HomeMy WebLinkAboutC-5625 - PSA for Asbestos Abatement Oversight for 1770 Balboa Blvd. (Marina Park)(ti
PROFESSIONAL SERVICES AGREEMENT
WITH STEARNS, CONRAD AND SCHMIDT CONSULTING ENGINEERS, INC.
DBA SCS ENGINEERS FOR
v ASBESTOS ABATEMENT OVERSIGHT FOR 1770 BALBOA BLVD.
(MARINA PARK)
THIS PROFESSIONAL SERVICES AGREEMENT ( "Agreement") is made and
entered into as of this 13th day of September, 2013 ( "Effective Date "), by and between
the CITY OF NEWPORT BEACH, a California municipal corporation and charter city
( "City "), and STEARNS, CONRAD AND SCHMIDT CONSULTING ENGINEERS, INC.,
a Virginia corporation, doing business as SCS ENGINEERS ( "Consultant "), whose
address is 3900 Kilroy Airport Way, Suite 100, Long Beach, CA 90806 -6810, and is
made with reference to the following:
RECITALS
A. City is a municipal corporation duly organized and validly existing under the laws
of the State of California with the power to carry on its business as it is now being
conducted under the statutes of the State of California and the Charter of City.
B. City desires to engage Consultant to perform asbestos abatement oversight at
1770 Balboa Blvd. (Marina Park) ("Project ").
C. Consultant possesses the skill, experience, ability, background, certification and
knowledge to provide the professional services described in this Agreement.
D. City has solicited and received a proposal from Consultant, has reviewed the
previous experience and evaluated the expertise of Consultant, and desires to
retain Consultant to render professional services under the terms and conditions
set forth in this Agreement.
NOW, THEREFORE, it is mutually agreed by and between the undersigned
parties as follows:
1. TERM
The term of this Agreement shall commence on the Effective Date, and shall
terminate on dune 30, 2015, unless terminated earlier as set forth herein.
2. SERVICES TO BE PERFORMED
Consultant shall diligently perform all the services described in the Scope of
Services attached hereto as Exhibit A and incorporated herein by reference ("Services"
or "Work "). City may elect to delete certain Services within the Scope of Services at its
sole discretion.
DMNNEURAi i' 0
3.1 Time is of the essence in the performance of Services under this
Agreement and Consultant shall perform the Services in accordance with the schedule
included in Exhibit A. In the absence of a specific schedule, the Services shall be
performed to completion in a diligent and timely manner. The failure by Consultant to
strictly adhere to the schedule set forth in Exhibit A, if any, or perform the Services in a
diligent and timely manner may result in termination of this Agreement by City.
3.2 Notwithstanding the foregoing, Consultant shall not be responsible for
delays due to causes beyond Consultant's reasonable control. However, in the case of
any such delay in the Services to be provided for the Project, each party hereby agrees
to provide notice within two (2) calendar days of the occurrence causing the delay to the
other party so that all delays can be addressed.
33 Consultant shall submit all requests for extensions of time for performance
in writing to the Project Administrator as defined herein not later than ten (10) calendar
days after the start of the condition that purportedly causes a delay. The Project
Administrator shall review all such requests and may grant reasonable time extensions
for unforeseeable delays that are beyond Consultant's control.
3.4 For all time periods not specifically set forth herein, Consultant shall
respond in the most expedient and appropriate manner under the circumstances, by
hand - delivery or mail.
4. COMPENSATION TO CONSULTANT
4.1 City shall pay Consultant for the Services on a time and expense not -to-
exceed basis in accordance with the provisions of this Section and the Schedule of
Billing Rates attached hereto as Exhibit B and incorporated herein by reference.
Consultant's compensation for all Work performed in accordance with this Agreement,
including all reimbursable items and subconsultant fees, shall not exceed Eleven
Thousand Seven Hundred dollars ($11,700.00), without prior written authorization
from City. No billing rate changes shall be made during the term of this Agreement
without the prior written approval of City.
4.2 Consultant shall submit monthly invoices to City describing the Work
performed the preceding month. Consultant's bills shall include the name of the person
who performed the Work, a brief description of the Services performed and/or the
specific task in the Scope of Services to which it relates, the date the Services were
performed, the number of hours spent on all Work billed on an hourly basis, and a
description of any reimbursable expenditures. City shall pay Consultant no later than
thirty (30) calendar days after approval of the monthly invoice by City staff.
4.3 City shall reimburse Consultant only for those costs or expenses
specifically identified in Exhibit B to this Agreement or specifically approved in writing in
advance by City.
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4.4 Consultant shall not receive any compensation for Extra Work performed
without the prior written authorization of City. As used herein, "Extra Work° means any
Work that is determined by City to be necessary for the proper completion of the
Project, but which is not included within the Scope of Services and which the parties did
not reasonably anticipate would be necessary at the execution of this Agreement.
Compensation for any authorized Extra Work shall be paid in accordance with the
Schedule of Billing Rates as set forth in Exhibit B.
5. PROJECT MANAGER
5.1 Consultant shall designate a Project Manager, who shall coordinate all
phases of the Project. This Project Manager shall be available to City at all reasonable
times during the Agreement term. Consultant has designated Udo G. Steinberger, P.E.,
C.A.C. to be its Project Manager. Consultant shall not remove or reassign the Project
Manager or any personnel listed in Exhibit A or assign any new or replacement
personnel to the Project without the prior written consent of City. City's approval shall
not be unreasonably withheld with respect to the removal or assignment of non -key
personnel.
5.2 Consultant, at the sole discretion of City, shall remove from the Project
any of its personnel assigned to the performance of Services upon written request of
City. Consultant warrants that it will continuously furnish the necessary personnel to
complete the Project on a timely basis as contemplated by this Agreement.
5.3 If Consultant is performing inspection services for City, the Project
Manager and any other assigned staff shall be equipped with a cellular phone to
communicate with City staff. The Project Manager's cellular phone number shall be
provided to City.
6. ADMINISTRATION
This Agreement will be administered by the Public Works Department. City's
Senior Civil Engineer or designee shall be the Project Administrator and shall have the
authority to act for City under this Agreement. The Project Administrator shall represent
City in all matters pertaining to the Services to be rendered pursuant to this Agreement.
