HomeMy WebLinkAbout2017-365-E Planning - Wellsmont Landscaping - annual mowing of Lake Orange dam DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
[Departmental Use Only]
TITLE LakeOrangeMowing
FY 17-18
ORANGE COUNTY
CONTRACT UNDER$1,000.00
NORTH CAROLINA
THIS AGREEMENT, made and entered into this 1st day of August, 2017, ("Effective Date") by
and between Orange County, North Carolina, a body politic and corporate organized under the laws of the
State of North Carolina, (the "County"),party of the first part; and Wellsmont Landscaping (the "Provider"),
party of the second part;
WITNESSETH:
For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby
contracts for the services of the Provider, and the Provider agrees to provide the following services to the
County in accordance with the terms of this Agreement, time being of the essence:
The services and/or materials and/or construction (hereinafter referred to collectively as "Services")
to be furnished under this Agreement are as follows: Mow and trim brush on dam and surrounding area
(approximately 4 acres in total) at Lake Orange to within 6 inches of the ground in a manner that does not
cause rutting. This includes cutting and removing trees and limbs that have grown into or fallen across the
entry way to the dam and cutting any saplings or scrubby vegetation that may be growing at the water line of
the dam. This also includes trimming around instrumentation stand and light near the bridge to the dam outlet
structure(please see attached quote for reference).
The term of this agreement rendered shall be from August 1,2017 to September 30, 2017.
Provider represents and agrees that Provider is qualified to perform and fully capable of performing and
providing the services required or necessary under this Agreement in a fully competent, professional and
timely manner to the satisfaction of the County. Provider shall be responsible for all errors or omissions, in
the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies,
ambiguities, mistakes or conflicts at no additional cost to the County. Provider agrees that Provider shall not
sub-contract any of the services to be provided in this Agreement, nor shall Provider assign any right or
responsibility granted or required by this Agreement,without the prior written approval of the County.
SPECIFIC TERMS
1. Payment: The County agrees to pay at the rates specified for Services satisfactorily
performed in accord with this Agreement. The amount to be paid by the County shall not exceed FIVE
HUNDRED AND SIXTY DOLLARS, (S560.00). Payment shall be made within thirty (30) days of an
invoice properly submitted to County. Should Provider fail to perform its duties under the terms of this
Agreement, County may, without fault or penalty, withhold any payment associated with the work to be
performed until such time as said work is completed.
2. Non—waiver: Failure by County at any time to require the performance by Provider of any
of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor
shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of
this Non-Waiver Clause.
3. Independent Contractor: The Provider shall operate as an independent contractor, and the
County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated
as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or
workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of
any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider.
Revised 2/17 1
DocuSign Envelope ID:OD06ADD8-36E0-405B-96F0-B574A8D290B3
4. Insurance: Provider shall obtain, at its sole expense, Commercial General Liability
Insurance, Automobile Insurance, Workers' Compensation Insurance, and any additional insurance as may
be required by County's Risk Manager as such insurance requirements are described in the Orange County
Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements (each document is
incorporated herein by reference and may be viewed at
http://www.orangecountync.gov/departments/purchasing division/contra cts.php). If County's Risk
Manager determines additional insurance coverage is required such additional insurance shall be designated
here (if no additional insurance required mark N/A as being not applicable). Provider shall not
commence work until such insurance is in effect and certification thereof has been received by the County's
Risk Manager.
5. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County
from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable
attorney's fees) arising from bodily injury, including death, to any person or persons or damage to or
destruction of any property caused in whole or in part by any negligent or intentional act or omission on the
part of the Provider in carrying out Provider's duties and obligations related to the Services to be provided in
this Agreement.
6. Termination: This Agreement may be terminated at any time by mutual written agreement of
the parties or by the County upon written notice to the Provider. County may suspend this Agreement upon
reasonable notice to Provider.
7. Entire Agreement and Signatures: The parties have read this Agreement and agree to be
bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the
Agreement between the parties unless and until modified in writing and signed by the parties. Modifications
may be evidenced by telefacsimile signature. This Agreement together with any amendments or
modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent
of the Parties to utilize electronic signatures and the intent of the parties to comply with Article 11A and
Article 40 of North Carolina General Statute Chapter 66.
