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HomeMy WebLinkAbout2020-104-E AMS - Smith Sinnett Architecture Mobile Dental Clinic upfitRevised 11/19 1 [Departmental Use Only] TITLE Dental Unit FY 2019-20 NORTH CAROLINA SERVICES AGREEMENT NO RFP/RFQ ORANGE COUNTY This Services Agreement (hereinafter “Agreement”), made and entered into this 25th day of January, 2020, (“Effective Date”) by and between Orange County, North Carolina a political subdivision of the State of North Carolina (hereinafter, the "County") and Smith Sinnett Architecture, P.A., (hereinafter, the "Provider"). WITNESSETH: That the County and Provider, for the consideration herein named, do hereby agree as follows: 1. Services a. Scope of Work. i) This Agreement is for services to be rendered by Provider to County with respect to (insert type of project): Southern Human Services Mobile Dental Clinic ii) By executing this Agreement, the 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. iii) Time is of the essence with respect to this Agreement. iv) The services to be performed under this Agreement consist of Basic Services, as described and designated in Section 3 hereof. Compensation to the Provider for Basic Services under this Agreement shall be as set forth herein. 2. Responsibilities of the Provider a. Services to be provided. The Provider shall provide the County with all services required in Section 3 to satisfactorily complete the Project within the time limitations set forth herein and in accordance with the highest professional standards. b. Standard of Care. i) The Provider shall exercise reasonable care and diligence in performing services under this Agreement in accordance with the highest generally accepted standards of this type of Provider practice throughout the United States and in accordance with applicable federal, state and local laws and regulations applicable to the performance of these services. Provider is solely responsible for the professional DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE Revised 11/19 2 quality, accuracy and timely completion and/or submission of all work related to the Basic Services. ii) Provider shall be responsible for all errors or omissions of its agents, contractors, employees, or assigns 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. iii) The Provider shall not, except as otherwise provided for in this Agreement, subcontract the performance of any work under this Agreement without prior written permission of the County. No permission for subcontracting shall create, between the County and the subcontractor, any contract or any other relationship. iv) Provider is an independent contractor of County. Any and all employees of the Provider engaged by the Provider in the performance of any work or services required of the Provider under this Agreement, shall be considered employees or agents of the Provider only and not of the County, and any and all claims that may or might arise under any workers compensation or other law or contract on behalf of said employees while so engaged shall be the sole obligation and responsibility of the Provider. v) If activities related to the performance of this Agreement require specific licenses, certifications, or related credentials Provider represents that it and/or its employees, agents and subcontractors engaged in such activities possess such licenses, certifications, or credentials and that such licenses certifications, or credentials are current, active, and not in a state of suspension or revocation. vi) In determining the Basic Services to be provided, should any documents be referenced in 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. vii) Should this Agreement involve project designs, the construction or creation of which is to be bid out and/or fulfilled by other contractors, and bidding or negotiation with contractors produce prices which, when added to the other elements of the approved total project cost, produce a cost that is in excess of the approved total project cost, the Provider shall participate with the County in negotiation and design adjustments to the extent such are necessary to obtain prices within the approved total project cost. All activity of the Provider with respect to these matters shall constitute Basic Services and shall be performed by the Provider without additional compensation. If negotiation and design adjustments fail to bring costs within the total project cost the County may reject all bids and Provider will redesign and/or reduce portions of the project in an effort to reduce the bid prices to within the total project cost and rebid the project. One such redesign is included within Basic Services. If this second letting for bids does not produce bids that are within the approved total project cost initially or after negotiations with the contractor the cost is not reduced to an amount within the total project cost, the Provider is not obligated to engage in further redesign. DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE Revised 11/19 3 3. Basic Services a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows (fully describe services to be provided): SCOPE OF WORK - ENGINEERING: The scope of engineering services includes design documentation and construction administration for the following: 1. Domestic water service and sanitary sewer service to the proposed mobile unit location with the understanding that the domestic water service will be connected to the existing building and will not require a separate waterline tap, meter and backflow prevention device. Also assumed is that the new sanitary sewer service will connect to the existing sanitary sewer service or sewer main located in close proximity to the Southern Human Services Building. 