HomeMy Public PortalAbout032-2016 - Sanitary - Greensfork Alignment - Alignment Work for Sanitary DistrictORIGINAL
AGREEMENT
THIS AGREEMENT made and entered into this �Ak day of -C; , 1 , 2016, and referred
to as Contract No. 32-2016 by and between the City of Richmond, Indiana, a municipal corporation
acting by and through its Board of Sanitary Commissioners (referred to as the "City"), and
Greensfork Alignment and Service, = 2441 N. Centerville Road, Centerville, IN 47330 (hereinafter
referred to as the "Contractor").
SECTION I. STATEMENT AND SUBJECT OF WORK
City hereby retains Contractor for services relative to the alignment work for the Sanitary District
for a period ending December 31, 2016.
A Request for Quotes has been made available for inspection by Contractor, is on file in the office
of the Department of Sanitation for the City of Richmond, consisting of two (2) typewritten pages,
which is attached hereto and incorporated by reference herein as Exhibit "A".
The response of Contractor to said Request for Quotes is attached hereto and incorporated by
reference herein as Exhibit `B", consisting of four (4) typewritten pages, with specific reference to
page four (4) of said Exhibit due to the fact that this page is responsive to the awarded bid pertaining
to cost of mounting and balancing of light truck tires.
Should any provisions, terms, or conditions contained in any of the documents attached hereto and
incorporated by reference herein as Exhibits, conflict with any of the provisions, terms, or
conditions of this Agreement, this Agreement shall be controlling.
The Contractor shall furnish all labor, material, equipment, and services necessary for the proper
completion of all work specified. Contractor shall submit statements or bills monthly.
No performance of services shall commence until the following has been met:
1. The City is in receipt of any required certificates of insurance and/or warranties;
2. The City is in receipt of any required affidavit(s) signed by Contractor in accordance with
I.C. § 22-5-1.7-11(a)(2); and
3. A purchase order has been issued by the Purchasing Department.
SECTION H. STATUS OF CONTRACTOR
Contractor shall be deemed to be an independent contractor and is not an employee or agent of the
City of Richmond. The Contractor shall provide, at its own expense, competent supervision of the
work.
SECTION III. COMPENSATION
City shall pay Contractor at the rates indicated in Exhibit `B" in an amount not to exceed Two
Thousand Five Hundred Dollars and 00/100 ($2,500.00).
SECTION IV. TERM OF AGREEMENT
This Agreement shall become effective when signed by all of the parties hereto and shall continue
in effect until to an including December 31, 2016 with an option to renew for two (2) additional
years with the expiration of the third (3") year ending on December 31, 2018, unless the parties
Contract No. 32-2016
1 1 Page
extend this Agreement by a written and signed Addendum. The Agreement shall automatically be
renewed each year, unless, by written notice more specifically set forth in this Section below, is
issued by either party to the other.
Notwithstanding the term of this Agreement, City may terminate this Agreement in whole or in
part, for cause, at any time by giving at least thirty (30) days written notice specifying the effective
date and the reasons for termination which shall include but not be limited to the following:
a. failure, for any reason of the Contractor to fulfill in a timely manner
its obligations under this Agreement;
b. submission of a report, other work product, or advice, whether oral or written, by the
Contractor to the City that is incorrect, incomplete, or does not meet reasonable
professional standards in any material respect;
c. ineffective or improper use of funds provided under this Agreement;
d. suspension or termination of the grant funding to the City under which this Agreement
is made; or
e. unavailability of sufficient funds to make payment on this Agreement.
This Agreement may also be terminated by either the City or the Contractor, in whole or in part,
by mutual Agreement setting forth the reasons for such termination, the effective date, and in the
case of partial termination, the portion to be terminated.
This Agreement may also be terminated by either the City or the Contractor, without cause, by
giving at least thirty (30) days written notice to the other party.
In the event of termination of this Agreement, the City shall be required to make payment for all
work performed prior to the date this Agreement is terminated, but shall be relieved of any other
responsibility herein.
SECTION V. INDEMNIFICATION AND INSURANCE
Contractor agrees to obtain insurance and to indemnify the City for any damage or injury to person
or property or any other claims which may arise from the Contractor's conduct or performance of
this Agreement, either intentionally or negligently; provided, however, that nothing contained in
this Agreement shall be construed as rendering the Contractor liable for acts of the City, its officers,
agents, or employees. Contractor shall as a prerequisite to this Agreement, purchase and thereafter
maintain such insurance as will protect it from the claims set forth below which may arise out of
or result from the Contractor's operations under this Agreement, whether such operations by the
Contractor or by any sub -contractors or by anyone directly or indirectly employed by any of them,
or by anyone for whose acts the Contractor may be held responsible.