8. Governing Law and Priority: Both parties agree that this Agreement shall be governed by
the laws of the State of North Carolina and Orange County. Provider shall at all times remain in compliance
with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state
and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-
Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by
reference and may be viewed at
http://www.orangecountync.gov/departments/purchasing_division/contracts.php.). Any violation of this
requirement is a breach of this Agreement and County may immediately terminate this Agreement without
further obligation on the part of the County. This paragraph is not intended to limit and does not limit the
definition of breach to discrimination. By executing this Agreement Provider certifies that Provider has not
been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State
Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider affirms Provider is and shall
remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. In determining
the basic services to be provided, should any documents be referenced in or attached to this Agreement, the
terms herein shall have priority in any conflict between the terms of referenced documents and the terms of
this Agreement.
9. Dispute Resolution: Neither party may initiate binding arbitration. Any disputes shall be
resolved by nonbinding mediation. Should either party initiate litigation to settle any dispute involving the
terms of this Agreement such litigation shall be initiated in the General Court of Justice of North Carolina
seated in Orange County,North Carolina.
Revised 2/17 2
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
10. Non Appropriation: Provider acknowledges that County is a governmental entity, and the
validity of this Agreement is based upon the availability of public funding under the authority of its statutory
mandate. In the event that public funds are unavailable and not appropriated for the performance of County's
obligations under this Agreement, then this Agreement shall automatically expire without penalty to County
immediately upon written notice to Provider of the unavailability and non-appropriation of public funds.
[SIGNATURE PAGE TO FOLLOW]
Revised 2/17 3
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
IN WITNESS WHEREOF,Orange County and the Provider have signed this Agreement, effective
as of the day first written above.
ORANGF C9NTY PROVIDER
ocu igne by.U DocuSigned by:
By
p
Oraii) f)t,ipn't,d id- By ` 2`> NAI
e�4 1LI11C11L 5f ector Titl . cow 4761447...
200 S. Cameron St. Doug Malinowski
P.O. Box 8181 Wellsmont Landscaping, 1005 Dimmocks Mill Rd
Hillsborough,NC 27278 Hillsborough NC 27278
Revised 2/17 4
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
Quote Wellsmont Landscaping
ry 1005 Dimmocks Mill Rd
1 ( i 1 Hillsborough, NC 27278
L A Ni I W) S - P I INC a-r 919.810.6282
1 9.8 1 6 2 8 2
Customer Customer Number OR1
Quote Date July 10,2017
Orange County Sales Person DPM
131 W. Margret Lane, PO Box 8181 Expiration Date August 09, 2017
Hillsborough, NC 27278 Terms
Proposal Name Orange Lake Dam Mowing
Project Name
Proposal Number 2017-116
Version Number 1
SKU Size/ Description Quantity Unit Extended
Unit Price Price
Mowing Orange lake Dam from water edge down to 1.00 $560.00 $560.00
Spill Way and follow woodline. Skidsteer with
bushhog.Annual mowing
Taxable $0.00
Tax Exempt $560.00
Tax $0.00
Total $560.00
Orange Lake Dam Mowing:
Mow approximately 4 acres at a height of 6"or less.
Mow grass/brush/sapplings along waters edge
Trimming around structures including outet spill way
Mow/Trim around entry gate for access to dam
Thank you
1
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY, INC.
CERTIFICATE OF LIABILITY INSURANCE
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).
INSURED DOUG MALINOWSKI JR CERTIFICATE ORANGEE COUNTY PLANNING AND
NAME AND DBA WELLSMONT LANDSCAPING HOLDER INSPECTIONS DEPARTMENT
ADDRESS 1005 DIMMOCKS MILL ROAD 131 W MARGARET LANE
HILLSBOROUGH, NC 27278 PO BOX 8181
HILLSBOROUGH, NC 27278
EMAIL:
AREINERT @ORANGECOUNTYNC.GOV
COVERAGES
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.
