HomeMy WebLinkAbout2017-418-E Planning - Wellsmont Landscaping to mow and clear Efland Sewer System DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
[Departmental Use Only]
TITLE Efland Sewer Mowing
FY 17-18
ORANGE COUNTY
CONTRACT UNDER $15,000.00
NORTH CAROLINA
THIS AGREEMENT, made and entered into this 23rd day of August, 2017, ("Effective Date")by
and between Orange County, North Carolina, a political subdivision 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 (hereinafter referred to collectively as "Services") to be furnished
under this Agreement are as follows: Mowing and clearing of the Efland Sewer Easements as described in
Exhibit A: Project Specifications for Sewer Line Easement Clearing.
The term of this agreement rendered shall be from August 23, 2017 to February 30, 2018.
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 THREE
THOUSAND AND FOUR HUNDRED AND EIGHTY DOLLARS, ($3,480.00). 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.
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
Revised 2/17 1
DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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 consist of
(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, its agents, or assigns directly or indirectly related to the Services to be performed
pursuant to this Agreement on the part of the Provider.
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 the 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. 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. Priority: In determining the basic services to be provided, should any documents be
referenced in or attached to this Agreement, the terms of this Agreement shall have priority in any conflict
between the terms of referenced documents and the terms of this Agreement.
9. Governing Law: Both parties agree that this Agreement shall be governed by the laws of the
State of North Carolina. 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 affirms that Provider is and
shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. 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.
10. Dispute Resolution: Any and all suits or actions to enforce, interpret, or seek damages with
respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in
the General Court of Justice of North Carolina sitting in Orange County,North Carolina. It is agreed by the
parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding
arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of
any dispute prior to the bringing of such suit or action.
11. 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
Revised 2/17 2
DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
IN WITNESS WHEREOF,County and the Provider have signed this Agreement, effective as of
the day first written above.
ORANGE COUNTY PROS ,,ed by:c DocuSigned by: pp�
B : botAA/ut, tkevAkwtt,V'StU1 B \ssi U�
ttiNger Title7dikhlef3A761447
200 S. Cameron St. Doug Malinowski
P.O. Box 8181 1005 Dimmocks Mill Road
Hillsborough,NC 27278 Hillsborough, NC 27278
Revised 2/17 4
DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
EXHIBIT A
Project Specifications for Sewer Line Easement Clearing
Overview
It is the intent of these specifications to provide enough information for a
Contractor with the proper equipment to clear the existing sewer easement such that
a maintenance truck can travel along the easement. Basically, this involves cutting all
vegetation growing within ten feet on either side of the sewer line, clearing any limbs
that may be growing into the space above the easement and removing trees, limbs
or other obstructions which may have fallen across the easement.
For this project, Orange County will supply the following:
1. A map of the easements to be cleared, attached as Exhibit B.
2. Notification to all the Efland Sewer customers that easement clearing will be
taking place.
3. Field flagging of the centerline of the force main clearing from the Richmond Hills
pump station at the east end of Alice Miller Ct. to the gravity sewer manhole
northeast of Efland Cheeks Elementary School.
The Contractor will be expected to provide all equipment and labor to clear the
easements as described below.
Scope of Work
The fee associated with this scope of services is for clearing the entire system
one time. All of the easements for the sewer lines shown on the map, Exhibit B, are
to be cleared to the standards listed below, except for those sewer lines that are
located under streets. The area to be cleared is ten feet on each side of a straight
line between each manhole in the sewer system. Therefore, the total cleared width
will be 20 feet. It is important that the cleared area be as straight as possible,
because we are not allowed to do any clearing outside of the easement. There are
some areas adjacent to existing road rights of way that originally involved fence
relocation. In such instances, clear to the fence line or 10' from sewer, whichever is
less.
All grass, bushes, vines, saplings or trees that can be mowed should be cut to
a height of no more than 5". Trees that cannot be mowed down should be cut so the
stump is level with the ground (no more than 5" above the ground) and the
remainder of the tree either chipped in the field or hauled away. The easement
needs to be cleared sufficiently for a maintenance vehicle to be able to drive to every
manhole for cleaning or inspection purposes. Should there be any significant trees of
question within the specified clearing limits, prior to removal, the Contractor should
contact the Orange County Engineering staff for specific direction.
S:\12_Engineering\Efland Sewer\Contracts\Easement Clearing\FY2016-2017\SewerLineEsmtClearingSpecifications_2016.docx
Specifications Page 1 of 2
DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
EXHIBIT A
Project Specifications for Sewer Line Easement Clearing
In addition to mowing the ground cover, the Contractor will remove any limbs or
other vegetative growth that projects into the easement area, up to a height of 10 feet.
There may also be trees or limbs that have fallen across the easement. These will
need to be cut to the limits described and either hauled away or chipped in the
field as described above.
