bids for contract no. 16-04 - utility tree pruning, …...three dog construction's bid allows...

TO:

FROM:

DATE:

RE:

General Manager 334 Front street Ketchikan. AK 99901

Phone (907) 22&-5603 Fax (907) 225-5075

TRANSMITTAL MEMORANDUM

The Honorable Mayor and City Council

Karl R. Amylon, General Manager

March 4, 2016

Bids for Contract No. 16-04 - Utility Tree Pruning, Three Dog Construction Inc.

In adopting the 2016 Ketchikan Public Utilities Annual Budget, the City Council appropriated $190,000 to the Electric Division for annual tree pruning. As indicated in the attached memorandum from Electric Division Operations Manager Mark Adams, the Utility has advertised for and received sealed bids for Contract No. 16-04, Utility Tree Pruning. Two bids were received and publicly opened on Tuesday, March 1, 2016 at 2:00 p.m. in the Office of the Council Chambers. The Operations Manager's report contains a summary of the bids received.

Three Dog Construction Inc. of Ketchikan submitted the apparent low bid at a rate of $21 ,719.40/week and no mobilization/demobilization cost. Mr. Adams is recommending the City Council accept the bid as submitted.

A Notice of Intent to Award was issued on March 4, 2016. As of the date of this report, no appeals have been filed .

The Electric Division Operations Manager will be attending the City Council meeting of March 17, 2016, in order to address any questions and/or concerns that Councilmembers may have.

A motion has been prepared for City Council consideration.

RECOMMENDATION

It is recommended that the City Council adopt the motion accepting the bid of Three Dog Construction Inc. of Ketchikan, Alaska at a rate of $21 ,719.40/week and no mobilization/demobilization cost for Contract No. 16-04, Utility Tree Pruning; authorizing funding in an amount not to exceed $190,000 from the Electric Division 's 2016 Technical Services account (Account No. 635-12); and directing the General Manager to execute the contract documents on behalf of the City Council.

Recommended Motion: I move the City Council accept the bid of Three Dog Construction Inc. of Ketchikan, Alaska at a rate of $21 ,719.40/week and no mobilization/demobilization cost for Contract No. 16-04, Utility Tree Pruning; authorize funding in an amount not to exceed $190,000 from the Electric Division's 2016 Technical Services account (Account No. 635-12); and direct the General Manager to execute the contract documents on behalf of the City Council.

AGENDA- 03/17/16- KPUCA1

Your Cmnmunity. Your Utility

Electric Division I 065 Fair Street Ketchikan, AK 9990 I

Phone: (907) 225-5505 Fax: (907) 247-0755

TRANSMITTAL MEMORANDUM

TO: Karl Arnylon, KPU General Manager

FROM: Mark Adams, Electric Operations Manager

DATE: March 4, 2016

SUBJECT: Request Authorization to Award Contract No. 16-04, Utility Tree Trimming, to Three Dog Construction

On January 281\ KPU issued a request for bids for the annual utility tree trimming contract,

consisting of removals and pruning of trees growing near energized electrical lines and telecommunication lines.

The bid period closed February 291h, with KPU receiving two bids, which were publicly opened at

City Hall. Bids were received from the following companies:

• Three Dog Construction Inc., Ketchikan o ($21,719.40/week, $0.00 mob/demob, 8.75 weeks ofwork)

• Carlos Tree Service Inc., Anchorage o ($23,044.00/week, $0.00 mob/demob, 8.20 weeks ofwork)

Three Dog Construction' s bid allows for the most weeks of work, after factoring in mob/demob costs. They will be providing a 2-person line clearance tree trimming crew, equipment & tools, and traffic control support.

A Notice oflntent to Award was sent to both companies on March 4, 2016.

Recommendation: It is recommended that the City Council award Contract No. 16-04 Utility Tree Trimming, to Three Dog Construction of Ketchikan, Alaska, in the not-to-exceed amount of $190,000.

