Loading...
HomeMy WebLinkAboutContracts & Agreements_95-2022PUBLIC WORK CONSTRUCTION CONTRACT This Public Work Construction contract ("Contract") is made and entered into this 7th day of June, 2022, by and between the City of Redlands, a municipal corporation, organized and existing under the laws of the State of California (hereinafter "City"), and Deark E&C, Inc (hereinafter "Contractor") City and Contractor are sometimes individually referred to herein as a "Party" and, together, as the "Parties." In consideration of the mutual promises contained herein, City and Contractor agree as follows 1 SCOPE OF WORK. Contractor shall furnish all materials and will perform all of the work for the following: Orange Blossom Trail Phase 3, Project No S241001 and, complete all items as required by the Contract Documents (as herein defined) and Specifications for City's Orange Blossom Trail Phase 3, Project No S241001 (the "Work") 2. CONTRACT SUM. City shall pay Contractor the sum of seven hundred eighty two thousand three hundred ninety six dollars ($782,396) as consideration for its performance of the Work in accordance with the teens and conditions set forth in the Contract Documents. Pursuant to Public Contract Code Section 22300, Contractor has the option to deposit securities with an escrow agent as a substitute for retention of earnings required to be withheld by City pursuant to an escrow agreement as set forth in Public Contract Code section 22300 3 TIME FOR COMPLETION The Work shall be completed within seventy (70) calendar days from and after the date of City's issuance of a Notice to Proceed to Contractor 4 LIQUIDATED DAMAGES Contractor's failure to complete the Work within the time allowed will result in damages being sustained by City Such damages are, and will continue to be, impracticable and extremely difficult to determine Accordingly, Contractor shall pay to City, or have withheld from monies due to Contractor, the sum of five hundred dollars ($500) for each consecutive calendar day in excess of the specified time for completion of the Work. Execution of this Contract shall constitute agreement by City and Contractor that five hundred dollars ($500) per day is the estimated damage to City caused by the failure of Contractor to complete the work within the allowed time. Such sum is liquidated damages and shall not be construed as a penalty, and may be deducted from payments due Contractor if such delay occurs. 5 CONTRACT DOCUMENTS This Contract incorporates by reference the following: Notice Inviting Bids, Instructions to Bidders, Contractor's Proposal, Bid Bond, Agreement, Performance Bond, Labor and Material Bond, Plans, General Conditions, Special Provisions and Specifications, and any addenda thereto (collectively, the "Contract Documents") 6 ATTORNEYS' FEES In the event any action is commenced to enforce or interpret the terms or conditions of this Contract, or the Contract Documents, the prevailing Party in such action, in addition to any costs and other relief, shall be entitled to recover its reasonable attorneys' fees, including fees for use of in-house counsel by a Party 7 RESOLUTION OF CONSTRUCTION CLAIMS Claims by Contractor in the amount of three hundred seventy five thousand dollars ($375,000) or less shall be made by Contractor and processed by the City pursuant to the provisions of Part 3, Chapter 1, Article 1 5 of the Pubhc Contract Code (commencing with Section 20104) All claims shall be in writing and include the documents necessary to substantiate the claim. Nothing in subdivision (a) of Public Contract Code L:\ca\djm\Agreements\Deark E&C Contract.PW 3 1 FY21-0117.doc.jn Section 20104 2 shall extend the time limit or supersede the notice requirements provided in this case from filing claims by Contractor 8. ELIGIBILITY OF CONTRACTOR/SUBCONTRACTOR. Contractor and all of its subcontractors shall abide by California Pubhc Contract Code, Section 6109, and California Labor Code Sections 1777 1 and/or 1777 7, and certify that they are not debarred and are eligible to work on this project. 9 ASSIGNMENT OF AGREEMENT No assignment by a Party of any rights or interests under this Contract shall be binding on another Party without the written consent of the Party sought to be bound. 10. SUCCESSORS AND ASSIGNS City and Contractor each binds itself and their respective successors and assigns in respect to all covenants, agreements, and obligations contained in the Contract Documents. 11 SEVERABILITY Any provision or part of the Contract Documents held to be void or unenforceable under any law or regulation shall be deemed stricken, and all remaining provisions shall continue to be vand and binding upon City and Contractor 2 L:\ca\djm\Agreements\Deark E&C Contract.PW 3 1 FY21-0117.doc.jn IN WITNESS WHEREOF, the Parties hereto have executed this Contract the day and year first wntten above (SEAL) ATTEST fine Donaldson, City Clerk CIT G DLANDS By - Paul T Barich, Mayoi Peark Name of Contractor By Signature of Authonzed Agent (SEAL) Title Signature of Authonzed Agent Of necessary) Title Contractor's License No 3 L \ca\djm\Agreements\Deark E&C Contract PW-3 1 FY21 0117 doc.jn WORKER'S COMPENSATION INSURANCE CERTIFICATION Descnption of Contract City of Redlands Municipal Utilities & Engmeenng Department ORANGE BLOSSOM TRAIL PHASE 3 Project No S241001 Every employer, except the State, shall secure the payment of compensation in one or more of the following ways a By being insured against liability to pay