HARTZELL PAINTING CONTRACTORSMaria M. Menendez, CMC, City Clerk, City of South Miami
Proposal Submittal Checklist Form
Bus Shelter Fabrication & Installation
RFP #PW-2015-21
H6 reqmre0-r0-UC-ST_ - I I
by the deadline set for within the solicitation. Fulfillment of all solicitation requirements listed is mandatory for
consideration of response to the solicitation. Additional documents may be required and, if so, they will be
identified in an addendum to this Solicitation. The response shall include the following items:
X
Indemnification and Insurance Documents EXHIBIT 2
X
Bid Form EXHIBIT 4
vo,
X
Respondents Cost and Technical Proposal, EXHBIT 5
x
Signed Contract Documents (All — including General Conditions
and Supplementary Conditions if attached) EXHIBIT 6; 7 & 8
Performance and Payment Bonds (As a Condition Award. Not
AIA
required with Submittal.) EXHIBIT 9 & 10
x
Respondents Qualification Statement
X
List of Proposed Subcontractors and Principal Suppliers
X
Non-Collusion Affidavit
X
Public Entity Crimes and Conflicts of Interest
X
Drug Free Workplace
X
Acknowledgement of Conformance with OSHA Standards
X
Affidavit Concerning Federal & State Vendor Listings
X
Related Party Transaction Verification Form
X
Presentation Team Declaration/Affidavit of Representation
,--nd/or documents.
A ilk I CEO] al 011110 leffig
RESPORDEAT QUALIFICATIOA STATEAEAT
Bus Shelter Fabrication & Installation
RFIP #PW-201 S-21
The response to this questionnaire shall be utilized as part of the CITY'S overall Proposal Evaluation and
RESPONDENT selection.
I. Number of similar projects completed,
a) In the past 5 years
In the past 5 years On Schedule
b) In the past 10 years
In the past 10 years On Schedule
2. List the last three (3) completed similar projects.
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Project Name:
Owner Name:
Owner Address:
Owner Telephone:
Original Contract Completion Time
(Days):
7M
70/3
,?0/3
Vk,cyo ce) -D
1E
I ao
— i2ol-
'20
9011f --
Original Contract Completion Time
(Days):
Original Contract Completion Date:
Actual Final Contract Completion
Date:
Original Contract Price:
Actual Final Contract Price:
3. Current workload
5. List and describe any:
W
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LIST OF PROPOSED SUBCONTRACTORS AND PRINCIPAL SUPPLIERS
Bus Shelter Fabrication & Installation
RFP #PW-20 I S-21
'�esgonclent shall list all DrODOsed subcontractors, if subcontractors are allowed bX the terms of this Solicitation vk
be used on this project if they are awarded the Contract.____
Landscape
Sodding and Turf Work
Electrical
Irrigation
Vt
Paving
r
Park Amenities
Graphics
Utilities
Excavation
0,\ wm rt 44el C*
Building
Ik
Structures
Plumbing
VL
Painting
Testing Laboratory
Vil,
Soil Fumigator
Signs
Other:
This list shall be provided to the City of South Miami by the apparent lowest responsive and responsible Bidder
within five (5) business days after Bid Opening.
END OF SECTION
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Signed, sealed and delivered in the presence of.
WpKess
of Florida, personally appeared (Name(s) of individual(s) who appeared before
LE
]h
The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes.
