other administrative costs. A Certificate of Workers'Compensation Insurance,as well as other insurances as required by the City,will be provided by Triangle Stagecraft to the City. 3. CALL MINIMUMS The minimtun load in call is three(3)hours,with the exception of all bus and truck tours,which will have a minimum load in call of four(4)hours. The minimum load out call is two(2)hours, with the exception of all bus and truck tours,which will have a minimum load out call of three(3)hours. 4. STEWARD/WORKING STEWARD A steward or non-working steward is required on all calls. On calls of fourteen(14)or less Triangle Stagecraft workers,the electrician shall assume the duties of steward. A non-working steward is required for administration purposes on all calls of fifteen(15)o-imre Triangle Stagecrafl workers. 5. LOADERS A minimum of two (2) loaders is required on all buses,trailers eighteen feet(18')or under and vans. A minimum of four(4)loaders is required on all semi and bobtail trucks. Loaders will work four(4)hours maximum,loading o-unloading. Vehicles not completed in this four(4)hour time frame will be charged one and one-half(x 1.5)the regular rate per man,per vehicle. This hour limit does not apply on shows that have in excess of four(4)semi and/or bobtai I trucks. Pagc 1 of 5 Letter of Understanding 2013—Triangle Stagecraft and City of Beaumont EXHIBIT "A" All loaders will be paid at one and one-half times(x 1.5)the applicable straight time rate for each truck, van or bus that begins loading or unloading after 12:00 midnight or before 8:00 A.M. 6. RIGGERS When requested by City, riggers will work under a four(4) hour minimum on all load in and load outs. Rigging not completed in this four(4)hour time frame will be charged at the regular hourly rate per rigger. When riggers are requested,there shall be a minimum call of two(2)high riggers and one(1) ground rigger. Shows in excess of twenty(20)points will require additional high riggers. The number of additional high riggers shall be determined by mutual agreement between the business agent and the building technical services coordinator. If an event only requires the hanging of decorations,only one rigger will be needed for this service. ?. REHEARSALS AND PERFORMANCE RATES Rehearsal and performance rates are based on a three(3)hour minimum,plus thirty(30)minute call back.time. The fourth(4th)liour,if needed,will be at the regular rate. Any additional hours after four(4)without a one(1)hour meal break, shall be charged at one and one-half times(x 1.5)the applicable hourly rate. Triangle Stagecraft workers shall be guaranteed at least two(2) hours of rehearsal/performance time upon returning from a rehearsal or performance meal break. If a performance runs after midnight,overtime will be applied at the applicable rates. 8. HOLIDAYS Holiday pay will be at two times(x 2)the regular rate at appropriate times. Holiday pay will be applied for all Triangle Stagecraft workers that work on the following holidays: New Year's Eve Labor Day New Year's Day Memorial Day Easter Sunday Thanksgiving Day Martin Luther King,Jr. Birthday Christmas Eve Fourth of July Christmas Day 9. MEAL PERIODS All Triangle Stagecraft workers will receive a meal period of one(1)hour,not earlier than four (4)hours nor later than five(5)hours after commencement of work,exclusive of performance time and with the exception of the meal hour as referenced below,provided that after said meal hour the Triangle Stagecraft workers will be guaranteed at least two(2)hours work. The Triangle Stagecraft workers may be rotated or staggered for the meal period. 'File steward will see that work proceeds as rapidly and efficiently as possible, but at the same time will see that the Triangle Stagecraft workers receive breaks,which may be on a staggered basis. In the event the Triangle Stagecraft workers are not permitted such a meal period,the Triangle Stagecraft workers will receive one and one-halftime(x 1,5)rate until such meal period is received. I0. BREAKS Each Triangle Stagecraft worker shall receive a fifteen(15)minute break approximately two(2) hours into the load in. The exact time shall be determined between the local steward and the show representative,however in all cases,breaks shall begin no later than two and one-half(2 ''/�) hours into the load in. Page 2 of 5 Letter of Understanding 2013—Triangle Stagecraft and City ol'Beamnom 1 1. HAZARDOUS CONDITIONS Hazardous conditions exist when a Triangle Stagecraft worker is working over thirty(30)feet above the floor and/or truss focusing white climbing,not to include working in loading bridges, fly floors,gridirons or any safety walk over thirty(30)inches in width that is enclosed with permanent safety railing. In hazardous locations,basic safety systems such as OSHA approved lifeline and fall restraint systems must be present or Triangle Stagecraft workers will not be allowed to work there. The base rate of Triangle Stagecraft workers in hazardous conditions will be the same as high riggers scale. 