Attachment: Three Dog Construction Bid

cc: Andrew Donato, Electric Division Manager

K E TCHIKAN PUBLI C U TI L ITI ES

BIDDER'S LIST rcontract No~ 16-o4 Bid Open Date: 03/01/2016

Bid Name: Utility Tree Pruning Bid Open Time: 2:00 pm

COMPANY NAME Local Non- Bid Ack.

BID AMOUNT (USD) Bidder Collusion Bond Addend Other

1 lhree- ThCA- C!Pn~trud;~n v v #I 8.7419 2 Ccvr-to~ lree- ~LU V' # ! c;.:J.. 3

4

5

6

7

8

9

10

Prepared by: /!<J Opened in: Council Chambers

..... winword\forms\bidlist.docx

BID PROPOSAL

TO: The City of Ketchikan, Alaska, herein called the City:

Section 1.6.2 Addendum I

Pursuant to and in compliance with your Notice to Contractors Inviting Bids, Information For Bidders, Agreement and the other Contract Documents relating thereto, the undersigned Bidder, being fully familiarized with all the terms of all the Contract Documents and with the project site and local conditions and costs affecting the performance as called for in the Contract Documents, hereby proposed and agrees to perform, within the time and in the manner stipulated, the Contract, including all of its component parts, and everything required to be performed, and to provide and furnish any and all of the work labor, materials, tools, supplies, and all transportation and other services necessary to perform the Contract in a skillful and timely manner, all in strict conformity with the Contract Documents, including addenda for the following project:

UTILITY TREE PRUNING Contract 16-04

for an amount computed on the basis of the quantity of work actually performed at the prices set forth on the Bid Schedule herein contained consisting of five (5) sheets, which is incorporated and made a part of this Bid Proposal:

The undersigned Bidder hereby proposes and agrees to obtain all necessary approvals, furnish all labor, tools, equipment, materials, temporary structures and services required to furnish work FOB Ketchikan at the following cost per hour:

BID SCHEDULE

TREE CREW LOADED HOURLY LABOR RATES _(Monday - Friday)

