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Cowaiux No. 973
5 w "TPA c-ors
CITY OF WATERLOO
CITY CLERK'S OFFICE
MAR 28 2019 pm: 2:44:20
25
FORM OF BID OR PROPOSAL
F.Y. 2019 LINCOLN PARK IMPROVEMENTS
CONTRACT NO. 973
CITY OF WATILRLOO, IOWA
Honorable Mayor and City Council
Waterloo, Iowa
Gentlemen:
1. The undersigned, being a Corporation existing under the laws of the State of
a Partnership consisting of the following partners:
30.44 -or CowrIR,kcrt,,v6 . , having familiarized
(himself) (themselves) (itself) with the existing conditions on the project area affecting the
cost of the work, and with all the contract documents listed in the Table of Contents and
Addenda (if any), as prepared by the City Engineer of the City of Waterloo now on file in the
office of the City Clerk, City Hall, Waterloo, Iowa, hereby proposes to furnish all supervision,
technical personnel, labor, materials, machinery, tools, appurtenances, equipment, and
services, including utility and transportation services required to construct and complete this
F.Y. 2019 LINCOLN PARK IMPROVEMENTS, Contract No. 973, all in accordance with the
above -listed documents and for the unit prices for work in place for the following items and
quantities:
F.Y. 2019 LINCOLN
CONTRACT
PARK IMPROVEMENTS
NO. 973
BID
ITEM
DESCRIPTION
UNIT
EST.
QTY.
UNIT BID
PRICE
TOTAL BID
PRICE
1
TRAFFIC CONTROL
LS
1.00
$ ISooa.on
$ 15,00o.cry
2
MOBILIZATION
LS
1.00
$ .111, 5-00,07;
$ .3%,5o0.ca
3
SILT FENCE, INSTALLATION, REMOVAL,
CLEANOUT
LF
1,298
$ 2.4O
$ 3,37s/. So
4
CONSTRUCTION FENCE
LF
2,998
$ 5".?5"
$ (5, 7St So
5
REMOVALS, EXISTING PAVEMENT
SY
1,879
$ 9.90
$ 16., 9//,0,0
6
REMOVALS, SUNKEN PLAZA
LS
1.00
$ 1,9So.co
$ --4,15-t, .610
7
REMOVALS, LIGHTING
EA
4
$ g5o•aa
$ 1,LI or) .va
8
EXCAVATION, CLASS 10
CY
yC5
37280
$ e, So
$ 3 567. 50
9
SITE GRADING
LS
1.00
$ 5,aaazz,
$ 6,Ozro.ere)
10
IMPORTED CLEAN FILL
CY
107
$ I y,crD
$ (, t/i 9.,70
11
IMPORTED TOP SOIL
CY
143
$ a�•vb
$ 5,1116.oa
FORM OF BID -ADD 1
CONTRACT NO. 973
Page 1 of 5
Bidder
12
ELECTRICAL INSTALLATION
LS
1
$ 113,000,0v
$ 113, oq4, vd
13
PLUMBING & DRINKING FOUNTAIN
INSTALLATION
LS
1
$ 3�,0ov.at,
$ 3,A,vw,vz.)
14
MODIFIED SUBBASE, COMPACTED
SY
1,755
$ 6.75
$ I/, Bei (p. aS
15
PCC PAVEMENT, 6"
SY
933
$ 5c .02,
$ V&&, 656.ero
16
CONCRETE CURB FOR BRICK
LF
307
$ 16r.crd
$ c{, q/ ce,
17
BRICK PAVERS WITH CONCRETE BASE
SF
3,321
$ 0o. cc)
$ 64, yea
18
PCC, 6" CONCRETE
STAMPED/COLORED
SY
1,286
$ 70. et)
$ crp oo,,..R.,
19
BENCHES
EA
54
$ °TOO. or,
$ cila,6,w.0-0
20
WASTE RECEPTACLES
EA
8
$ icKo.00
$ fq,eiao.oz.)
