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Home My WebLink About900943.tiff 01, 647.; MEMORAnDum Wilk Clerk to the Board October 18, 1990 Date (40 Denny Graham, Civil Engineer II JN COLORADO From Construction of Bridge 47/54A Subject: Enclosed for your information and file is the executed Agreement for the construction of Bridge 47/54A that has been signed by Ideal Construction Services, Inc. Also enclosed are the following documents: 1. Workers Compensation Certificate of Insurance 2. Performance Bond 3. Payment Bond 4. General Liability Certificate of Insurance DG/zw:zdmb cc: Commissioner Kirby Bridge File 47/54A ��rn0 AGREEMENT THIS AGREEMENT, made this 4th day of October _, 1990, by and between THE BOARD OF WELD COUNTY COMMISSIONERS, and Ideal Construction Services, Inc. doing business as Ideal Construction Services, Inc. hereinafter called "contractor". WITNESSETH: That for and in consideration of the payments and agreements hereinafter mentioned: 1. The contractor will commence and complete the phased construction of WELD COUNTY BRIDGE 47/54A 2. The contractor shall furnish all material, supplies, tools, equipment, labor and other services necessary for the construction and completion of the project described herein. 3. The contractor shall commence the work required by the Contract Documents in accordance with the date stated in the Special Conditions and shall complete the work within the time stated in the Special Conditions unless the period for completion is extended otherwise by the Contract Documents. 4. The contractor agrees to perform all of the work described in the Contract Documents and comply with the terms of therein for the sum of: One Hundred Three Thousand Four Hundred Seventy-Eight Dollars and 70/100's ($ 103.478.70 ) for the project CONSTRUCTION OF WELD COUNTY BRIDGE 47/54A 17 Or0513 5. The term "Contract Documents" means and includes the following: (A) Advertisement (B) Information for Bidders (C) Non-Collusion Statement (D) Bid (E) Bid Schedule (F) Bid Bond (G) Notice of Award (H) Acceptance of Notice (I) Agreement (J) Performance Bond (K) Payment Bond (L) Notice to Proceed (M) Change Order (N) Notice of Contractor's Settlement (0) Final Receipt and Guarantee (P) Special Conditions (0) General Conditions (R) Technical Provisions (S) Construction Drawings (T) Addendum No. None , dated , 1990 No. , dated , 1990 No. , dated , 1990 6. The County will pay the contractor in the manner and at such time as set forth in the General Conditions such amounts required by the Contract Documents. 7. This Agreement shall be binding upon all parties hereto and their respective heirs, executors, administrators, successors, and assigns. • 19 :,/ ' W , 1 • IN WITNESS WHEREOF, the parties hereto have executed, or caused to be executed by their duly authorized officials, this Agreement, each of which shall be deemed an original on the date first written above. BOARD OF WELD COUNTY COMMISSIONERS CONTRACTOR BY BY Ideal Construction Services, Inc. NAME Gene R. Brantner ` (Please Type) NAME Ct e"/ ��ayne Achsiner Please Typ TITLE Chairman TITLE President Address 3220 State Street LVans, Colo. 80620 (SEAL) /�/� �// (SEAL) ATTEST: ACA"/ ATTES : Oh die;e Fl/ae NAME Donald D. Warden NAME Christine H. Achziger (Please Type) (Please Type) TITLE Weld County Clerk to the Board TITLE Secretary 19 OCC 3 13 CERTIFICATE OF INSURANCE pip issued by the • p STATE COMPENSATION INSURANCE AUTHORITY i u r r 0 950 dRUADWAY -z 1 X • . OENVER, COLJRAOD u0203 4*• rR=e ;.!r/ PHONE ( 303) 837-4000 S 6 I A (��r) i �� . TO WHOM IT MAY CONCERN: This is to certify that this department has issued a Standard Workmen's Compensation and Employer's Liability Policy as described below covering the liability imposed upon subject employers by the Work- men's Compensation Act of Colorado, said policy being in good standing as of this date. 12/06/39 KULIL.Y NUMOLR X90059 0 RILILY