7. CITY'S RESPONSIBILITIES
To assist Consultant in the execution of its responsibilities under this Agreement,
City agrees to provide access to and upon request of Consultant, one copy of all
existing relevant information on file at City. City will provide all such materials in a
timely manner so as not to cause delays in Consultant's Work schedule.
8. STANDARD OF CARE
8.1 All of the Services shall be performed by Consultant or under Consultant's
supervision. Consultant represents that it possesses the professional and technical
personnel required to perform the services required by this Agreement, and that it will
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perform all services in a manner commensurate with community professional standards.
The term 'community professional standards' shall be defined as the skill and care of a
reasonably prudent member of the profession in the community where the project is
located.
82 All Services shall be performed by qualified and experienced personnel
who are not employed by City. By delivery of completed Work, Consultant certifies that
the Work conforms to the requirements of this Agreement, all applicable federal, state
and local laws, and the highest professional standard.
8.3 Consultant represents and warrants to City that it has, shall obtain, and
shall keep in full force and effect during the term hereof, at its sole cost and expense, all
licenses, permits, qualifications, insurance and approvals of whatsoever nature that is
legally required of Consultant to practice its profession. Consultant shall maintain a City
of Newport Beach business license during the term of this Agreement.
8.4 Consultant shall not be responsible for delay, nor shall Consultant be
responsible for damages or be in default or deemed to be in default by reason of strikes,
lockouts, accidents, acts of God, or the failure of City to furnish timely information or to
approve or disapprove Consultant's Work promptly, or delay or faulty performance by
City, contractors, or governmental agencies.
9. HOLD HARMLESS
9.1 To the fullest extent permitted by law, Consultant shall indemnify, defend
and hold harmless City, its City Council, boards and commissions, officers, agents,
volunteers and employees (collectively, the "Indemnified Parties ") from and against any
and all claims (including, without limitation, claims for bodily injury, death or damage to
property), demands, obligations, damages, actions, causes of action, suits, losses,
judgments, fines, penalties, liabilities, costs and expenses (including, without limitation,
attorneys' fees, disbursements and court costs) of every kind and nature whatsoever
(individually, a Claim; collectively, "Claims "), which may arise from or in any manner
relate (directly or indirectly) to any breach of the terms and conditions of this
Agreement, any Work performed or Services provided under this Agreement including,
without limitation, defects in workmanship or materials or Consultant's presence or
activities conducted on the Project (including the negligent, reckless, and /or willful acts,
errors and /or omissions of Consultant, its principals, officers, agents, employees,
vendors, suppliers, consultants, subcontractors, anyone employed directly or indirectly
by any of them or for whose acts they may be liable, or any or all of them).
9.2 Notwithstanding the foregoing, nothing herein shall be construed to
require Consultant to indemnify the Indemnified Parties from any Claim arising from the
sole negligence or willful misconduct of the Indemnified Parties. Nothing in this
indemnity shall be construed as authorizing any award of attorneys' fees in any action
on or to enforce the terms of this Agreement. This indemnity shall apply to all claims
and liability regardless of whether any insurance policies are applicable. The policy
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limits do not act as a limitation upon the amount of indemnification to be provided by
Consultant.
10. INDEPENDENT CONTRACTOR
It is understood that City retains Consultant on an independent contractor basis
and Consultant is not an agent or employee of City. The manner and means of
conducting the Work are under the control of Consultant, except to the extent they are
limited by statute, rule or regulation and the expressed terms of this Agreement. No
civil service status or other right of employment shall accrue to Consultant or its
employees. Nothing in this Agreement shall be deemed to constitute approval for
Consultant or any of Consultant's employees or agents, to be the agents or employees
of City. Consultant shall have the responsibility for and control over the means of
performing the Work, provided that Consultant is in compliance with the terms of this
Agreement. Anything in this Agreement that may appear to give City the right to direct
Consultant as to the details of the performance of the Work or to exercise a measure of
control over Consultant shall mean only that Consultant shall follow the desires of City
with respect to the results of the Services.
Consultant agrees to work closely and cooperate fully with City's designated
Project Administrator and any other agencies that may have jurisdiction or interest in the
Work to be performed. City agrees to cooperate with the Consultant on the Project.
12. CITY POLICY
Consultant shall discuss and review all matters relating to policy and Project
direction with City's Project Administrator in advance of all critical decision points in
order to ensure the Project proceeds in a manner consistent with City goals and
policies.
13. PROGRESS
Consultant is responsible for keeping the Project Administrator informed on a
regular basis regarding the status and progress of the Project, activities performed and
planned, and any meetings that have been scheduled or are desired.
14. INSURANCE
Without limiting Consultant's indemnification of City, and prior to commencement
of Work, Consultant shall obtain, provide and maintain at its own expense during the
term of this Agreement or for other periods as specified in this Agreement, policies of
insurance of the type, amounts, terms and conditions described in the Insurance
Requirements attached hereto as Exhibit C, and incorporated herein by reference.
SCS Engineers Page 5
Except as specifically authorized under this Agreement, the Services to be
provided under this Agreement shall not be assigned, transferred contracted or
subcontracted out without the prior written approval of City. Any of the following shall
be construed as an assignment: The sale, assignment, transfer or other disposition of
any of the issued and outstanding capital stock of Consultant, or of the interest of any
general partner or joint venturer or syndicate member or cotenant if Consultant is a
partnership or joint - venture or syndicate or co- tenancy, which shall result in changing
the control of Consultant. Control means fifty percent (50 %) or more of the voting
power or twenty -five percent (25 %) or more of the assets of the corporation, partnership
or joint - venture.
16. SUBCONTRACTING
The subcontractors authorized by City, if any, to perform Work on this Project are
identified in Exhibit A. Consultant shall be fully responsible to City for all acts and
omissions of any subcontractor. Nothing in this Agreement shall create any contractual
relationship between City and any subcontractor nor shall it create any obligation on the
part of City to pay or to see to the payment of any monies due to any such
subcontractor other than as otherwise required by law. City is an intended beneficiary
of any Work performed by the subcontractor for purposes of establishing a duty of care
between the subcontractor and City. Except as specifically authorized herein, the
Services to be provided under this Agreement shall not be otherwise assigned,
transferred, contracted or subcontracted out without the prior written approval of City.