12. 'PERM FOR LETTER OF AGREEMENT This letter of Agreement shall be in effect for a period of one(1)year beginning OCTOBER 2013,with the option to renew on an annual basis. Any renewals will be subject to the same terms and conditions referenced in this Agreement. Renewals will be offered through an extension letter generated by the City of Beaumont and approval with signature provided by Triangle Stagecraft. The hourly rate increase shal I be based upon the Consumer Price Index(CPI)for the Houston- Brazoria-Galveston area effective year ending December 31. The hourly increase will be the percentage ofthe CPI or three(3)percent,which ever is the lower amount, 13. TERMINATION OF AGREEMENT This Agreement may be terminated for any reason by either Triangle Stagecraft or the City of Beaumont upon providing thirty(30)days' written notice to the other party. 14. INDEMNITY Triangle Stagecraft agrees to indemnify and save harmless the City of Beaumont and its officers, agents and employees from any and all claims,causes or action and damages of every kind,for injury to or death of any person and damages to property arising out of or in connection with the work done by Triangle Stagecraft under this Agreement,and including acts or ornissions of the City of Beaumont or its officers,agents or employees in connection with said Agreement, The requirements of this paragraph shall survive the termination of this Agreement. 15. INSURANCE Triangle Stagecraft shall obtain and maintain in full force and effect for the duration of this Agreement,and any extension hereof,at Triangle Stagecraft's sole expense,insurance coverage called for in Exhibit"A"attached hereto. Triangle Stagecraft shall require its insurance agent provider such insurance to complete City-approved Certificate of Insurance forms. 'file requirements of this paragraph shall survive the termination of this Agreement. Page 3 of 5 Letter of Understanding 2013—"Triangle Stagecraft and City of Beaumont 16. CONTACT INFORMATION TRIANGLE STAGECRAFT,INC. CI'T'Y OF BEAUMONT 681 Ridgewood Drive Finance Dept./Purchasing Div. Port Neches,TX 77651 Physical Address: Phone: 409-626-1880 801 Main Street,Suite 315 Fax: 409-729-0578 Beaumont,TX 77701 Mailing Address: P.O.Box 3827 Beaumont,TX 77704 Phone: 409-880-3720 Phone: 409-880-3747 IN WITNESS WHEREOF,the undersigned have caused this Agreement to be duly executed as of the date set forth within this Agreement. AGREED AND ACCEPTED-. AGREED AND ACCEPTED: TRIANGLE STAGECRAFT,INC. CITY OF BEAUMONT 13�: By: Name: James B. Strawther Name: Kyle Hayes Title: Operations Manager Title: City Manager Date: Date: Page 4 of 5 Letter of Understanding 2013—Triangle Stagecraft and City of Beaumont LETTER OF UNDERSTANDING BETWEEN TRIANGLE STAGECRAFT, INC. AND CITY OF BEAUMONT RATES EFFECTIVE OCTOBER ,2013 POSITION RATE PER HOUR Non working steward $23.18 Steward $20.17 Electrician $20.17 - Flyman $18.34 Forklift $18.34 Stagehand $18.34 Sound man $18.34 Wardrobe $18.34 Technical Assistance(Work Calls) $18.34 Truckloaders Van/Bus $38.62 Bobtail $38.62 Semi $52.74 i Riggers Nigh ^�— $29.77 —� Ground $23.18 Performance Rate 3 horns $64.18 Rehearsals Rate 3 hours $64.18 Page 5 0f'5 Letter o['Understanding 2013—Triangle Stagecraft and City of[3eauntont EXHIBIT"A" Letter of Understanding Between "Triangle Stagecraft,Inc.and City of Beaumont ATTACHMENT A Insurance Requirements—City of Beaumont (Revised 4/1/2013) INSURANCE SECTION A. Prior'to the approval of this contract by the City,CONTRACTOR shall furnish a completed Insurance Cenificate to the Purchasing office. The certificate shall be completed by an agent authorized to bind the named under-writer(s)to the coverages,limits,and termination provisions shown thereon,and shall furnish and contain all required information referenced or indicated thereon. CITY SMALL I IAVt?NO DUTY TO PAY OR PERFORM UNDI?R H IIS CONTRACT