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Roofing Stonebrook® A TM iY aati Standard Form of Agreement Between Owner and Contractor where the basis of payment is a Stipulated Sum AGREEMENT made as of the day of in the year Two Thousand Fifteen BETWEEN the Owner: City of Blair 218 So. 16th Blair, Nebraska 68008 Telephone Number: (402) 426 -4191 Fax Number: (402) 426 -4195 and the Contractor: Stonebrook Roofing 11414 West Center Road Omaha, Nebraska 68144 (Paragraph deleted) for the following Project: City of Blair - Hail Damage Phase II - GROUP B Location No. 04- Steyer Park Location No. 05- Stemmermann Park Location No. 06 -Lions Park Location No. 07 -Bob Hardy RV Park Location No. 08- Black Elk Park Location No. 14- Cemetery Location No. 24- Restroom and Fish Cleaning Station/Park Shelter Location No. 39: The Depot The Work includes but is not limited to removing and replacing shingled roofs. Materials include shingles, metal flashing. Mechanical items also included. Refer to bid proposals and bidding documents for description of work per each location. Bidding documents are included with specification book per location. The Architect: HGM Associates Inc. 640 Fifth Avenue Council Bluffs, Iowa 51501 -6427 Telephone Number: 712 - 323 -0530 Fax Number: 712 - 323 -0779 The Owner and Contractor agree as follows. ADDITIONS AND DELETIONS: The author of this document has added Information needed for its completion. The author may also have revised the text of the original AIA standard form. An Additions and Deletions Report that notes added information as well as revisions to the standard form text is available from the author and should be reviewed. A vertical line in the left margin of this document indicates where the author has added necessary information and where the author has added to or deleted from the original AIA text. This document has important legal consequences. Consultation with an attorney is encouraged with respect to its completion or modification. AIA Document A201 TM -2007, General Conditions of the Contract for Construction, is adopted in this document by reference. Do not use with other general conditions unless this document is modified. Init. AIA Document Al 01 TM — 2007. Copyright © 1915, 1918, 1925, 1937, 1951, 1958, 1961, 1963, 1967, 1974, 1977, 1987, 1991, 1997 and 2007 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the / maximum extent possible underthe law. This documentwas produced by AIA software at 11:35:32 on 05/07/2015 under Order No.7955845282_1 which expires on 04/29/2016, and is not for resale. User Notes: (1985238090) TABLE OF ARTICLES 1 THE CONTRACT DOCUMENTS 2 THE WORK OF THIS CONTRACT 3 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION 4 CONTRACT SUM PAYMENTS DISPUTE RESOLUTION TERMINATION OR SUSPENSION MISCELLANEOUS PROVISIONS ENUMERATION OF CONTRACT DOCUMENTS 10 INSURANCE AND BONDS ARTICLE 1 THE CONTRACT DOCUMENTS The Contract Documents consist of this Agreement, Conditions of the Contract (General, Supplementary and other Conditions), Drawings, Specifications, Addenda issued prior to execution of this Agreement, other documents listed in this Agreement and Modifications issued after execution ofthis Agreement, all ofwhich form the Contract, and are as fully a part of the Contract as if attached to this Agreement or repeated herein. The Contract represents the entire and integrated agreement between the parties hereto and supersedes prior negotiations, representations or agreements, either written or oral. An enumeration of the Contract Documents, other than a Modification, appears in Article 9. ARTICLE 2 THE WORK OF THIS CONTRACT The Contractor shall fully execute the Work described in the Contract Documents, except as specifically indicated in the Contract Documents to be the responsibility of others. ARTICLE 3 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION § 3.1 The date of commencement of the Work shall be the date of this Agreement unless a different date is stated below or provision is made for the date to be fixed in a notice to proceed issued by the Owner. Not Applicable (N/A) If, prior to the commencement of the Work, the Owner requires time to file mortgages and other security interests, the Owner's time requirement shall be as follows: N/A § 3.2 The Contract Time shall be measured from the date of commencement. § 3.3 The Contractor shall achieve Substantial Completion of the entire Work not later than ( ) days from the date of commencement, or as follows: (Paragraph deleted) The project shall be complete by October 1, 2015 Portion of Work Substantial Completion Date Substantial Completion of all work unless October 1, 2015 extended by approved change order Init. AIA Document A101 TM — 2007. Copyright ©1915, 1918, 1925, 1937, 1951, 1958, 1961, 1963, 1967, 1974, 1977, 1987, 1991, 1997 and 2007 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. Unauthorized 2 reproduction or distribution of this AIA Document, or any portion of it, may result In severe civil and criminal penalties, and will be prosecuted to the t maximum extent possible under the law. This document was produced by AIA software at 11:35:32 on 05/0712015 under Order No.7955845282_1 which expires on 04/29/2016, and is not for resale. User Notes: (1985238090) , subject to adjustments of this Contract Time as provided in the Contract Documents. (Paragraph deleted) If the Contractor shall fail to complete the Work on agreed date of Substantial Completion, the Contractor agrees to pay the Owner as liquidated damages and not as a penalty, the sum of $250.00 for each and every calendar day that the Contractor is in default of substantial completion of the work under this Contract. ARTICLE 4 CONTRACT SUM § 4.1 The Owner shall pay the Contractor the Contract Sum in current funds for the Contractor's performance of the Contract. The Contract Sum shall be Seventy -three Thousand Eight Hundred Dollars and Zero Cents ($ 73,800.00 ), subject to additions and deductions as provided in the Contract Documents. § 4.2 The Contract Sum is based upon the following alternates, if any, which are described in the Contract Documents and are hereby accepted by the Owner: N/A § 4.3 Unit prices, if any: (Paragraph deleted) These unit prices will only be used ifthere is a need for Replacing roof sheathing for any building receiving anew roof after removal of the existing roof Item Units and Limitations Price Per Unit ($0.00) Unit price for removal and replacement of Per SF 3.00 roof sheathing § 4.4 Allowances included in the Contract Sum, if any: (Paragraph deleted) Item Price N/A ARTICLE 5 PAYMENTS § 5.1 PROGRESS PAYMENTS § 5.1.1 Based upon Applications for Payment submitted to the Architect by the Contractor and Certificates for Payment issued by the Architect, the Owner shall make progress payments on account of the Contract Sum to the Contractor as provided below and elsewhere in the Contract Documents. § 5.1.2 The period covered by each Application for Payment shall be one calendar month ending on the last day of the month, or as follows: Provided that an Application for Payment is received by the Architect no later than a week prior to the last working day of the month, the Owner will make payment of the certified amount to the Contractor which will be ready by the Wednesday following the second Tuesday of the month. Blair City Council only approves claims at their first meeting each month § 5.1.3 Provided that an Application for Payment is received by the Architect not later than the First day of a month, the Owner shall make payment of the certified amount to the Contractor not later than the Thirtieth day of the same month. If an Application for Payment is received by the Architect after the application date fixed above, payment shall be made by the Owner not later than thirty ( 30 ) days after the Architect receives the Application for Payment. § 5.1.4 Each Application for Payment shall be based on the most recent schedule of values submitted by the Contractor in accordance with the Contract Documents. The schedule of values shall allocate the entire Contract Sum among the various portions of the Work. The schedule of values shall be prepared in such form and supported by such data to substantiate its accuracy as the Architect may require. This schedule, unless objected to by the Architect, shall be used as a basis for reviewing the Contractor's Applications for Payment. § 5.1.5 Applications for Payment shall show the percentage of completion of each portion of the Work as of the end of the period covered by