17. OWNERSHIP OF DOCUMENTS
17.1 Each and every report, draft, map, record, plan, document and other
writing produced (hereinafter "Documents "), prepared or caused to be prepared by
Consultant, its officers, employees, agents and subcontractors, in the course of
implementing this Agreement, shall become the exclusive property of City, and City
shall have the sole right to use such materials in its discretion without further
compensation to Consultant or any other party. Consultant shall, at Consultant's
expense, provide such Documents to City upon prior written request.
17.2 Documents, including drawings and specifications, prepared by
Consultant pursuant to this Agreement are not intended or represented to be suitable
for reuse by City or others on any other project. Any use of completed Documents for
other projects and any use of incomplete Documents without specific written
authorization from Consultant will be at City's sole risk and without liability to
Consultant. Further, any and all liability arising out of changes made to Consultant's
deliverables under this Agreement by City or persons other than Consultant is waived
against Consultant, and City assumes full responsibility for such changes unless City
has given Consultant prior notice and has received from Consultant written consent for
such changes.
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17.3 All written documents shall be transmitted to City in formats compatible
with Microsoft Office and /or viewable with Adobe Acrobat.
18. CONFIDENTIALITY
All Documents, including drafts, preliminary drawings or plans, notes and
communications that result from the Services in this Agreement, shall be kept
confidential unless City expressly authorizes in writing the release of information.
19. INTELLECTUAL PROPERTY INDEMNITY
Consultant shall defend and indemnify City, its agents, officers, representatives
and employees against any and all liability, including costs, for infringement or alleged
infringement of any United States' letters patent, trademark, or copyright, including
costs, contained in Consultant's Documents provided under this Agreement.
20. RECORDS
Consultant shall keep records and invoices in connection with the Services to be
performed under this Agreement. Consultant shall maintain complete and accurate
records with respect to the costs incurred under this Agreement and any Services,
expenditures and disbursements charged to City, for a minimum period of three (3)
years, or for any longer period required by law, from the date of final payment to
Consultant under this Agreement. All such records and invoices shall be clearly
identifiable. Consultant shall allow a representative of City to examine, audit and make
transcripts or copies of such records and invoices during regular business hours.
Consultant shall allow inspection of all Work, data, Documents, proceedings and
activities related to the Agreement for a period of three (3) years from the date of final
payment to Consultant under this Agreement.
21. WITHHOLDINGS
City may withhold payment to Consultant of any disputed sums until satisfaction
of the dispute with respect to such payment. Such withholding shall not be deemed to
constitute a failure to pay according to the terms of this Agreement. Consultant shall
not discontinue Work as a result of such withholding. Consultant shall have an
immediate right to appeal to the City Manager or designee with respect to such disputed
sums. Consultant shall be entitled to receive interest on any withheld sums at the rate of
return that City earned on its investments during the time period, from the date of
withholding of any amounts found to have been improperly withheld.
22. ERRORS AND OMISSIONS
In the event of errors or omissions that are due to the negligence or professional
inexperience of Consultant which result in expense to City greater than what would
have resulted if there were not errors or omissions in the Work accomplished by
Consultant, the additional design, construction and /or restoration expense shall be
SCS Engineers Page 7
borne by Consultant. Nothing in this Section is intended to limit City's rights under the
law or any other sections of this Agreement.
23. CITY'S RIGHT TO EMPLOY OTHER CONSULTANTS
City reserves the right to employ other Consultants in connection with the
Project.
24. CONFLICTS OF INTEREST
24.1 Consultant or its employees may be subject to the provisions of the
California Political Reform Act of 1974 (the "Act "), which (1) requires such persons to
disclose any financial interest that may foreseeably be materially affected by the Work
performed under this Agreement, and (2) prohibits such persons from making, or
participating in making, decisions that will foreseeably financially affect such interest.
24.2 If subject to the Act, Consultant shall conform to all requirements of the
Act. Failure to do so constitutes a material breach and is grounds for immediate
termination of this Agreement by City. Consultant shall indemnify and hold harmless
City for any and all claims for damages resulting from Consultant's violation of this
Section.
25. NOTICES
25.1 All notices, demands, requests or approvals, including any change in
mailing address, to be given under the terms of this Agreement shall be given in writing,
and conclusively shall be deemed served when delivered personally, or on the third
business day after the deposit thereof in the United States mail, postage prepaid, first -
class mail, addressed as hereinafter provided.
25.2 All notices, demands, requests or approvals from Consultant to City shall
be addressed to City at:
Attn: Iris Lee, Senior Civil Engineer
Public Works Department
City of Newport Beach
100 Civic Center Drive
PO Box 1768
Newport Beach, CA 92658
253 All notices, demands, requests or approvals from City to Consultant shall
be addressed to Consultant at:
Attn: Udo G. Steinberger, P.E., C.A.C.
SCS Engineers
3900 Kilroy Airport Way, Suite 100
Long Beach, CA 90806
SCS Engineers Page 8
26. CLAIMS
Unless a shorter time is specified elsewhere in this Agreement, before making its
final request for payment under this Agreement, Consultant shall submit to City, in
writing, all claims for compensation under or arising out of this Agreement.
Consultant's acceptance of the final payment shall constitute a waiver of all claims for
compensation under or arising out of this Agreement except those previously made in
writing and identified by Consultant in writing as unsettled at the time of its final request
for payment. Consultant and City expressly agree that in addition to any claims filing
requirements set forth in the Agreement, Consultant shall be required to file any claim
Consultant may have against City in strict conformance with the Government Claims Act
(Government Code sections 900 et seq.).
27. TERMINATION
27.1 In the event that either party fails or refuses to perform any of the
provisions of this Agreement at the time and in the manner required, that party shall be
deemed in default in the performance of this Agreement. If such default is not cured
within a period of two (2) calendar days, or if more than two (2) calendar days are
reasonably required to cure the default and the defaulting party fails to give adequate
assurance of due performance within two (2) calendar days after receipt of written
notice of default, specifying the nature of such default and the steps necessary to cure
such default, and thereafter diligently take steps to cure the default, the non - defaulting
party may terminate the Agreement forthwith by giving to the defaulting party written
notice thereof.