X TYPE OF INSURANCE NSD WVD POLICY NUMBER POLICY M/D /YYW) POLICY M//D //YYYY) LIMITS
® COMMERCIAL GENERAL LIABILITY X GL 0483161 2/23/2017 2/23/2018 GENERAL AGGREGATE $1,000,000
-OCCURRENCE PRODUCTS-COMP/OPS
AGGREGATE $
GEN'L AGGREGATE APPLIES PER POLICY PERSONAL&ADV INJURY $1,000,000
EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED $100,000
PREMISES(Ea Occurrence)
MED EXP(Any one person) $5,000
❑ EACH OCCURRENCE $
BUSINESSOWNERS
AGGREGATE $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Each accident)
❑ SCHEDULED AUTOS BODILY INJURY(Per person) $
❑ HIRED AUTOS BODILY INJURY(Per accident) $
❑ NON-OWNED AUTOS PROPERTY DAMAGE
(Per accident)
❑ GARAGE LIABILITY
(Other)
❑ EXCESS LIABILITY— EACH OCCURRENCE $
OCCURRENCE AGGREGATE $
WC STATUTORY LIMITS
❑ WORKERS COMPENSATION N/A
AND EMPLOYERS'LIABILITY WCO253741 8/24/2016 8/24/2017 E .EACH ACCIDENT $100,000
POLICY APPLIES TO THE WORKERS E .DISEASE-EA EMPLOYEE $100,000
COMPENSATION LAW IN THE STATE OF NC
E .DISEASE-POLICY LIMIT $500,000
OTHER:
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES:
CANCELLATION r`
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED AUTHORIZED REPRESENTATIVE
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DATE 7/26/2017 •
COI 0910
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
BAP 2177023 2, 705
NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 BUSINESS AUTO POLICY
POLICY RENEWAL DECLARATION — COVERAGE WILL
ITEM ONE— EXPIRE ON 02/24/17 IF PREMIUM IS NOT PAID.
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BAP 2177023 02/24/17 08/24/17 1644652 BAP DELL 0515 0685538
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DOUG MALINOWSKI JR
DBA WELLSMONT LANDSCAPING
1740 JOHNSON RD WILL LAWS II, LUTCF
BURLINGTON, NC 27217-8179 TELE: (919) 732-7430
110 MILLSTONE DR
HILLSBOROUGH, NC 27278
FORM OF NAMED INSUREDS BUSINESS— INDIVIDUAL
ITEM TWO— SCHEDULE OF COVERAGES AND COVERED AUTOS
THIS POLICY PROVIDES ONLY THOSE COVERAGES WHERE A CHARGE IS SHOWN IN THE PREMIUM
COLUMNS BELOW. EACH OF THESE COVERAGES WILL APPLY ONLY TO THOSE AUTOS SHOWN AS
COVERED AUTOS. AUTOS ARE SHOWN AS COVERED AUTOS FOR A PARTICULAR COVERAGE BY
THE ENTRY OF ONE OR MORE OF THE SYMBOLS FROM THE COVERED AUTO SECTION OF THE
BUSINESS AUTO COVERAGE FORM NEXT TO THE NAME OF THE COVERAGE. "
COVERAGES COVERED LIMIT— THE MOST WE WILL PAY FOR PREMIUM
AUTOS ANY ONE ACCIDENT OR LOSS
LIABILITY INSURANCE 07 $500, 000 $258.00
AUTO MED. PAY. INS. 07 $5, 000 EA PERSON $24.00
UNINS/UNDRINS MTR BI 07 $500, 000 EA PERSON $500, 000 EA ACCIDENT $74. 00
UNINSURED MTRST PD $500, 000 PER ACCIDENT $4.00
PHYSICAL DAMAGE INS. ACTUAL CASH VALUE OR COST OF REPAIR,
WHICHEVER IS LESS MINUS— DEDUCTIBLE SHOWN
COMPREHENSIVE 07 SEE ITEM THREE FOR DEDUCTIBLE FOR EACH $122. 00
COVERED AUTO FOR ALL LOSS EXCEPT FIRE
OR LIGHTNING
COLLISION 07 SEE ITEM THREE FOR DEDUCTIBLE FOR EACH $221.00
COVERED AUTO
TOTAL PREMIUM $703. 00
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WE APPRECIATE YOUR BUSINESS.