There are some manholes that are enclosed within fenced-in yards or may
otherwise be inaccessible, due to structures built by property owners around the
easements. To the greatest extent possible, the Orange County Engineering staff
will advise the Contractor of any known structures that might impede clearing before
work begins. However, if the Contractor comes across an area that would require
destruction of such fences or other structures in order to clear the easement, the
Contractor should contact Orange County Engineering Staff for guidance, prior to
taking any further action.
Exclusions
1. The grounds within the fence lines of the Richmond Hills Pump Station and the
Brookhollow Pump Station.
Schedule
Once notified to begin work, please note that time is of the essence. Work on
this project should commence as soon as possible and continue without interruption
until the project is completed. Should there be delays, for whatever reason, the work
shall be completed no later than the termination date of contract.
S:\12_Engineering\Efland Sewer\Contracts\Easement Clearing\FY2016-2017\SewerLineEsmtClearingSpecifications_2016.docx
Specifications Page 2 of 2
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DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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 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
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WE APPRECIATE YOUR BUSINESS.
DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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.
Sr._; :s.:e:_:: � :__.....�;..,..__,....-.._..-.._. F[p3i
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BAP 2177023 02/24/17 08/24/17 1644652 BAP DECL 0515 0685538
_NAMED:INS REDA.D_. D S ° ::_:: ; _ € _ i':AG 3=_::: i € : is ;_::<_=
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:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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.
: .....NL(K1lBEt�...._.........._.._._...._..... ...:.................. .......................AtiEt�HEF�6H►P.Nv..........................._.............._...._............_..................................
BAP 2177023 02/24/17 08/24/17 1644652 BAP DECL 0515 0685538
VjVlglNSf gg0. f..HMOBRIES51::-:. ::::.:::.::-,_:::::::.:;.:::;..__;__:_;:.::_.; _:::::::;:::::=::::_:::<:::_::::__; ;::::_::_:_::;- _ :.:::::::.::::-;;:_ligUiR+_:€€ _ [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
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:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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.
::::_:.::::-.::,:::::::El)}JGY::!?ERaC7D's:*:;::=..:::::::::::::::::::: _...._,.....:..,..,..:: .. . ., _: .: ::- _::::::-:_-:.:__: ...:c....:::e..,,...,..
:::-::::;; --;::-:::: : : :::::::::::___:i�i1�Ev�B�F�fiHIF�Nt�......_........_........................................_...._..................................-..:.....AS3ENT::: t1' E=
BAP 2177023 08/24/17 02/24/18 1644652 BAP DECL 0515 0685538
NAl1REl?_INSU REIN?AtitiM 3RE5 s€s:: :_:=...--...__::::::::EETT:..::=::_:_.:::. >::::;,:::.-.:::=:.:-:_:-::::::=::_::. ::::::__:::::..::_:_::
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 $703. 00
e: .:..- : ......::.. ..:__:: .- :;:;:::.:.: -R::-P::::-:::::::Y-::::D --:LA-; -- ._. ._....A ...le. __ ::::::::::::::,::::
�P��_:Au�E+ RAE ::� t.TR.:Pt�T,I:. �:.-IJECLARA_TT...:.::: I3::::-P. ;:L,�. ;.. :::::_:::::::::_::_:.:
PRONOSTON$::::_.- :10ORMY::.::;:::.= 1 'I`A:-::::_::::::: :: .-::: -::::::::_:::-::::::: :::-:;::::: : ::_..:::_
::::: :::::_:::: -.._-----._..._........_._._._..__._fib_....----C'I'._:��bU ,::�i�� �,::,T�.::_Y��::::� �TE.....�1NY._.___..._....
WE APPRECIATE YOUR BUSINESS.
DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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.
°EQLF
_BE0...:..............._....._...._.. ....................._..............._... .............._.......te1EMBEiKPHNO......................_.,................._.._............_..............._......:.._._.._....._........A13ENS{?FfE!°:
BAP 2177023 08/24/17 02/24/18 1644652 BAP DECL 0515 0685538
.6FAMED.NS 31 ANt7..DRES :;: ,::::::::_:: :::::.::_::::::_:.;.:::: ;.:.:.:::;;:::;:; E.;_:: :::::: =:: - :::: :=.::::;:::: _::::_: ;:::
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
I.
DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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.
CY._NLINIBER..................._............._ _....:......._............._..... .......................MEMHEF�&HIix.N�7Af3ENT'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.
l ii :i _ =;;;i';-;;;;;= ii;€iiiiNN- €=- €;€!'-;_€;€ i i€€i;:igsi;€i;€;;€i €;E=;i;` ;; iZi;;; `;- i;- `-i; €;€€:;;;;;=€s;;;€€:° ; ::=::;[ -:€ -- ;;
DocuSign Envelope ID:F4AB36D7-6659-49D9-816A-AC4ABC1AF4D6
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.
:
Ill;tdJBERBHtf*:N.Cs
BAP 2177023 08/24/17 02/24/18 1644652 BAP DECL 0515 0685538
NAMED IN ,m-_ ,._._.... .
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.