Res ondents must disclose with their Proposals, the name of an ffi
- &ouicer, director, partner, associate or atrent wh#:
RVIIN _ M
110166-01M.'M 'kill I I , I �02N
LOOMMUM"VIIII-MUMIDA 0 1 Dial 10111,111 AIRIMMIG
I � This sworn statement is submitted t M A
M
M
ffrint name of the public entity]
[print name of entity submitting sworn statement]
1 understand that "convicted" or "conviction" as defined in Paragraph 287.133 (1) (b), I rii
Statutes, means a finding of guilt or a conviction of a public entity crime, with • without an adjudicati
• guilt, in any federal or state trial court of record relating to charges brought by indictment
information after July 1, 1989, as a result o n-
f a jury verdict, nojury trial, or entry of a plea of guilty
nolo contenclere. I
4. 1 understand that an "affiliate" as defined in Paragraph (a), Florida Statutes, means:
(a) A predecessor or successor of a person convicted of a public entity crime; or
(b) An entity under the control of any natural person who is active in the management of the entity
and who has been convicted of a public entity crime. The term "affiliate" includes those officers,
E
6� Based on information and belief, the statement which | have marked below is true in relation to the
entity submitting this sworn statement. [indicate which statement npp|ies]
Neither the entity submitting this oxom statement, nor any of its o0cen, dinecturu, execudves,
partmcrs, shareho|ders, emp|oyee,, members, or agents who are active in the management of the entity,
nor any affiliate ofthe entity has been charged with and convicted of a public entity crime subsequent to
July 1, 1989.
-
Sworn to and subscribed b f his day of
Personally known
OR Produced identification
RiEl: YF )k 0
C(�MM�%Ajo�IEE 1872`19
1.1
My commission expires
(Printed, typed or stamped commissioned
name of notary public)
Whenever two or more £Ucb or Proposals which are equal with respect to price, quality and service are received
by the State or by any political subdivisions for the procurement of commodities or contractual services, a Bid or
Proposal received from a business that certifies that ithas implemented u drug-free workplace program shall be
given preference in the award process. Established procedures for processing tie Bids ur Proposals shall be
followed if none of the tied vendors have a drug-free workplace program. In order to have a drug-free workplace
program, u business shall:
EE
ACKNOWLEDGEMENT OF CONFORMANCE
Bus Shelter Fabrication & Installation
RFP I
We, 2 d ` K4v C (Name of CONTRACTOR), hereby acknowledge and agree that as
. .
al
Witness
-I DYNTA Iii dWoUl W IQ j I I
1Z 10101 1
The person, • entity, who is responding to the City's solicitation, hereinafter referred to as "Respondent", must
certi4 that the Res • ondent's name Does Not a ear on the State of Florida Dpartment of Management Services,
54 1 0
LISTINGS".
'f the Respondent's name Does appear on one or all the "Listings" summarized below, Respondents must "Check
'f Applies" next to the applicable "Listing." The "Listings" can be accessed through the following link to the Florida
Wepartment of Management Services website:
tiqp asguilbusinos �6
ended discriminatory complaints vendor lists
• th9i 8 day of Oke 20/f beff�Oersigned authority, personally
appeared
�CA41VA -whd' is persitally k" Uot to me • who provided the
L
following identification and w ic, took an oath • 7i Irme that that he/she/they executed the
foregoing Affidavit as the Declarant. A
nz
individually and on behalf of
043
Print Name & Title: A
Mwc-
Date: t
Sec. 8A°|'- Conflict wf interest and code pf ethics ordinance.
(a)
This section shall be designated and known authe "City mf South Miami Conflict cf Interest and Code cdEthics
Drdinunce.^ This section shall bc applicable ooall city personnel ox defined below, and shall also constitute
standard of ethical conduct and behavior for all autonomous personnel, quasi-judicial personnel, advisory
personnel and departmental personnel. The provisions of this section shall be applied in a cumulative manner. By
way of example, and not as a limitation, subsections (c) and (d) may be applied to the same contract or transaction.
(b) Definitions. For the purposes of this section the following definitions shall be effective:
(1) The term "commission members" shall refer to the mayor and the members of the city commission.
(2) The term "autonomous personnel" shall refer to the members of autonomous authorities, boards and agencies,
such u, the city community redevelopment agency and the health facilities authority.
(3) The term "quasi-judicial personnel" shall refer to the members of the planning board, the environmental review
and preservation board, the code enforcement board and such other individuals, boards and
agencies of the city a^ perform quasi-judicial functions.