27.2 Notwithstanding the above provisions, City shall have the right, at its sole
and absolute discretion and without cause, of terminating this Agreement at any time by
giving no less than seven (7) calendar days' prior written notice to Consultant. In the
event of termination under this Section, City shall pay Consultant for Services
satisfactorily performed and costs incurred up to the effective date of termination for
which Consultant has not been previously paid. On the effective date of termination,
Consultant shall deliver to City all reports, Documents and other information developed
or accumulated in the performance of this Agreement, whether in draft or final form.
28. STANDARD PROVISIONS
28.1 Recitals. City and Consultant acknowledge that the above Recitals are
true and correct and are hereby incorporated by reference into this Agreement.
28.2 Compliance with all Laws. Consultant shall, at its own cost and expense,
comply with all statutes, ordinances, regulations and requirements of all governmental
entities, including federal, state, county or municipal, whether now in force or hereinafter
enacted. In addition, all Work prepared by Consultant shall conform to applicable City,
county, state and federal laws, rules, regulations and permit requirements and be
subject to approval of the Project Administrator and City.
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28.3 Waiver. A waiver by either party of any breach, of any term, covenant or
condition contained herein shall not be deemed to be a waiver of any subsequent
breach of the same or any other term, covenant or condition contained herein, whether
of the same or a different character.
28.4 Integrated Contract. This Agreement represents the full and complete
understanding of every kind or nature whatsoever between the parties hereto, and all
preliminary negotiations and agreements of whatsoever kind or nature are merged
herein. No verbal agreement or implied covenant shall be held to vary the provisions
herein.
28.5 Conflicts or Inconsistencies. In the event there are any conflicts or
inconsistencies between this Agreement and the Scope of Services or any other
attachments attached hereto, the terms of this Agreement shall govern.
28.6 Interpretation. The terms of this Agreement shall be construed in
accordance with the meaning of the language used and shall not be construed for or
against either party by reason of the authorship of the Agreement or any other rule of
construction which might otherwise apply.
28.7 Amendments. This Agreement may be modified or amended only by a
written document executed by both Consultant and City and approved as to form by the
City Attorney.
28.8 Severability. If any term or portion of this Agreement is held to be invalid,
illegal, or otherwise unenforceable by a court of competent jurisdiction, the remaining
provisions of this Agreement shall continue in full force and effect.
28.9 Controlling Law and Venue. The laws of the State of California shall
govem this Agreement and all matters relating to it and any action brought relating to
this Agreement shall be adjudicated in a court of competent jurisdiction in the County of
Orange, State of California.
28.10 Equal Opportunity Employment. Consultant represents that it is an equal
opportunity employer and it shall not discriminate against any subcontractor, employee
or applicant for employment because of race, religion, color, national origin, handicap,
ancestry, sex, age or any other impermissible basis under law.
28.11 No Attorneys' Fees. In the event of any dispute or legal action arising
under this Agreement, the prevailing party shall not be entitled to attorneys' fees.
28.12 Counterparts. This Agreement may be executed in two (2) or more
counterparts, each of which shall be deemed an original and all of which together shall
constitute one (1) and the same instrument.
[SIGNATURES ON NEXT PAGE]
SCS Engineers Page
IN WITNESS WHEREOF, the parties have caused this Agreement to be
executed on the dates written below.
APPROVED AS TO FORM: CITY OF NEWPORT BEACH,
CITY ATTORNEY' OFFICE a California municipal corporation
Date: Date: 13
By:"�ecllC '60 By.
Aaron C. arp Da ' eb
City Attorney Director of Public Works
ATTEST: CONSULTANT: STEARNS, CONRAD
Date: /0` %g, �3 AND SCHMIDT CONSULTING
ENGINEERS, INC., a Virginia corporation,
doing business as SCS ENGINEERS
Date: I
c
By: By: _
Leilani I. Brown Vce
Nuno
City Clerk President
��RN►P
Date: Io/'7/13
B -. 9�� C -W-t�
Jane Webb
Assistant Secretary
[END OF SIGNATURES]
Attachments: Exhibit A — Scope of Services
Exhibit B — Schedule of Billing Rates
Exhibit C — Insurance Requirements
SCS Engineers Page 11
EXHIBIT A
SCOPE OF SERVICES
SCS Engineers Page A-1
Environmental Consultants
and Contractors
August 26, 2013
Proposal No. 0108072I3
City of Newport Beach
C/O Jon Hughes- Construction Manager
100 Civic Center Drive
Newport Beach, California 92660
3940 Kilroy Airport Way 562 426 -9544
Suite 100 FAX 562 427 -0805
Long Beach, CA 90806 -6816 www.scsenginaers.eom
Via email (1hughes6Dgriftinholdings.net) and US Mail
Subject: Proposal for Asbestos Abatement Oversight
1770 Balboa Boulevard (Marina Park), Newport Beach, California (Package 1)
This letter serves as SCS Engineers' proposal to perform asbestos abatement oversight at
the above-referenced property. The scope of this project includes conducting one contractor
bid walk, one pre - construction meeting, oversight during removal of Asbestos- Containing
Materials (ACMs), air sampling during ACM removal, and preparation of an abatement
completion letter. ACMs were identified during inspections performed by Envirocheck,
Inc. in June and July, 2012. Identified ACMs consist of various vinyl flooring, drywall, and
roofing materials identified within fifty-eight (58) mobile homes,
Abatement observation and air monitoring will be performed by SCS personnel who are
Cal -OSHA certified asbestos consultants (C.A.C.).
Proposed site activities include conducting an abatement contractor bid walk, pre - construction
meeting, oversight and documentation of contractor performance during abatement activities, as
well as air sampling performed during abatement work. Air samples will be collected utilizing
low and/or high volume air sampling pumps. Collected air samples will be analyzed by an
accredited laboratory via phase contrast microscopy (PCM) techniques to determine airborne
fiber concentrations. Each day of inspection will be invoiced at a rate of $600 and will include
the following:
• Air sampling (maximum of 4 air samples per day)
• Transportation of air samples to the laboratory
• Interpretation of analytical results
• Observation of ACM removal activities
• Preparation of daily observation reports
• Interpretation of air sample analysis results
• Travel time and mileage
During abatement of ACMs, SCS will prepare daily reports of observations and document any
comments or instructions given to the abatement contractor. If situations are observed that warrant
Offices Nationwide
Proposal No. 010807213
August 26, 2013
Page 2
work stoppage, SCS will contact a Client representative and make appropriate recommendations,
Situations, which would warrant such action include excessive (e.g., visible) airborne fiber
concentrations, significant health and safety violations by the contractor, and/or lack of compliance
with federal, state, or local regulations with respect to asbestos abatement activities.