Hours 1-8 Hours 9-10 Additional Hours (1) Qualified Line $ $ $ Clearance Tree

~~~ '2.~ ~.5"' if Trimmer - !Sl Foreman/Lead -~

(1) Qualified Line $ $ $ (Jl:? Clearance Tree /t)O~ }00

6)0 JSO ---Trimmer

$ $ $ TOTAL TREE CREW

~tl2~ j~?r_! 31:< ;a.> COST PER HOUR -(Monday- Friday)

BID SCHEDULE CONTINUED NEXT PAGE

Uti lity Tree Pruning, Contract 16-04 Page I of5

(1) Qualified Line $ Clearance Tree

Trimmer-Foreman/Lead

(1) Qualified Line $ Clearance Tree

Trimmer

$ TOTAL TREE CREW

COST PER HOUR (Saturday)

$ 151 Traffic Control

Person

$ 2"d Traffic Control

Person

$ TOTAL 2-PERSON

TRAFFIC CONTROL COST PER HOUR

(Monday- Saturday)


TREE CREW LOADED HOURLY LABOR RATES (Saturday)

Hours 1-8 Hours 9-10 Additional Hours $ $

IS"~ Jl~

'~" ~~ ;l~ ,._-- ~

$ $

()'(/) /00 tH? oo

/00 ·~ 1 s-o ·=-

$ $

's~~- ~~ 2S 1-~ zs-- 3 ~

2-PERSON TRAFFIC CONTROL LOADED HOURLY LABOR RATE (Monday- Saturda'll

Hours 1-8 Hours 9-10 Additional Hours $ $

;-:;- ss- 8'0 $ $

ss- ss- 80 $ $

I I 0' /I tl I tV

LUMP SUM $

MOBILIZATION I DEMOBILIZATION --e-The Basis of Award shall be the highest number of 6-day 10-hour/day work weeks possible, after the

Contractor's Mobilization/Demobilization costs have been subtracted from the not-to-exceed total contract amount of $190,000.

Uti lity Tree Pruning, Contract 16-04 Page 2 of5

A $190,000- Mobilization/Demobilization Lump Sum $

Total Tree Crew Cost Per Hour (Hours 1-8) $ /01~0?0 ~ (Monday- Friday) x 40 Hours

Total Tree Crew Cost Per Hour (Hours 9-10) $ :i. 51 ~ .. 2£ (Monday- Friday) x 10 Hours

Total Tree Crew Cost Per Hour (Hours 1-8) $ ;j' 0()}. C)_£_ (Saturday) x 8 Hours Total Tree Crew Cost Per Hour (Hours 9-10) /50"/ -ro (Saturday) x 2 Hours

Total 2-Person Traffic Control Cost Per Hour $ sl ~~ Bo "" (Hours 1-8) (Monday- Saturday) x 48 Hours /""

Total 2-Person Traffic Control Cost Per Hour ., o.·"

(Hours 9-10) (Monday- Saturday) x 12 Hours $ },3~0


B Total Crew Cost For a 6-Day 10-Hour/Day $ ~~ I r ;c; 'if2 Work Day (Monday- Saturday)

/

BASIS OF AWARD

AlB Highest Number of 6-Day 10-Hour/Day g,l-'177 WorkWeeks

The Contractor shall be paid the following additional cost per hour when additional traffic control personnel are required to perform work under this contract:

LOADED HOURLY LABOR RATE PER EACH PERSON (Monday- Saturday)

Hours 1-8 Hours 9-10 Additional Hours

$ $ $ Additional Traffic 80"...! gs- c?2 ;~s-~ Control Person

The Contractor shall include, with this bid packet, copies of training records as required in Section 3.1(V).

The Contractor shall include, with this bid packet, proof of enrollment in an approved controlled substance and alcohol use testing program, as required in Section 3.1 (XXII)(C).

Util ity Tree Pruning, Contract 16-04 Page 3 of 5


1. Award of Contract. The City shall have the right to reject this bid proposal and such bid proposal shall remain open and may not be withdrawn for a period of sixty (60) days after the date prescribed for its opening.

2. Execution of Contract and Performance Security. It is understood and agreed that if written notice of the acceptance of this proposal and award of the Contract is mailed, telefaxed or delivered to the undersigned Bidder within sixty (60) days after the opening of the proposal, or at any time thereafter before it is withdrawn in writing, the undersigned Bidder will execute and deliver the Agreement in the form set forth in the Contract Documents to the City in accordance with the proposal as accepted, and will also furnish and deliver to the City the performance and payment bonds on the forms provided in the Contract Documents, the Certificate of Insurance and policies of insurance and any other documents or bonds called for in the Contract Documents, all within ten (10) days after notice of acceptance and award of the Contract is given.