compensation by one or more insurers duly authorized to write compensation insurance in this State b By securing from the Director of Industrial Relations, a certificate of consent to self - insure, either as an individual employer, or as one employer in a group of employers, which may be given upon furmshmg proof satisfactory to the Director of Industrial Relations of ability to self -insure and to pay any compensation that may become due to his or her employees CHECK ONE I am aware of the provisions of Section 3700 of the Labor Code which requires every employer to be insured against liability for Workers' Compensation or to undertake self-insurance in accordance with the provisions of that Code, and I will comply with such provisions before commencing the perfonnance of the work and activities required or permitted under this Agreement (Labor Code § 1861) I affinn that at all times, in performing the work and activities required or permitted under this Agreement, I shall not employ any person in any manner such that I become subject to the workers' compensation laws of California However, at any time, if I employ any person such that I become subject to the workers' compensation laws of California, immediately I shall provide the City with a certificate of consent to self -insure, or a certification of workers' compensation insurance I certify under penalty of perjury under the laws of the State of California that the infonnation and representations made in this certificate are true and correct Dated this / S day of TA 1' Q , 2022 (SEAL) PPark , jai( (Contractor) (Signature) J (Official Title) (Labor Code Section 1861 provides that the above certificate must be signed and filed by the Contractor with the Owner prior to performing the work of the contract ) 4 L \ca\djm\Agreements\Deark E&C Contract PW 3 1 FY21-0117 doc.jn THE FINAL PREMIUM IS PREDICATED ON THE FINAL CONTRACT AMOUNT FAITHFUL PERFORMANCE BOND Bond No CAC721359 Premium: $19,560 00 Whereas, the City of Redlands ("City"), State of California, and Deark E&C, Inc (hereinafter designated as "Principal") have entered into an agreement dated June 7, 2022 ("Agreement") whereby Principal agrees to install and complete certain public improvements (the "Work"), which said Agreement is identified as Orange Blossom Trail Phase 3, Project No S241001 and is hereby referred to and made a part hereof; and Whereas, said Principal is required under the terms of the Agreement to furnish a bond for the faithful performance of the Work, now, therefore, we, the Principal and, Merchants Bonding Company (Mutual) , as Surety, are held and firmly bound unto the City in the penal sum of seven hundred eighty two thousand three hundred ninety six dollars ($782,396 00) lawful money of the United States, for the payment of which sum we bind ourselves, and our heirs, successors, executors and administrators, jointly and severally, firmly by these presents. The condition of this obligation is such that if the above bounded Principal, his or its heirs, executors, administrators, successors or assigns, shall in all things stand to and abide by, and well and truly keep and perform the covenants, conditions and provisions in the Agreement and any alteration thereof made as therein provided, on his or its part, to be kept and performed at the time and in the manner therein specified, and in all respects according to their true intent and meaning, and shall faithfully fulfill the one-year guarantee of all materials and workmanship, and shall defend, indemnify and save harmless the City and its elected officials, officers, agents and employees, as therein stipulated, then this obligation shall become null and void, otherwise it shall be and remain in full force and effect. As a part of the obligation secured hereby and in addition to the face amount specified therefor, there shall be included costs and reasonable expenses and fees, including reasonable attorneys' fees, incurred by the City in successfully enforcing such obligations, all to be taxed as costs and included in the judgment rendered. As a condition precedent to the satisfactory completion of the Work, the above obligation shall hold good for a period of one (1) year or longer if required by the Agreement after the acceptance of the work by the City, during which time if the Principal shall fail to make full, complete, and satisfactory repair and replacements and totally protect the City from loss or damage made evident during this period from the date of completion of the Work, and resulting from or caused by defective materials or faulty workmanship, the above obligation in penal sum thereof shall remain in full force and effect. The obligations of Surety hereunder shall continue so long as any obligation of the Principal remains. Whenever the Principal shall be, and is declared by the City to be, in default under the Agreement, the City having performed the City obligations thereunder, the Surety shall promptly remedy the default, or shall promptly, at the City's option 1 Complete the Work in accordance with its terms and conditions, or 2. Obtain a bid or bids for completing the Work in accordance with its terms and conditions, and upon determination by Surety of the lowest responsive and responsible bidder, arrange for a contract between such bidder and the City, and make available as work progresses sufficient funds to pay the cost of completion of the Work less the balance of the Agreement price, but not exceeding, including other costs and damages for which Surety may be liable hereunder, the amount set forth above The term "balance of the Agreement price," as used in this paragraph, shall 5 L.