Coverage Limits
A. Worker's Compensation & Statutory
Disability Requirements
Page
B. Employer's Liability
$100,000
C. Comprehensive General Liability
Section 1. Bodily Injury
Section 2. Property Damage
D. Comprehensive Auto Liability
Section 1. Bodily Injury
Section 2. Property Damage
E. Comprehensive Umbrella Liability
$1,000,000 each occurrence
$2,000,000 aggregate
$1,000,000 each occurrence
$1,000,000 each person
$1,000,000 each occurrence
$1,000,000 each occurrence
$1,000,000 each occurrence
$1,000,000 aggregate
F. Malpractice/Errors & Omissions Insurance $1,000,000 each occurrence
$2,000,000 aggregate
SECTION VI. COMPLIANCE WITH WORKER'S COMPENSATION LAW
Contractor shall comply with all provisions of the Indiana Worker's Compensation law, and shall,
before commencing work under this Agreement, provide the City a certificate of insurance, or a
certificate from the industrial board showing that the Contractor has complied with Indiana Code
Sections 22-3-2-5, 22-3-5-1 and 22-3-5-2. If Contractor is an out of state employer and therefore
subject to another state's worker's compensation law, Contractor may choose to comply with all
provisions of its home state's worker's compensation law and provide the City proof of such
compliance in lieu of complying with the provisions of the Indiana Worker's Compensation Law.
SECTION VII. COMPLIANCE WITH INDIANA E-VERIFY PROGRAM
REQUIREMENTS
Pursuant to Indiana Code 22-5-1.7, Contractor is required to enroll in and verify the work
eligibility status of all newly hired employees of the contractor through the Indiana E-Verify
program. Contractor is not required to verify the work eligibility status of all newly hired
employees of the contractor through the Indiana E-Verify program if the Indiana E-Verify
program no longer exists. Prior to the performance of this Agreement, Contractor shall provide
to the City its signed Affidavit affirming that Contractor does not knowingly employ an
unauthorized alien in accordance with IC 22-5-1.7-11 (a) (2). In the event Contractor violates
IC 22-5-1.7 the Contractor shall be required to remedy the violation not later than thirty (30)
days after the City notifies the Contractor of the violation. If Contractor fails to remedy the
violation within the thirty (30) day period provided above, the City shall consider the
Contractor to be in breach of this Agreement and this Agreement will be terminated. If the
City determines that terminating this Agreement would be detrimental to the public interest or
public property, the City may allow this Agreement to remain in effect until the City procures
a new contractor. If this Agreement is terminated under this section, then pursuant to IC 22-5-
1.7-13 (c) the Contractor will remain liable to the City for actual damages.
SECTION VIII. IRAN INVESTMENT ACTIVITIES
3 1 Page
Pursuant to Indiana Code (IC) 5-22-16.5, Contractor certifies that Contractor is not
engaged in investment activities in Iran. In the event Board determines during the course
of this Agreement that this certification is no longer valid, Board shall notify Contractor in
writing of said determination and shall give contractor ninety (90) days within which to
respond to the written notice. In the event Contractor fails to demonstrate to the Board that
the Contractor has ceased investment activities in Iran within ninety (90) days after the
written notice is given to the Contractor, the Board may proceed with any remedies it may
have pursuant to IC 5-22-16.5. In the event the Board determines during the course of this
Agreement that this certification is no longer valid and said determination is not refuted by
Contractor in the manner set forth in IC 5-22-16.5, the Board reserves the right to consider
the Contractor to be in breach of this Agreement and terminate the agreement upon the
expiration of the ninety (90) day period set forth above.
SECTION IX. PROHIBITION AGAINST DISCRIMINATION
A. Pursuant to Indiana Code 22-9-1-10, Contractor, any sub -contractor, or any person acting
on behalf of Contractor or any sub -contractor shall not discriminate against any employee
or applicant for employment to be employed in the performance of this Agreement, with
respect to hire, tenure, terms, conditions or privileges of employment or any matter directly
or indirectly related to employment, because of race, religion, color, sex, disability,
national origin, or ancestry.