(4) The term "advisory personnel" shall refer to the members of those city advisory boards and agencies whose
sole nr primary responsibility is to recommend legislation or give advice to the city commission.
(S) The term "departmental personnel" shall refer tothe city clerk, the city manager, department heads, the city
wttorney, and all assistants tothe city clerk, city manager and city attorney, however titled.
(6) The term "cmp|uyees" shall refer to all other personnel employed by the city.
(7) The term "compensation" shall refer to any money, gift, favor, thing of value or financial benefit conferred, or
to be conferred, in return for services rendered or to be rendered.
(8) The term "controlling financial interest" shall refer to ownership, directly or indirectly, of ten percent or more
of the outstanding capital stock in any corporation or a direct or indirect interest of ten percent or more in a firm,
partnership, or other business entity at the time of transacting business with the city.
(9) The term "immediate family" shall refer to the spouse, parents, children, brothers and sisters of the person
involved.
(10) The term "transact any business" shall refer to the purchase or sale by the city of specific goods or services
for consideration and to submitting a bid, a proposal in response to a Solicitation, a statement of qualifications in
response to request bythe cicy, or entering into contract negotiations for the provision
on any goods or services, whichever first occurs.
(c) Prohibition pntransacting business with the city.
No person included in the terms defined in paragraphs (b)(1) through (6) and in paragraph (b)(9) shall enter into
any contract or transact any business in which that person or a member of the immediate family has a financial
interest, direct or indirect with the city or any person or agency acting for the city, and any such contract,
agreement or business engagement entered in violation of this subsection shall render the transaction voidable.
Willful violation of this subsection shall constitute malfeasance in office and shall affect forfeiturc of office or
position. Nothing in this subsection shall prohibit or make illegal:
(1) The payment of taxes, special assessments or fees for services provided by the city government;
(2) The purchase of bonds, anticipation notes or other securities that may be issued by the city through
underwriters or directly from time totime.
Waiver of prohibition. The requirements of this subsection may be waived for a particular transaction only by four
affirmative votes of the city commission after public hearing upon finding that:
(1) An open-to-all sealed competitive proposal has been submitted by a city person as defined in paragraphs (b)(2),
(3) and (4);
(2) The proposal has been submitted by a person or firm offering services within the scope of the practice of
architecture, professional engineering, or registered land surveying, as defined by the laws of the state and
pursuant to the provisions of the Consultants' Competitive Negotiation Act, and when the proposal has been
submitted bya city person defined in paragraphs (b)(2).(]) and (4);
(3) The property orservices to be involved in the proposed transaction are unique and the city cannot avail itself
of such property or services without entering a transaction which would violate this subsection but for waiver of
its requirements; and
(4) That the proposed transaction will bein the best interest of the city.
This subsection shall be applicable only to prospective transactions, and the city commission may in no case ratify a
transaction entered in violation of this subsection.
Provisions cumulative. This subsection shall be taken to be cumulative and shall not be construed to amend or repeal
any other law pertaining to the same subject matter.
M
(d) Further prohibition *ntransacting business with the city.
No person included inthe terms defined in paragraphs (b)(|) through (6) and in paragraph (b)(Y) shall enter into
any contract or transact any business through a firm, corporation, partnership or business entity in which that
person nr any member uf the immediate family has ucontrolling financial interest, direct or indirect, with the city
or any person or agency acting for the city, and any such contract, agreement or business engagement entered in
violation of this subsection shall render the transaction voidable. The remaining provisions of subsection (c) will
also br applicable to this subsection ao though incorporated byrecitation.