21
ENTRANCE SIGNS
EA
2
$ (Kl5oo.ci-
$ 1yCoe)
22
FLOWER BASKETS FOR LIGHT POLES
EA
16
$ 40.o0
.Ca
$ oglo,oz)
23
SHADE TREES
EA
10
$ 6ZS.az
.7r
$ GI so.os
24
TURFGRASS SEEDING
, SF
16,000
$ , 9.4-
$ ci cr.b.ez
25
DANCE CHIMES & INSTALLATION
LS
1.00
$ S?,aoo.az)
$ 59,.r-0
26
POROUS PAVEMENT FOR TREE
SURROUNDS
SF
288
$ 0/0.av
$ 5,-160, da
27
REMOVALS, MISC
LS
1
$ 75ae.cD
$ 7saz,.c-ro
28
CONSTRUCTION SURVEYING & STAKING
LS
1
$ 3,re5o.o7)
$ 3,&5o.oa
TOTAL BID
$
S
696, $7S. 65-
Bidder will complete the Work in accordance with the Contract Documents for the following
prices. Items annotated as an ALTERNATE will be considered for inclusion in the contract at the
discretion of the Owner
BASE BID PROPOSAL: Bidder agrees to perform all the work described in the proposed
Contract Documents and shown on the Drawings for the sum of
i x Hu IPita Fair/ FZ✓ii Er64r I NOQc:-b SE N1 Y Favi ,4Np 1'J e T S
Dollars
($ 6'i , 675.D5 ). Amount shall be shown in both words
and figures. In case of discrepancy, the amount shown in words will govern.
FORM OF BID -ADD 1
CONTRACT NO. 973 Page 2 of 5
Net Alternate Price ADD
circle one) Total:
CzfrY rtVe 111040ea,vp Twu i,4uivOIZ1 Twr5NtY
($
05, 2 ao.ao
).
Dollars
Alternate No. 5: If the Owner elects to proceed with Alternate No. 4, DEDUCT the cost stamped
colored concrete and ADD the cost of PCC, 6" Concrete.
Deduct sum of:
!s4
"rwkr t -Y Sziv4IV 7-00‘4540I Sty Dvu.r4ts l Dollars
($ p 000.60
Add sum of:
($
0.ua
Zr A -o
Net Alternate Price ADD /(EDUCT (circle one) Total:
o�
i
17.giv Sg,,,EN 7"�fa w5A�O Sr? Qoid-rags
Dollars
($
a 1,006. co
).
Dollars
Alternate No. 6: If the Owner elects to proceed with Alternate No. 6, ADD the cost of the
electrical contractor furnishing and installing electrical cabinet #3, and providing all associated
devices, equipment and materials. Refer to the documents for additional information.
Add sum of:
1 Y 'Fast 'f ftov S,W' rtvrr
($ qq, 5'uo. t2v ).
Dollars
1. It is understood and agreed by the undersigned that OWNER reserves the unrestricted
privilege to reject any or all of the foregoing prices which it may consider excessive or
unreasonable. It is also understood that OWNER reserves the right to select any
combination of Bid Items that are in the OWNER's best interest.
2. It is understood that the quantities set forth are approximate only and subject to variation
and that the unit bid price for the work done shall govern in the actual payment to Contractor.
3. In submitting this bid, the bidder understands that the right is reserved by the City of
Waterloo, Iowa, to reject any or all bids. If written notice of the acceptance of this bid is
mailed, telegraphed, or delivered to the undersigned within thirty (30) days after the opening
thereof, or at any time thereafter before this bid is withdrawn, the undersigned agrees to
execute and deliver an agreement in the prescribed form and furnish the required bond and
certificate of the insurance within ten (10) days after the agreement is presented to him for
signature, and start work within ten (10) days after "Notice to Proceed" is issued.
FORM OF BID -ADD 1
CONTRACT NO. 973 Page 4 of 5
4. Security in the sum of S t
Dollars ($ Bro ) in the form of (3co (3oNn is
submitted herewith in accordance with the INSTRUCTIONS TO BIDDERS.
5. Attached hereto is a Non -Collusion Affidavit of Prime Contractor.
6. Attached hereto is a Resident Bidder Certification ( ), or Non•Resident Bidder
Certification ( ). (Mark one.)
7. The bidder is prepared to submit a financial and experience statement upon request.
8. The Prime Contractor and Subcontractor(s), which have performed an aggregate of
$10,000.00 in work for the City in the current calendar year, are prepared to submit an AAP
or Update and an EOC, within ten (10) days of notification that the bid submitted is lowest
and acceptable.