A final letter report of oversight activities will be submitted to the Client as soon as abatement
contractor submittals have been received by SCS. The final report will include the following:
• Air monitoring results
• Daily inspection reports
• Abatement contractor records package
• SCAQMD notification
• Waste disposal manifests
The total estimated cost to provide the above - described asbestos abatement oversight services, as
summarized in the enclosure, is $7,404 based on ten (10) days of abatement activities. This
proposal includes SCS attendance at the abatement contractor bid walk and at a pre - construction
meeting. If requested, attendance at additional contractor and/or progress meetings will be
provided on a time- and - material basis.
If this proposal meets with your approval, please sign and return the enclosed Agreement to our
office. A completed copy of the Agreement will be returned for your files. The project will be
completed under the terms and conditions of the attached Agreement. Client agrees to arrange
access to the site during normal working hours.
This proposal is valid for a period of 45 days from the date of submittal. Should you have any
questions regarding this proposal, please contact either of the undersigned at (562) 426 -9544.
Sincerely,
Udo G. Steinberg r, P E., C.A.C.
Project Manager
(CAC 98 -2491)
SCS ENGINEERS
k
olio A. Nuno,
Vice President
SCS ENGINEERS
Enclosures: Cost Estimate and Professional Services Agreement
s �
SCHEDULE OF BILLING RATES
SCS Engineers Page B -1
ENCLOSURE 1
COST ESTIMATE FOR ACM ABATEMENT OVERSIGHT
770 WEST BALBOA BOULEVARD, NEWPORT BEACH
(PACKAGE 1)
Abatement, Oversight, and Reporting
SCS will monitor abatement activities, and collect a maximum of 4 air samples per day
during abatement. These samples will be collected during ACM removal activities in order to
monitor airborne fiber concentrations inside as well as upwind and downwind of the
structures. Following asbestos removal, SCS will prepare an abatement completion letter to
be used to obtain renovation /demolition permits. This letter will include copies of daily
inspection logs describing site activities and observations, air samples analyses, waste
manifests, and SCAQMD project notifications. A daily rate of $600 (includes staff,
equipment, air sampling, misc.) will be invoiced for oversight.
• Daily Rate of $520 ............................. . .......................................... :................ $ 520
• Air Monitoring (4 air samples per day at $20 per sample) .................... $ 80
• Total (per day) .................................................................... ..............................$ 600
For an anticipated project duration of 10 working days ............................$ 6,000
• Completion Letter: .......................... .................................................................. $ 900
• Coordination, Administration, and Project Management: .......................... $ 500
Total anticipated project cost: ......................................................... $ 7,400
(Note: Additional working days will be invoiced at $600 per day. Additional bulk sampling
and analysis will be invoiced on a time and material basis)
INSURANCE REQUIREMENTS — PROFESSIONAL SERVICES
1. Provision of Insurance. Without limiting Consultant's indemnification of City, and
prior to commencement of Work, Consultant shall obtain, provide and maintain at
its own expense during the term of this Agreement, policies of insurance of the
type and amounts described below and in a form satisfactory to City. Consultant
agrees to provide insurance in accordance with requirements set forth here. If
Consultant uses existing coverage to comply and that coverage does not meet
these requirements, Consultant agrees to amend, supplement or endorse the
existing coverage.
2. Acceptable Insurers. All insurance policies shall be issued by an insurance
company currently authorized by the Insurance Commissioner to transact
business of insurance in the State of California, with an assigned policyholders'
Rating of A- (or higher) and Financial Size Category Class VII (or larger) in
accordance with the latest edition of Best's Key Rating Guide, unless otherwise
approved by the City's Risk Manager.
3. Coverage Requirements
A. Workers' Compensation Insurance. Consultant shall maintain Workers'
Compensation Insurance, statutory limits, and Employer's Liability
Insurance with limits of at least one million dollars ($1,000,000) each
accident for bodily injury by accident and each employee for bodily injury
by disease in accordance with the laws of the State of California, Section
3700 of the Labor Code.
Consultant shall submit to City, along with the certificate of insurance, a
Waiver of Subrogation endorsement in favor of City, its officers, agents,
employees and volunteers.
B. General Liability Insurance. Consultant shall maintain commercial general
liability insurance, and if necessary umbrella liability insurance, with
coverage at least as broad as provided by Insurance Services Office form
CG 00 01, in an amount not less than one million dollars ($1,000,000) per
occurrence, one million dollars ($1,000,000) general aggregate. The
policy shall cover liability arising from premises, operations, personal and
advertising injury, and liability assumed under an insured contract
(including the tort liability of another assumed in a business contract) with
no endorsement or modification limiting the scope of coverage for liability
assumed under a contract.
C. Automobile Liability Insurance. Consultant shall maintain automobile
insurance at least as broad as Insurance Services Office form CA 00 01
covering bodily injury and property damage for all activities of Consultant
arising out of or in connection with Work to be performed under this
Agreement, including coverage for any owned, hired, non -owned or rented
SCS Engineers Page C -1
vehicles, in an amount not less than one million dollars ($1,000,000)
combined single limit each accident.
D. Professional Liability (Errors & Omissions) Insurance. Consultant shall
maintain professional liability insurance that covers the Services to be
performed in connection with this Agreement, in the minimum amount of
one million dollars ($1,000,000) per claim and in the aggregate. Any policy
inception date, continuity date, or retroactive date must be before the
Effective Date of this Agreement and Consultant agrees to maintain
continuous coverage through a period no less than three years after
completion of the Services required by this Agreement.