Additionally, no person included in the term defined in paragraph (b)(|)shaUvuoconorpurbcipueinunywuyin
any matter presented to the city commission if that person has any of the following relationships with any of the
persons or entities which would be or might be directly or indirectly affected by any action of the city commission:
(1) Officer, director, partner, of counsel, consultant, employee, fiduciary or beneficiary; or
(2) Stockholder, bondholder, debtor, orcreditor, ifin any instance the transaction or matter would affect the
person defined in paragraph (b)(1) in a manner distinct from the manner in which it would affect the public
generally. Any person included in the term defined in paragraph (b)( |) who has any o/ the specified relationships
or who would or might, directly or indirectly, realize a profit by the action of the city commission shall not vote on
or participate in any way in the matter.
(E) Gifts.
(/)Dcfindion. The term °gift' shall refer »nthe transfer of anything of economic value, whether in the form of
money, service, loan, travel, entertainment, hospitality, item or promise, or in any other form, without
adequate and lawful consideration.
(DEKz«pbunu. The provisions of paragraph (e)(|) shall not apply to:
o. Political contributions specifically authorized by state {mm;
b. Gifts from relatives or members of one's household, unless the person is a conduit on behalf ufa third party to
the delivery ofagift that is prohibited under pamgmph(3);
c. Awards for professional or civic achievement;
d. Material such as books, reports, periodicals or pamphlets which are solely informational or of an advertising
nature.
(3) Prohibitions. Apeson described in paragraphs (b)(|) through (6) shall neither solicit nor demand any gift. It is
also unlawful for any person or entity tv offer, give or agree to give to any person included in the terms defined in
paragraphs (b)(|) through (6).or for any person included inthe terms defined in paragraphs (b)(|) through (&)co
accept or agree to accept from another person or entity, any gift for or because of.-
a. An official public action taken, or to be taken, or which could be taken, or an omission or failure to take apublic
action;
b. A legal duty performed or to be performed, or which could be performed, or an omission or failure to perform
u legal duty;
cA legal duty violated or to be violated, or which could be violated by any person included in the term defined in
paragraph (b)(|);or
d. Attendance orabsence from a public meeting at which official action is tobetaken.
A8 Disclosure. AnypemonindudedindhetermdeAnedinparagruphs (b)(|) through (6) shall disclose any gift, or
series of gifts from anyone person or entity, having a value in excess of $25.00. The disclosure shall be made by
filing a copy of the disclosure form required by chapter 112, Florida Statutes, for "local
officers" with the city clerk simultaneously with the filing of the form with the clerk of the county and with the
Florida Secretary ofState.
(f) Compulsory disclosure by employees offimma doing business with the city.
Should any person included inthe terms defined in paragraphs (b)(1) through (6) be employed by a corporation,
Orm, partnership or business entity in which that person or the immediate family does not have ucunt,o||ing
financial interest, and should the corporation, firm, partnership orbusiness entity have substantial business
commitments to or from the city or any city agency, or be subject to direct regulation by the city or a city agency,
then the person shall file a sworn statement disclosing such employment and interest with the clerk of the city.
(0) Exploitation of official position prohibited.
No person included in the terms defined in paragraphs (b )(1) through (6) shall corruptly use or attempt to use an
official position to secure special privileges ur exemptions for that person orothers.
(h) Prohibition on use of confidential information.
No person included in the terms defined in paragraphs (b)(1) through (6) shall accept employment or engage in
any business or professional activity which one might
reasonably expect would require or induce one to disclose confidential information acquired by reason of an
official position, nor shall that person infact ever disclose confidential information garnered or gained through an
W.
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(Ord. No. 6-99-1680, § 2, 3-2-99)
Editor's note- Ord. No. 6-99-1680, § 1, adopted 3-2-99, repealed §§ 8A- I and 8A-2 in their entirety and replaced
them with new §§
BA- I and 8A-2. Former §§ 8A- I and 8A-2 pertained to declaration of policy and definitions, respectively, and
derived from Ord. No. 634, §§ I (I A -1), 1 (1 A-2) adopted Jan. 11, 1969.