3. Notice of acceptance and award of the Contract or requests for additional information may be addressed to the undersigned Bidder at the business address set forth at the end of this proposal.

4. Wherever in this proposal an amount is stated in both words and figures, in case of discrepancy between words and figures, the words shall prevail; if all or any portion of the proposal is required to be given in unit prices and totals and a discrepancy exists between any such unit prices and totals so given, the unit prices shall prevail.

5. Receipt of the following Addenda to the Contract Documents is hereby acknowledged.

ADDENDUM DATE OF RECEIPT NO. OFADDENDUM

d.Y~/2. G /a..12~b 2

3

4

SIGNED ACKNOWLEDGMENT

&U;b~=->

(Note: Failure to acknowledge receipt of any addenda may be considered an irregularity in the proposal and grounds for rejection of the bid.)

BIDDER:

Three DotJ CoYJrfrve-fiiM In L

(Title)

Alaska Contractor License No._3~8:....'f~8:...l6oL' ___ _

Telephone & Fax 9oi)22 )-I] ':3"{:, !Fc..x 9&·1= ~'/1: -1 3<.>- 6

Business Mailing Address p D Bo 2( /35"6 w~ I'J Cove. @!< fn~§ Email Address fhr-ee.J4f] &11 £?74hoiJ.CCJtn

Utility Tree Pruning, Contract 16-04 Page 4 of5

Section 1.6.2

'2016.

NOTE: If Bidder is a corporation, the legal name of the corporation shall be set forth above together with the signatures of the officer or officers authorized to sign contracts on behalf of the corporation; if Bidder is co-partnership the true name of the firm shall be set forth above together with the signature of the partner or partners authorized to sign contracts in behalf of the co-partnership, and if Bidder is an individual, the appropriate signature shall be placed above.

Utility Tree Pruning, Contract No. 16-04 Page 5 ofS

Section 1.6.3

CONTRACTOR QUALIFICATION RECORD

CONTRACTOR's Qualified Line Clearance Tree Trimmers performing tree pruning & removal services

within the 10-foot Minimum Approach Distance (MAD) of KPU's transmission & distribution (T&D)

system shall be trained and qualified under the OSHA 1910.269 standard, in particular 1910.269{r), as

well as all other pertinent OSHA regulations.

YES (f!{ NO 0 OSHA 1910.269 is fully understood and shall be complied with

YES if No 0 MADs shall be abided by

YES ~NO 0 Qualified Line Clearance Tree Trimmers have a working knowledge of electrical T&D

systems and are capable of identifying potentially dangerous situations, and trained in the related safe

work practices.

YES ~0 0 Qualified Line Clearance Tree Trimmers shall utilize properly maintained, tested, and

inspected insulated tools and equipment when working within the MAD of energized electrical

components.

YES G"'No 0 Qualified Line Clearance Tree Trimmers shall be trained in climbing techniques and

rescue procedures.

YES ~NO 0 Qualified Line Clearance Tree Trimmers shall comply with the specifications and the

arborist standards of this contract.

List below any and all training that the Contractor provides its Qualified Line Clearance Tree Trimmers

1) I B_c.tV Lo c:._~l '

2) 1 I J4 I ·r, e. I

/J () I ~.J I L '...t . {tg t h 0:_ 3Jm !?"' ;)/...17 ...L-v J ~ ~,

3) __________________________________________________________ _

4) ____________________________________________________________ _

List below the on-the-job experience the Contractor's Qualified Line Clearance Tree Trimmers have

working in the vicinity of energized high-voltage electrical components:

{A li l;'/t 'r' . 9

Bidder/Contractor Signature:-------------- ---Date:-------

Utility Tree Pruning, Contract 16-04 Page 1 of 1

I

' ~ .. ~ .... 1'11- 11'1 ..... ~ t· a.u. BM1 . ..,. ___ Endorsements • NONE

Rellriction& · 1L -EXPIRES -ll2..o2-2019 ~

Nuaiber - .0