UNTIL SUCH Cl.,R'TIPICATE IS RECEIVEDI3Y 111E CITY OP BEAUMONT'S PURCHASING DIVISION,and no officer or employee of the City shall have authority to waive this requirement. INSURANCE COVERAGE REQUIRED SECTION B. CITY reserves the right to reviewthe insurance requirements ofthis section during the cffectivcperiod oflhecontract and to adjust insurance coverages and their limits when deemed necessary and prudent by CI'T'Y,based upon changes in statutory law. couil decisions,or the claims history of the indusb)l as well as the CONTRACTOR. SECTION C. Subject to CONTRAC'TOR'S right to maintain reasonable deductibles in such anhounls as are approved by CITY, CON'T'RACTOR shall obtain and maintain in full force and effect for the duration of this contract, and any extension hereof, at CONTRACTOR'S sole expense,insurance coverage written by companies approved by the State ofTexas and acceptable to CITY,in the iollowing typc(s)and amount(s). TYPE AMOUNT 1. Workers'Compensation and Statutory Employer's Liability NOTE: For building or construction projects,and services provided at City-owned facilities,the successful Contractor shall meet the minimum requirements defined in the Texas Workers'Compensation Connnission Rule 28 TAC§110.110 which follows this insurance attachment. 2. Corner cial General(public)Liability including coverage for the following: a. Premises operations Combined single limit for bodily injury and b_ Independent contractors and properly damage of` 1,000,000 per- Cr Products/completed operations occurrence or its equivalent with an aggregate d, Personal injury limit of$2,000,000. c. Advertising injury f Cootraclualliability g. Medical payments h Professional liability* i. Underground hazu'd* j. Explosion and collapse hazard* k. Liquor liability* - 1 - I, lire legal liability* III, City's property in Contractor's* care,custody,or control n. Asbestos specific liability* Not required f'or this contract 3. Comprehensive Automobile Liability Combined single limit for bodily injury and insurance,including coverage for loading property damage of`500.000 per occurrence and unloading hazards,for: or equivalent. a. Owned/leased vehicles b. Non-owned vehicles C. Hired vehicles 4. Errors and Omissions provide a prudent amount of coverage for the insurance policy willful or negligent acts or omissions of any (when applicable) officers,employees or agents thereof. ADDITIONAL POLICY ENDORSEMENTS CITY shall be entitled,upon request,and without expense,to receive copies of the policies and all endorsements thereto and may make any reasonable request for deletion,revision,or modification of particular policy terms,conditions,limitations.or exclusions (except where policy provisions are established by law or regulation binding upon either of the parties hereto or the underwriter of any of such policies). Upon such request by CITY,CONTRACTOR shall exercise reasonable efforts to accomplish such changes in policy coverages,and shall pay the cost thereof. REQUIRED PROVISIONS CONTRACTOR agrees with respect to the above required insurance,all insurance contracts and certificate(s)of insurance will contain and state,ill writing,on the certificate or its attachment,the following required provisions. a. Namc,the City of Beaumont and its officers,employees,and elected representatives as additional insured(s),(as the interest of each insured may appear)to all applicable coverage. 1). Provide for 30 days'notice to City for cancellation,non-renewal,or material change. C. Provide for notice to City at the address shown below by registered mail, d. CONTRACTOR agrees to waive subrogation against the City of Beaumont,its officers,employees,and elected representatives for injuries,including death,property damage,or any other loss to the extent same may be covered by the proceeds of insurance. c. Provide that all provisions of this agreement concerning liability,duty,and standard of care together shall be underwritten by contractual liability coverage sufficient to include such obligations within applicable policies. For coverages that are only available with claims made policies,the required period of coverage will be determined by the following formula: Continuous coverage for the life of the contract,plus one year(to provide coverage for the warranty period)and an extended discovery period for it minimum of five years which shall begin at the end of the warranty period, - 2- NOTICES CONTRACTOR shall notify CITY in the