A 01 FBI NJ 9 W X41 •
PRESENTATION TEAM
Listed below are all individuals who may make a presentation on behalf of the entity that the affiant
represents. Please note; No person shall appear before any committee on behalf of anyone unless he
iNg ml imtT
r Tzlmz FaW.
fees.
9M
For the purpose • this Affidavit • Representation only, the listed members • the presentation tea
with the exception of any person otherwise required to register as a lobbyist, shall not be required
pay any registration fees. The Affidavit • Representation shall be filed with the City Clerk's office at t
time the committee's proposal is submitted to the City as part of the procurement process.
Under penalties of perjury, I declare that I have read the foregoing declaration and that the facts stat
in it are true and specifically that the persons listed above are the members of the presentation team
the entity listed below I
W-1
�r = ME 11 l�illillill:ll:!Illl 11 ; 11111111!1111111vjLjr -� i�
aESOLUTION OF PROTESTED SOLICITATIONS AND AWARDS (FORMAL
PROCEDURE)
The following procedures shall be Used for resolution of protested Solicitations and awards.
The word "bid as well as all of its derivations, shall mean a response to a solicitation, including
requests for proposals, requests for a letter • interest and requests for qualifications.
a
described in and attached to the Protest Letter at the time • its filing shall • permitted
tr considered in support of the protest.
(c) Computation of time. No time will be added to the above time limits for service by
mail. The last day of the period so computed shall be included unless it is a Saturday,
Sunday, or legal holiday in which event the period shall run until the next day which is
not a Saturday, Sunday, • legal holiday.
(d) Challenges. The written protest may not challenge the relative weight of the evaluation
criteria or any formula used for assigning points in making an award determination, nor
shall it challenge the City's determination • what is in the City's best interest which is
one of the criteria for selecting a bidder whose offer may not be the lowest bid price.
rf
EXHIBIT 4
Bus Shelter Fabrication &Installation
RF P#PW-2Q|S-21
Steven Alexander
City Manager
City o{ South Miami
6|3D Sunset Drive
South Miami, FL33|49
b Respondent has familiarized himself with the nature and extent ofthe ContracDmcumenc.dhcproposed
work, site, locality, and all local conditions and laws and regulations that in any manner may affect cost,
progress, performance or furnishing of the Work.
c. Subsurface conditions: If applicable to this Solicitation, the Respondent represents that:
i Respondent has studied carefully all reports and drawing,, if applicable, of subsurface conditions and
drawings of physical conditions.
ii Respondent has obtained and carefully studied (o, u,,umc, responsibility for obtaining and carefully
studying) all such cxaminzuiunx, invcsdgotiono, cxp|orations, tests and studies in addition to or to
supplement those referred to in this paragraph which pertain to the subsurface or physical conditions
at the site er otherwise may affect the cost, progress, performance, pr the furnishing uf the Work ct
the Contract Pricc, within the Contract Time and in accordance with the other terms and conditions
of the Contract Documents. The Respondent hereby acknowledges that no additional examinations,
<nvcsdgauions, exp|omcions, tcoo, reports or similar information or data ara, or will, be required by
Respondent for any reason in connection with the Proposal. The failure of the Respondent to request
a pre-bid marking of the construction site by any or all utility companies shall create on irrefutable
presumption that the Respondent', bid, or proposal price, has taken into consideration all possible
underground conditions and Respondent, if awarded the contract, shall not be entitled coachange
order for any such condition discovered thereafter.
iii. Respondent has correlated the results of all such observatiuns, examinacions, invesdgations,
explorations, tests, reports and studies with the terms and conditions o/the Contract Documents.
rV
LUMP SUM BASE PRICE: ATTACH EXHIBIT 5. Respondents Cost and Technical Proposal
Alternates: #1 )er' 42 V
A fee breakdown for each task included in the lump sum contract price, if applicable, must beprovided.
Failure to provide this information shall render the proposal non-responsive.