the Application for Payment. Init. AIA Document A101 TM — 2007. Copyright ©1915, 1918, 1925, 1937, 1951, 1958, 1961, 1963, 1967, 1974, 1977, 1987, 1991, 1997 and 2007 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. Unauthorized 3 reproduction or distribution of this AIA Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the f maximum extent possible under the law. This document was produced by AIA software at 11:35:32 on 05/07/2015 under Order No.7955845282_1 which expires on 04129/2016, and is not for resale, User Notes: (1985238090) § 5.1.6 Subject to other provisions of the Contract Documents, the amount of each progress payment shall be computed as follows: .1 Take that portion of the Contract Sum properly allocable to completed Work as determined by multiplying the percentage completion of each portion of the Work by the share of the Contract Sum allocated to that portion of the Work in the schedule of values, less retainage of Five percent ( 5 %). Pending final determination of cost to the Owner of changes in the Work, amounts not in dispute shall be included as provided in Section 7.3.9 of AIA Document A201TM -2007, General Conditions of the Contract for Construction; .2 Add that portion of the Contract Sum properly allocable to materials and equipment delivered and suitably stored at the site for subsequent incorporation in the completed construction (or, if approved in advance by the Owner, suitably stored off the site at a location agreed upon in writing), less retainage of Five percent( 5 %); .3 Subtract the aggregate of previous payments made by the Owner; and .4 Subtract amounts, if any, for which the Architect has withheld or nullified a Certificate for Payment as provided in Section 9.5 of AIA Document A201 -2007. § 5.1.7 The progress payment amount determined in accordance with Section 5.1.6 shall be further modified under the following circumstances: .1 Add, upon Substantial Completion of the Work, a sum sufficient to increase the total payments to the full amount of the Contract Sum, less such amounts as the Architect shall determine for incomplete Work, retainage applicable to such work and unsettled claims; and (Paragraph deleted) .2 Add, if final completion of the Work is thereafter materially delayed through no fault of the Contractor, any additional amounts payable in accordance with Section 9.10.3 of AIA Document A201 -2007. § 5.1.8 Reduction or limitation of retainage, if any, shall be as follows: None § 5.1.9 Except with the Owner's prior approval, the Contractor shall not make advance payments to suppliers for materials or equipment which have not been delivered and stored at the site. § 5.2 FINAL PAYMENT § 5.2.1 Final payment, constituting the entire unpaid balance of the Contract Sum, shall be made by the Owner to the Contractor when .1 the Contractor has fully performed the Contract except for the Contractor's responsibility to correct Work as provided in Section 12.2.2 of AIA Document A201 2007, and to satisfy other requirements, if any, which extend beyond final payment; and .2 a final Certificate for Payment has been issued by the Architect. § 5.2.2 The Owner's final payment to the Contractor shall be made no later than 30 days after the issuance of the Architect's final Certificate for Payment, or as follows: Not Applicable ARTICLE 6 DISPUTE RESOLUTION § 6.1 INITIAL DECISION MAKER The Architect will serve as Initial Decision Maker pursuant to Section 15.2 of AIA Document A201 -2007, unless the parties appoint below another individual, not a parry to this Agreement, to serve as Initial Decision Maker. N/A Init. AIA Document A101 TM — 2007. Copyright ©1915, 1918, 1925, 1937, 1951, 1958, 1961, 1963, 1967, 1974, 1977, 1987, 1991, 1997 and 2007 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. Unauthorized 4 reproduction or distribution of this AIA Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document was produced by AIA software at 11:35:32 on 05/07/2015 under Order No.7955845282_1 which expires on 04/29/2016, and is not for resale. User Notes: (1985238090) § 6.2 BINDING DISPUTE RESOLUTION For any Claim subject to, but not resolved by, mediation pursuant to Section 15.3 of AIA Document A201 2007, the method of binding dispute resolution shall be as follows: (Paragraph