Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My Public Portal
About
Contractor Pre-Qualification Application 2023-2024
PAGE 1 OF 42 THE METROPOLITAN ST. LOUIS SEWER DISTRICT 2350 Market Street St. Louis, MO 63103 Attn: Purchasing Department Stacey Hunter (314) 436-8738 shunter@stlmsd.com Damita Morris (314) 335-2222 djmorris@stlmsd.com CONSTRUCTION PRE-QUALIFICATION APPLICATION (5/17/23) For the Period of 9/1/2023 thru 8/31/2024 (USED IN PRE-QUALIFYING ALL NEW BIDDERS, EXISTING BIDDERS REQUESTING NEW WORK CATEGORIES & ANNUAL RENEWALS ON CAPITAL CONSTRUCTION WORK) ___________________________________________________________ SUBMITTED BY (COMPANY NAME) ___________________________________________________________ ADDRESS ___________________________________________________________ CITY, STATE, ZIP CODE ___________________________________________________________ DATE ___________________________________________________________ CONTACT NAME (FOR BID NOTICES, PROJECT COMMUNICATION & QUESTIONS) _____________________________________________________________ CONTACT TELEPHONE NUMBER & EMAIL ADDRESS _____________________________________________________________ TAX ID NUMBER (Any Company name or combination, other than the one listed above on this Pre-Qualification Application, wishing to perform work for the Metropolitan St. Louis Sewer District will have to submit a separate, full Pre-Qualification Application) PAGE 2 OF 42 PRE-QUALIFICATION CHECK LIST (IMPORTANT: Below is a checklist of required documentation) Signed Vendor’s Conflict of Interest Questionnaire (Page 5). Boxes checked indicating type of work for which qualification is requested (Page 8). Type of Organization & bonding capacity indicated (Pages 9-11). Project experience in the category(s) for which you want to qualify (Pages 12-28). Equipment Sheet is complete (Page 29). Affidavit is complete with Notary Seal for whichever type of business is applicable (38-42). Attach Certificate from the Secretary of State (Certificate of Good Standing) showing company is authorized to transact business in the State of Missouri. A copy of screenshot of Certificate of Good Standing is acceptable). Contractor and Contractor’s Insurance Broker must sign the Insurance Requirements for Annual Pre-Qualification Document (Page 37). Attach copy (front/back) of drain layers license for City of St. Louis and/or St. Louis County (required for Sewer Construction and Deep Sewer Construction categories). Required for Demolition work for MSD within the City of St. Louis – attach certification for specific CITY classification. o Class I – no building size restrictions.o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet area/200,000 cubicfeet volume.o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no demolitionlicense.o St. Louis County does not require license/certification. New Supplier Form (can be found here: https://msdprojectclear.org/doing-business/suppliers/ (Download “New Supplier Data Form”). Please submit this with your package if you are a new bidder or if you are an existing bidder and you have any changes to your contact information or company. Attach copy of your W-9 PAGE 3 OF 42 RULES FOR PRE-QUALIFICATION OF CONTRACTORS ON WORK LET BY CONTRACT WITH THE METROPOLITAN ST. LOUIS SEWER DISTRICT 1.An applicant for pre-qualification must furnish detailed information with respect to its equipment, pastrecord, personnel, and experience, together with other information as is called for in this Pre-qualification Application. 2.A contractor must be prequalified prior to bid opening of a project. 3.Any combination of contractors bidding jointly becomes a new contracting firm and it must be pre-qualified in accordance with these rules. All applications shall be in writing and signed by the principalparties in the new contracting firm. 4.Pre-qualification Renewal Application forms must be submitted to the District by July 30 of each year.This form must be completed in detail. The District may require any additional information deemednecessary for pre-qualification. 5.No bidder will be pre-qualified unless its Pre-qualification Application indicates that it has theexperience, organization, and equipment, sufficient in the judgment of the District, that it cansatisfactorily execute its contracts and meet its obligations therein incurred. 6.The Financial Statement of the controlling individual or corporate owner of the business may berequested by MSD as part of the pre-qualification review. 7.If any significant change occurs in the information included on the contractors’ pre-qualificationapplication, notice shall be given to the District immediately. 8.All corporations must furnish a certificate from the Secretary of State showing that it is authorized totransact business in the State of Missouri. 9.A copy (front/back) of the applicable drain layers license from the City and/or County of St. Louis isrequired for Sewer Construction and/or Deep Sewer Construction. 10.Demolition work for MSD within the City of St. Louis – attach certification for specific CITYclassification.o Class I – no building size restrictions.o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet area/200,000 cubicfeet volume.o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no demolitionlicense.o St. Louis County does not require a license/certification. NOTE: It is important that the work experience pages in Section V be completed and that it contains projects of the type for which pre-qualification is being requested. Pre-qualification will not be granted for types of work that you subcontract to others. PAGE 4 OF 42 IMPORTANT INFORMATION FOR PROSPECTIVE BIDDERS 1.CONTRACT DOCUMENTSContract documents include, but may not be limited to the advertisement, Instructions to Bidders, Proposal, General Specifications, Detailed Specifications, Agreement, Bond Form, and Plans. The documents are available on and after the day advertisement is published and will be available via MSD’s website at https://msdprojectclear.org/doing-business/capital-improvement-replacement-program/capital-construction/. Look for a link to “ELECTRONIC PLANROOM”. Plans and specifications are also available for viewing or purchase at Cross Rhodes Reprographics located at 2731 South Jefferson, St Louis, Missouri 63118. 