S. The ENTIRE WORK shall be completed, in full, within 120 calendar days from the commencement
date set forth in the NOTICE TO PROCEED. Failure to complete the entire work during the described
time period shall result in the assessment of liquidated damages as may be set forth in the Contract.
PNVORNUM
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7. The terms used in this Proposal which are defined in the Contract shall have the same meaning as is
assigned to them in the Contract Documents, unless specifically defined in this Solicitation Package.
8. If a cost & technical proposal is required by the Solicitation, Respondent hereby certifies that all of the
facts and responses to the questions posed in the cost & technical proposal, if such an exhibit is made
a part of the Solicitation, are true and correct and are hereby adopted as part of this Bid Form, and are
made a part of this proposal, by reference.
L-tcl — &vivC'4T'
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RESPONDENTS COST & TECHNICAL PROPOSAL
Bus Shelter Fabrication & Installation
RFP #PW-2015-21
Respondents shall quote each area separately; Area I & Area 2, in accordance with the Scope
of Services, EXHIBIT 1, Attachment A, B & C. The City, at its discretion, may award one
Area to a single contractor or,
of Areas to a single contractor.
F-111WAIII
$ 2sz, 1, ?�G-A .�
Respondent affirms their submittal reflects the specifications for the Bus Bench and Tra-2
Receptacle in accordance with EXHIBIT 1, Attachment C, "Specifications," as prepared
Wabash Valley Manufacturing. I
If an approved equal is submitted, Respondent must acknowledge an approveN-
equal is submitted, with corresponding specifications and plans included as part
Respondents proposal:
APPROVED EQUAL SUBMITTED, check one: Yes: No: (if YES Checked,
Submit Plans and Specifications of Approved Equal.
SUBMITTED THIS J-7) DAY OF 0?
Title
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, Uq —�q— e6f
Telephone Number
Fax Number
Email –Address T-
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IMFM . P-PPRM
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Attachment
Bus Shelter Fabrication & Installation
RFP -2 1 -21
Along SW 62 "d Avenue:
1. Approximately 50 feet South of 64 Street, on the East side
t. Approximately 230 feet South of 64" Street, on the West side
111111. Plans and Specifications:
The current estimate to complete construction of the project is 120 calendar days
from issuance of Notice to Proceed.
V. Project Funding:
IMM =,11sz�?vv1R11!1F �ilill��illi�l���ill�l�l!��ll��ilill��, ! V! 'Ill: I I � ! � Ill I � � I i Ill 1111111 11 1 � i I � 1 11
V1, Warranty:
If equipment is being provided, the standard manufacturer's warranty information must
be provided in writing for all equipment being proposed, including installation by an
tuthorized dealer before final payment is made.
A NO VD3 FOYA V Xe- 1 •
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EXHIBIT #1
ESVF2
Attachment A
Bus Shelter Fabrication & Installation
RFP #PW-2015-21
MOMEMMANIM3
I I p1Mf=-
Along SW Sq,h Place/ Church Street:
1. South of East side of SW 59" Place
2. End of SW 67" ST, West side of SW 59" Place
3. North • SW 68 ST, East side of SW 59' Place
4. North of SW 69" ST, West side of SW 59' Place
w
EXHIBIT #1
Attachment
Bus Shelter Fabrication & Installation
RFP - 2015 -21
III Iililillillil 1111 ". .
M.
2301 N.W. '' Co
Pompano Beach., Ft 33069
M - -
Raton
Miramar 6�1 of
Angelica . - Public Works Supervisor .:
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• •
:OZA�M-Xo MIN 0 CoNflim •"
Forro Wliiiilg
�Rev Decem er 4)
191MIM - a,
1 Name (as shown on your income tax return).
Hartzell Construction, Inc,
Business njfli n IdI s wga rded en- it name , I f c
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11 a
rn
Request for Taxpayer
"IMMIRIMITERM=
ZZOOEMIMM
2301 NW 33 Court, Suite 112
6 City, state, and ZIP code
3ornpano Beach, FL 33029
7 List account rwinber() here (optional)
Enter your TIN in the appropriate box. The TIN pfd4idibd must malch the name given on W I to avoid
bac�up Withholding. Fcir'Odlvals' this is genertjily yor social seounty number (SSN). HioWover. for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
Fritities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. It the account is in more than one name, see the Instructions for line 1 and the chart on page 4 for
guidelines on whose number to enter.