\ca\djm\Agreements\Deark E&C Contract.PW 3 1.FY21-0117.doc jn mean the total amount payable to the Principal by the City under the Agreement and any modifications thereto, less the amount previously properly paid by the City to the Principal Surety expressly agrees that the City may reject any contractor or subcontractor which may be proposed by Surety in fulfillment of its obligations in the event of default by the Principal Surety shall not utilize the Principal in completing the Work nor shall Surety accept a bid from the Principal for completion of the Work if the City, when declaring the Principal in default, notifies Surety of the City's objection to the Principal's further participation in the completion of the Work No right of action shall accrue on the bond to or for the use of any person or corporation other than the City named herein or the successors or assigns of the City Any suit under this bond must be instituted within the applicable statute of limitations period The said Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Agreement or to the work to be performed thereunder or the Specifications accompanying the same shall in any way affect its obligations on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the Agreement or to the work or to the specifications No final settlement between the City and the Principal shall abridge the right of any beneficiary hereunder whose claim may be unsatisfied The Principal and Surety agree that if the City is required to engage the services of any attorney in connection with the enforcement of this bond, each shall pay the City's reasonable attorneys' fees incurred, with or without suit, in addition to the above sum In witness whereof, this instrument has been duly executed by the Principal and Surety above named, on May 23rd , 2022 Deark E&C, Inc (Contractor) i� -1 7 (SEAL) (SEAL) Merchants B BY ng Company (Mutual) (Signature) (Signature)Frank Morones, Attorney -in -Fact (Seal and Notarial Acknowledgment of Surety) Address 6700 Westown Parkway West Des Moines, IA 50266 Telephone ( 800 ) 678-8171 L \ca\djm\Agreements\Deark E&C Contract.PW 3 1.FY21 0117 doc.in 6 POSE ACKNOWLEIDGAIIIEhUr �ehZ2 e sA v CIVAL CODE § 1189 emaiszsernimmunamimemisstummemt A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document State of California CALPFDII INIA ALL-PRIJ County of On 6 Date lore Insert Name and Title of the Officer personally :appeared Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose narne(s) is/ar-e subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their slgnature(s) on the instrument the person s or the entity upon behalf of which the person(s) acted, executed the instrument Z before me, JIN Y GONG Comm # 2330490 rn NOTARY PUBLIC CALIFORNIA \!} Los ANGELES COUNTY MY Comm Exp Jay 18, 2024 " Place Notary Seal Above I certify under PENAL"iY OF PCRJURY under the laws of the State of California that the foregoing paragraph is true and correct WITNESS my hand and official seal Signature ature.of Notary Public OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document Descriptor' of Attached Document Title or Type of Document Number of Pages Signer(s) Other I han Named Above Capacity(les) Claimed by Signer(s) Signer's Name ❑ Corporate Officer — Title(s)' D Partner 0 Limited 0 General ❑ Individual 0 Attorney in Fact 0 Trustee 0 Guardian or Conservator ❑ Other Signer Is Representing. Document Date Signer's Name 0 Corporate Officer — Title(s) ❑ Partner — ❑ Limited 0 General D Individual ❑ Attorney in Fact O Frustee 0 Guardian or Conservator CI Other Signer Is Representing, ©2014 National Notary Association ^ www NatlonalNl taty or 0 1-800 L1S NOTARY (I Q00 Q76 Gl3?_7) item #5907 ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document State of California County of Orange On 05/23/2022 before me, Melissa Ann Vaccaro, Notary Public (insert name and title of the officer) personally appeared Frank Morones who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct WITNESS my hand and official seal Signatur 01%1� L4-,\v(Seal) Melissa Ann Vaccaro ME sA ANN VACCARO COMM #2401942 r, Notary Public -California C ORANGE COUNTY a My Comm Expires May 12, 2021 MERcI-1 .NT BONDING COMPANY, POWER OF ATTORNEY Bond No. CAC721359 Know All Persons By These Presents, that MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC. both being corporations of the State of Iowa (herein collectively called the 'Companies") do hereby make, constitute and appoint, individually Arturo Ayala; Ben Stong• Benjamin Wolfe; Chelsea Arnold, Daniel Huckabay Dwight Reilly Frank Morones; Michael D Stong; R Nappi; Shaunna Rozelle Ostrom their true and lawful Attorney(s)-in-Fact, to sign its name as surety(les) and to execute, seal and acknowledge any and all bonds, undertakings, contracts and other written instruments in the nature thereof on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law This Power -of -Attorney is granted and is signed and sealed by facsimile under and by authority of the following By -Laws adopted by the Board of Directors of Merchants Bonding Company (Mutual) on April 23, 2011 and amended August 14 2015 and adopted by the Board of Directors of Merchants National Bonding, Inc. on October 16, 2015. 