RfRI("0 1/01/90 TO 1/01/91 LUARTCRLY ADJUSTMENT 1 'iSUrt_D: IU_AL CUNSr SERV INC 16sU 25TH AVE ("KELLEY CO dJ631 Ni , JE ..KI >IN4L ISSJe: 3/02/73 ** EXCESS LIMITS : (" 1 ,0009036 . ):, e• All policies are subject to the following provision of the Workmen's Compensation Act with respect to cancellation: Section 8-54-114. If any employer shall be in arrears for more than twenty days in any payment required to be made by him to the State Compensation Insurance Authority as provided by this Act, he shall by virtue of such arrangement be in default of such payment and any policy issued to him by said Authority shall thereupon be cancelled without notice as of the effective date or renewal date of said policy. STATE COMPENSATION INSURANCE AUTHORITY JE (THA CHAVLI INSURANCr KEPn`. �ENTATIVF *. rt. . ...—) ITI .I^tAL TOI :3 f -�( IU- ICATE .MAY E KtPR.11)UCi.O. • • 900943 • ,em V 2E/ (4/0]) ^'DEPENDENT CONTRACTOR INSURANCE STATUS A. DECLARATION - RUST BE COMPLETED Ideal Construction Service, Inc. 096059 0 The undersigned performs contractual work for policy number name of person, company or corporation Po (herein referred to as the "prime contractor") as an "independent contractor" and claims to be exempt frail workers compensation insurance coverage by virtue of meeting the following provisions of CRS 8-48-101(2.5), as amended: (I) 1 own the assets of a business, company or service known as Ideal Construction Service, Inc. insert name of business and located at 3220 State Street Lyons, Colo. 80620 Insert canplete address of business (2) 1 manage and control such business crnpany or service. (3) I have ultimate responsibility for all decisions affecting such business, company or service. (4) I am subject to realize any profit or loss from such business, company or service as evidenced by my being required to file a Tax Schedule C, or Schedules A and L (Form 1065) of the Partnership Tex Return with the Federal Internal Revenue Service annually. Because 1 am exempt, I understand that if I am injured while performing contracture, work for the prime contractor, 1 will not be covered for such injury under the prime contractor's insurance policy unless 1 have chee;ked item B-3 below. I further understand that 1 am still required to provide worker's compensation insurance for all of my employees. Having read and understood the above provisions, I certify under the penalty of perjury that 1 meet all of the above requirements and am thereby exempt frail the Workmen's Conpensation Act. Wayne Achziger President name of independent contrac r and/or business 'title B �r ? �� 10/5/90 84-0749325 - y: date social security number or s netu�of independen rector federal tax identification number B. ELECTION - MUST INDICATE INSURAN .:. ELECTION PREFERENCE X (I) Being exempt fran the Colorado Workman's Compensation Act, I have elected not to be covered under a workers' compensation insurance policy. X (2) Although 1 am exempt from the Act as evidenced above, I have elected to be covered under my own policy number GLH-214 M-446lwith Life Investors Insurance Company of America name of insurance company which expires on monthly . date (3) The prime contractor has agreed to cover me on its policy beginning on __ _--- I understand that the cost of my coverage will be deducted fran payments to me by the prime contractor as provided by law. Wayne Achziger President Ideal Construction Service, Inc. acme of independent contractor and/or business title By: Ca��, „ _ -1-}r— Oct. 5, 1990 -- - sign6tura of in contractor date By: date signature of prime contractor SCIA Copy (White) Prime Contractor Copy (Pink) Accountant Copy (yellow) nr fir :, ::1 L 1 I,I11 11 -A 11 111 1.._i. K.A.vl 1 /pc coil. issued by the �� S 7*- I'' $TA^COMPENSATION INSURANCE AUTHORI' s � S t �' t p 950 NRUADWAY ,r .