FS.6.1 securitir, number
IMMOnuffill
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General Instructi ns L/
It"
Section references a it 1 Revenue Code unless otherwise noted.
"e elo en1i IA1AahonQout de.I.,%&nts,.;,ffec1ing Form W-9 (such
Date ►
• Form 1098 (home mortgage interest), 1098 -E (student loan interest), 1098-T
(luition)
• 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
Purpose of Form
provide your correct TIM.
An individual or entity (Form W-9 requester) who is required to file an information
If - you do hol n5lum Form W-9 to the requeAter w4h a TIN, you might be subject
to bkkoeioiio� Soo What a backup Wghhpjdi�? on page 2.
r turn with the IRS must obtain your correct taxpayer identification number (TIN)
which may be your social security number SSN), individual taxpayer identification
By signing the filled-out or
number (ITIN), adoption taxpayer identification number (ATIN), or employer
11, Certify that the TIN you are giving is correct (or you are waiting for a number
identification number (EIN), to report on an information return the amount paid to
to be issued),
you. • other amount reportable on an information return, Examples of information
returns include. but are not limited to, [he following:
2, Certify that you are not subject to backup withholding, or
Form 1099-INT (interest earned or paid)
3. Claim &emption from backup withholding if yod Are a U.S. oxombLPO"e If
applicable. you irg also cerlifying that as a U.& pergofl� your allocAhla share of
Form 1099-DIV (dividends, including those from stocks • mutual funds)
any partnership income from a U,S. trade or business is not subject to the
Forin 1099-MISC (various types of income, prizes, awards, or gross proceeds)
withhotding tax on foreign parineW share of etfec*lnected mcome. and
Form 1099-B (stock or mutual fund sales and certain other transactions by
4. Cerlity that FATCA code(s) entered on [his term (if any) indicating that you are
brokers)
exempt from the FATCA reporting, is correct See What is FATCA reporting? on
Form 1099-S (proceeds from real estate transactions)
page 2 for further information
Form 1099-K (merchant card and third party network transactions)
Cat. No 10231X Form W-9 (Rev 12-2014)
e <... r a ..
-• ,: _.. r : I 1 +, +.l YEN + I 1 +ri��•1 '
# 'Fr
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MED EXP (Any one person)
GENERAL AGGREGATE
f ;a
X
ANY AUTO
n
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS
HIREDAUTOS
BODILY INJURY 1 1 is I I C:
is
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• : ,.:
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AGGREGATE
DEDUCTIBLE
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSKINS ADDED BY ENOORSEMENT I SPECLAL PROVISIONS
..I 0444 E04 59
EFFECTIVE DATE FOR ALL POLICIES 07/28/15 0712811 G
1 25-A28-59 9113068 D19 59
893 4027-A2 -59 D
4028-A28-59 D16 0148 C115 59
• r I s. fl 7-59 *A Waiver of Subrogation applies in fays of - additional respect r general liability
SOOULD ANY OF THE AWVE DESCIIIIIIIIED POLICIES 13E CANCELLED BEFORE THE EIMRATION
DATE THEREOF. THE ISOLW40 INSUM91 WALL ENDEAVOR TO MAIL 45 DAYS
NOTICE TO THE CERnFICATE HOLDIER NAMED TO THE LEFT. BUT FAILURE TO ra 90
IMPOSE NO OBLIGATION OR LLABIL11TY OF ANY KIND UPON THE wsupwx ITS AGEMS OR