'The President, Secretary Treasurer or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and authority to appoint Attorneys -in -Fact, and to authorize them to execute on behalf of the Company and attach the seal of the Company thereto, bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attorney or Certification thereof authorizing the execution and delivery of any bond undertaking recognizance, or other suretyship obligations of the Company and such signature and seal when so used shall have the same force and effect as though manually fixed. In connection with obligations in favor of the Florida Department of Transportation only it is agreed that the power and aut hority hereby given to the Attorney -In -Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department of Transportation making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of its obligations under its bond In connection with obligations in favor of the Kentucky Department of Highways only it is agreed that the power and authority hereby given to the Attorney -in -Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner Department of Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modification or revocation. In Witness Whereof, the Companies have caused this instrument to be signed and sealed this 13th day of May 2022 C,©����9, M 2003 d r STATE OF IOWA COUNTY OF DALLAS ss. Coo•". Pt?q '0''': fi • 4. 1933 �: By MERCHANTS BONDING COMPANY (MUTUAL) MERCHANTS NATIONAL BONDING, INC. President On this 13th day of May 2022 before me appeared Larry Taylor to me personally known, who being by me duly sworn did say that he is President of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC. and that the seals affixed to the foregoing instrument are the Corporate Seals of the Companies; and that the said instrument was signed and sealed in behalf of the Companies by authority of their respective Boards of Directors, POLLY MASON Commission Number 750576 My Commission Expires January 07 2023 (Expiration of notary's commission does not invalidate this instrument) I, William Warner Jr Secretary of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC do hereby certify that the above and foregoing is a true and correct copy of the POWER -OF -ATTORNEY executed by said Companies, which is still in full force and effect and has not been amended or revoked. Notary Public In Witness Whereof I have hereunto set my hand and affixed the seal of the Companies on this 23rd day of May ,2022 _ -- s10Ott � � ." Cs P 49 IA. s.(34 �. * " C>� 9.a yc i EZ Y Q ., p. d o.- p i �y 2003 • t9a3 (mac; • •. by •. POA 0018 (1/20) 1. Secretary THE FINAL PREMIUM IS PREDICATED ON THE FINAL CONTRACT AMOUNT Bond No CAC721359 (Seal and Notarial Acknowledgement of Surety) LABOR AND MATERIAL BOND Whereas, the City Council of the City of Redlands, State of Cahfornia, and Deark E&C, Inc (hereinafter designated as "Principal") have entered into an agreement (the "Agreement") whereby Prmcipal agrees to install and complete certain designated public improvements (the "Work"), which said agreement, dated June 7, 2022, and identified as Orange Blossom Trail Phase 3, Project No S241001 is hereby referred to and made a part hereof, and Whereas, under the terms of the Agreement, Principal is required before commending the performance of the Work, to file a good and sufficient Labor and Material bond with the City of Redlands to secure the claims to which reference is made in Title 3 (commencing with Section 9550) of Part 6 of Division 4 of the Civil Code of the State of California Now, therefore, said Principal and the undersigned as corporate surety, are held firmly bound unto the City and all contractors, subcontractors, laborers, material men and other persons employed in the performance of the Agreement and referred to in the aforesaid Code of Civil Procedure in the sum of seven hundred eighty two thousand three hundred nmety six dollars ($782,396) for materials furnished or labor thereon of any kind, or for amounts due under the Unemployment Insurance Act with respect to such work or labor, that said surety will pay the same in an amount not exceeding the amount hereinabove set forth, and also in case suit is brought upon this bond, will pay, in addition to the face amount thereof, costs and reasonable expenses and fees, including reasonable attorneys' fees, incurred by the City in successfully enforcing such obligation, to be awarded and fixed by the court, and to be taxed as costs and to be included in the judgment therein rendered *Merchants Bonding Company (Mutual) It is hereby expressly stipulated and agreed that this bond shall insure to the benefit of any and all persons, companies and corporations entitled to file claims under Title 3 (commencing with Section 9550) of Part 6 of Division 4 of the Civil Code, so as to give a right of action to them or their assigns in any suit brought upon this bond Should the condition of this bond be fully performed, then this obligation shall become null and void, otherwise it shall be and remain in full force and effect The surety hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Agreement or the specifications accompanying the same shall in any manner affect its obligations on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition In witness whereof, this instrument has been duly executed by the Principal and surety above named, on May 23rd , 2022 (SEAL) Deark E&C Inc (SEAL) Merchants Bonding Company (Mutual) (Contractor) BY ractor) Surety) (Signature) (Signature)Frank Morones, Attorney -in -Fact Address 6700 Westown