9. The bidder has received the following Addendum or Addenda:
Addendum No. ( Date 3/2oJF
3lu�,s
10. The bidder shall list the MBE/WBE subcontractor(s), amount of subcontracts and bid items
on the City of Waterloo Minority and/or Women Business Pre-bid Contact Information Form
submitted with this Form of Bid or Proposal. The apparent low Bidder shall submit a list of
all other Subcontractor(s) to be used on this Project to the City of Waterloo by 5:00 p.m. the
business day following the day Bids on this Project are due along with the Non -Collusion
Affidavits of All Subcontractor(s).
The Contractor shall submit information on subcontractors on "SUBCONTRACTOR REQUEST
AND APPROVAL" Form to be provided by City prior to approval of contract.
The subcontractors listed on this proposal and/or submitted to the Contract Compliance
Officer cannot be changed except for the following reasons:
1) The City of Waterloo does not approve the subcontractors.
2) The subcontractors submit in writing that they cannot fulfill their subcontracts.
11. The bidder has filled in all blanks on this proposal. Those blanks not applicable are marked
"none" or "NA".
12. The bidder has attached all applicable forms.
13. The Owner reserves the right to select alternates, delete line items, and/or to reduce
nnquantities prior to the award of a contract due to budgetary limitations.
(,NLOlt(L Co,, crGNGLt.( • 3/289
(Name of Bidder) (Date)
�%
BY: "L /iC Title r91.v
Official Address: (Including Zip Code):
,15789 /V. Ave./ice. - Grt-NNOY CriNrkf„DA 5010?$
I.R.S. No. a7-307 24/63
FORM OF BID -ADD 1
CONTRACT NO. 973 Page 5 of 5
Bidder Status Form
To be completed by all bidders
Part A
Please answer "Yes" or "No" for each of the following:
[l Yes ❑ No
® Yes ❑ No
• Yes ❑ No
• Yes ❑ No
Yes ❑ No
My company is authorized to transact business in Iowa.
(To help you determine if your company is authorized, please review the worksheet on the next page).
My company has an office to transact business in Iowa.
My company's office in Iowa is suitable for more than receiving mail, telephone calls, and e-mail.
My company has been conducting business in Iowa for at least 3 years prior to the first request for
bids on this project.
My company is not a subsidiary of another business entity or my company is a subsidiary of another
business entity that would qualify as a resident bidder in Iowa.
If you answered "Yes" for each question above, your company qualifies as a resident bidder. Please
complete Parts B and D of this form.
If you answered "No" to one or more questions above, your company is a nonresident bidder. Please
complete Parts C and D of this form.
To be completed by resident bidders Part B
My company has maintained offices in Iowa during the past 3 years at the following addresses:
Dates: ( / f / P. to / ,t34i V Address' a5189 N• ,ideMwe.
City, State, Zip: 6r.,u'DY Cur+i'.,_ t4 5-4.1e
Dates: / / to / / Address.
City, State, Zip.
Dates: / / to / / Address:
You may attach additional sheet(s) if needed. City, State, Zip:
To be completed by non-resident bidders Part C
1. Name of home state or foreign country reported to the Iowa Secretary of State:
2. Does your company's home state or foreign country offer preferences to resident bidders, resident labor ❑
force preferences or any other type of preference to bidders or
Yes 0 No
3. If you answered "Yes" to question 2, identify each preference offered by your company's home state or foreign country
and the appropriate legal citation.
You may attach additional sheet(s) if needed.
To be completed by all bidders Part D
I certify that the statements made on this document are true and complete to the best of my knowledge and I know that my
failure to provide accurate and truthful information may be a reason to reject my bid.
Firm Name:
/Oi44LO Oft yAe AI" r Li -C•
Signature: Date: -0'0/9
You must submit the completed form to the governmental body requesting bids per 875 Iowa Administrative Code
Chapter 156. This form has been approved by the Iowa Labor Commissioner.
309-6001 (09-15)
Worksheet: Authorization to Transact Business
This worksheet may be used to help complete Part A of the Resident Bidder Status form. If at least one of the following
describes your business, you are authorized to transact business in Iowa.