B. Pursuant to Indiana Code 5-16-6-1, the Contractor agrees:
That in the hiring of employees for the performance of work under this Agreement
of any subcontract hereunder, Contractor, any subcontractor, or any person acting
on behalf of Contractor or any sub -contractor, shall not discriminate by reason of
race, religion, color, sex, national origin or ancestry against any citizen of the State
of Indiana who is qualified and available to perform the work to which the
employment relates;
2. That Contractor, any sub -contractor, or any person action on behalf of Contractor
or any sub -contractor shall in no manner discriminate against or intimidate any
employee hired for the performance of work under this Agreement on account of
race, religion, color, sex, national origin or ancestry;
That there may be deducted from the amount payable to Contractor by the City
under this Agreement, a penalty of five dollars ($5.00) for each person for each
calendar day during which such person was discriminated against or intimidated
in violation of the provisions of the Agreement; and
4. That this Agreement may be canceled or terminated by the City and all money due
or to become due hereunder may be forfeited, for a second or any subsequent
violation of the terms or conditions of this section of the Agreement.
C. Violation of the terms or conditions of this Agreement relating to discrimination or
intimidation shall be considered a material breach of this Agreement.
SECTION X. RELEASE OF LIABELITY
4 1 Page
Contractor hereby agrees to release and hold harmless the City and all officers, employees, or
agents of the same from all liability which may arise in the course of Contractor's performance of
its obligations pursuant to this Agreement.
SECTION XI. MISCELLANEOUS
This Agreement is personal to the parties hereto and neither party may assign or delegate any of its
rights or obligations hereunder without the prior written consent of the other party. Any such
delegation or assignment, without the prior written consent of the other party, shall be null and
void. This Agreement shall be controlled by and interpreted according to Indiana law and shall be
binding upon the parties, their successors and assigns. This document constitutes the entire
Agreement between the parties, although it may be altered or amended in whole or in part at any
time by filing with the Agreement a written instrument setting forth such changes signed by both
parties. By executing this Agreement the parties agree that this document supersedes any previous
discussion, negotiation, or conversation relating to the subject matter contained herein.
This Agreement may be simultaneously executed in several counterparts, each of which shall be an
original and all of which shall constitute but one and the same instrument.
The parties hereto submit to jurisdiction of the courts of Wayne County, Indiana, and any suit
arising out of this Contract must be filed in said courts. The parties specifically agree that no
arbitration or mediation shall be required prior to the commencement of legal proceedings in said
Courts. By executing this Agreement, Contractor is estopped from bringing suit or any other action
in any alternative forum, venue, or in front of any other tribunal, court, or administrative body other
than the Circuit or Superior Courts of Wayne County, Indiana, regardless of any right Contractor
may have to bring such suit in front of other tribunals or in other venues.
Any person executing this Contract in a representative capacity hereby warrants that he/she has
been duly authorized by his or her principal to execute this Contract.
In the event of any breach of this Agreement by Contractor, and in addition to any other damages
or remedies, Contractor shall be liable for all costs incurred by City in its efforts to enforce this
Agreement, including but not limited to, City's reasonable attorney's fees.
In the event that an ambiguity, question of intent, or a need for interpretation of this Agreement
arises, this Agreement shall be construed as if drafted jointly by the parties, and no presumption or
burden of proof shall arise favoring or disfavoring any party by virtue of the authorship of any of
the provisions of this Agreement.
S I Page
IN WITNESS WHEREOF, the parties have executed this Agreement at Richmond, Indiana, as of
the day and year first written above, although signatures may be affixed on different dates.
"CITY"
The City of Richmond, Indiana, by and through
its Board of Sanitary Commissioners
President
C
Dated:
APPROVED:
Dave Snow, Mayor
Dated:
"CONTRACTOR"
Greensfork Alignment and Service
(Pry
Title
Dated:C.1 1 ?
er
6 1 Page
BALANCING OF
QUOTED COST PER TIRE:
• 2016 PRICE PER TIRE $ 1 0
• 2017 PRICE PE $ f
FRONT END ALIGNMENT COST
Vehicle -
• 2016
$'
• 2017
$ , 3
Light Truck
-
• 2016
$
• 2017
$ -3
Large Truck
-
• 2016
$ 150
• 2017
$ 56
Please include the following with quote:
Vendor Name: f"6 � �+� ✓��'
Date: d — ,2 Z —
Quote Valid Till: —I; - 31- 1(4
Include Warrantees /
E-Verify: YES NO
Indiana Local Preference YES z NO s
Iran Investment Activities YES NO �f
n
i
ARTICLE F
INSTRUCTIONS TO BIDDERS
INDEMNIFICATION, INSURANCE, AND PROTECTION OF LIVES AND PROPERTY
F.1 INDEMNIFICATION
F. 1..1. The contractor shall indemnify and hold harmless the City of Richmond and its officers and
employees from and against all claims, damages, losses, expenses, including but not limited to
attorney's fees, arising out of or resulting from the performance of the contract, provided that
any such claim, damage, loss or expense (a) is attributable to bodily injury, sickness, disease or
death, or to injury to or destruction of tangible property (other than goods, materials and
equipmentiminished under this contract) including the loss of use resulting there from, and (b)
is caused in' whole or in part by, any negligent act or omission of the contractor, any
-subcontractor, or anyone directly employQdd by any of them or anyone for whole acts any of
them maybe liable, regardless of whether or not it is caused in part by a party indemnified
hereunder.