Parkway West Des Moines IA 50266 Telephone (800 ) 678-8171 7 L \ca\djm\Agreements\Deark E&C Contract.PW 3 1.FY21-0117 doc.jn CALIFORNIA ALL-PURPOSE ACG'GdlIllrifLEG GINIl INIT CIVIL CODE § 1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document State of California County of L On / '2 r2 Dame personally appearod before me, /--lere Insert Name and Title of the Officer T Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their- slgnature(s) on the instrument the person(s), -or the entity upon behalf of which the person(s) acted, executed the instrument RS�oFT""y'�jIN Y GONG comm # 2330490 111 r� N NOTARY PUBLIC CALIFORNIA u' LL LOS ANGELES COUNTY ALfPOR " MY COMM EXP JULY 18 2024 "A Place Notary Seal Above I certify under PENALTY OF PERJURY under the laves of the State of California that the fdregoing paragraph is true and correct WITNESS my hand . d official seal Signature gnature.of Notary OPTIONAL 'Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document Number of Pages Capacity(ies) Clammed by Signer(s) Signer's Name ❑ Corporate Officer Title(s) ❑ Partner — 0 Limited 0 General O Individual 0 Attorney in Fact ❑ Trustee 0 Guardian or Conservator 0 Other, Signer Is Representing, Signer(s) Other fhf:ui Narned Aboveocrrment Date Signer's Name 0 Corporate Officer — Title(s). ❑ Par trier -- 0 Limited 0 General 0 Individual 0 Attorney in Fact 0 Trustee 0 Guardian or Conservator 0 Other Signer Is Representing, ©2014 National Notary Association www Nationaliy�org • i-800-US NOTARY (I-800-876-6827) Item #5907 ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document State of California County of Orange On 05/23/2022 before me, Melissa Ann Vaccaro, Notary Public (insert name and title of the officer) personally appeared Frank Morones who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct WITNESS my hand and official seal Melissa Ann Vaccaro rw—MEL'--;."------w—lSA ANN VACCARO n COMM. #2401942 (Ia''' ?� Notary PubllcCllfornla w u.r , ORANGE COUNTY E My Comm OIr:e May i2, 2028i MERCHAN, BONDING COMPANYrM POWER OF ATTORNEY Bond No. CAC721359 Know All Persons By These Presents, that MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC both being corporations of the State of Iowa (herein collectively called the 'Companies") do hereby make, constitute and appoint, individually Arturo Ayala, Ben Stong; Benjamin Wolfe; Chelsea Arnold; Daniel Huckabay Dwight Reilly Frank Morones, Michael D Stong; R Nappi; Shaunna Rozelle Ostrom their true and lawful Attorney(s)-in-Fact, to sign its name as surety(ies) and to execute, seal and acknowledge any and all bonds, undertakings, contracts and other written instruments in the nature thereof on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law This Power -of -Attorney is granted and is signed and sealed by facsimile under and by authority of the following By -Laws adopted by the Board of Directors of Merchants Bonding Company (Mutual) on April 23, 2011 and amended August 14 2015 and adopted by the Board of Directors of Merchants National Bonding, Inc. on October 16, 2015. 'The President, Secretary Treasurer or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and authority to appoint Attorneys -in -Fact, and to authorize them to execute on behalf of the Company and attach the seal of the Company thereto, bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof 'The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attorney or Certification thereof authorizing the execution and delivery of any bond undertaking, recognizance, or other suretyship obligations of the Compariy and such signature and seal when so used shall have the same force and effect as though manually fixed. In connection with obligations in favor of the Florida Department of Transportation only It is agreed that the power and aut hority hereby given to the Attorney -in -Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department of Transportation making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of its obligations under its bond. In connection with obligations in favor of the Kentucky Department of Highways only it is agreed that the power and authority hereby given to the Attorney -in -Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner Department of Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modification or revocation. In Witness Whereof, the Companies have caused this instrument to be signed and sealed this STATE OF IOWA '++++•+.r+ COUNTY OF DALLAS ss. 6 Fa+ • 1LP°' MERCHANTS NATIONAL BONDING, INC. -.0- t10 0 d: 2003 1933 e; By 13th day of May 2022 MERCHANTS BONDING COMPANY (MUTUAL) President On this 13th day of May 2022 before me appeared Larry Taylor to me personally known, who being by me duly sworn did say that he is President of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC. and that the seals affixed to the foregoing instrument are the Corporate Seals of the Companies; and that the said instrument was signed and sealed in behalf of the Companies by authority of their respective Boards of Directors. FOLLY MASON Commission Number 750576 My Commission Expires January 07, 2023 (Expiration of notary's commission does not invalidate this instrument) I, William Warner Jr Secretary of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC do hereby certify that the above and foregoing is a true and correct copy of the POWER -OF -ATTORNEY executed by said Companies, which Is still In full force and effect and has not been amended or revoked, In Witness Whereof I have hereunto set my hand and affixed the seal of the Companies on this 23rd day of May 2022 +!a\Nti C©, "r O1JA. • Co +M- -0- et 1933 ye; POA 0018 (1/20) Secretary CITY OF REDLANDS BUSINESS TAX CERTIFICATE For Services Provided in the City of Redlands, California Only' Business Name Business Location Business Owner(s) DEARK E&C INC 1830 W 147Th St Gardena, Ca 90249-3328 DEARK E&C INC DEARK E&C INC 1830 W 147TH ST GARDENA, CA 90249-3328 THIS BUSINESS TAX CERTIFICATE DOES NOT PERMIT A BUSINESS THAT IS OTHERWISE PROHIBITED. DEARK E&C INC' 2023 TO BE POSTED IN A CONSPICUOUS PLACE AND NOT TRANSFERABLE OR ASSIGNABLE Business Type Contractor General Description GENERAL CONTRACTOR -Certificate Number. 