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Section 1.8

NON-COLLUSION AFFIDAVIT

CITY OF KETCHIKAN ) ) ss.

KETCHIKAN, ALASKA )

E.rnesf /fa.n?; /fon , first being duly sworn, on his oath says that the bid above submitted is a genuine and not a sham or collusive bid, or made in the interest or behalf of any person not herein named, and he further says that the said bidder has not directly or indirectly induced or solicited any bidder on the above work or supplies to put in a sham bid, or any other person or corporation to refrain from bidding; and that said bidder has not in any manner sought by collusion to secure to h/$ self an advantage over any other bidder or bidders.

Subscribed and sworn to before me this 8'1#-day of & b Yl./ a· "if= , 2016.

Yfla[JCe<'-& ovtM/ STATE OF ALASKA ---.~: .. ~.

NOTARY PUBLIC

MICHELLE BROWN ..

NOTARY PUBLIC FOR ALASKA)? . My Commission Expires: - {- /8

My commission Expires August 1. 2018

Utility Tree Pruning, Contract 16-04 Page I of I

Section 1.9

LOCAL BIDDER PREFERENCE STATEMENT

I, F-rnes.-f I HanJ,ifvVJ , certify that I am an authorized agent for i'h ~el!- Oo9 C<J .. ifn&t;c., :,,c.- , hereinafter referred to as CONTRACTOR is a local person, firm, or corporation as set forth in KMC 3.12.040(c); that CONTRACTOR holds a current Alaska business license; that CONTRACTOR submits a bid for goods or services under the name appearing on the CONTRACTOR's current Alaska business license; that CONTRACTOR has maintained a place of business within the boundaries of the Ketchikan Gateway Borough for a period of not less than six (6) months immediately preceding the date of the bid; and that CONTRACTOR is not delinquent in the payment of any taxes, charges, or assessments owing to the City of Ketchikan or to the Ketchikan Gateway Borough on account of that business.

Jhree. Do/JG~,slic.~C:.fi&ct ];,L ONTRACTOR

By:flme;/-)~ Title: J?r~(;c/e~,e·f' Alaska Business License No. '?9 3.:>7 ~

(Corporate Seal)

Utility Tree Pruning, Contract 16-04 Page 1 of 1

TIs Is the safety specialists

8800 Glacier Hwy #105

Juneau, AK 99801

(907) 523-8402

1325 Craig Klawock Hwy

Craig, AK 99921

(907)-401-0900 apt. only

906 Main St.

Keokuk, lA 52632

(319) 524-5051

416-R North 24th Street

Quincy, II 62301

(217)-223-2300

18 Northport Plaza

Hannibal, Mo 63401

(217)-223-2300 apt. only

1-877-225-1431

WIMW t.~.~-.~AfP.tV r.nm

"World class education and screening services for workplace and community safety."

we support a Drug Free Worleforce!

2016 C:E2lil'fiC.J2lil'O.?V"

Three Don

Construction

is enrolled in the

FMCSA-DOT Consortium Managed By

TSS Inc. All contracts expire 12/ 31/2016

7/29/2015

81576

Mr. Ernest Hamilton Three Dog Construction 320 Alder St. Ketchikan, AK 99901 ·

Dear Mr. Hamilton,

SAFER ROADS SAVE LIVES

The American Traffic Safety Services Association (ATSSA) appreciates your participation in our Traffic Control Supervisor course held in Ketchikan, AK. Your certificate of attendance is enclosed.

Please call us at 877-642-4637 if you have any questions.

Sincerely,

Training and Business Development Department

-Educated Employees Do Save Lives-

AMER I CAN TRAFFIC SAFE T Y SERVICES ASSOC I ATION

15 RIVERSIDE PARKWAY • SUITE 100 ·FREDERICKSBURG, VA22406-1022

TEL 540-368-1701 • FAX 540-368-1717 • TOLL FREE 800-272-8772 •TRAINING 877-642-4637

www.atssa.com

rrfie .!4merican rrraffic Safety Services Yl.ssociation

~J{erebl/ recoqnizes tfiat - ....

Ernest Hamilton has attended

Traffic Control Technician

07/21/2015 Training Course

Date

Ketchikan , AK Locatron

Trainrng & Products Dept Drrector

K:;~ 1/. J~ President CEO

rrfie .!4merican rrraffic Safety

07/23/2015 Date

Ketchikan , AK Locatror

Services Yl.ssociation :J(ere6LJ recoqni.::,es tfiat - ._