4. tither Insurance Requirements. The policies are to contain, or be endorsed to
contain, the following provisions:
A. Waiver of Subrogation. All insurance coverage maintained or procured
pursuant to this Agreement shall be endorsed to waive subrogation
against City, its elected or appointed officers, agents, officials, employees
and volunteers or shall specifically allow Consultant or others providing
insurance evidence in compliance with these requirements to waive their
right of recovery prior to a loss. Consultant hereby waives its own right of
recovery against City, and shall require similar written express waivers
from each of its subconsultants.
B. Additional Insured Status. All liability policies including general liability,
excess liability, pollution liability, and automobile liability, if required, but
not including professional liability, shall provide or be endorsed to provide
that City and its officers, officials, employees, and agents shall be included
as insureds under such policies.
C. Primary and Non Contributory. All liability coverage shall apply on a
primary basis and shall not require contribution from any insurance or self -
insurance maintained by City.
D. Notice of Cancellation. All policies shall provide City with thirty (30)
calendar days notice of cancellation (except for nonpayment for which ten
(10) calendar days notice is required) or nonrenewal of coverage for each
required coverage.
5. Additional Agreements Between the Parties. The parties hereby agree to the
following:
A. Evidence of Insurance. Consultant shall provide certificates of insurance
to City as evidence of the insurance coverage required herein, along with
a waiver of subrogation endorsement for workers' compensation and other
endorsements as specified herein for each coverage. Insurance
certificates and endorsement must be approved by City's Risk Manager
prior to commencement of performance. Current certification of insurance
shall be kept on file with City at all times during the term of this
SCS Engineers Page C -2
Agreement. City reserves the right to require complete, certified copies of
all required insurance policies, at any time.
B. City's Right to Revise Requirements. City reserves the right at any time
during the term of the Agreement to change the amounts and types of
insurance required by giving Consultant sixty (60) calendar days advance
written notice of such change. If such change results in substantial
additional cost to Consultant, City and Consultant may renegotiate
Consultant's compensation.
C. Enforcement of Agreement Provisions. Consultant acknowledges and
agrees that any actual or alleged failure on the part of City to inform
Consultant of non - compliance with any requirement imposes no additional
obligations on City nor does it waive any rights hereunder.
D. Requirements not Limiting. Requirements of specific coverage features
or limits contained in this Section are not intended as a limitation on
coverage, limits or other requirements, or a waiver of any coverage
normally provided by any insurance. Specific reference to a given
coverage feature is for purposes of clarification only as it pertains to a
given issue and is not intended by any party or insured to be all inclusive,
or to the exclusion of other coverage, or a waiver of any type.
E. Self - insured Retentions. Any self- insured retentions must be declared to
and approved by City. City reserves the right to require that self- insured
retentions be eliminated, lowered, or replaced by a deductible. Self -
insurance will not be considered to comply with these requirements unless
approved by City.
F. City Remedies for Non - Compliance. If Consultant or any subconsultant
fails to provide and maintain insurance as required herein, then City shall
have the right but not the obligation, to purchase such insurance, to
terminate this Agreement, or to suspend Consultant's right to proceed until
proper evidence of insurance is provided. Any amounts paid by City shall,
at City's sole option, be deducted from amounts payable to Consultant or
reimbursed by Consultant upon demand.
G. Timely Notice of Claims. Contractor shall give City prompt and timely
notice of claims made or suits instituted that arise out of or result from
Contractor's performance under this Contract, and that involve or may
involve coverage under any of the required liability policies. City assumes
no obligation or liability by such notice, but has the right (but not the duty)
to monitor the handling of any such claim or claims if they are likely to
involve City.
H. Consultant's Insurance. Consultant shall also procure and maintain, at its
own cost and expense, any additional kinds of insurance, which in its own
judgment may be necessary for its proper protection and prosecution of
the Work.
SCS Engineers Page C -3
CERTIFICATE OF INSURANCE
CHECKLIST
City of Newport Beach
This checklist Is comprised of requirements as outlined by the City of Newport Beach. *
Date Received: 10/9/13 Dept /Contact Received From: Vladimir
Date Completed: 10/9/13 Sent to: Vladimir By: Chris
Company /Person required to have certificate:
Type of contract:
1. GENERAL LIABILITY
EFFECTIVE /EXPIRATION DATE:
3- 3/31/14
SCS Engineers
All Other
A. INSURANCE COMPANY: Chartis Specialty Insurance Company
B. AM BEST RATING (A-: VII or greater): A:XV
C. ADMITTED Company (Must be California Admitted ):
Is Company admitted in California? N Yes ❑ No
D. LIMITS (Must be $1 M or greater): What is limit provided? 2,000,000/2,000,000
E. ADDITIONAL INSURED ENDORSEMENT — please attach
F. PRODUCTS AND COMPLETED OPERATIONS (Must
include): is it included? (completed Operations status does
not apply to Waste Haulers or Recreation)
G. ADDITIONAL INSURED FOR PRODUCTS AND
COMPLETED OPERATIONS ENDORSEMENT (completed
Operations status does not apply to Waste Haulers)
H. ADDITIONAL INSURED WORDING TO INCLUDE (The City
its officers, officials, employees and volunteers): Is it
included?
I, PRIMARY & NON - CONTRIBUTORY WORDING (Must be
included): Is it included?
J. CAUTION! (Confirm that loss or liability of the named insured
is not limited solely by their negligence) Does endorsement
include "solely by negligence" wording?