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
BAP 2177023 2, 706
NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 BUSINESS AUTO POLICY
POLICY RENEWAL DECLARATION — COVERAGE WILL
ITEM ONE— EXPIRE ON 02/24/17 IF PREMIUM IS NOT PAID.
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BAP 2177023 02/24/17 08/24/17 1644652 BAP DECL 0515 0685538
_NED AM INSUREDA.D_. D S •
DOUG MALINOWSKI JR
DBA WELLSMONT LANDSCAPING
1740 JOHNSON RD WILL LAWS II, LUTCF
BURLINGTON, NC 27217-8179 TELE: (919) 732-7430
110 MILLSTONE DR
HILLSBOROUGH, NC 27278
ITEM THREE— SCHEDULE OF COVERED AUTOS YOU OWN
SYMBOL CA9928
TYPE CMPCOL COST STATED
VEH ST TER YR DESCRIPTION VEH SERIAL NUMBER AGE NEW CLASS AMT
010 NC 024 13 DODGE DUMP TD 3C7WRLEL9DG591406 5 55000 21179
011 NC 024 08 CHEV PU TO 1GCHK23698F163036 10 50000 01189
PREMIUMS— MED UN—UD SPEC DEDUCTIBLE
AUTO LIAB PAY MTRST COMP PERIL COLL OTHER COMP COLL PREMIUM
010 $129. 00 $12 $39 $57 $129 250 500 $366. 00
011 $129. 00 $12 $39 $65 $92 250 500 $337 . 00
DRIVER ID DRIVER NAME
01 DOUG MALINOWSKI JR
APPLICABLE FORMS
FORM# DATE FORM# DATE FORM# DATE FORM# DATE FORM# DATE
CA-0001 1013* IL-0003 0908 IL-0017 1198 IL-0021 0908 CA-9917 1013*
CA-0126 1013* CA-0199 0189 CA-2384 1013* CA-2394 1013* QRBAP 0716*
CA-2345 1116* CA-9903 1013* CA-2116 1013* CA-2107 1293
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
BAP 2177023 2,707
NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 BUSINESS AUTO POLICY
POLICY RENEWAL DECLARATION — COVERAGE WILL
ITEM ONE— EXPIRE ON 02/24/17 IF PREMIUM IS NOT PAID.
: .....NLlK1lElEt�...._.........._.._._...._..... ...:.................. .......................AtiEt�HEF�6H►P.Nv..........................._.............._...._............_..................................
BAP 2177023 02/24/17 08/24/17 1644652 BAP DECL 0515 0685538
DOUG MALINOWSKI JR
DBA WELLSMONT LANDSCAPING
1740 JOHNSON RD WILL LAWS II, LUTCF
BURLINGTON, NC 27217-8179 TELE: (919) 732-7430
110 MILLSTONE DR
HILLSBOROUGH, NC 27278
OTHER POLICIES FOR MEMBERSHIP NUMBER 1644652:
POLICY INSURED NAME
WC 0253741 DOUG MALINOWSKI
GL 0483161 DOUG MALINOWSKI
HP 6269018 DOUG MALINOWSKI
AP 8359301 DOUG MALINOWSKI
WHEN THE NUMBER OF VEHICLES IS FIVE OR MORE, FLEET RATES APPLY.
01/07/17/11f41.4-01...-1--...../.
X/91 DATE
THESE DECLARATIONS TOGETHER WITH THE BUSINESS AUTO POLICY PROVISIONS AND ENDORSE-
MENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY.