I Yes ❑ No
❑Yes VINo
❑ Yes p No
(Z]Yes 0 N
O Yes 0 N
My business is currently registered as a contractor with the Iowa Division of Labor.
My business is a sole proprietorship and I am an Iowa resident for Iowa income tax purposes.
My business is a general partnership or joint venture. More than 50 percent of the general
partners or joint venture parties are residents of Iowa for Iowa income tax purposes.
My business is an active corporation with the Iowa Secretary of State and has paid all fees
required by the Secretary of State, has filed its most recent biennial report, and has not filed
articles of dissolution.
My business is a corporation whose articles of incorporation are filed in a state other than Iowa,
the corporation has received a certificate of authority from the Iowa secretary of state, has filed
its most recent biennial report with the secretary of state, and has neither received a certificate of
withdrawal from the secretary of state nor had its authority revoked.
❑ Yes 5-4 No My business is a limited liability partnership which has filed a statement of qualification in this
state and the statement has not been canceled.
O Yes inNo
My business is a limited liability partnership which has filed a statement of qualification in a
state other than Iowa, has filed a statement of foreign qualification in Iowa and a statement of
cancellation has not been filed.
❑ Yes I1 No My business is a limited partnership or limited liability limited partnership which has filed a
certificate of limited partnership in this state, and has not filed a statement of termination.
O Yes bn No
My business is a limited partnership or a limited liability limited partnership whose certificate of
limited partnership is filed in a state other than Iowa, the limited partnership or limited liability
limited partnership has received notification from the Iowa secretary of state that the application
for certificate of authority has been approved and no notice of cancellation has been filed by the
limited partnership or the limited liability limited partnership.
1:Z1 Yes 0 No My business is a limited liability company whose certificate of organization is filed in Iowa and has
not filed a statement of termination.
❑ Yes 0No
My business is a limited liability company whose certificate of organization is filed in a state other
than Iowa, has received a certificate of authority to transact business in Iowa and the certificate
has not been revoked or canceled.
309-6001 (09-15)
EQUAL OPPORTUNITY CLAUSE
(As provided in Executive Order No. 11246)
All contractors, subcontractors, vendors and suppliers of goods and services doing business
with the City and value of said business equals or exceeds ten thousand dollars ($10,000.00)
annually agree as follows:
1. The contractors, subcontractor, vendor and supplier of goods and services will not
discriminate against any employee or applicant for employment because of race,
color, creed, sex, national origin, economic status, age, mental or physical handicap,
political opinions or affiliations. The contractor, subcontractor, vendor and supplier
will develop an Affirmative Action program to ensure that applicants are employed
and that employees are treated during employment without regard to their race,
creed, color, sex, national origin, religion, economic status, age, mental or physical
disability, political opinions or affiliations. Such actions shall include but not be
limited to the following:
a. Employment
b. Upgrading
c. Demotion or Transfer
d. Recruitment and Advertising
e. Layoff or Termination
f. Rates of Pay or Other Forms of Compensation
g. Selection for Training Including Apprenticeship
2. The contractor, subcontractor, vendor and supplier of goods and services will, in all
solicitations or advertisements for employees, state that all qualified applicants will
receive consideration for employment without regard to race, creed, color, sex,
national origin, religion, economic status, age, mental or physical disabilities,
political opinion or affiliations.
3. The contractor, subcontractor, vendor and supplier or his/her collective bargaining
representative will send to each labor union or representative of workers which
he/she has a collective bargaining agreement or other contract or understanding, a
notice advising said labor union or workers' representative of the contractor's
commitment under this section.
4. The contractor, subcontractor, vendor and supplier of goods and services will
comply with all published rules, regulations, directives, and order of the City of
Waterloo Affirmative Action Program Contract Compliance Provisions.
5. The contractor, subcontractor, vendor and supplier of goods and services will furnish
and file compliance reports within such time and upon such forms as provided by
the Affirmative Action Officer. Said forms will elicit information as to the policies,
procedures, patterns, and practices of each subcontractor as well as the contractor
himself/herself and said contractor, subcontractor, vendor and supplier will permit
access to his/her employment books, records and accounts to the City's Affirmative
Action Officer, for the purpose of investigation to ascertain compliance with this
contract and with rules and regulations of the City's Affirmative Action Program—
Contract Compliance Provisions relative to Resolution No. 24664.