F. 1.2 In any and all.claims against the City or -any of, N officers or employees by any employee of the
contractor, any subcontractor, anyone directly or indirectly -employed by any of them or anyone
for whose acts any of them may be liable, the indemnification obligation under this paragraph
G. I shall not be limited in any way by any limitation of the amount or type of damages,
compensation or benefits payable by or for the contractor or any sub -contractor under worker's
or workmen's compensation acts, disability benefit acts or other employee benefit acts.
F:2 WORKER'S COMPENSATION IINrSURANCE
F. 2.1 For contracts involving performance of work pursuant to the provisions of Indiana Code IC 22-
3-2-14 (a) bidders are required to furnish a certificate, from the Indiana Worker's Board
showing that such bidder has complied with IC 22-3-2-5, 22-3-5-1 and IC 22-3-5-2.
F.3 INSURANCE.
F. 3.1 The Contractor shall, as prerequisite to this Agreement, purchase and thereafter maintain such
insurance as will protect him from the claims set forth below which may arise out of or result
from the Contractor's operations under this Agreement, whether such operations by the
Contractor or by any Sub -contractors or by anyone who directly or indirectly employed by any
of them, or by anyone for whose acts any of them may be liable.
Coverage Limits.
A.- Worker's Compensation & Statutory
Disability Requirements
B. Employer's Liability 1100,000
C. Comprehensive'General Liability
Section 1. :'Bodily Injury $I,000,000 each occurrence
$2,000,000 aggregate
Section 2. Property Damage $1,000,000 each occurrence
F.3.1
(con't)
D. Comprehensive Auto Liability
Section 1. Bodily Injury
Section 2: • Property Damage
E. Comprehensive Umbrella Liability
F. Malpractice/Errors & Omissions
Insurance
$1,000,000. each person
$1,000,000 each occurrence
$1,000,000 each occurrence
$1,000,000 each occurrence
$2,000,000 each aggregate
.$1,000,000 per claim
$2,000,000 each aggregate
E-Verify Requirements:
Definitions:
E-Ver' . Program — A electronic verification of work authorization program of the Illegal
Immigration Reform and Immigration Responsibility Act of 1996 (P.L. 104-208), Division C, Title
IV,s.403 (a), as amended, operated by the United States Department of Homeland Security or
successor work authorization program designated by the United States Depart of Homeland Security
or other federal agency authorized to verify the work authorization status of newly hired employees
under the Immigration Reform and control Act of 1986 (P.L. 99-603).
No performance of services shall commence until the following has been met:
1. The City is in receipt of any required certificates of insurance;
2. The City is in receipt of any required affidavit signed by Contractor in accordance with
Indiana Code 22-5-1.7-11 (a) (2); and
3. A purchase order has been issued by the Purchasing Department.
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COMPLIANCE WITH INDIANA E-VERIFY PROGRAM REQUIREMENTS
Pursuant to Indiana Code 22.5.1,7, Contractor is required to enroll in and verify the work eligibility
status of all newly hired employees of the contractor through the Indiana E-Verify program. Contractor
is not required to verify the work eligibility status of allnewly hired employees of the contractor through
the Indiana E-Verify program if the Indiana E-Verify program no longer exists. Prior to the
performance of the Agreement, Contractor shall provide to the City its signed Affidavit affirming that
Contractor does not knowingly employ an unauthorized alien in accordance with IC 22-5-1.7 (a) (2). In
the event Contractor violates IC 22-5-1.7 the Contractor shall be required to remedy the violation no
later than thirty (3 0) days after the City notifies the Contractor of the violation. If the Contractor fails to
remedy the violation withinn the thirty (30) day period provided above, the City shall consider the
Contractor to be in breach of this Agreement and this Agreement will be terminated. If the City
determines that terminating this Agreement would be detrimental to the public interest or public
property, the City may allow this Agreement to remain in effect until the City procures a new contractor.
If this Agreement is terminated under this section, then pursuant to IC 22-5-1.7-13 (c) the Contractor
will remain liable to the City for actual damages.