•0•le UcNVERs COL JRAU0 u02u3 j • • rare PHONE ( 103) 837-4000 fr@ C tom, /' ks'�- ; �, IiMi i n ne] TO WHOM IT MAY CONCERN: This is to certify that this department has issued a Standard Workmen's Compensation and Employer's Liability Policy as described below covering the liability imposed upon subject employers by the Work- men's Compensation Act of Colorado, said policy being in good standing as of this date. 12/0 r/J 9 ?MALY Nu.Mtsr_ K J9o0S9 0 NULICY PIR [J0 1/01/90 rO 1/01/9l GUAATEkLY ADJUSTNi-NT 1 "i'i U tt E Ds IJLAL CuNSI SEAV INC 1630 25TH AVE lar(tELEY LO 83631 ci\ l , it- i,A ( ANAL ISSUE: 3/02/ 7d •• EXCESS LIMITS : 1. 1 .0uJ ,0J" iti •• All policies are subject to the following provision of the Workmen's Compensation Act with respect to cancellation: Section 8-54-114. If any employer shall be in arrears for more than twenty days in any payment required to be made by him to the State Compensation Insurance Authority as provided by this Act, he shall by virtue of such arrangement be in default of such payment and any policy issued to him by said Authority shall thereupon be cancelled without notice as of the effective date or renewal date of said policy. STATE COMPENSATION INSURANCE AUTHORITY Itt ATHA Gtlavt. I INS:MANG ' e.lP..• :.ii NIA • • rl, . A. Jill elAL t; Jr)I , iii 11th. C .: III- ( (Art' .HAY r, rl l+t_' h11JLi J. • • ”ra l4 zt.t iaierl C'0n,'2:1 INDEPENOENT CONTRACTOR INSURANCE STATUS A. DECLARATION - MUST BE COMPLETED ^ Ideal Construction Service, Inc. 096059 0 The undersigned performs contractual work for policy number nave of person, company or corporation Po (herein referred to es the "prime contractor") es an "Independent contractor" and eleime to be exempt from workers compensation insurance coverage by witfus of meeting the following provisions of CRS 8-48-101(2.5), as amended: (I) I own the assets of a business, company or service known as Ideal Construction Service, Inc. insert name of business and located at 3220 State Street vans, Col u. 80620 insert complete address of business (2) 1 menage and control such business company or service. (3) I have ultimate responsibility for all decisions affecting such business, company or service. (4) I am subject to realize any profit or loss from such business, company or service as evidenced by my being required to file a Tax Schedule C, or Schedules A and L (Form 1065) of the Partnership Tax Return with the Federal Internal Revenue Service annually. Because 1 am exempt, I understand that If 1 am injured while performing contracture' work for the prime contractor, I will not be covered for such injury under the prism contractor's insurance policy unless I have checked item B-3 below. I further understand that 1 as still required to provide worker's compensation insurance for a'1 of my employees. Having read and understood the above provisions, 1 certify under the penalty of perjury that I meet all of the above requirements and am thereby exempt from the Workmen's Compensation Act. 'Jn_mc Achciger President name of independent contrac and/or business 'title "By: to r ../9e! 10/5/90 84-X749325 s`gnatu�i of Independ en raetor date social security number or federal tax identification number B. ELECTION - MUST INDICATE INSURAN..:. ELECTION PREFERENCE X (1) Being exempt from the Colorado Workmen's Compensation Act, I have elected not to be covered under a workers' compensation insurance policy. X (2) Although I am exempt from the Act es evidenced above, I have elected to be covered under my own policy number GLH-214 M-4L61with Life Investors Insurance Company of rv.,erica _ name of insurance company which expires on monthly . ate (3) The prime contractor has agreed to cover me on its policy beginning on — 1 understand that the cost of my coverage will be deducted from payments to me by the prime contractor as provided by law. ;Layne dcdziger Ideal Construction Service, Inc. President _. name of independent contractor and/or business title By: (,if oyAcet.Q A s .i�git^-. Oct. 5, i,^90 si ture of 1 contractor date By: dates — signature of prime contractor SCIA Copy (White) Prime Contractor Copy (Pink) Accountant Copy Proll.wl 9C09.1.11 PERFORMANCE BOND BOND N0. 