2.PRE-QUALIFICATIONA contractor must be pre-qualified prior to bids being opened. 3.MINIMUM WAGE AND EMPLOYMENT DISCRIMINATIONThe minimum wage to be paid to all labor will be shown in the contract documents where applicable. Prevailing rates of pay shall be paid to skilled and unskilled labor, and there shall be no discrimination in the selection or employment of labor on account of race, creed, or color. 4.BID SECURITYThe bid shall be accompanied by a certified check or cashier's check drawn on a bank or trust company located in either St. Louis City or County or by a bid bond issued by a surety company satisfactory to the District and which is authorized to transact business in Missouri. 5.RIGHT TO REJECTThe Metropolitan St. Louis Sewer District reserves the right to reject any and all bids and to waive technicalities. PAGE 5 OF 42 VENDOR'S CONFLICT OF INTEREST QUESTIONNAIRE 1. Name the individual or company requesting to do business with The Metropolitan St. Louis Sewer District (MSD): 2.In the past two (2) years, has the individual or company named in No. 1 above or any principal of such company, (i.e. partner, officer, director, etc.) contributed cash or gifts in excess of $200.00 in value in the aggregate in any calendar year to any of the individuals or organizations listed on Attachment A (updated 2/1/22) hereto? Yes No If yes, describe in detail (date/amount/description): 3. In the past two (2) years, has the individual or company named in No. 1 above done business with any person listed in Attachment A and/or their respective companies? Yes No If yes, describe in detail (date/amount/description): 4.The undersigned certifies that the above information is true and correct to the best of his or her knowledge and belief. Dated this day of , 20____ Printed Name: ______________________________________________ Title: Company: Signature: PAGE 6 OF 42 ATTACHMENT A NOTE: Attachment A contains a list of the MSD Trustees and their respective employer, MSD officers and Directors, and the organizations which each are individually associated with, as applicable. Trustee/Director MSD BOARD OF TRUSTEES & DIRECTORS Name of Firm, Organization or Company Affiliation Bret A. Berthold American Water Works Association (AWWA) Member Director Engineers Club of St. Louis Member Missouri Water Environment Association Member National Association of Clean Water Agencies (NACWA) Member Water Environment Federation Member Tracey Coleman Association for Talent Development Member Director St. Elizabeth Mother of John the Baptist Member Society for Human Resource Management Member Michael Evans AFL-CIO Lawyers Coordinating Committee Member Trustee Bar Association of Metropolitan St. Louis Member Hartnett Reyes-Jones, LLC Partner International Foundation of Employee Benefit Plans Member Kentucky Bar Association Member Missouri Bar Association Member St. Louis City Labor Legislative Club Member Amy L. Fehr Algonquin Golf Club Member Trustee American Bar Association Member Bar Association of Metropolitan St. Louis Member Capes, Sokol, Goodman and Sarachan, PC Shareholder & Director Federal Bar Association, St. Louis Chapter Member Missouri Bar Association Member Marion M. Gee American Water Works Association (AWWA) Member Director Church on The Rock Member Government Finance Officers Association (GFOA) Executive Board Missouri Government Finance Officers Association Member Brian Hoelscher Engineers Club of St. Louis Member Executive Director Missouri Water Environment Association Member National Association of Cleanwater Agencies (NACWA) Executive Board Project MOSAIC Ambassador/Connector Washington University in St. Louis - W Club Executive Council Water Environment Federation Member Susan M. Myers Association of Corporate Counsel Member Director Association of Missouri Cleanwater Agencies (AMCA) Board Member Bar Association of Metropolitan St. Louis Member Missouri Bar Association Member National Association of Cleanwater Agencies (NACWA) Member Greg Nicozisin Plumbers & Pipefitters Local 562 Member Trustee Betsy Schubert Institute for Supply Management Member Manager Updated February 1, 2022 PAGE 7 OF 42 Trustee/Director MSD BOARD OF TRUSTEES & DIRECTORS Name of Firm, Organization or Company Affiliation Timothy R. Snoke Association of Financial Professionals Member Director Government Finance Officers Association Member Institute of Management Accountants Member Lutheran Church of Webster Gardens Member St. Louis Treasury Management Association Member Jonathon Sprague American Water Works Association (AWWA) Member Director Engineers Club of St. Louis Member Missouri Water Environment Member National Association of Clean Water Agencies (NACWA) Member Water Environment Federation Member Rich L. Unverferth Engineers Club of St. Louis Member Director Knights of Columbus - Council 2119 Webster Groves Member National Association of Clean Water Agencies (NACWA) Member St. Michael the Archangel Catholic Parish Member Brian Wahby Democratic National Committee Member Trustee St. Raymond's Maronite Catholic Church Member Brian K. Watson Laborers' Local 42 Member Trustee Ret. Col. Richard R. Wilson American Institute of Parliamentarians Member Trustee Anniversary Club Member Oaks Social Club Treasurer Pathfinders Golf Club Treasurer Pin High Golf Club Member Reserve Officers Association Member Royal Vagabonds Foundation, Inc. Board Member Royal Vagabonds, Inc. Member Updated February 1, 2022 PAGE 8 OF 42 APPLICATION FOR CERTIFICATE OF QUALIFICATION TO BID The undersigned hereby applies to the Metropolitan St. Louis Sewer District for approval to bid the following types of work: (Check each type of work for which qualification is requested). ________ Sewer Construction Section V. A., Pages 12-13. Drain layers license required for City &/or County. ________ Deep Sewer