deleted) [ X ] Arbitration pursuant to Section 15.4 of AIA Document A201-2007 Litigation in a court of competent jurisdiction [ ] Other (Specify) ARTICLE 7 TERMINATION OR SUSPENSION § 7.1 The Contract may be terminated by the Owner or the Contractor as provided in Article 14 of AIA Document A201-2007. § 7.2 The Work may be suspended by the Owner as provided in Article 14 of AIA Document A201-2007, ARTICLE 8 MISCELLANEOUS PROVISIONS § 8.1 Where reference is made in this Agreement to a provision of AIA Document A201-2007 or another Contract Document, the reference refers to that provision as amended or supplemented by other provisions of the Contract Documents. § 8.2 Payments due and unpaid under the Contract shall bear interest from the date payment is due at the rate stated below, or in the absence thereof, at the legal rate prevailing from time to time at the place where the Project is located. 0 % Zero Percent § 8.3 The Owner's representative: Al Schoemaker City of Blair 218 So. 16th Blair, Nebraska 68008 § 8.4 The Contractor's representative: Stonebrook Roofing 11414 West Center Road Omaha, Nebraska 68144 § 8.5 Neither the Owner's nor the Contractor's representative shall be changed without ten days written notice to the other party. § 8.6 Other provisions: N/A ARTICLE 9 ENUMERATION OF CONTRACT DOCUMENTS § 9.1 The Contract Documents, except for Modifications issued after execution of this Agreement, are enumerated in the sections below. § 9.1.1 The Agreement is this executed AIA Document A101 -2007, Standard Form of Agreement Between Owner and Contractor. § 9.1.2 The General Conditions are AIA Document A201 2007, General Conditions of the Contract for Construction. Init. AIA Document A101 TM — 2007. Copyright © 1915, 1918, 1925, 1937, 1951, 1958, 1961, 1963, 1967, 1974, 1977, 1987, 1991, 1997 and 2007 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. Unauthorized 5 reproduction or distribution of this AIA Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the f maximum extent possible under the law. This document was produced by AIA software at 11:35:32 on 05/07/2015 under Order No.7955845282_1 which expires on 04/29/2016, and is not for resale. User Notes: (1985238090) § 9.1.3 The Supplementary and other Conditions of the Contract: Document ALL SECTIONS § 9.1.4 The Specifications: (Paragraphs deleted) Section ALL SECTIONS § 9.1.5 The Drawings: (Paragraph deleted) N/A Number § 9.1.6 The Addenda, if any: Number Addendum No. 1 Title Project Manual for Hail Damage Emergency Package, Phase II GROUP B, City of Blair, Nebraska INCLUDING Contract Documents and Specifications and Site Information and Plans Title Project Manual for Hail Damage Emergency Package, Phase II GROUP B, City of Blair, Nebraska INCLUDING Contract Documents and Specifications and Site Information and Plans Title Date Date Pages April 1, 2015 1 -5 Pages INCLUSIVE Pages INCLUSIVE Portions of Addenda relating to bidding requirements are not part of the Contract Documents unless the bidding requirements are also enumerated in this Article 9. § 9.1.7 Additional documents, if any, forming part of the Contract Documents: .1 AIA Document E201TM -2007, Digital Data Protocol Exhibit, if completed by the parties, or the following: N/A .2 Other documents, if any, listed below: City of Blair — Hail Damage Phase II GROUP B Schedule of Values, attached. ARTICLE 10 INSURANCE AND BONDS The Contractor shall purchase and maintain insurance and provide bonds as set forth in Article 11 of AIA Document A201-2007. (Paragraph deleted) Date FEBRUARY 2015 Date FEBRUARY 2015 AIA Document A101 TM — 2007. Copyright ©1915, 1918, 1925, 1937, 1951, 1958, 1961, 1963, 1967, 1974, 1977, 1987, 1991, 1997 and 2007 by The American Init. Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. Unauthorized 6 reproduction or distribution of this AIA Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document was produced by AIA software at 11:35:32 on 05/07/2015 under Order No.7955845282_1 which expires on 04129/2016, and is not for resale. User Notes: (1985238090) Type of insurance or bond Performance Bond Payment Bond Limit of liability or bond amount ($0.00) 100% 100% This Agreement entered into as of the day and year first wri OWNER (Si Q atu Cit y of Blaaska (Row deleted) Init. AIA Document A101Tm — 2007. Copyright ©1915, 1918, 1925, 1937, 1951, 1958, 1961, 1963, 1967, 1974, 1977, 1987, 1991, 1997 and 2007 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. Unauthorized 7 reproduction or distribution of this AIA Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the t maximum extent possible under the law. This document was produced by AIA software at 11:35:32 on 05/07/2015 under Order No.7955845282_1 which expires on 04/29/2016, and is not for resale. User Notes: (1985238090) Stonebrook Roofing Blair Hail II - Package B Stonebrook Construction Location: Building: Bathroom Building . Scope: Labor Total ($): $ 1,498.00 Material $ 4,077.00 Equipment $ 200.00 Administration $ 300.00 TOTAL: $' _ 6,075.00 Park.Shelter 1' ; . ;' Labor $ 2,100.00 Material $ 3,426.00 . ; Equipment $ 200.00 Administration $ 300.00 TOTAL`: $ ; 6,026.00 Park "Shelter 2 Labor $ 1,904.00 Material $ 3,061.00 Equipment $ 200.00 Administration $ 300.00 TOTAL`: $ 5,465.00 TOTAL: $ 17,566.00 Ste �mie, �man a . ;�No X 05 ParkShelterl "" `.. Labor $ 525.00 Material $ 1,073.00 Equipment $ 100.00 Administration $ 125.00 TOTAL: $ 1,823.00 Park Shelter 2 Labor $ 440.00 Material $ 914.00 Equipment $ 150.00 Administration $ 200.00 TOTAL: $ 1,704.00 Park Shelter 3 Labor 531 Material 1072 Equipment 150 Administration 200 TOTAL: $ 1 TOTAL:: $ 5,480.00 Bathroom Building Labour $ 525.00 Material $ 1,645.00 Equipment $ 150.00 .!; Administration $ 200.00 TOTAL: $ 2,520.00`' Park Shelter Labor $ 1,164.00 Material $ 2,097.00 Equipment $ 200.00 Administration $ 300.00 TOTAL: $ 3,761.00 TOTAL:: $ 6,281.00 Bo a gestroor> Building'. Labor $ 525.00 � Material $ 1,110.00 " Equipment $ 150.00 Administration $ 200.00 TOTAL; $ ?, 1,985.00 TOTAL:: $ 1,985.00 ` Labor $ 6,690.00 Material $ 10,500.00 -,..' Equipment $ 650.00 Administration $ 300.00 TOTAL: $ 18,140.00 TOTAL:: $ 18,140.00 Park Shelter 1,.. '> Labor $ 1,800.00 ,.,., Material $ 3,082.00 Equipment $ 300.00 Administration $ 300.00 TOTAL: $ 5,482.00 TOTAL:: $ 5,482.00 Ii.�,s. �omJ��s�► le ntn'SL►ell�ei o��24"�'� Restro "om %F�sh %Bath .;' Labor, $ 700.00 Material $ 1,520.00 Equipment $ 50.00 Administration $ 150.00 TOTAL: $, 2,420.00 TOTAL:: $ 2,420.00 1P Labor $ 5,032.00 Material $ 10,364.00 "Equipment $ 650.00 Administration $ 400.00 TOTAL: $ 16,446.00 TOTAL:: $ 16,446.00 GRAND TOTAL': $ 73,800.001: ` 0 DATE (MMIDOIYYYY) A � `.. CERTIFICATE OF L I AB ILI TY ' U 5/27/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Mary Kent UNICO Group PHONE uz , (402) 434-7200 FAX (402)434 -7272 C No 4435 0 Street EMAIL .mkent@unicogroup.com INCI IRFRIRI AFFr1RMNG OVERAGE NAIL # Lincoln NE 68510 INSURERA:MidWest Family Mutual Ins Co. 23574 INSURED INSURER B: Stonebrook Roofing Inc INSURERC: Stonebrook Enterprises, LLC INSURER D: 1919 S 40th Suite 222 INSURERE: Lincoln NE 68508 -1356 INSURER F: COVERAGES CERTIFICATE NUMBER GL,AU,wc,UMB REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AD SU R POLICY NUMBER MMIDD MMIDDY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 50 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ 5,000 A CLAIMS - MADE 5Z OCCUR k CHE0560059018 /25/2015 /25/2016 PERSONAL & ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOPAGG $ 2,000,000 $ POLICY X PRO LOC AUTOMOBILE LIABILITY Ea acciden SINGLE LIMIT 1,000,000 BODILY INJURY (Per person) $ X A ANY AUTO ALLOWNED SCHEDULED 2ME0560068467 /25/2015 /25/2016 BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE Per accident $ HIRED AUTOS AUTOS X UMBRELLA DAB OCCUR EACH OCCURRENCE $ 9,000,000 — 1 AGGREGATE $ 9,000,000 A EXCESS LIAR CLAIMS MADE DED I X I RETENTION$ 10,000 $ UNE0560076769 /25/2015 /25/2016 A WORKERS COMPENSATION X WC STATU- OTH- ER E.L. EACH ACCIDENT $ 100,000 AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE � E.L. DISEASE - EAEMPLOYE $ 100,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) N 1 A CNE056006 1579 /25/2015 /25/2016 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below CCO0560106499 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Bid Package B SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Blair 218 South 16th Street Blair, NE 68008 AUTHORIZED REPRESENTATIVE Cockle /BR ACORD 25 (2010105) V IVOO=AU'IU A%oUMU %.VRrVlvwnvrY. M11 nyuw 1vmv1vcu. IAIq(19G 11MAAM M 'Th.. ­1L. Ar f%on