event of any change in coverage and shall give such notices not less than thirty(30)days prior to the change,which notice must be accompanied by it replaccincnt CE'RTIFICA'TE OF INSURANCE. All notices shall be given to CITY at the following address: Purchasing Division City of Beaumont P.O.Box 3827 Beaumont,Texas 77704 SECTION D. Approval,disapproval,or failure to act by CITY regarding any insurance supplied by CONTRACTOR shall not relieve CONTRACTOR of full responsibility or liability for damages and accidents as set forth in the contract documents. Neither shall the bankruptcy,insolvency,or denial of liability by the insurance company exonerate CONTRACTOR from liability. - 3 - WORKERS COMPENSATION INSURANCE for Building or Construction Projects and Services Provided at City-Owned Facilities TEXAS WORKERS'COMPENSATION COMMISSION RULE 28,§110.110 x**iekxxxxk**x**ik*9t*Sc*�Fh'*rc****k*x**xx**9:*iFA*�i ti*ti it*+4 se Y't fMxi'st kit*it*ix is*�ixx*+k�4+k*fk ie itx+k it is ik if*ir*x+r T'i�+��i i(x i�x**ie As required by the 1'exas Workers'Compensation Rule 28,§1 16.1 10,the Contractor shall accept the following definitions and comply with the following provisions: Workers'Compensation Insurance Coverage A. lief ititions: I. Certificate of coverage("certificate")-A copy of a certificate of insurance,a certificate of authority to self-insure issued by the commission, or a coverage agreement(TWCC-81, TWCC-82, TWCC-83, or TWCC-84), showing statutory workers compensation insurance coverage for the person's or entity's employees providing services on a project,for the duration of the project. 2. Duration of the project-includes the tittle from the beginning of the nvork on the project until the Contractor's/person's work on the project has been completed and accepted by the City of Beaumont. 3. Persons providing services on the project("subcontractor"in§406.096)-includes all persons or entities performing all or pall of the services the Contractor has undertaken to perform on the project, regardless of whether drat person contracted directly with the Contractor and regardless of whether that person has employees. This includes,without limitation,independent Contractors,subcontractors,leasing companies,motor carriers,owner-operators,employees of any such entity,or employees of ally entity which furnishes persons to provide services on the project."Services"include, without limitation,providing,hauling,or delivering equipment or materials,or providing labor,transportation,or other service related to a project."Services"does not include activities unrelated to the project,such as food/beverage vendors, office supply deliveries,and delivery of potable toilets. 13. Th:;Contractor shall provide coverage,based on proper reporting of classification ication codes and payroll anlotutts and filing of any coverage agreements,which nnects the statutory requirements of Texas labor Code,Section 401.01 1(44)for all employees oMie Contractor providing services on the project,for the duration of the project. C. The Contractor must provide a certificate of coverage to the City of 13caumort prior to being awarded the contract. D. if the.coverage period shonvn on the Contractor's current certificate of coverage ends during the duration of the project, the Contractor must,prior to the end of the coverage period,file a new certificate of coverage with the City of l3caumont showing that coverage has been extended. f;. fhc Contractor shall obtain from each person providing services on a project,and provide to the City of Beawnont: 1. A certificate of coverage,prior to that person beginning work on the project,so the City of Beaumont will have on file certificates of coverage showing coverage for all persons providing services on the project;and 2 No later than seven(7)days after receipt by the Contractor,a nc%v certificate ofcoverage showing extension ofcovelage, if the coverage period shown on the current certificate of coverage ends during the duration of the project. P. The Contractor shall retain all required certificates of coverage for the duration of the project and for one(1)year thereafter. G. The Contractor shall notify the City of Beaumont in writing by certified mail or personal delivery,within tell(10)days after the Contractor knew or should have known,of any change that materially affects the provision of coverage o€'any person providing services on the project. If. The Contractor shall post on each project site a notice, in the text, form and manner prescribed by the 'Texas Workers' Compensation Commission, informing all persons providing services on the project that they are required to be covered,and -4- stating how a person may verify coverage and report lack of coverage. 