Ernest Hamilton has attended

Traffic Control Supervisor Training Course

Training & Products Dept Director

K::~ 1/. k/A1ff-Presrdent CEO

SIIIIIIAIS SAIIIIIIS

SAMPLE ACORD® CERTIFICATE OF LIABILITY INSURANCE l DATE (MMIDDNYYY)

~ 1/14/2016

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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s).

PRODUCER ~~~~~CT BiH Troupe

Davies-Barry Insurance ~~g~~o.Exll: (907)225-9841 I FAX iAIC Nol: (907) 225-1639

4205 Cambria Dr West #201 ~~A~~ss:biH@davies-barry. com

INSURER(S) AFFORDING COVERAGE NAIC# Ketchikan AK 99901 INSURERA:Great Divide Insurance Co 25224 INSURED INSURER B :Alaska National Insurance Co 38733 Three Dog Construction Inc., DBA: Three Dog INSURERC :

320 Al.der Street INSURER D :

INSURER E:

Ketchikan AK 99901 INSURER F :

COVERAGES CERTIFICATE NUMBER·LJ.ab2016 REVISION NUMBER·

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR TYPE OF INSURANCE ~~~~ = ~~3:5%~1 , ,~ghl&~, LIMITS LTR POLICY NUMBER

X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1 , 000 ,000 - tJ CLAIMS-MADE W OCCUR ~~~~~J~E~~~~~encel A - s 100 ,000

GC59B98408 3/15/2015 3/ 15/2016 MED EXP (Any one person) s 5,000 r--r-- PERSONAL & ADV INJURY s 1,000, 000

~'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2 , 000,000

DPRO· D PRODUCTS · COMPIOP AGG 2,000,000 POLICY JECT LOC s

OTHER: s

AUTOMOBILE LIABILITY I )'i:~~~~d~~l\SI Nt:,;LE LIMIT s -

ANY AUTO BODILY INJURY (Per person) s - ALLOv.t>IED r-- SCHEDULED

AUTOS AUTOS BODILY INJURY (Per accldenl) S - }-- NON-OWNED _fp~?~;~~~~AMAGE HIREOAUTOS AUTOS s r--- }--

s UMBRELLA UAB

HOCCUR EACH OCCURRENCE s I--

EXCESS LIAB CLAIMS-MADE AGGREGATE s OED I I RETENTION s s

WORKERS COMPENSATION I ~¥~TUTE I X I ~~H· AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE [!] NIA E.L. EACH ACCIDENT s 1 000,000 OFFICER/MEMBER EXCLUDED?

B (Mandatory In NH) 15GWW96047 7/13/2015 7/13/2016 E.L. DISEASE · EA EMPLOYEE s 1 000 000

~~;~~f~irJ~ 'b1'i)PERATIONS below E.L. DISEASE · POliCY LIMIT $ 1 000 000

DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addlllonal Remarks Schedule, may be attached lr more space Is required)

CERTIFICATE HOLDER

Paul Hamilton

P & T Construction

PO Box 1054

Ward Cove,

ACORD 25 (2014/01)

INS025 (201401 1

AK 99928

CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

Bill Troupe/BILL ~~~ © 1988-2014 ACORD CORPORATION. All nghts reserved.

The ACORD name and logo are registered marks of ACORD

Additional Named Insureds

Other Named Insureds

Three Dog Construction Doing Business As

OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC

ADDITIONAL COVERAGES Ref# I Description I Coverage Code Form No. I Edition Date

Alaska Insurance Guaranty Association AlGA

Limit 1 I Limit 2 I Limit 3 I Deductible Amount I Deductible Type Premium

Ref# I Description I Coverage Code Form No. I Edition Date Schedule rate adjustment SRA


$75.00

Ref# I Description I Coverage Code Form No. I Edition Date Contractors Prem Adjust Program CPAP


$10.00

Ref# I Description I Coverage Code Form No. I Edition Date Surcharges SURC


Ref# I Description I Coverage Code Form No. I Edition Date Increased employer's liability INEL


$100.00

Ref# I Description I Coverage Code Form No. I Edition Date Add'i for policy minimum premium APMP

Limit 1 I Limit 2 I Limit 3 I Deductible Amount J Deductible Type Premium

Ref# I Description I Coverage Code Form No. I Edition Date Terrorism TERR


Ref# I Description I Coverage Code Form No. I Edition Date Experience Mod Factor 1 EXP01

Limit 1 I Limit2 I Limit 3 I Deductible Amount I Deductible Type Premium

Ref# I Description I Coverage Code Form No. I Edition Date



Limit 1 I Limit2 I Limit 3 I Deductible Amount I Deductible Type Premium



OFADTLCV Copyright 2001, AMS Services, Inc.