6646 KNOW ALL MEN BY THESE PRESENTS: That IDEAL CONSTRUCTION SERVICES, INC. Name of Contractor 3220 STATE STREET, EVANS, COLORADO 80620 Address of Contractor a CORPORATION , hereinafter called Principal, and Corporation, Partnership, or Individual PIONEER GENERAL INSURANCE COMPANY • Name of Surety P.O. BOX 730, LITTLETON, CO 80160 Address of Surety hereinafter called Surety, are held and firmly bound unto THE BOARD OF WELD COUNTY COMMISSIONERS, 915 10th Street, Greeley, Colorado 80632, hereinafter called County, in the penal sum of ONE HUNDRED THREE THOUSAND FOUR HUNDRED SEVENTY EIGHT AND 70/100 Dollars ($ 103-,478.70 ) in lawful money of the United States, for the payment of which sum well and truly to be made, we bind ourselves, successors, and assigns, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION is such that whereas, the Principal entered into a certain contract with the County, dated the 4TH day of OCTOBER , 1990, a copy of which is attached and made apart hereof for the construction of: WELD COUNTY BRIDGE 47/54A NOW, THEREFORE, if the Principal shall well, truly and faithfully perform its duties, all the undertaking, covenants, terms, conditions, and agreements of said contract during the original term thereof, and any extensions thereof which may be granted by the County, with or without notice to the Surety and during the one year guarantee period, and if he shall satisfy all claims and demands incurred under such contract, and shall fully indemnify and save harmless the County from all costs and • damages which it may suffer by reason of failure to do so, and shall reimburse and repay the County all outlay and expense which the County may incur in making good any default, then this obligation shall be void; otherwise to remain in full force and effect. 20 9C'094, PROVIDED, FURTHER, that the said Surety, for value received hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the contract or to work to be performed thereunder or the specifications accompanying the same shall in any ways affect its obligation on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the contract of the work or to the specifications. PROVIDED, FURTHER, that no final settlement between the County and the contractor shall abridge the right of any beneficiary hereunder, whose claim may be unsatisfied. IN WITNESS WHEREOF, this instrument is executed in 11TH day of OCTOBER , 1990 . ATTEST: IDEAL CONSTRUCTION SERVICES, INC. Princip Christine H. Achziger /// A � Principal Secretary By v ar 1/4/ir (S) (SEAL) 3220 STATE STREET, EVANS, CO 80620 /(Attitc;x4-pithe/erie,0 Witness s to Prilicfpal Address 3220 State Street, Evans, Colo, 80620 Address ATTEST: PIONEER GENERAL INSURANCE COMPANY Surety Secretary (SEAL) �/� By �Z-C4L Let e . i r�a.e.) Witness as to Surety Attorney-in-Fact P.0. BOX B P.O. BOX 730 Address Address GREELEY, CO 80632 LITTLETON, CO 80160 NOTE: Date of bond must not be prior to date of contract. If contractor is a partnership, all partners should execute bond. IMPORTANT: Surety companies executing bonds must appear on the Treasury Department's most current list (circular 570 as amended) and be authorized to transact business in the state where the project is located. 21 PAYMENT BOND BOND N0. 