2. Erosion control design. Based on previous experience, it is our assumption that the Town of Chapel Hill will require review of an erosion control plan and thus erosion control plans have been included in this proposal. However, permitting with NCDEQ has been specifically excluded as this project is understood to involve less than 1 acre disturbance. 3. Power for the vehicle to be located at the parking area with the understanding that a separate meter is not needed. 4. A chain-link fence around the perimeter of the proposed mobile unit parking. Landscaping is not anticipated and is excluded. It is understood that the proposed mobile dentist unit will be located on the existing pavement along the south edge of the Southern Human Services Building; 5. Note: Surveys and testing (before, during and after construction) are assumed to be provided by the owner. SCOPE OF WORK - ARCHITECTURE: The project consists of a study regarding the architectural and engineering implications and cost estimates for the following possible solutions: 1. Coordination of engineering with owner requirements. 2. Specification writing and estimating. 3. CDC submission, presentation and approval. It is anticipated that since the fencing is an exterior improvement, the Town of Chapel Hill will need to review the project through the Community Design Commission. 4. Bidding services. An informal bid process is anticipated.(Per proposal dated December 20, 2019) 4. Duration of Services a. Term. The term of this Agreement shall be from January 25, 2020 to January 25, 2021. b. Scheduling of Services. i) The Provider shall schedule and perform its activities in a timely manner. ii) Should the County determine that the Provider is behind schedule, it may require the Provider to expedite and accelerate its efforts, including providing additional resources and working overtime, as necessary, to perform its services in accordance with the approved project schedule at no additional cost to the County. iii) The Commencement Date for the Provider's Basic Services shall be January 25, 2020. 5. Compensation DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE Revised 11/19 4 a. Compensation for Basic Services. Compensation for Basic Services shall include all compensation due the Provider from the County for all services satisfactorily (as determined by the County) performed pursuant to this Agreement. The maximum amount payable for Basic Services shall not exceed Forty Five Thousand Five Hundred Forty Dollars ($45,540.00). Payment for satisfactorily performed Basic Services shall become due and payable within thirty (30) days of Provider properly invoicing County. Payment shall be subject to provisions of Section 5(b). b. Disputes. In the event the amount stated on an invoice is disputed by the County, the County may withhold payment of all or a portion of the amount stated on an invoice until the parties resolve the dispute. 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. c. Additional Services. County shall not be responsible for costs related to any services in addition to the Basic Services performed by Provider unless County requests such additional services in writing and such additional services are evidenced by a written amendment to this Agreement. 6. Responsibilities of the County a. Cooperation and Coordination. The County has designated (Angel Barnes) to act as the County's representative with respect to the Project and shall have the authority to render decisions within guidelines established by the County Manager and/or the County Board of Commissioners and shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. Insurance a. General Requirements. 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/contracts.php). If County’s Risk Manager determines additional insurance coverage is required such additional insurance shall consist of N/A (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. 8. Indemnity a. Indemnity. To the extent authorized by North Carolina law the Provider agrees, without limitation, to defend, indemnify and hold harmless the County from all loss, liability, claims or expense, including attorney's fees, arising out of or related to the Project and arising from property damage or bodily injury including death to any person or persons caused in whole or in part by the negligence or misconduct of the Provider except to the extent same are caused by the negligence or willful misconduct of the County. It is the DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE Revised 11/19 5 intent of this provision to require the Provider to indemnify the County to the fullest extent permitted under North Carolina law. 9. Amendments to the Agreement a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional compensation or a change in duration of this Agreement shall be made by a written Amendment to this Agreement executed by the County and the Provider. The Provider shall proceed to perform the Services required by the Amendment only after receiving a fully executed Amendment from the County. 10. Termination a. Termination for Convenience of the County. This Agreement may be terminated without cause by the County and for its convenience upon seven (7) days’ prior written notice to the Provider. b. Other Termination. The Provider may terminate this Agreement based upon the County's material breach of this Agreement; provided, the County has not taken all reasonable actions to remedy the breach. The Provider shall give the County seven (7) days' prior written notice of its intent to terminate this Agreement for cause. c. Compensation After Termination. i) In the event of termination, the Provider shall be paid that portion of the fees and expenses that it has earned to the date of termination, less any costs or expenses incurred or anticipated to be incurred by the County due to errors or omissions of the Provider. ii) Should this Agreement be terminated, the Provider shall deliver to the County within seven (7) days, at no additional cost, all deliverables including any electronic data or files relating to the Project. d. Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. e. Suspension. County may suspend the Basic Services and this Agreement at any time for County’s convenience and without penalty to County upon three (3) days’ notice to Provider. Upon any suspension by County, Provider shall discontinue work on the Basic Services and shall not resume the Basic Services until notified to proceed by County. 11. Additional Provisions a. Limitation and Assignment. The County and the Provider each bind themselves, their successors, assigns and legal representatives to the terms of this Agreement. Neither the DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE Revised 11/19 6 County nor the Provider shall assign or transfer its interest in this Agreement without the written consent of the other. b. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are 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 identified, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. c. Non-Discrimination. 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 non-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 the Orange County Non-Discrimination Policy 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. d. 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. e. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. f. Severability. If any provision of this Agreement is held as a matter of law to be unenforceable, the remainder of this Agreement shall be valid and binding upon the Parties. g. Ownership of Work Product. Should Provider’s performance of this Agreement generate documents, items or things that are specific to this Project such documents, items or things shall become the property of the County and may be used on any other project without additional compensation to the Provider. The use of the documents, items or things by the County or by any person or entity for any purpose other than the Project as set forth in this Agreement shall be at the full risk of the County. DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE Revised 11/19 7 h. 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. It is expressly agreed that County shall not activate this non-appropriation provision for its convenience or to circumvent the requirements of this Agreement, but only as an emergency fiscal measure during a substantial fiscal crisis. In the event of a change in the County’s statutory authority, mandate and/or mandated functions, by state and/or federal legislative or regulatory action, which adversely affects County’s authority to continue its obligations under this Agreement, then this Agreement shall automatically terminate without penalty to County upon written notice to Provider of such limitation or change in County’s legal authority. i. Signatures. 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. j. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Orange County Provider’s Name Attention:AMS SmithSinnettArchitecture PA P.O. Box 8181 4600 Lake Boone Trail Hillsborough, NC 27278 Raleigh, NC 27607 [SIGNATURE PAGE TO FOLLOW] DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE Revised 11/19 8 IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have hereunder set their hands and seal, all as of the day and year first above written. ORANGE COUNTY: PROVIDER: By: _________________________________ Bonnie Hammersley, County Manager By: __________________________________ Rhonda Angerio, President Printed Name and Title DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE  4600 Lake Boone Trail, Suite 205 | Raleigh, NC 27607 | 919.781.8582 | HUB Certified | www.smithsinnett.com December 20, 2019 Orange County 200 South Cameron Street Hillsborough, North Carolina 27278 Attn.: Ms. Angel Barnes Asset Management Services, Capital Projects Manager Dear Ms. Barnes: FEE PROPOSAL: Orange County Southern Campus Expansion – Mobile Dental (Life Line) Clinic Smith Sinnett Architecture greatly appreciates the opportunity to provide Orange County with a proposal for Architectural and Engineering Services for the design of parking facilities for a new Life Line Dental Clinic for the Southern Human Services Center located at the Orange County Southern Campus. SCOPE OF WORK - ENGINEERING: The scope of engineering services includes design documentation and construction administration for the following: 1. Domestic water service and sanitary sewer service to the proposed mobile unit location with the understanding that the domestic water service will be connected to the existing building and will not require a separate waterline tap, meter and backflow prevention device. Also assumed is that the new sanitary sewer service will connect to the existing sanitary sewer service or sewer main located in close proximity to the Southern Human Services Building. 2. Erosion control design. Based on previous experience, it is our assumption that the Town of Chapel Hill will require review of an erosion control plan and thus erosion control plans have been included in this proposal. However, permitting with NCDEQ has been specifically excluded as this project is understood to involve less than 1 acre disturbance. 3. Power for the vehicle to be located at the parking area with the understanding that a separate meter is not needed. 4. A chain-link fence around the perimeter of the proposed mobile unit parking. Landscaping is not anticipated and is excluded. It is understood that the proposed mobile dentist unit will be located on the existing pavement along the south edge of the Southern Human Services Building; 5. Note: Surveys and testing (before, during and after construction) are assumed to be provided by the owner. SCOPE OF WORK - ARCHITECTURE: The project consists of a study regarding the architectural and engineering implications and cost estimates for the following possible solutions: 1. Coordination of engineering with owner requirements. 