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
BAP 2177023 3,280
NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 BUSINESS AUTO POLICY
POLICY RENEWAL DECLARATION — COVERAGE WILL
ITEM ONE— EXPIRE ON 08/24/17 IF PREMIUM IS NOT PAID.
iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii::::_:.::::-.::,:::::::E1)}JGY:PERaC7D's:*:5::=.:::::::::::::::::::: _...._:.....:..,..,..:: .. .::::..::,_::_:::.::;:::::..:.::::_.::_.:_,__:s:::-:__:.:_:: :...: ....:::..,,...,..
:::-::::;; --;::-:::: : : :::::::::::___:i�itEEv�BEF�fiHIF�Nt�......_........_..........................................._...._.....................................:.....AS3ENT::: t� E=
BAP 2177023 08/24/17 02/24/18 1644652 BAP DECL 0515 0685538
DOUG MALINOWSKI JR
DBA WELLSMONT LANDSCAPING
1740 JOHNSON RD WILL LAWS II, LUTCF
BURLINGTON, NC 27217-8179 TELE: (919) 732-7430
110 MILLSTONE DR
HILLSBOROUGH, NC 27278
FORM OF NAMED INSUREDS BUSINESS— INDIVIDUAL
ITEM TWO— SCHEDULE OF COVERAGES AND COVERED AUTOS
THIS POLICY PROVIDES ONLY THOSE COVERAGES WHERE A CHARGE IS SHOWN IN THE PREMIUM
COLUMNS BELOW. EACH OF THESE COVERAGES WILL APPLY ONLY TO THOSE AUTOS SHOWN AS
COVERED AUTOS. AUTOS ARE SHOWN AS COVERED AUTOS FOR A PARTICULAR COVERAGE BY
THE ENTRY OF ONE OR MORE OF THE SYMBOLS FROM THE COVERED AUTO SECTION OF THE
BUSINESS AUTO COVERAGE FORM NEXT TO THE NAME OF THE COVERAGE.
COVERAGES COVERED LIMIT— THE MOST WE WILL PAY FOR PREMIUM
AUTOS ANY ONE ACCIDENT OR LOSS
LIABILITY INSURANCE 07 $500, 000 $258.00
AUTO MED. PAY. INS. 07 $5, 000 EA PERSON $24.00
UNINS/UNDRINS MTR BI 07 $500, 000 EA PERSON $500, 000 EA ACCIDENT $74 . 00
UNINSURED MTRST PD $500, 000 PER ACCIDENT $4. 00
PHYSICAL DAMAGE INS. ACTUAL CASH VALUE OR COST OF REPAIR,
WHICHEVER IS LESS MINUS— DEDUCTIBLE SHOWN
COMPREHENSIVE 07 SEE ITEM THREE FOR DEDUCTIBLE FOR EACH $122 . 00
COVERED AUTO FOR ALL LOSS EXCEPT FIRE
OR LIGHTNING
COLLISION 07 SEE ITEM THREE FOR DEDUCTIBLE FOR EACH $221 . 00
COVERED AUTO
TOTAL PREMIUM $703. 00
PR :-=:;s_ ;::: -......: :'sue: ;, :. _, _' '::v:::::.:;_::v::;.._ :::.. .__._ _ :_.. .. - :�,:_::: .::: :::_,...:: :....: :::-:. : ..
PRf V I ION$::::_.- :REFULLY:: 1 'I`A:-::::_::::::: :: .-::: -::::::::_:::-::::::: :::-:;::::: : ::_..:::_
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WE APPRECIATE YOUR BUSINESS.
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
BAP 2177023 3, 281
f
NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 BUSINESS AUTO POLICY
POLICY RENEWAL DECLARATION - COVERAGE WILL
ITEM ONE- EXPIRE ON 08/24/17 IF PREMIUM IS NOT PAID.