6646 KNOW Mt MEN BY THESE PRESENTS: That IDEAL CONSTRUCTION SERVICES, INC. Name of Contractor 3220 STATE STREET, EVANS, COLORADO 80620 Address of Contractor a CORPORATION , hereinafter called Principal, and Corpora-don, Partnership or Individual PIONEER GENERAL INSURANCE COMPANY Name of Surety of OCTOBER 4TH , 1990, a copy of which is hereto attached and made a part hereof for the construction of: WELD COUNTY BRIDGE 47/54A NOW, THEREFORE, if the Principal shall during the entire length of said contract and any extension thereof promptly make payment to all persons, firms, subcontractors, and corporation furnishing materials for or performing labor in the prosecution of the work provided for in such contract, and any authorized extension or modification thereof, including all amounts due for materials, lubricants, oil, gasoline, coal and coke, repairs on machinery, equipment and tools, consumed or used in connection with the construction of such work, and all insurance premiums on said work, and for all labor, performed in such work whether subcontractor or otherwise, then this obligation shall be void; otherwise to remain full force and effect. PROVIDED, FURTHER, that the said Surety, for value received hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the contract or to the work to be performed thereunder or the specifications accompanying the same shall in any way affect its obligation on time, alteration or addition to the terms of the contract or to the work or to the specifications. PROVIDED, FURTHER, that a final settlement between the County and the contractor shall abridge the right of any beneficiary hereunder, whose claim may be unsatisfied. I 22 9C0943 IN WITNESS WHEREOF, this instrument is executed in 1 (number) counterparts, each one of which shall be deemed an original, this the 11TH day of OCTOBER , 1990. IDEAL CONSTRUCTION SERVICES, INC. Principal ATTEST: �% BY G� icto4G /i(/ (S) Chrintine H. Achziger ' Principal Secretary 3220 STATE STREET (SEAL) Address EVANS, CO 80620 Witness as to Pri i al 3220 State Street, Evans, Colo. 80620 Address ATTEST: PIONEER GENERAL INSURANCE COMPANY Surety Secretary (SEAL) C }it fitness as to Sty Attorney-in-Fact p.n. BOX R P.O. BOX 730 Address Address GREELEY, CO 80632 LITTLETON, CO 80160 NOTE: Date of bond must not be prior to date of contract. If contractor is a partnership, all partners should execute bond. IMPORTANT: Surety companies executing bonds must appear on the Treasury Department's most current list (circular 570 as amended) and be authorized to transact business in the • state where the project is located*. 23 9C0943 PIONEER GENERAL INSURANCE COMPANY w Littleton, Colorado POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: Then the PIONEER GENERAL INSURANCE COMPANY,a corporation of the Slate of Colorado has In Its prindpnl°lace In the City of Littleton.Colorado pursuant to following By•lmv,which was adopted by the Board of Directors of the snld Company In 1990,to wit: 'Article VI Section 2 RESIDENT OFFICERS AND ATTORNEYS-IN-FACT.The President ce any Vice-Presldom,acting with any Secretary or Assistant Secretary,r have tho authority to appoint Resident Vice.Presidents and Anomnys.lnf act,with the privity and authority to sign,execute,acknowledge and deliver on Its bohnlf,as Sul Any and all undertakings of suretyship and to affix thereto the corporate seal of the corporation.The President or nny Vice-President,acting with any Secretary or Assts Secreary,shrill also havo the authority to remove and revolt°ihn authority of any such appointee at nny unto. does hereby make,constitute nod appoint ***NORMAN D. NOE, STEVEN S. NOE, RONALD P. OTTO, GLENDA E. MAAS*** of GREELEY, COLORADO its true and lawful Attorney(s)-In-Fact,to make,execute,seal and deliver for and on its behalf,as Surety: And nny and all undertakings of suretyship • • And the execution of such bonds or undertakings In pursuance of those presents,shell be as binding upon said Compnny,as luny and amply,to all intents and purpo• as II they had been duly oxocutod and acknowledgod by the regularly olocted officers of the Company slits°fficos In Littleton,Colorado,In Iholr own persona, The following Resolution was adopted at the Regular Meeting of the Board of Directors of the Ploneer General Insurance Company,held on June 1,1990. 