Construction Section V. B., Pages 14-15. Drain layers license required for City &/or County. To qualify in this category a contractor must demonstrate experience on multiple projects that are deemed complex by the District. Typically, a project would be considered complex when the installation of the pipe required excavation at depths greater than 20 feet for an extended length along with one or more of the following additional construction challenges: significant involvement with trench bracing for urban type features; significant amounts of Class “A” or Class “B” excavation; significant amount of poor soil conditions; significant length of large diameter pipe installation (36-inch or larger); or installation in locations having extremely limited working room. The District shall be the sole judge as to whether a project is considered complex. ________ Building Construction Section V. C., Page 16 ________ Natural Channel Stabilization Section V. D., Page 17 ________ Green Infrastructure and Bio-Retention Section V. E., Page 18 ________ Pipe and Manhole Rehabilitation Section V. F., Page 19 Cured-In-Place Pipe (CIPP) Section V. G, Pages 20 - 21 Cured-In-Place Lateral Liner (CIPL) Section V. H, Pages 22 & 23 ________ Concrete Channels, Walls and Structures Section V. I., Page 24 ________ Mechanical/Electrical/Plumbing Section V. J., Page 25 ________ Tunneling / Trenchless Section V. K., Page 26 ________ Demolition Section V. L., Pages 27-28; and for explanation of Class I & II ________ St. Louis County Demolition ________ St. Louis City – Class I and II ________ St. Louis City – Class II only Attach required certification for specific CITY classification requested PAGE 9 OF 42 TYPE OF ORGANIZATION (Check Applicable Category) _____ Corporation ______ Partnership ______ *Joint Venture______ Individual _____ LLC Firm Name: ________________________________Firm Address: ________________________ By (print name)___________________________________ Title _________________________ _________________________________ (Signature) *NOTE: JOINT VENTURES - All parties to a Joint Venture must be individuallypre-qualified in the work category(s) requested. Please list individual companies that comprise the Joint Venture: Name Individual Participant or Company to the Joint Venture:_______________ Name of Company representative to Joint Venture:_______________________ Print Name:_________________Signature:_____________________________ Contact Phone #:_____________Contact Email:_________________________ Name Individual Participant or Company to the Joint Venture:_______________ Name of Company representative to Joint Venture:_______________________ Print Name:_________________Signature:_____________________________ Contact Phone #:_____________Contact Email:_________________________ THE SIGNATORY OF THIS APPLICATION GUARANTEES THE TRUTH AND ACCURACY OF ALL STATEMENTS AND OF ALL ANSWERS HEREINAFTER MADE Please list any previous experience or projects your company has completed for each category you are requesting approval for, and any references you can provide. Attach additional sheets if necessary. Name of Contractor/Firm _____________________________________________________ Principal Firm Address _______________________________________________________ ( ) A corporation ( ) A partnership ( ) A joint venture ( ) An individual ( ) A limited liability corporation ( ) MWBE (Minority or Woman Business Enterprise) If MWBE, what is the name of the agency/organization that issued the certification document? _______________________________________________________________ Please attach a copy of your certification document to this application. Incorporated or organized: Date _______________________ State ______________________________________ Radius of operations: ______________________________________________________ Type of work done: ______________________________________________________ PAGE 10 OF 42 Work usually sublet: Name of Bonding Company _______________________________________________ Total Bonding Capacity of Firm $__________________________________________ I.How many years have you operated under the above name: (a) As general contractor _____________________________________________ (b)As subcontractor ______________________________________________ II.List other names under which you have operated: Name of company _____________________________________________ Type of work done ______________________________________________ Operated during period ______________________________________________ Name of company ______________________________________________ Type of work done ______________________________________________ Operated during period _____________________________________________ III.List of all partners or officers: (Note: if partnership limited, explain and please listfull 100% ownership) Name and title_________________________________________________ Address, City and State____________________________________________ Fractional interest in firm or number of shares owned______________________ Name and title____________________________________________________ Address, City and State____________________________________________ Fractional interest in firm or number of shares owned ______________________ Name and title ___________________________________________________ Address, City and State____________________________________________ Fractional interest in firm or number of shares owned ______________________ IV.What is the construction experience of the principal individuals of your organization?