EQUAL OPPORTUNITY CLAUSE PAGE 1 OF 2
6. In the event of the contractor's non-compliance with the non-discrimination clauses
of this contract or with any of such rules, regulations and orders, this contract may
be canceled, terminated or suspended in whole or in part and the contractor may
be declared ineligible for further contracts in accordance with procedures authorized
by the City Council.
7. The contractor, subcontractor, vendor and supplier of goods and services will
include, or incorporate by reference, the provisions of the non-discrimination clause
in every contract, subcontract or purchase order unless exempted by the rules,
regulations or orders of the City's Affirmative Action Program, and will provide in
every subcontract, or purchase order that said provisions will be binding upon each
contractor, subcontractor, or supplier.
8. We, the undersigned, recognize that we are morally and legally committed to non-
discrimination in employment. Any person who applies for employment with our
company will not be discriminated against because of race, creed, color, sex,
national origin, economic status, age, mental or physical disabilities.
(Signed)
(Appropriate Official)
OWIV 04L -
(Title)
(Date)
EQUAL OPPORTUNITY CLAUSE PAGE 2 OF 2
MBE/WBE BUSINESS ENTERPRISE
PRE-BID CONTACT INFORMATION FORM
Prime Contractor Name: gemiokco CovninrcrZL' ( «(. Project: Lziic4,z.n0 P,...K r,4eitougro&NTS Letting Date: ZfaS/g
NO MBE/WBE SUBCONTRACTORS: If you are NOT using any MBE/WBE subcontractors to complete this project, sign below. Attach a brief
explanation as to why subcontracting was not feasible with this project. If any MBE/WBE subcontractors will be used, please use the bottom
portion of this form.
Contractor Signature:
Title: duw. -
Date: 11/4$/11
SUBCONTRACTORS APPLICABLE: You are required, in order for your bid to be considered responsive, to provide the information on this form
showing ALL of your MBE/WBE subcontractor contacts made for your bid submission. This information is subject to verification. Any questions
should be directed to Contract Compliance Office 319-291-4429.
You are required, in order for your bid to be considered responsive, to provide the information on this Form showing your MBE/WBE Business
Enterprise contacts made prior to your bid submission. This information is subject to verifications and confirmation.
If you are unable to identify MBE/WBE firms to perform portions of the work, please contact Rudy Jones, Contract Compliance Officer, for
assistance at (319) 291-4429.
In the event it is determined that the MBE/WBE Business Enterprise goals are not met, then before awarding the contract the City of Waterloo will
make a determination as to whether or not the apparent successful low bidder made good faith efforts to meet the goals.
TABLE OF INFORMATION SHOWING BIDDER'S PRE-BID
MBE/WBE BUSINESS ENTERPRISE CONTACTS
Quotes Received Quotation used in bid
MBE/WBE
Subcontractors
Dates
Contacted
Yes/No
Dates
Contacted
Yes/No
Dollar Amount Proposed to
be Subcontracted
bc- CoaPoa-4-,- v
319$/4
Ne
iIld,v2 .
(Form CCO-4) Rev. 06-20-02
NONCOLLUSION AFFIDAVIT OF PRIME BIDDER
State of ir"a )
County of Gwu•Jc
that:
)ss
1t4I t- , being first duly sworn, deposes and says
1. He is (Owner. Partner. Officer Representative, or Agent) , of
gvr�uo�ir� Co,,,,►zµ-crtiviiLtC. , the Bidat has submitted the attached Bid;
2. He is fully informed respecting the preparation and contents of the attached Bid
and of all pertinent circumstances respecting such Bid;
3. Such Bid is genuine and is not a collusive or sham Bid;
4. Neither the said Bidder nor any of its officers, partners, owners, agents,
representatives, employees, or parties in interest, including this affiant, has in any
way colluded, conspired, connived or agreed, directly or indirectly, with any other
Bidder, firm or person to submit a collusive or sham Bid in connection with the
Contract for which the attached Bid has been submitted or to refrain from bidding
in connection with such Contract, or has in any manner, directly or indirectly,
sought by agreement or collusion or communication or conference with any other
Bidder, firm or person to fix the price or prices in the attached Bid or of any other
Bidder, or, to fix any overhead, profit or cost element of the bid price or the bid
price of any other Bidder, or to secure through any collusion, conspiracy,
connivance, or unlawful agreement any advantage against the City of Waterloo,
Iowa, or any person interested in the Proposed Contract; and
5. The price or prices quoted in the attached Bid are fair and proper and are not
tainted by any collusion, conspiracy, connivance or unlawful agreement on the part
of the Bidder or any of its agents, representatives, owners, employees, or parties in
interest, including this affiant.
(Signed)
Subbscr ped and sworn to before me this
1111 VN , 201 .
Title
My commission expires 0`
day of
Title
S3lIdX3 NOISSIIN NOO JOIN
8L2ti6L d38WfN NOISSIWINOO,
HONJk1 a K1H39ViI)1
BID BOND
KNOW ALL MEN BY THESE PRESENTS, that we, Boulder Contracting, LLC
as Principal, and Westfield Insurance Company
as Surety are held and firmly bound unto the CITY OF WATERLOO , Iowa, hereinafter called
"OWNER." In the penal sum Five Percent of Amount Bid
Dollars ($ 5% ) lawful money of the United States, for the payment
of which sum will and truly be made, we bind ourselves, our heirs, executors, administrators, and
successors, jointly and severally, firmly by these presents. The condition of this obligation is such
that w cpreas the Principal has submit#�d the accompanying bid dated the 28th day of _
vian , 20 ff , for FY 2019 Lincoln Park Improvements
NOW, THEREFORE,
(a) If said Bid shall be rejected, or in the alternate,
(b) If said Bid shall be accepted and the Principal shall execute and deliver a contract in the form
specified and shall furnish a bond for his faithful performance of said contract, and for the payment
of all persons performing labor or furnishing materials in connection therewith, and shall in all other
respects perform the agreement created by the acceptance of said Bid,
Then this obligation shall be void, otherwise the same shall remain in force and effect; it being
expressly understood and agreed that the liability of the Surety for any and all claims hereunder shall,
in no event, exceed the -penal. amount of this obligation as herein stated.
By.virtue of statutory authority, the full amount of .this bid bond shall be forfeited to the Owner in
liquidation of damages sustained. in -.the event that the Principal fails to execute the contract and
provide the bond as provided in the specifications or by law.
The Surety, for value received, hereby stipulates and agrees that the obligations of said Surety and its
bond shall be in no way impaired or affected by any extension of the time within which the Owner may
accept such Bid or execute such contract; and said Surety does hereby waive notice of any such
extension.
IN WITNESS WHEREOF, the Principal and the Surety, have hereunto set their hands and seals, and
such of them as are corporations, have caused their corporate seals to be hereto affixed and these
presents to be signed by their proper offi;;ers this28th day of March 201 9
(Seal)
Witness
Wlness
By
Principal Boulder Contracting, LLC
(Title)
Westfield Insurance Company (Seal)
Surety
By.
At.
is
•
THIS POWER OF ATTORNEY SUPERCEDES ANY PREVIOUS POWER BEARING THIS SAME
POWER t/ AND ISSUED PRIOR TO 06107116, FOR ANY PERSON OR PERS,ONS NAMED BELOW.
'etleYa( POWER NO. 1429172 00
Power Westfield Insurance Co.
of Attorney Westfield National Insurance Co.
Ohio Farmers Insurance Co.
Westfield Center, Ohio
CERTIFIED COPY
Know All Men by These Presents, That WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO
FARMERS INSURANCE COMPANY, corporations, hereinafter referred to individually as a "Company" and collectively as "Companies," duly
organized and existing under the laws of the State of Ohio, and having its principal office in Westfield Center, Medina County, Ohlo, do by these
presents make, constitute and appoint
MARK E. KEAIRNES, JOSEPH I. SCHMIT, JEFFREY R. BAKER, JILL SHAFFER, GREG T. LAMAIR, NANCY D. BALTUTAT,
PATRICK K. DUFF, CHRISTOPHER R. SEIBERLING, JOINTLY OR SEVERALLY
of WEST DES MOINES and State of IA its true and lawful Attorney(s)-in-Fact, with full power and authority hereby conferred in Its name,
place and stead, to execute, acknowledge and deliver any and all bonds, recognizances, undertakings, or other instruments or contracts of
suretyship
LIMITATION: THIS POWER OF ATTORNEY CANNOT BE USED TO EXECUTE NOTE GUARANTEE, MORTGAGE DEFICIENCY, MORTGAGE
GUARANTEE, OR BANK DEPOSITORY BONDS.
and to bind any of the Companies thereby as fully and to the same extent as If such bonds were signed by the President, sealed with the corporate
seal of the applicable Company and duly attested by its Secretary, hereby ratifying and confirming all that the said Attorney(s)-In-Fact may do In
the premises. Said appointment Is made under and by authority of the following resolution adopted by the Board of Directors of each of the
WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE COMPANY:
"Be It Resolved, that ths President, any Senior Executive, any Secretary or any Fidelity & Surety Operations Executive or other Executive shall
be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attorney(s)-in-Fact to represent and act for
and on behalf of the Company subject to the following provisions:
The Attorney -in -Fact. may be given full power and authority for and in the name of and on behalf of the Company, to execute, acknowledge and
deliver, any and all bonds, recognizances, contracts, agreements of indemnity and other conditional or obligatory undertakings and any and all
notices and documents canceling or terminating the Company's liability thereunder, and any such Instruments so executed by any such
Attorney -in -Fact shall be as binding upon the Company as if signed by the President and sealed and attested by the Corporate Secretary."
"Be it Further Resolved, that the signature of any such designated person and the seal of the Company heretofore or hereafter affixed to any
power of attorney or any certificate relating thereto by facsimile, and any power of attorney or certificate bearing facsimile signatures or facsimile
seal shall be valid and binding upon the Company with respect to any bond or undertaking to which It is attached." (Each adopted at a meeting
held on February 0, 2000).
In Witness Whereof, WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE
COMPANY have caused these presents to be signed by their National Surety Leader and Senior Executive and their corporate seals to be hereto
affixed this 07th day of JUNE A.D., 2016 .
Corporate '",x1041 4
Seals
Affixed c�vr^,...�••.. \ in 1 SEAL
r
1 W! SE I n • SEAL ni
State of Ohlo "� •••'"'
County of Medina ss.:
;.O`,Pj�nNAC INS.
ftetORTIRE 1 t\ f! „ t
s.,%0 1848 ;'j ° JJI vww V \ c-- —.J
10 inu„n•`a By:
Dennis P. Baus, National Surety Leader and
Senior Executive
WESTFIELD INSURANCE COMPANY
WESTFIELD NATIONAL INSURANCE COMPANY
OHIO FARMERS INSURANCE COMPANY
On this 07th day of JUNE A.D., 2016 , before me personally came Dennis P. Baus to me known, who, being by me duly sworn, did
depose and say, that he resides In Wooster, Ohlo; that he Is National Surety Leader and Senior Executive of WESTFIELD INSURANCE
COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE COMPANY, the companies described In and which
executed the above Instrument; that he knows the seals of said Companies; that the seals affixed to said Instrument are such corporate seals; that
they were so affixed by order of the Boards of Directors of said Companies; and that he signed his name thereto by like order.
Notarial
Seal
Affixed
State of Ohio
County of Medina ss,:
" 4
David A. Kotnik, Attorney at Law, Notary Public
My Commission Does Not Expire (Sec. 147.03 Ohio Revised Code)
1, Frank A. Carrino, Secretary of WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS
INSURANCE COMPANY, do hereby certify that the above and 'foregoing is a true and correct copy of a Power of Attorney, executed by said
Companies, which is still in full force and effect; and furthermore, the resolutions of the Boards of Directors, set out in the Power of Attorney are
in Lull force and effect.
In Witness Whereof, 1 have hereunto set my hand and affixed the seals of said Companies at Westfield Center, Ohio, this - 28if day of
March ,?tP;»,
11-1111•41,
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CftoACP.,(combijted) (fu•02}
A, Czar, inc,. Secretary