K. ELECTED SCMAF COVERAGE (RECREATION ONLY):
L. NOTICE OF CANCELLATION:
IL AUTOMOBILE LIABILITY
N Yes ❑ No
To ■
N Yes ❑ No
1GREME1111111M
■ Yes
0 No
[K ■ Yes
■ No
■ NIA 0 Yes
■ Ni,
EFFECTIVE/EXPIRATION DATE: 3/31/13- 3131/14
A. INSURANCE COMPANY: National Union Fire Insurance Company of Pittsbur¢ PA
B. AM BEST RATING (A-: VII or greater) A:XV
C. ADMITTED COMPANY (Must be California Admitted):
Is Company admitted in California? N Yes ❑ No
D. LIMITS - If Employees (Must be $1 M min, BI & PD and $500,000
UM, $2M min for Waste Haulers): What is limits provided? 1,000,000
E. LIMITS Waiver of Auto insurance / Proof of coverage (if individual)
(What is limits provided ?) NIA
F. PRIMARY & NON - CONTRIBUTORY WORDING (For Waste
Haulers only): N N/A ❑ Yes ❑ No
G. HIRED AND NON -OWNED AUTO ONLY: ❑ N/A ❑ Yes N No
H. NOTICE OF CANCELLATION: ❑ N/A N Yes ❑ No
III. WORKERS' COMPENSATION
EFFECTIVE/EXPIRATION DATE: 4/1/13- 4 11/14
A. INSURANCE COMPANY: Insurance Company of the State of PA
B. AM BEST RATING (A-: VII or greater): A:XV
C. ADMITTED Company (Must be California Admitted): ® Yes ❑ No
D. WORKERS' COMPENSATION LIMIT: Statutory ® Yes ❑ No
E. EMPLOYERS' LIABILITY LIMIT (Must be $1 M or greater) 1,000,000
F. WAIVER OF SUBROGATION (To include): Is it included? ® Yes ❑ No
G. SIGNED WORKERS' COMPENSATION EXEMPTION FORM: ® N/A ❑ Yes ❑ No
H. NOTICE OF CANCELLATION: ❑ N/A ® Yes ❑ No
ADDITIONAL COVERAGE'S THAT MAYBE REQUIRED
IV. PROFESSIONAL LIABILITY
V POLLUTION LIABILITY
HAVE ALL ABOVE REQUIREMENTS BEEN MET?
IF NO, WHICH ITEMS NEED TO BE COMPLETED?
Approved:
.'rte,...
Agent of Alliant Insurance Services
Broker of record for the City of Newport Beach
10/4/13
Date
® N/A ❑ Yes ❑ No
■ ■ +
O ■ ■ +
RISK MANAGEMENT APPROVAL REQUIRED (Non - admitted carrier rated less than
Self Insured Retention or Deductible greater than $ 1 ❑ N/A ❑ Yes ❑ No
Reason for Risk Management approval /exception /waiver:
Approved:
Risk Management Date
* Subject to the terms of the contract.
■EM
orrv� CERTIFICATE OF LIABILITY INSURANCE
WWDW3
DATI MAD/YYYV)
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 policypes) 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 ruts to the
certificate holder in lieu of such endomement(s).
PRODU m
AOn Risk insurance
Los Angeles A Office services West, Inc.
CONTACT
NON
Exl: (666) 283 -]122 FAx 800 -363 -0105
A G. No. 1:
Iu61ANa
-p
ADDRESS:
707 Wilshire
suite 2600
INSUREWSI AFFORDING COVERAGE
NAICa
LOS Angeles CA 90017 -0460 USA
INSURED
INSURER M1 Chartis Specialty Insurance Company
26883
SCS Engineers
3900 Kilroy Airport Wapi suite 100
Long Beach CA 90806 -6816 USA
INSURER 8: National Union Fire Ins CO of Pittsburgh
19445
INSURER C,- Insurance CO of the state of PA
19429
INSURER D:
INSURER E:
DAUAGE
S RENTED
PREMISES
$1,000,600
INSURER F:
CWMSeIAOE ❑X OCCUR
COVERAGES CERTIFICATE NUMBER: 570051656854 REVISION NUMBER:
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. Limits shown are as requested
Lim
TYPE OF INSURANCE
N
yyyD
POLICY NUMBER
MW PQ
IM
GENERAL LUeaitt
Paoli
EACHOCCURRENCE
$2,000,040
X COMMERCW GENERAL UABIUTY
DAUAGE
S RENTED
PREMISES
$1,000,600
CWMSeIAOE ❑X OCCUR
WD EXP(My one person)
,$$,400
PERSONAL A ADV INJURY
52,000,000
GENERPI AGGREGATE
$2,000,000
GENL AGGREGATE
LIMIT AMES
PER
PRODUCTS, COMPIOP AEG
52,000,000
POLICY X
PRO-
LOC
B
AUTOMOBILE LIABILITY
CA 1 -37
03/31/2013
0
COMBINED SINGLE LMR
E. amidevil
$1,000,000
BODILY INJURY (Per perwn)
X ANYAUTO
BODAY IN,IJRY(Pet ecddent)
X ALL OWNED SCHEDUtEO
AUTOS AUTOS
NOFYCWNED
% HIRED AUTOS X AUTOS
PROPERTY DAMAGE
Per acddeM
UMBRELLAUAB
OCCUR
EACH OCCURRENCE
AGGREGATE
EXCESS UAB
CLARWAIADE
DED I RETENTION
C
O
C
WORKERS COMPENSATION MID
EMPLOYERS' UMILITY YIN
CFFlLENM IEMBER EXCLUNDEDx �IW N
(Mwdamry In NN)
NIA
wc0
wc048250326
wc04825D328
"'01'201"
04/01/2013
04/01 /2013
1
04/01/2014
04/01/2014
% WC STATU� OTFH
TORY UMns ER
E.L. EACH ACCIDENT
E1, 000,000
EL OiSEASSEA EMPLOYEE
$1,000,000
I yee. desnNe unde,
DESCRIPTION OF OPERATIONSnebw
EL.DISEMCPOLICYLUT
$1,0001000
A
Env Pro (E&0)
PROP
03/31/2013
03/51/2014
Each Claim
$2,000,005
Prof /Poll Liab
Aggregate
S2,000,000
DEacRwTroN Of OPERATNONS i LOCATgNSt VEHICi.EB (AttaM ATARp tat, A44a6nei 1Nmahe 8cneduk,ImdlA aryca iF rtqutred)
RE: scs Job No. 90000016.01 Task 000, Asbestos Abatement Oversight.
city of Newport Beach, its officers, officials, employees and agents are included as Additional insured with respect to the
General Liability and Automobile Liability policies; granted a Waiver of Subrogation for General Liability, Automobile
Liability and workers' Compensation policies; and the General Liability policy evidenced herein is Primary and Nan - Contributory
to other insurance available, as required by written contract, but limited to the operations of the Insured under said
contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
MUCY PROVISIONS,
City Of Newport Beach AUTHORREO REPRESENTATIVE
Public works Department
Attu: Lucie Del Orme ,rV _ w M,+Aw y
100 civic Center Drive ( ✓ /91w,)P� Imm, 0Ey,IO0 /�<y// eJN�900L
Newport Beach CA 92660 USA
®1986 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
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D
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ENDORSEMENT
This endorsement, effective 12M AM, 313112013
Forms a part of Policy No: PROP 17322480
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED 1 PRIMARY COVERAGE ENDORSEMENT_
COMMERCIAL GENERAL LIABILITY AND
PROFESSIONAL LIABILITY POLICY
In consideration of an additional premium of $Included it is hereby agreed that the following Is included as an Additional
Insured as respects Coverage A and B but only as respects liability adsing out of your Work for the Additional Insured
by or for you,
Additional Insured:
BLANKET WHERE REQUIRED BY WRITTEN CONTRACT.