1. The Contractor shall contractually require each person with whom it contracts to provide services on a project,to: I. Provide coverage,based on proper reporting of classification codes and payroll amounts and filing of any coverage agreements,which meets fie statutory requirements of Texas Labor Code,Section 401.011(44)for all of its employees providing services on the project,for the duration of the project; 2. Provide to the Contractor, prior to that person beginning work on the project,a certificate of coverage showing that coverage-is being provided for all employees of the person providing services on the project,for the duration of the project. 3. Provide the Contractor, prior to the end of the coverage period, it new certificate of coverage showing extension of coverage,if the coverage period shown on the current certificate of coverage ends during the duration of the project; �t. Obtain from each other person with whom it contracts,and provide to the Contractor: a A certificate of coverage,prior to the other person beginning work on the project;and b. n new certificate of coverage showing extension of coverage,prior to the end of the coverage period,if the coverage period Shown on the current certificate of coverage ends during the duration of the project. :i. Retain all required certificates of coverage on file for the duration of the project and for one(1)year thereafter; 6. Notify the City of Beaumont in writing by certified mail or personal delivery,within ten(10)days after the person knew or should have known,of any change that materially affects the provision of coverage of any person providing services on the project:and 7. Contractually require each person with whom it contracts,to perform as required by paragraphs(1)- (7), with the certificates of coverage to be provided to the person for whom they are providing services, .I. By signing this contract or providing or causing to be provided a certificate of coverage,the Contractor is representing to the City of Beaumont that all employees of the Contractor who will provide services on the project will be covered by workers'compensation coverage for the duration ofthe project,that the coverage will be based on proper reporting of'classification codes and payroll amounts,and that all coverage-agreements will be filed with the appropriate insurance carrier or,in the case of a self-insured,with the commission's Division of Self-insurance Regulation. Providing false or misleading information may subject the Contractor to administrative penalties,criminal penalties,civil penalties,or other civil actions. tC. The Contractor's failure to comply with any,of these-provisions is a breach of contract by the Contractor which entitles the City of Beaumont to declare the contract void if the Contractor does not remedy the breach within ten(10)days after receipt of notice of breach from the City of Beaumont. A,,defined by the Texas Labor Code,Chapter 269,Section 406.096(c),building or construction is defined as: L I'reetingor preparing tocaectastruc(ure,including a building,bridge,roadway,public utility facility, or related appurtenance; 2. Remodeling,extending,repairing,or demolishing a structure;or 3. Otherwise improving real property or art appurtenance to real property through similar activities. The employment of a maintenance employee who is not engaging in building or construction as the employer's primary business does not constitute engaging in building or construction. - 5 - CITY OF BEAUMONT INSURANCE REQUIREMENT AFFIDAVIT To be Completed By Appropriate Insurance Agent and submitted with bid proposal. 