'RESOLVED,That tho signatures of olficers of the Company and the sent of the Company may be affixed by facsimile to any Power of Attorney executed In accord° with Article VI•"Soction 2 0l tho Company Bylaws; end that any such Power of Attorney beadng such facsimile signatures,Including the facsimile signature of•oenih Assistant Secretary and'nonfinite seal shalt be valid and binding upon the Compnny with respect to any bond,undertaking or contract of suretyship to which II Is attached' All authority hereby conferred shall remain In full lorce and°fled until terminated by the Company. IN WITNESS WI IF:nE:OF,PIONEER GENERAL INSURANCE COMPANY has caused these presents to be signod by its President and 9s corporate seal to be era. affixod this j.R0 day of July 1s_90__ PIONEER GEN nm.INSURANCE COMPANY • Secretary • • Slate of Colorado ) I 1 I I ss. By PRESIDENT j County of Arapahoe ) - • On this_]_Yd day of ,1-Uay ,t9,2_Q,before me personally came_Robert H.Warburton j to me known,who being by me duty sworn,did depose and say that(s)he reeldes In the County o1 Adams,State o1 Colorado;that(s)h°Is the President of the NONE GENERAL INSURANCE COMPANY,the corporation described In which executed the shove Instrument;that(s)ho knows the seal of the geld corporation;that the seal net to the said instrument is such mromote sent;that It was so affixed by ardor of the hoard of Medea of said corporation;that(s)ho*mod pals)Cher)name by like order;1 rant Dydnw,Article VI•Section 2,adopted by the Bard of Directors of said County,Warred to in the preceding Instrument,Is now In force. • My Commission Expires_6122/92 Notary PuMci/Z�C.!L. .(!J y�. Jr QQdrr.4L/- I, M.J. PRICK Secretary of PIONEER GENERAL INSURANCE COMPANY,do hereby Certify:bat the above r loregoing Is o true and correct copy of a Power of Attorney executed by said PIONEE It GENERAL INSURANCE COMPANY,which is still In lull force rod°fleet. Signed and sealed el the City of Littleton,Colorado Ihls 11TH dny of OCTOBER _ 19 90. Secretary 7J,Y1it�:./ - n. al:ORII. VERTIFICAI i OF INSURANCE ISSUEI Q T;(MM90 YY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONI 'ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE BARTELS & NOE AGENCY DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE P.O. BOX B POLICIES BELOW. GREELEY, CO 80632 COMPANIES AFFORDING COVERAGE COMPANY A LETTER AMERICAN STATES COMPANY B INSURED LETTER IDEAL CONSTRUCTION SERVICES, INC. ETTER" .• 3220 STATE STREET EVANS, CO 80620 LETER"Y D COMPANY a LETTER COVERAGES 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. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION -TR DATE(MWDD/YV)DATE(MM/DD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ 500,000 A X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ 500,000 CLAIMS MADE X OCCUR. O1-CC-537807-1 4-1-90 4-1-91 PERSONAL S ADV.INJURY $ 500,000 OWNER'S 8 CONTRACTOR'S PROT. EACH OCCURRENCE $ 500,000 FIRE DAMAGE(Any one fire) $ 50,000 MED.EXPENSE(Any one person) $ 5-000 AUTOMOBILE LIABILITY COMBINED SINGLE ANY AUTO LIMIT $ 500,000 A X ALL OWNED AUTOS OI—CC-537807-1 4-1 -90 4-1-91 BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM STATUTORY LIMITS WORKER'S COMPENSATION EACH ACCIDENT AND $ DISEASE—POLICY LIMIT $ EMPLOYERS'LIABILITY DISEASE—EACH EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS ---- WELD COUNTY, COLORADO, BY AND THROUGH THE BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY, ITS EMPLOYEES AND AGENTS IS ALSO NAMED AS ADDITIONAL INSURED. CERTIFICATE HOLDER CANCELLATION 0039- r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE BOARD OF WELD COUNTY COMMISSIONERS EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO P.O. BOX 758 MAIL 14_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE 915 10TH STREET LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR GREELEY, CO 80632 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. ATTN: MR. PAT PERSICHINO AUTHORIZED REPRESENTATIVE ACORD 25-S (7/90) ©ACORD CORPORATION 1990 Hello