08132205 Effective Date June 01 2022 Expiration Date June 30 2023 For all inquiries regarding this license, contact HdL Business Tax Support Center at (909) 479-2111 3 MOD VA.2. ��,e � ,� ._, Thank you for your payment on your City of Redlands Business Tax Certificate. ALL CERTIFICATES MUST BE AVAILABLE FOR INSPECTION UPON REQUEST If you have questions concerning your business tax certificate, contact the Business Tax Support Center via email at: Redlands@hdlgov com or by telephone at: (909) 479-2111 Keep this portion for your tax certificate separate in case you need a replacement for any lost, stolen or destroyed tax certificate. A fee may be charged for a replacement or duplicate tax certificate. This certificate does not entitle the holder to conduct business before complying with all requirements of Redlands Municipal code and other applicable laws, nor to conduct business in a zone where conducting such business violates law If you have a fixed place of business within the city limits of City of Redlands, please display the Business Tax certificate above in a conspicuous place at the premises. Otherwise, every Business Tax Certificate holder not having a fixed place of business in the City shall keep the Business Tax Certificate upon his or her person, or affixed in plain view upon any cart, vehicle, van or other movable structure or device at all times if required by the Collector Starting January 1 2021 Assembly Bill 1607 requires the prevention of gender -based discrimination of business establishments. A full notice is available in English or other languages by going to• https://www.dca.ca.gov/publications/ BUSINESS SUPPORT CENTER 8839 N CEDAR AVE #212 pKp FRESNO CA 93720-1832 ElFkom DEARK E&C INC 1830 W 147TH ST GARDENA, CA 90249-3328 City of Redlands BUSINESS TAX CERTIFICATE Certificate Number. 08132205 Date of Issue 06/01/2022 =orm Rev October2018) )epartment of the Treasury nternal Revenue Service Request for Taxpayer Identification Number and Certification O. Go to www irs gov/FormW9 for instructions and the latest information Give Form to the requester Do not send to the IRS Print or type See Specific Instructions on page 3 1 Name (as shown on your income tax return) Name is required on this line do not leave this line blank. DEARK E&C, INC 2 Business name/disregarded entity name if different from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1 Check only one of the following seven boxes 4 Exemptions certain entities instructions Exempt payee Exemption code (if any) (Applies to accounts (codes apply only to not individuals, see on page 3) code (if any) il Individual/sole or El C Corporation 12 S Corporation i• Partnership III Trust/estate single member proprietor LLC company Enter the tax classification (C=C corporation S=S corporation P=Partnership) the appropriate box in the line above for the tax classification of the single member owner is classified as a single member LLC that is disregarded from the owner unless the owner is not disregarded from the owner for U.S. federal tax purposes Otherwise a single from the owner should check the appropriate box for the tax classification of its owner ► ► from FATCA reporting Ill Limited liability Note Check LLC if the LLC another LLC that is disregarded j• Other (see instructions) Do not check of the LLC is -member LLC that maintained outside the U.S.) 5 Address (number street and apt or suite no.) See instructions 1830 W 147TH ST Requester's name and address (optional) 6 City, state and ZIP code GARDENA CA 90249 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box The TIN provided must match the name given on line 1 to avoid backup withholding For individuals, this is generally your social security number (SSN) However for a resident alien, sole proprietor or disregarded entity, see the instructions for Part I later For other entities it is your employer identification number (EIN) If you do not have a number see How to get a TIN later Note If the account is in more than one name, see the instructions for line 1 Also see What Name and Number To Give the Requester for guidelines on whose number to enter octal secure or Employer identification number 8 3 1 9 8 7 2 7 8 Part II Certification Under penalties of perjury, I certify that 1 The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me) and 2 I am not subject to backup withholding because- (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding and 3 I am a U S citizen or other U S person (defined below) and 4 The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct Certification instructions You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return For real estate transactions item 2 does not apply For mortgage interest paid acquisition or abandonment of secured property