1,the undersigned Agent/Broker,certify that the insurance requirements contained in this bid document have been reviewed by me with the below identified Contractor. If the below identified Contractor is awarded this contract by the City of Beaumont, I will be able to,within ten (10)days after being notified of such award, furnish a valid insurance certificate to the City meeting all of the requirements defined in this bid. Agent(Signature) Agent(Print) Name of Agency/Broker: Address of Agent/Broker: City/State/Zip: Agent/Broker Telephone CONTRACTOWS NAME: (Print or Type) NOTE TO AGENT/BROKER If this time requirement is not met,the City has the right to invalidate the bid award and award the contract to the next lowest bidder meeting specifications. Should an awarded bid be invalidated the Contractor may be liable for breach of contract. If you have any questions concerning these requirements,please contact the Purchasing Manager for the City of Beaumont at(409)880-3720. -6- CERTIFICATE OFINSURANCE Form No.GOBI Edition Date: 12n2o012 Page Imn This form is for informational purposes only and certifies that policiesof insurance listed below have been issued to insured named below and are in force at this time. Notwithstanding kemen(s, t:nn or condition nf any contract or other document with respect to which this certificate may be issued or may pertain,insurance afforded by policies described herein is subject to all terms,exclusions and conditions of such policies, Prior(o the beginning of work,the vendor shall obtain the minimum insurance and endorsements apeuifind. Agents must complete the form providing all requested information and submit hyfax, U.S. mail nr e-mail ax requested by the City of Beaumont(^C0B'). The endorsements listed below are required asattachments to this ceUifioote;copies uf the endorsements are also acceptable, PLEASE ATTACH ALL ENDORSEMENTS TO THIS FORM AND INCLUDE THE MATCHING POLICY NUMBER ON THE ENDORSEMENT, Only City of Beaumont certificates of insurance are acceptable:commercial carriers' certificates are not, This certificate shall be completed hye licensed insurance agent: Name and Address of Agency: City uf Beaumont Reference: Project Name: Project Location-, Phonei ManagingDep .: wame and Address ofInsured: Project&qQc Insurers Affording Coverages: Insurer A: Phone:— Insurer B: Prime orSub-Conbaol.or?: Insurer C: Name of Prime Contractor, if different from Insured: Insurer D� INSR TYPE OF INSURANCE POLICY POLICY EFF.DATE POLICY EXP. LIMITS OF LIABILITY LTR NO. (MM/DDfYYYY) DATE Commercial General Liability Policy Each Occurrence $ As defined in the Policy,does the Policy General Aggregate $ Completed $ 1 Yes L1 No – Completed Operation s/Products Operations/ Products Aggregate Advertising Injury []Yes 5 No – Explosion Deductible or Self Insured Retention CERTIFICATE OF INSURANCE Form No,COBI Edition Date: 12112/2012 Page 2 of 3 INSR T POLICY POLICY EFF.DATE POLICY EXP. TYPE OF INSURANCE LTR NO. (MMIDDrYYYY) DATE LIMITS OF LIABILITY I I (MMIDDffYYY) 11 Yes ONo Collapse 1]Yes 0 No Underground Yes 0 No Contractors I Subcontractors Work Ca Yes n No Aggregate Limits per Project Form CG 2503 L]Yes 0 N Additional Insured Form—CG 2010 Yes E)No M Day Notice of Cancellation Form-CG 0205 Yes D No Waiver of Subrogation Form-CG 2404 Pollution I Environmental Occurrence Impairment Policy Aggregate $ Auto Liability Policy CSL $ As defined in the Policy, does the Policy provide, Bodily Injury $ Per Incident) 1,1 Yes 0 No Any Auto Bodily Injury $ (Per Person) 1 Yes i-I No All Owned Autos Property Damage $ Per Accident) I I Yes 01 No Non-Owned Autos t Yes 0 Na Hired Autos Yes 0 No Waiver of Subrogation CA0444 I Yes E No 30 Day Notice of Cancellation-CA0244 1-1 Yes 0 No Additional Insured-CA2048 l_.Yes FJ No MCS 90 Excess Liability C' Umbrella Form Occurrence $ I.] Excess Liability Follow Form Aggregate $ Workers Compensation& D Statutory Employers Liability As defined in the Policy, does the Policy provide Each Accident $ 1 1 Yes 0 No Waiver of Subrogation-WC420304 Disease- $ Policy Limit U Yes IJ No 30 Day Notice of Cancellation-VVC420601 Disease- $ Each Employee Is a Builders Risk or $ Installation Insurance 1 Policy provided? [_�Yes 0 No F.-I Yes E)No — Is the City shown as loss payeelmortgagee? Professional Liability As defined in the Policy, Each Claim $ _does the Policy provide: Ll Yes 0 No -- 30 Day Notice of Cancellation Deductible or Self Retroactive Date: Insured Retention CERTIFICATE Form No. sumnnn�� 1zn2�n1z .____�. Page omu AGENT CERTIFICATION: THIS IS TO CERTIFY TO THE CITY OF BEAUMONT that the insurance policies above are in full force and effect, Name of Insurance Company: Name of Authorized Agent: Company Addressi Agent's Address: City� State: Zip: City: State: Zip: Authorized Agent's Phone Number(including Area Code), Original signature of Authorized Agent: CERTIFICATE HOLDER: DATE |SSUED: City of Beaumont P. 0. Box 3827 AUTHORIZED REPRESENTATIVE SIGNATURE Beaumont, Texas 77704'8027 Licensed Insurance Agent PrmiedName: -9-