This does not apply to bodily irduty or property damage arising out of the sole negligence or willful misconduct of, or
for defects in design furnished by, the Additional Insured.
This endorsement does not increase the Company's limits of liability as specified in the Declarations of this policy.
All other terms, conditions, and exclusions stall remain the same.
9967 (04/08)
Ct2791 PAGE 1 OF 1
ENDORSEMENT
This endorsement, effective 12:01 AM, 3/31/2013
Forms a part of Policy No: PROP 17322480
WAIVER OE SUBROGATION - SPECIFIC PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY AND PROFESSIONAL LIABILITY POLICY
Name of Person or Organization'.
BLANKET WHERE REQUIRED BY WRITTEN CONTRACT.
(If no entry appears above, inforraWon required to complete this endorsement +,till be shown in the Declarations as
applicable to this endorsement)
It is hereby agreed that SECTION IV, Conditions, paragraph 9. Subrogation is amended to include the following:
We agree to waive this right of subrogation against the person or organization shown in the Schedule above to ft
extent that you had, prior to an occurrence or claim, a written agreement to waive such rights.
All other terms, condiTwns, and exclusions shall remain the same.
78011 (5101) Includes copyrighted material of fnsursnoe Services PAGE I OF 1
Ci1442 offices, Inc., with its permission.
Insurance services Office, Ina., IM
ENDORSEMENT
This endorsement, effective 12:01 A.M. 03131/2013 forms a part of
policy No. CA 3275137
by NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following.
BUSINESS AUTO COVERAGE FORM
SCHEDULE
ADDITIONAL INSURED:
WHERE REQUIRED BY WRITTEN CONTRACT
I. SECTION II • LIABILITY COVERAGE, A. Coverage, 1. - Who Is Insured, is amended to add:
d. Any person or organization, shown in the schedule above, to whom you become obligated
to include as an additional insured under this policy, as a result of any contract or agreement
you enter into which requires you to furnish insurance to that person or organization of the
type provided by this policy, but only with respect to liability arising out of use of a covered
"auto ". However, the insurance provided will not exceed the lesser of:
(1) The coverage and/or limits of this policy, or
(2) The coverage and /or limits required by said contract or agreement.
87960 (10105) Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
This endorsement, effective 12:01 A.M. 3/31/2013 forms a part of
Policy No. CA 3275137 Issued
By National Union Fire Insurance Company of Pittsburg, PA
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
Section IV - Business Auto Conditions, A. - Loss Conditions, 5. - Transfer of Rights of
Recovery Against Others to Us, is amended to add:
Where Required by written contract provided such contract was executed prior to the date of
loss.
However, we will waive any right of recovery we have against any person or organization with
whom you have entered into a contract or agreement because of payments we make under this
Coverage Form arising out of an "accident" or "loss" if:
(1) The "accident" or "toss" is due to operations undertaken in accordance with the
contract existing between you and such person or organization; and
(2) The contract or agreement was entered into prior to any "accident" or "loss ".
No waiver of the right of recovery will directly or indirectly apply to your employees or
employees of the person or organization, and we reserve our rights or lien to be reimbursed
from any recovered funds obtained by any injured employee.
62897 (6195)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different
date is indicated below.
(The foils» N "anaohing dause" need be completed only when INs endorsement is issued subsequent to prepannion of the policy).
This endorsement, effective 12:01 AM 4101/2013 forms a part of Policy No. WC 4825 03 26
Issued
By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA
Premium I NCLUDED
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.
This agreement shall not operate directly or Indirectly to benefit any one not named in the Schedule.
Schedule
THE PREMIUM FOR THE ENDORSEMENT IS INCLUDED
ANY PERSON OR ORGANIZAITON TO WHOM YOU BECOME
OBLIGATED TO WAIVE YOUR RIGHTS OF RECOVERY
AGAINST, UNDER ANY CONTRACT OR AGREEMENT YOU ENTER
INTO PRIOR TO THE OCCURRENCE OF LOSS.
This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee,
Texas, Utah, or Washington.
WC DD 03 13 Countersigned by
(Ed. 04184) '
Authorized Representative
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different
date is indicated below.
(The following "anaching clause" need be completed only when this endorsemenl Is FMUed subsequem to preparallon of the policy).
This endorsement, effective 12:01 AM 4/01/2013 forms a part of Policy No. WC 4825 03 27
Issued
By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA
Premium I NCLUDED
We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.
This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule.
Schedule
THE PREMIUM FOR THE ENDORSEMENT IS INCLUDED
ANY PERSON OR ORGANIZAITON To WHOM YOU BECOME
OBLIGATED TO WAIVE YOUR RIGHTS OF RECOVERY
AGAINST, UNDER ANY CONTRACT OR AGREEMENT YOU ENTER
INTO PRIOR TO THE OCCURRENCE OF LOSS,
This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee,
Texas, Utah, or Washington.
WC 00 03 13 Countersigned by
(Ed. 04184)
Authorized Representative
BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different
date is indicated below.
(The following "attaching clause" need be canpleted only when this endorsement is issued subsequent to prepararim of the policy).
This endorsement, effective 12:01 AM 04/0112013 forms a part of Policy #WC 4825 03 28
By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA
We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against any person or organization with whom you have a written contract that requires you to obtain this
agreement from us, as regards any work you perform for such person or organization.
The additional premium for this endorsement shall be TBD
for this policy.
WC 04 03 61
(Ed. 11/90)
of the total estimated workers compensation premium