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BAP 2177023 08/24/17 02/24/18 1644652 BAP DECL 0515 0685538
DOUG MALINOWSKI JR
DBA WELLSMONT LANDSCAPING
1740 JOHNSON RD WILL LAWS II, LUTCF
BURLINGTON, NC 27217-8179 TELE: (919) 732-7430
110 MILLSTONE DR
HILLSBOROUGH, NC 27278
ITEM THREE- SCHEDULE OF COVERED AUTOS YOU OWN
SYMBOL CA9928
TYPE CMPCOL COST STATED
VEH ST TER YR DESCRIPTION VEH SERIAL NUMBER AGE NEW CLASS AMT
010 NC 024 13 DODGE DUMP TD 3C7WRLEL9DG591406 5 55000 21179
011 NC 024 08 CHEV PU TO 1GCHK23698F163036 10 50000 01189
PREMIUMS- MED UN-UD SPEC DEDUCTIBLE
AUTO LIAB PAY MTRST COMP PERIL COLL OTHER COMP COLL PREMIUM
010 $129. 00 $12 $39 $57 $129 250 500 $366. 00
011 $129. 00 $12 $39 $65 $92 250 500 $337 . 00
DRIVER ID DRIVER NAME
01 DOUG MALINOWSKI JR
APPLICABLE FORMS
FORM# DATE FORM# DATE FORM# DATE FORM# DATE FORM# DATE
CA-0001 1013 IL-0003 0908 IL-0017 1198 IL-0021 0908 CA-9917 1013
CA-0126 1013 CA-0199 0189 CA-2384 1013 CA-2394 1013 QRBAP 0716
CA-2345 1116 CA-9903 1013 CA-2116 1013 CA-2107 1293
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
BAP 2177023 3,282
f NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 BUSINESS AUTO POLICY
POLICY RENEWAL DECLARATION — COVERAGE WILL
ITEM ONE— EXPIRE ON 08/24/17 IF PREMIUM IS NOT PAID.
OrN1 Nf3ER..................._............._ _....:......._............._..... .......................MEMHEF�&HIix.N�7 :Af3ENT'C#,)i�E;=;
BAP 2177023 08/24/17 02/24/18 1644652 BAP DECL 0515 0685538
DOUG MALINOWSKI JR
DBA WELLSMONT LANDSCAPING
1740 JOHNSON RD WILL LAWS II, LUTCF
BURLINGTON, NC 27217-8179 TELE: (919) 732-7430
110 MILLSTONE DR
HILLSBOROUGH, NC 27278
,
OTHER POLICIES FOR MEMBERSHIP NUMBER 1644652 :
POLICY INSURED NAME
WC 0253741 DOUG MALINOWSKI
GL 0483161 DOUG MALINOWSKI
HP 6269018 DOUG MALINOWSKI
AP 8359301 DOUG MALINOWSKI
IM 9729537 DOUG MALINOWSKI
WHEN THE NUMBER OF VEHICLES IS FIVE OR MORE, FLEET RATES APPLY.
'€ €_ _' _ =?;€':?-;i-= € € Z ?'- €=- -€;€!- _€€ €€€;€€ _is€;€i`i€;€i €;E€i s ;-i€€ `;-=M;- °_`-€ t;;€€:;€ss=€.:::'sF;'€€ ° =-a;;l;€'-€"`- `
DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3
BAP 2177023 3, 283
NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 BUSINESS AUTO POLICY
POLICY RENEWAL DECLARATION — COVERAGE WILL
ITEM ONE— EXPIRE ON 08/24/17 IF PREMIUM IS NOT PAID.
:::::::::::.::::::.-::: °:=::::::< .:; :: =:- ~: _............. -.............,>
M Et�-........_._.:::::..::::::::::: _..:. I�iill;tdJBERBHtf*:N.Cs _-:::::_._.::::_:::::;:::_.-:::.:.-_::::.::.::._::-::.:_:::__:....:__:::::::
BAP 2177023 08/24/17 02/24/18 1644652 BAP DECL 0515 0685538
DOUG MALINOWSKI JR
DBA WELLSMONT LANDSCAPING
1740 JOHNSON RD WILL LAWS II, LUTCF
BURLINGTON, NC 27217-8179 TELE: (919) 732-7430
110 MILLSTONE DR
HILLSBOROUGH, NC 27278
07/08/17
/45444■LA ... .
DATE
THESE DECLARATIONS TOGETHER WITH THE BUSINESS AUTO POLICY PROVISIONS AND ENDORSE-
MENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY.