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FORM OF BID OR PROPOSAL
FY 2020 WATERLOO AR ADD RAHL PARK IFS* CLLARRNG
CONTRACT MO 1017
CITY G WATERLO:9 001f-id'A
Honorable Mayor and City Council
Waterloo, Iowa
Gentlemen:
1. The undersigned, being a Corporation existingunder p the laws of the State of
a Partnership. consisting of the following partners:
having familiarized (himself) (themselves)with the • i '
existing conditions on
the project area affecting the cost of the work, and with all the co
ntract documents
listed in the Table of Contents and Addenda(if an as re '
. y}, prepared by the City
Fngineer of the City of Waterloo now on file in the office of City City Clerk, City
Hall, Waterloo, lowa, hereby proposes to furnish all supervision, '
personnel, p islon, technical
p nnel, labor, materials, machinery, tools, appurtenances, equipment,
.. pp � and
services, including utility and transportation services required to construct q and
complete this FY 2020 WATERLOO AIR AND RAIL PARK TEE CLEARING,
Contract No. 1017, all in accordance with the above -listed docume
nts and for the
unit prices for work in place for the followingitems and quantities:
q .
BID
ITEM
FY 2020 WATERLOO AIR AND RAIL !ARK TREE CLEARING
PEScRI TION
CONTRACT NO. 1017
•
•
•
•
•
MOBILIZATION
TREE CLEARING
TRAFFIC CONTROL
UNIT
LS
AC
LS
EST: QTY.,
1.0
UNIT BID
PRICE...:
•
•
18.7I66a
�
1
1.0
TOTAL AID $_ p/ sy
TOTAL BID PRICE
$ 'AO c/a°
2. It is understood that the quantities set forth area approximate mate only and subject to
variation and that the unit bid price for the work done shall over
a 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 d thirty (30)
days after the opening thereof, or at anytime 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withdrawn, the undersigned agrees to execute and deliver '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 m for signature, and
start work within ten (10) days after "Notice to Proceed" is issued.
.
•
FORM OF BID
CONTRACT NO. 1017 Page 1 of 3
1
4. Security in the sum of 3 76
Dollars ($ ) in the form of role- IL,
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 ( X ), 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 a'II ,A00
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 quantities prior to the award of a contract due to budgetary limitations.
FORM OF BID
CONTRACT NO. 1017 Page 2 of 3
BY'
CcAAS
(Name of Bidder)
J(ii 'A. i tee_
a '9• -)J6
(Date)
Title U`-
Official Address: (including Zip Code):
17O, 001< WS1
\;(le as q
I.R.S. No. q7—
FORM OF BID
CONTRACT NO. 1017 Page 3 of 3
State of
NON -COLLUSION AFFIDAVIT OF PRIME BIDDER
County of 8)cuy K L.N % )
)ss
, being first duly sworn, deposes and says that:
1. He is (Owner, Partner, Off"cer, 'ep ese
ithfve orA•ent
of 7‘,
t-" it Jan-, , the Bidder tha as submitted the attached Bid;
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)
Subscribed and sworn to before me this
,cd, . , 204O.
My commission expires 3 - / t-ad
0
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411041/11
IIIIIIili11G
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•
LINDA K SENN
COMMISSION NO 803307
MY COMMISSION EXPIRES
3 /5-07Md
Title
day of
Title
Bidder Status Form
To be competed by all bidders Part A
Please answer "Yes" or "No' for each of the following:
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).
Yes U No My company has an office to transact business in Iowa.
0 es No My company's office in Iowa is suitable for more than receiving mail, telephone calls, and e mail.
Yes ❑ No My company has been conducting business in Iowa for at least 3 years prior to the first request for
bids on this project.
Yes 111 No 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 lB
My company has maintained offices in Iowa during the past 3 years at the following addresses:
Dates: / / ( / r to �' / 7 / Address:
City, State, Zip. ('/ ` ` Ks6 r jle /%
Dates: / / to / / Address:
City, State, ZipN
Dates: / / to / / Address:
You may attach additional sheet(s) if needed. City, State, Zip'
To be completed by nonresident bidders
GP 3 rt 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 laborers?
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.
Yes I♦ No
You may attach additional sheet(s) if needed.
To be completed by all bidders
Part®
I certify that the statements made on this document are true and complete to the best of my knowledge and 1 know that my
failure to provide accurate and truthful information may be a reason to reject my bid.
Firm Name:
Signature:
Date: 4 - -�
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)
orksheet: A ithor w tt on to Transact o usDness
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.
s ri No My business is currently registered as a contractor with the Iowa Division of Labor.
es ❑ No My business is a sole proprietorship and I am an Iowa resident for Iowa income tax purposes.
❑ Yes 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.
Yes ❑ No 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.
❑ Yes
ID Yes
Yes
Yes
❑ Yes
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.
My business is a limited liability partnership which has filed a statement of qualification in this
state and the statement has not been canceled.
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.
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.
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.
Yes cNlo My business is a limited liability company whose certificate of organization is filed in Iowa and has
not filed a statement of termination.
Yes [L bk
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)
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(Form CCO-4) Rev. 06-20-02
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.
EQUAL OPPORTUNITY CLAUSE PAGE 1 OF 2 PAGES
The contractor, subcontractor, vendor and supplier of goods and services
will furnish and file compliance reports within such tirne 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
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)
(Title)
c 7
(Date)
EQUAL OPPORTUNITY CLAUSE PAGE 2 OF 2 PAGES
Revised February 2003
CONTRACTOR'S OR SUBCONTRACTOR'S AFFIRMATIVE ACTION PROGRAM
Check box that applies to party completing program:
) General Contractor
( ) Subcontractor
I, Section A to be completed by GENERAL CONTRACTORS only:
A
N ame of Company Lo i e c-ctfisr c A• \AL1
1
Address of Company pot Doe 0-7 `lu(K5414 Zip 5-0(01)%
Telephone Number ( 3/7 ) ,;r — 3
Federal ID Number (if no Federal ID Number, Owner/President's Social
Security Number) (7 -- 021 "& 8t)
N ame of Equal Employment Officer 5-kJ `' LU elf a -
N ame of Project 900 i c, kc /00 c c} Cot- i l P4t K 4-(€ e (� ,
P roject Contract Number
/aa 17
Estimated Construction Work Dates . '` - _ / ' J/
Start Finish
Section B to be completed by SUBCONTRACTORS only:
B
N ame of General or Prime Contractor
N ame of Subcontractor
Subcontractor's Address Zip
Subcontractor's Telephone Number ( )
S ubcontractor's Federal ID Number (if no Federal ID Number
Owner/President's Social Secunty Number)
N ame of Equal Employment Officer
-1 -
C. Remainder of program to be completed by party completing program,
either Prime or Subcontractor.
The Owners and/or Principals of your company:
Name Address
Position
,Sk-Ne P.D. Do/ 61
3-716(
2. Other Areas of Interest
LA-tezi e
Ethnic
Sex Origin
If your company has branches or subsidiaries, or if your company is a
branch or subsidiary of a parent organization, give the following
information:
Type of
Name Address Affiliation Degree
11. EMPLOYER'S POLICY (Please read carefully.)
A. We, the undersigned, recognize that we are morally and legally
committed to nondiscrimination in employment. Any person who
applies for employment with our company wilt not be discriminated
against because of race, color, creed, sex, national origin, economic
status, age, mental or physical handicap.
B The employment policies and practices of the undersigned are to recruit
and hire employees without discrimination, and to treat them equally
with respect to compensation and opportunities for advancement,
including training, upgrading, promotion, and transfer However, we
realize the inequities associated with employment training, upgrading
contracting and subcontracting for minorities and women and we will
direct our efforts to correcting any deficiencies to the maximum extent
possible The same will be required of our SUBCONTRACTORS and
suppliers.
We submit this program to assure compliance with Executive Order
11246 as amended, and other subsequent orders that may pertain to
equal employment opportunity and merit employment policies, fully
III. AFFIRMATIVE ACTION
(Na
effective
just a polic
realizing that our qualification and/or merit system should be evaluated
and revised, if necessary
We agree to put f• 1,
and utilization of
regard to
and men
aximum effort to achieve full employment
and productivity of all our citizens without
lonal origin, economic status, age,
N STRUCTION I.N't
(NamInt 4(r gaMPAvosvuti, IA 50619
and employment opp+un..-s to local residents of Waterloo, Iowa, to
the greatest extent fear+
err
will give training
' r 1 tcrEvitswIsrat IA 50619
will, therefor- , re_
equal emplo
merit, and t
to seek em
valuate our Affirma
pportunities are
encourage mi gibx
with our company on this
P.O. BOX 459 I CLARKSVILLE, IA 50619
1. Minority Recruitment and Employment;
2. Local Recruitment and Employment;
3. Disabled Veteran and Vietnam Era Veteran Recruitment and
Employment;
4. Handicapped Recr V:Jir1 and Employment;
5. Female Recruitme 'Cliff:14110 ployment; and
6. Training, Upgrade �] ;�!'omotionalOpportunities.
�
hat the
es more than
_, IA 50619
will undertake the
e our Affirmative Action Program:
e that
idual
ents
(Name
whatever ste 4> 1 < j at our total work force has
adequate minodg, ntation. We will utilize the
following methods in our recruitment attempts:
1. Local advertising media. (newspapers, radio, TV);
2. Community organizations (churches, clubs, schools);
3. Public and private institutions in the area (UNI, Hawkeye
will take
Community College);
4. Job Service of Iowa; and
5. Other.
3..
D
will seek qualified minority,
(
fema O, r» t s., swig t Ei p ' s for all job categories and will make
asserted efforts to increase minority, female and group representation
in occupations at the higher levels or skill and responsibility.
All sources of employment used shall be aware that we are an Equal
Employment Opportunity Employer Labor organizations representing
our employees will be notified of our Equal Employment Opportunity
Policy and Affirmative Action Program
F. Training, upgradin
monitored to ens
minority
H.
(Na
comparlps
same an
(Nam
Affirm ` , ; _do up inority, female, local contractors
and/or suppliers Were p • •dastgiVortunities to negotiate and/or bid on
this project: (if none, write 'NONE")
�l
tion and transfer activities at all levels will be
uli consideration has been given to qualified
employees.
•
will encourage other
ed and/or do business, to do the
eir efforts
has taken the following
1.
1. As a result of the above efforts, we have involved minority, female, and
local contractors and/or suppliers in the following areas of
subcontracting: (if none, write "NONE")
1. 0.
2.
(Name
Affirmati
propos
necessar9otao atArtlavtLLn1Js
representation of minority, female
force.
will require approved
all nonexempt contractors who
d will take whatever steps are
ity contractors have adequate
and local persons in their total work
L.
In further accordance with rules and guidelines issued pursuant to
Executive Order 1 4 ; .s amended, we establish the goals for our
company, based percentages supplied by the City, and we
realize these goaln'"'ev€ewed on an annual basis
specifi
and p
relative to saxr
suppliers as necessa
M. Parity figures for co
will keep records of
nt, employment, training, upgrading
I ity of Waterloo with any information
ii iadklles of our SUBCONTRACTORS and
en requested.
cated in Waterloo are as follows:
Affirmative Action
(Name ofPOCupanyiLARKsviLtE, IA 50619
Employment Goals:
The definition of Affirmative Action Goals is as follows: "Goals may not
be rigid and inflexible quotas which must be met but must be targets
reasonably attainable by means of applying every good faith effort to
make all aspects of the entire Affirmative Action Program work."
For the year 201b , please submit percentage targets for employing
minorities and women. If you already have reached your target for
hinrig minorities and women, please submit that percentage.
*Goals for Minorities:
Goals for Women:
*your affirrnative action goals should be between 1 % and 10% or more
for minorities and 1 % and 5% or more for women.
Please be advised that the goals or targets are purely your estimation
of how many women and minorities your company can reasonably
expect to hire in 200 Note, that none of the goals are rigid or
inflexible. They are targets that your company calculates as reasonably
attainable. This will help the City in its monitoring procedures as
required by City of Waterloo Resolution No. 1984-142(4).
We hereby certify that we are in compliance with all City and Federal
Affirmative Action Regulations and agree to accept all liability for failure to
comply.
Respectfully submitted,
By: jA-co e to 49 r s
Company Executive
By:
City of Waterloo Affirmative Action Officer
Approved
Disapproved Reason:
Date
Equal Employment
Opportunity Officer
Date
By:
Date:
BID BOND
KNOW ALL MEN BY THESE PRESENTS, that we, Lodge Construction, Inc.
as Principal, and North American Specialty Insurance Company
as Surety are held and firmly bound unto the CITY OF WATERLOO , Iowa, hereinafter called
"OWNER." In the penal sure ---Five Percent of the Bid Submitted ---
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
whereas the Principal has submitted the accompanying bid dated the 27th day of February
2020 , for FY 2020 Waterloo Air and Rail Park Tree Clearing, Contract No. 1017,
_ _aterloD1Jo
NOW, THEREFORE,
•
(a) If said Bid shall be rejected, or in the altemate,
(b) If said Bid shall be accepted and the Principal shall execute and deliver a contract in the form specified
and shall fumish 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 officers this 21st day of February , A.D. : 2020
North Ame
Witness Stacie Christensen
By
Lodge Construction, Inc.