cancellation of debt contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends you are not required to sign the certification but you must provide your correct TIN See the instructions for Part II later Sign Here Signature of U.S person ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted Future developments For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published go to www.irs.gov/FormW9 Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN) adoption taxpayer identification number (ATIN) or employer identification number (EIN) to report on an information return the amount paid to you, or other amount reportable on an information return Examples of Information returns include, but are not limited to the following • Form 1099-INT (interest earned or paid) Date ► • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income prizes awards or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest) 1098-E (student loan interest) 1098 T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U S person (including a resident alien), to provide your correct TIN If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding See What is backup withholding, later Cat No 10231X Form W-9 (Rev 10-2018) A aTh CERTIFICATE OF LIABILITY INSURANCE DATEpA1NDElYYYY) 05/23/2022 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 tho certificate holder is an ADDITIONAL INSURED, the pollcy(tes) 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 endorsemont(s). PRODUCER Kingdom Global Insurance Solutions, LLC 780 N. Euclid Street Suite 208 Anaheim, CA 92801 NAME CT Shawn Jln, Managing Member {pusNNo: 582-275 3155 f { No); 582-275-3156 &MAIL SJin k Isus.com isonRD l.D INSURE/0) AFFORDING COVERAGE NAIL 0 INSURERA. Evanston Insurance Company 35378 INSURED Deark E&C, Inc. 1830 West 147th Street Gardena, CA 90249 INSURERS, Infinity Select Insurance Company 20260 Munn c. Evanston insurance Company 35378 INSURER D: Everest Premier Insurance Company 35378 a. Evanston Insurance Company 35378 INSURER F . UV IX.IM1VFO ..........4 ...r..— ... ...—.,—... THIS Is To CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERtoO 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 PAID CLAIMS. INSR LTB TYPE OF INSURANCE pprn 8v POLICY NUMBER E��pBppY 9.1WDO{YYYYt tMM/DtIYYYYI WAITS X COMMERCIAL GENERAL LABILITY EACH OCCURRENCE $ 1,000,000 CLAMS X OCCUR DAMAGE TO RENTED PREMISES (Ea ocamencel $ 300,000 -MADE MED EXP (Any one person) $ 5,000 A Y Y MKLV5PBC003B53 08/18/2021 08/18/2022 PERSONAL & ADV INJURY s 1,000,000 GENERAL AGGREGATE $ 2,000,000 ''������O�EE�jjNIAOOREOATELIMITAPPUEjSPER: ■ YES LiLOC PRODUCTS COMP/OPAGO $ 2,000,000 5qPOLICY OTHER $ AUTOMOBILE LIABILITY /CEa SIN, DDt]SINOI.E LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY (Par penwn) $ B OWNED SCHEDULED Y Y 504-610143072-001 08/18/2021 08/18/2022 BODILY INJURY (Per sccIdefA) $ X A AUTOS ONLY X AUTOS L PROPERTY DAMAGE IPer ecddent) $ AIUTOS ONLY AUTOS ONY „ $ UMBRELLALIAB X OCCUR EACH occURRsNCE s 4,000,000 C EXCESS LAE CLAIMS MADE Y Y MPXC3002613 0811612021 08/18/2022 AGGREGATE $ 4,000.000 DED 1 RETENTION $ $ WORKERS COMPENSATION X1 9TATtIre 1 (( _ ERR- AND EMPLOYERS' LABILITY DUIVE Y� E.L. EACH ACCIDENT $ 1,000,000 D OYVEGR/MEMBEREARLUDED7 In NH) NIA Y 7600022621211 08/18/2021 08/18/2022 E.L. DISEASE. EA EMPLOYEE $ 1,000,000 (Mandatory DESCRIPTe IO 'OPERATIONS below E.L. DISEASE POLICY LIMIT $ 1,000,000 E Pollution LJabtflly Y Y CPLMOL1076B1 08/06/2021 08/06/2022 Occurrence Aggregate $1,000,000 $2,000,000 DESCRIPTION OF OPERATIONS /LOCATIONSIVEHICLES (ACORD 101, AdcRtIonel HAntarka Schedule, may be attached If mon space Is required) Re: City of Redlands Municipal Utilities & Engineering Department ORANGE BLOSSOM TRAIL PHASE 3 Project No. S241001 Certificate Holder Is listed as additional insured as respects to CG 20 10 07 04 and CG 2012 05 09 and CG 20 37 07 04 and 50461A1S01 Waiver of Subrogation Is Included as respects to certificate holder and to CO 24 04 05 09 and WC 04 03 08 end 50481SWF01 Primary and noncontributory endorsement Is included as respects to CG 20 01 0413 30 days written notice will be given to certificate holder In the event of cancellation CERTIFICATE HOLDER A City of Redlands 35 Cajon St Suite 15A Redlands, Ca 92373 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE P OUCY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ®1988=2e'(5 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PI Infinity Commercial Auto 11700 Great Oaks Way Suite 450 Alpharetta, GA 30022 Underwritten by' Infinity Select Insurance Company Customer Service: (800) 722-3391 ADDITIONAL NAMED INSURED ENDORSEMENT Claims Service: (800) 334.1801 copy To City of Redlands 35 Cajon St Suite 15A Redlands CA 92373 Policy D Number 504-81014-3072-001 Expiration Date 06/18/2022 1201 a.m. Named Insured Deark E&C Inc This endorsement S attached to and forms a part of the listed policy No changes will be effective prior to the time changes are requested. Additional Insured City of Redlands Part A - Liability Coverage, is changed as follows: The definition of insured is changed to include the additional insured named above. Adding an insured will not increase the limit of our liability The insurance provided by this endorsement will be excess over any other valid and collectible insurance All other parts of this Policy remain unchanged. ADDL INSURED COPY 50461A1S01 AMEND DATE: 05/23/2022 ENDORSEMENT 6-1 KEMPER Auto I IIINF1NITY Infinity Commercial Auto 11700 Great Oaks Way, Suite 450 