Affidavit of Employment Ellgibility Verification
The.- Contractor, r� v `k h 79*4affirms under, the .penalties of 'perjury that
Contractor does not knowingly employ alt authorized alien. If Contractor is self-employed and
does not ervploy any employees, Co*actor verifies he or she is a* United States citizen or qualified
alien. r ,
21 a Contractor has not Knowingly employed or, contracted with an unauthorized alien and'sball not
retain an employee or contract with • a person that the Contractor- subsequently learns is • an'
unauthorized alien. ' Pursnaiit to Indiana Code 22-5-11, Contractor has enrolled in and verified the
work eligibi7ify_ ,Status of all newly hired employees of the contractor fbrough the .Indiana E-Verify •
ProgTAM
The Contractor has required Contractor's subcontractors to certify to the Contractor that the
subcontractor does not knowingly employ or contract with an .unauthorized alicli and that tfie
subcontractor bas enrolled and is paiticipating in the E . Verify program. Tb e Contractor wIZ maintain
this certification throughout the duration of the term of a contract with a subcontractor.
I hereby verify under the penalty of perjury that the foregoing statement is true.
Dated this day of d 20 A6
(Slgnat[II'
�Lj r-CA A /L264
OPIud . . e)
IRAN INVESTMENT ACTIVITIES
Pursuant to Indiana Code (IC) 5-22-16.5, Contractor certifies that Contractor is not engaged in
investment activities in Iran. ha the event City determines during the course of this Agreement that
this certification is no longer valid, City shall notify Contractor in writing of said determination
and shall give contractor ninety (90) days within which to respond to the written notice. In the
event Contractor fails to demonstrate to the City that the Contractor has ceased investment
activities in Iran within ninety (90) days after the written notice is given to the Contractor, the City
may proceed with any remedies it may have pursuant to IC 5-22-16.5. In the event the City
determines during the course of this Agreement that this certification is no longer valid and said
determination is not refuted by Contractor in the manner set forth in IC 5-22-16.5, the City reserves
the right to consider the Contractor to be in breach of this Agreement and terminate the agreement
upon the expiration of the ninety (90) day period set forth above.
Ali a CERTIFICATE OF LIABILITY INSURANCE
D1�25�2016 )
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
CONTACT Tina Gibson
NAME:
PHCNNo,
o Ext: (765) 216-7725 FVC No: (765)3B1-1041
ISU George Insurance Group
311 South Walnut St.
E-MAIL ADDRESS: tina@ sbpinsurance.com
INSURERS AFFORDING COVERAGE
NAIC A
INSURERA:West Bend Mutual Insurance Company
15350
Muncie IN 47305
INSURED
INSURER BACcident Fund Company
10166
INSURERC:
Greens Fork Alignment and Service
INSURER0:
2441 N. Centerville Road
INSURER E :
INSURERF:
Centerville IN 47330
COVERAGES CERTIFICATE NUMBER 2015-2016 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
ADDL
SUER
POLICY NUMBER
POLICY EFF
MM/DDIYYYY
POLICY EXP
MM/DD/YYYY
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
A
CLAIMS -MADE OCCUR
PREMI ETORENTED
PREMISES Ea occurrence
200 000
� $
MED EXP (Any one person)
$ 10,000
A040883
6/12/2015
6/12/2016
PERSONAL & ADV INJURY
$ 1,000,000
GEM_ AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 3,000,000
X POLICY PRO ❑
JECT LOC
PRODUCTS - COMP/OP AGG
$ 3,000,000
Employee Benefits
$ 1,000,000
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$ 1 , 000 , 000
BODILY INJURY (Per person)
$
A
X
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
A040883
6/12/2015
6/12/2016
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
X
NON -OWNED
HIRED AUTOS X AUTOS
Underinsuredmotodst
$ 1,000,000
X
UMBRELLA UAB
X
OCCUR
EACH OCCURRENCE
$ 3,000,000
AGGREGATE
$ 3,000,000
A
EXCESS LIAB
CLAIMS -MADE
DED I X I RETENTIONS 0
$
A040883
6/12/2015
6/12/2016
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED? N
(Mandatary in NH)
NIA
WCV6112895
6/12/2015
6/12/2016
X PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE - EA EMPLOYEE
$ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE- POUCY LIMIT
$ 500,000
A
GARAGEKEEPERS
A040883
6/12/2015
6/12/2016
DIRECT PRIMARY LIMIT $2,000,000
Comp Deductible $1000/$5000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
L;tK I II-IL;A I t HULUtK L ANL MLLA I IUN
Richmond Sanitation Department
2380 Liberty Ave
Richmond, IN 47374
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
David George/TLG
ACORD 25 (2014/01)
INS025 (201401)
U 1988-2014 AGUKU GUKI'UKA I IUN. All rigms reservea.
The ACORD name and logo are registered marks of ACORD
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