2. Specification writing and estimating. 3. CDC submission, presentation and approval. It is anticipated that since the fencing is an exterior improvement, the Town of Chapel Hill will need to review the project through the Community Design Commission. 4. Bidding services. An informal bid process is anticipated. DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE 4600 Lake Boone Trail, Suite 205 | Raleigh, NC 27607 | 919.781.8582 | HUB Certified | www.smithsinnett.com It is anticipated as a part of the overall design process, that we will hold meetings with the client and their stakeholders as needed. Additionally, we will also meet with the Town of Chapel Hill as needed to achieve all necessary approvals. We will provide preliminary cost per square foot estimates at the conclusion of the study. DESIGN FEE: For Architectural/Engineering Services, compensation shall be based on a fixed fee of Thirty-Nine Thousand Six Hundred Dollars ($39,600). FEE SCHEDULE: The Design Fee shall be billed on a percentage of work completed on a monthly basis. HOURLY RATES: Any modifications to the additional services are to be mutually determined and agreed to in writing prior to the commencement of the work. Hourly rates, if needed for Architectural or engineering shall be as follows: Architectural: Principal $ 175/hour Project Manager $ 150/hour Architect $ 130/hour Project Designer $ 110/hour Administration $ 75/hour Engineering: Principal $ 175/hour Project Manager $ 150/hour Senior Engineer $ 150/hour Engineer $ 125/hour Senior Designer $ 125/hour Designer $ 110/hour CAD $ 75/hour Administration $ 65/hour REIMBURSABLE EXPENSES Reimbursable expenses include, but may not be limited to, all review and permit fees, overnight postage, mileage, and reproduction and printing costs. The Architect will provide prints to the Owner if requested, otherwise the Owner may elect to print documentation directly in house. INSTRUMENTS OF SERVICE Plans and specifications are instruments of service and remain the property of Smith Sinnett Architecture, P.A. INDEMNIFICATION Architect and Client agree to mutually indemnify, defend and hold each other harmless from and against any and all claims, liabilities, suits, demands, losses, costs and expenses, including, but not limited to, reasonable DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE 4600 Lake Boone Trail, Suite 205 | Raleigh, NC 27607 | 919.781.8582 | HUB Certified | www.smithsinnett.com attorneys' fees and all legal expenses and fees incurred on appeal, and all interest thereon, accruing or resulting to any and all persons, firms or any other legal entities on account of any damages or losses to property or persons, including injury or death, or economic losses, arising out of the Project and/or the performance or non- performance of obligations under this Agreement, except to the extent such damages or losses are found by a court or forum of competent jurisdiction to be caused by the Architect's or Client’s negligent errors or omissions. TERMINATION The Owner or the Architect upon giving ten days’ written notice can terminate this Agreement at any time. Termination by the Owner shall comply with all other items herein. This Agreement, unless previously terminated by written notice, shall be terminated by the final payment for the finished work. If Agreement is terminated, Client agrees to pay the Architect for all Services rendered and Reimbursable Expenses incurred up to the date of termination. Upon not less than seven days' written notice, the Architect may suspend the performance of its services if Client fails to pay the Architect in full for services rendered or expenses incurred. Architect shall have no liability because of such suspension of service or termination due to nonpayment. ADDITIONAL SERVICES Should the Owner request any major changes in the scope of the work after the completion of previously approved additional services study, this work shall be performed as an additional service. Prior to commencement of additional design and documentation services, the Owner and Architect shall agree in writing to a specified additional cost to accomplish the work. ADDITIONAL SERVICES CONSULTANTS (AS NEEDED): MPE&FP Engineering: Progressive Design Collaborative, Civil Engineering: Grounded Engineering, Until such time as an Owner’s contract document may be prepared and signed by both parties, this agreement shall serve as a binding contract entered into as of the day and year first written above. ACCEPTED FOR: Smith Sinnett Architecture Orange County By: Drew Wilgus, Architect, Associate By: (Name and Title) (Name and Title) Signature: Signature: Date: 12-20-2019 Date: : DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE 08/28/2019 Insurance Management Consultants, Inc. P.O. Box 2490 Davidson NC 28036 Rebekah Rosko (704) 799-1600 (704) 799-2955 cert@imcipls.com Smith Sinnett Architecture, P.A. 4600 Lake Boone Trail Suite 205 Raleigh NC 27607 RLI Insurance Company 13056 Travelers Casualty & Surety Company of America 19038 8/17/19-3/16/20 A PSB0006123 03/16/2019 03/16/2020 2,000,000 1,000,000 10,000 2,000,000 4,000,000 4,000,000 A PSA0002171 03/16/2019 03/16/2020 1,000,000 Medical payments A PSE0002685 03/16/2019 03/16/2020 1,000,000 1,000,000 A PSW0003488 03/16/2019 03/16/2020 500,000 500,000 500,000 B Professional Liability 106969212 08/17/2019 08/17/2020 Per Claim $2,000,000 Aggregate $4,000,000 Waiver of subrogation applies in favor of Orange County for workers compensation. Orange County P.O. Box 8181 Hillsborough NC 27278 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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. 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EACH ACCIDENT ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY DocuSign Envelope ID: 10A85B79-5184-4395-AE79-413DB1556EEE