Alpharetta, GA 30022 Underwritten by Infinity Select insurance Company Customer Service: 800-722-3391 WAIVER OF SUBROGATION CALIFORNIA Claims Service: 800-334-1661 Copy To Policy ID Number Expiration Date Deark E&C Inc 504-61014-3072-001 08/18/2022 12:01 AM 1830 W 147th St Named Insured Gardena, CA 90249 Deark E&C Inc This endorsement Is attached to and forms a part of the listed policy. No changes will be effective prior to the time changes are requested. In return for your premium payment shown below we agree that our rights of subrogation or rights of recovery under the policy will not apply against the following person or organization: City of Redlands 35 Cajon St Suite 15A Redlands CA 92373 Additional premium in the amount of $25.00 will be retained by us regardless of any early termination of this endorsement or the policy All other policy provisions remain unchanged. 50461S1NF01 Amend Date: 05/23/2022 COMMERCIAL GENERAL LIABILITY CG 20 0i 0413 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following Is added to the Other Insurance Condition and supersedes any provision to the contrary. Primary And Noncontributory Insurance Thls insurance Is primary to and will not seek contribution from any other Insurance available to an additional Insured under your policy provided that: (1) The additional Insured is a Named Insured under such other insurance; and CG 20 01 0413 (2) You have agreed In writing In a contract or agreement that this Insurance would be primary and would not seek contribution from any other Insurance available to the additional Insured, © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER; MKLVSPBC003853 COMMERCIAL GENERAL. LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizatton(s): Locatlon(s) Of Covered Operations As agreed to by written contract or agreement All locations Information required to complete this Schedule, If not shown above, will be shown In the Declarations. A. Section II — Who Is An Insured is amended to Include as an additional Insured the person(s) or organlzatton(s) shown in the Schedule, but only with respect to liability for "bodily Injury", "property damage" or "personal and advertising injury" caused, In whole or In part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional Insured(s) at the location(s) designated above. CG 20 10 07 04 B. With respect to the Insurance afforded to these additional insureds, the following additional exclusions apply This Insurance does not apply to "bodily Injury" or "property damage" occurring after. 1 All work, Including materials, parts or equipment furnished in connection with such work, an the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional Insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out •of which the injury or damage arises has been put to Its Intended use by any person or organization other than another contractor or subcontractor engaged In performing operations for a principal as a part of the same project. © iSO Properties, inc., 2004 Page 1 of 1 i:I POLICY NUMBER: MKLV5PBC003653 COMMERCIAL GENERAL LIABILITY CG 20 12 05 09 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies Insurance provided under the following: COMMERCIAL_ GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: As required by permits Information required to complete this Schedule, if not shown above, will be shown In the Declarations. Section ii — Who Is An Insured Is amended to include as an Insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has Issued a permit or authorization. CG 2012 05 09 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising Injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard* © Insurance Services Office, Inc., 2008 Page 1 of 1 POLICY NUMBER: MKLV5PBC003653 COMMERCIAL GENERAL LIABILITY CCU 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organlzatlon(s): As agreed to by written contract or agreement Location And Description Of Completed Operations All locations Information required to complete thls Schedule, if not shown above, will be shown In the Declarations. Section II — Who Is An Insured is amended to include as an additional Insured the person(s) or organizaUon(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, In whole or In part, by your work" at the location designated and described In the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard" © ISO Properties, Inc., 2004 Page 1 of 1 El CG 20 37 07 04 POLICY NUMBER: MKLV5PBC003853 COMMERCIAL GENERAL LABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE~ Name Of Person Or Organization: As agreed to by written contract or agreement Information required to complete this Schedule, If not shown above, will be shown In the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV— Conditions: We waive any right of recovery we may have against the person or organization shown In the Schedule above because of payments we make for Injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard" This waiver applies only to the person or organization shown In the Schedule above. © Insurance Services Office, Inc., 2008 Page 1 of 1 CG24040509 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged In the work described In the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due an such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER BLANKET WAIVER OF SUBROGATION -1998 by the Workers' Compensation Insurance Rating Bureau of California. Alt rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999. INSURED COP*(