Principal
Specialty Insuranc
rety
Attorney -
pang (Seal)
act r��'o ' R. Young
Seal)
(Title)
1
SWISS RE CORPORATE SOLUTIONS
NORTH AMERICAN SPECIALTY INSURANCE COMPANY
WASHINGTON INTERNATIONAL INSURANCE COMPANY
WESTPORT INSURANCE CORPORATION
GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, THAT Noith American Specialty Insurance Company, a corporation duly organized and existing under
laws of the State of New Hampshire, and having its principal office in the City of Overland Park, Kansas and Washington International Insurance
Company a corporation organized and existing under the laws of the State of New Hampshire and having its principal office in the City of Overland
Park Kansas, and Westport Insurance Corporation organized under the laws of the State of Missouri, and having its principal office in the City of
Overland Park, Kansas each does hereby make constitute and appoint•
JAY D. FREIERMUTH, CRAIG E. HANSEN, BRIAN M. DEIMERLY, SHIRLEY S. BARTENHAGEN, CINDY BENNETT, ANNE CROWNER,
TIM McCULLOH„ STACY VENN, DIONE R. YOUNG, and WENDY ANN CASEY JOINTLY OR SEVERALLY
Its true and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings
obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by
law, regulation, contract or otherwise provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the
amount of:
ONE HUNDRED TWENTY FIVE MILLION ($125,000,000.00) DOLLARS
This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of
Directors of North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held
on March 24 2000 and Westport hnsurance Corporation by written consent of its Executive Committee dated July 18, 2011.
"RESOLVED, that any two of the President, any Senior Vice President, any Vice President, any Assistant Vice President,
the Secretary or any Assistant Secretary be, and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named
in the given Power of Attorney to execute on behalf of the Company bonds, undertakings and all contracts of surety, and that each or any of them
hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company; and it is
FURTHER RESOLVED, that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any
certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be
binding upon the Company when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached."
•\`• lzIONgtui4.
o
F •
SEAL
a0
Steven P. Anderson, Senior Vice Pres'dent of Washington International Insurance Company
& Senior Vice President of North American Specialty Insurance Company
& Senior Vice Presiden of Westport Insurance Corporation
Miky
e A. Ito, Senior Vice President of Washington International Insurance Company
& Senior Vice President of North American Specialty Insurance Company
& Senior Vice President of Westport Insurance Corporation
IN WITNESS WHEREOF, North American Specialty Insurance Company, Washington Internnational Insurance Company and Westport
Insurance Corporation have caused their official seals to be hereunto affixed, and these presents to be signed by their authorized officers this
this 3rd day of November
State of Illinois
County of Cook
On this 3rd day of
ss:
,20 17 .
North American Specialty Insurance Company
Washington International Insurance Company
Westport Insurance Corporation
November , 20 17, before me, a Notary Public personally appeared Steven P. Anderson , Senior Vice President of
Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and Senior Vice President of
Westport Insurance Corporation and Michael A. Ito Senior Vice President of Washington International Insurance Company and Senior Vice President
of North American Specialty Insurance Company and Senior Vice President of Westport Insurance Corporation, personally known to me, who
being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and acknowledged said instrument to be the
voluntary act and deed of their respective companies.
1
4
1
OFFICIAL SEAL
M.KENNY
Notary Public State of Iliiuio s
My Commission Expires
12104/2021
M. Kenny, Notary Public N
I, Jeffrey Goldberg , the duly elected Vice President and Assistant Secretary of North American Specialty Insurance Company, Washington
International Insurance Company and Westport Insurance Corporation do hereby certify that the above and foregoing is a true and correct copy of a
Power of Attorney given by said North American Specialty Insurance Company, Washington International Insurance Company and Westport Insurance
Corporation which is still in full force and effect.
IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this 21 st day of February
efj •
2020
Jeffrey Goldberg, Vice President & Assistant Secretary of Washington International Insurance Company &
North American Specialty Insurance Company & Vice President & Assistant Secretary of Westport Insurance Corporation