(This includes the job superintendent). An individual’s name Present position or office PAGE 11 OF 42 Years of construction experience Magnitude and type of work An individual’s name Present position or office Years of construction experience Magnitude and type of work An individual’s name Present position or office Years of construction experience Magnitude and type of work PAGE 12 OF 42 V.Only list projects completed or in progress within the last five years in the categories forwhich you want to qualify. Attach additional sheets if necessary. SECTION A. - Sewer Construction (See definition on page 8 – Drain Layers License required for CITY &/or COUNTY – Please attach copy - front/back) (Includes storm sewer, sanitary sewers, and small pump stations) 1.Contract Amount _________________________________________________________ When Completed or Percent Complete_________________________________________ Project Description/Scope of Work: ____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2.Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: ____________________________________________ Pipe size and length laid______________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner__________________________________________ 3.Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 13 OF 42 4. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 5. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 14 OF 42 SECTION B. - Deep Sewer Construction (See definition Page 8 - Drain Layers License required for CITY &/or COUNTY – please attach copy - front/back) (Includes sanitary sewer, storm sewer, and small pump stations) 1.Contract Amount ____________________________________________________________ When Completed or Percent Complete____________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid___________________________________________ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2.Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3.Contract Amount ___________________________________________________________ When Completed or Percent Complete _______________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ PAGE 15 OF 42 Name, Address & Phone # of Owner_____________________________________________ 4. Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 5.Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 16 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION C - Building Construction (Includes large pump stations, treatment plants, and operational facilities) 1.Contract Amount ___________________________________________________________ When Completed or Percent Complete___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project __________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone Number of Owner _______________________________________ 2.Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: ____________________________________________ Location of Project__________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3.Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner____________________________________________ 4.Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ Name, Address & Phone # of Owner_____________________________________________ PAGE 17 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION D. Natural Channel Stabilization: 1.Contract Amount _____________ When Completed or Percent Complete Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ____________________________________ Location of Project ________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner _____________________________________________ 2.Contract Amount _____________When Completed or Percent Complete _______________ Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ___________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_________________________________________ 3.Contract Amount ______________When Completed or Percent Complete ______________ Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ____________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner 4.Contract Amount ______________When Completed or Percent Complete ______________ Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ____________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 18 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION E. Green Infrastructure and Bio-Retention 1. Contract Amount ____________When Completed or Percent Complete Project Description/Scope of Work: _____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project ________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner ____________________________________________ 2. Contract Amount _______________When Completed or Percent Complete _____________ Project Description/Scope of Work: _____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount _______________ When Completed or Percent Complete _____________ Project Description/Scope of Work: _____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner__________ _____________________________ 4. Contract Amount _______________When Completed or Percent Complete _____________ Project Description/Scope of Work: ____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 19 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION F. - Pipe and Manhole Rehabilitation (Give pipe sizes) (Includes point repair, pipe bursting, slip lining, etc.) 1.Project name, scope and description: ___________________________________________ Contract Amount __________________________________________________________ When Completed or Percent Complete ________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2.Project name, scope and description: ___________________________________________ Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3.Project name, scope and description: ____________________________________________ Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner 4.Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 20 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION G. – Cured-in-Place Pipe (CIPP) Statement of Qualifications for Cured-in-Place Pipe 1. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Manufacturer of CIPP product ___________ Trade Name of CIPP product ______________ Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) __________________________________________________________________________ Installation Method: Invert: _____ Pull-In: _____ Installed Pipe Length: _____ Pipe Sizes: _____ Pipe Type: Gravity ____ Pressure _______ Project Owner: ______________________________________________________________ Contact Name: ___________________________Contact No.:________________________ Relevant ASTM Specification: ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________________ Lowest 3rd Party D790 Testing Results on Project: Flexural Strength _____________ Flexural Modulus ___________________________ Tensile Strength _____________ (only applicable for pressure pipe) 2. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Manufacturer of CIPP product ___________ Trade Name of CIPP product ______________ Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) ___________________________________________________________________________ Installation Method: Invert: _____ Pull-In: _____ Length of Pipe Installed: _______ Pipe Size: _____________ Pipe Type: Gravity _______ Pressure _______ PAGE 21 OF 42 Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.: _________________ Relevant ASTM Specification: ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________ Lowest 3rd Party D790 Testing Results on Project: Flexural Strength _____________ Flexural Modulus _________________ Tensile Strength _____________ (only applicable for pressure pipe) PAGE 22 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION H. – Cured in Place Lateral Lining (CIPL) Statement of Qualifications for cured-in-place lateral lining (includes cured-in-place lateral connection repairs). 1.Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Manufacturer of CIPL product ___________ Trade Name of CIPL product _________________ Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ No. of Laterals Lined: ________ Total Length of Laterals Lined: _____________________ Manufacturer of Water Tight Seal (waterstop): _____________________________________ Manufacturer of Lateral Connection Repair (LCR): _________________________________ (Attach written documentation from manufacturer certifying that contractor is an approved installer of their product). No. of LCR’s Installed: __________ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.: _________________ Relevant ASTM Specification: Lowest Value of 3rd Party D790 Testing Results on Project: Flexural Strength ____________ Flexural Modulus __________________ 2. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Manufacturer of CIPL product ___________ Trade Name of CIPL product ________ Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ No. of Laterals Lined: ________ Total Length of Laterals Lined: __________ PAGE 23 OF 42 Manufacturer of Water Tight Seal (waterstop): ______________________________ Manufacturer of Lateral Connection Repair (LCR): __________________________ (Attach written documentation from manufacturer certifying that contractor is an approved installer of their product). No. of LCR’s Installed: __________ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.: _________________ Relevant ASTM Specification: Lowest Value of 3rd Party D790 Testing Results on Project: Flexural Strength ____________ Flexural Modulus __________________ PAGE 24 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION I. - Concrete Channels, Walls & Structures 1.Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project __________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2.Contract Amount ____________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3.Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4.Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: ____________________________________________ Location of Project__________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 25 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION J. - Mechanical/Electrical/Plumbing 1.Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project__________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2.Contract Amount ____________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3.Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4.Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project__________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 26 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION K. – Tunneling / Trenchless 1.Contract Amount ____________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project __________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2.Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3.Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4.Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 27 OF 42 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION L. – Demolition Demolition work for MSD within the City of St. Louis – Please attach required certification for specific CITY classification. Class I–no building size restrictions. Class II -limited to buildings under 3 stories / 50 feet high / 50,000 square feet area / 200,000 cubic feet volume. Buildings under 1 ½ stories / 10,000 cubic feet volume, with no basement, require no demolition certification. St. Louis County – does not require certification. 1. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project __________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2.Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 28 OF 42 4. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ PAGE 29 OF 42 EQUIPMENT (What equipment do you own that is available for proposed work?) QUANTITY ITEM DESCRIPTION, SIZE, CAPACITY, ETC EQUIP HOURS CONDITION YEARS OF SERVICE PRESENT LOCATION * Condition shall be graded as follows: New under 12 months Over 12 months old Rebuilt N-1 0-1 (Good)R-10-2 (Average)R-20-3 (Fair)R-30-4 (Poor)R-4 (Poor) REVISED INSURANCE PROVISIONS Effective 10/15/22, Updated 12/07/22 BID SECURITY: Each bid shall be accompanied by a certified check or cashier's check for an amount not less than five (5%) percent of the bid amount, payable unconditionally to the District as a guarantee that the bidder will execute a contract and furnish the required contract bond and insurance requirements within fifteen (15) days after acceptance of the bid proposal. In lieu of the certified or cashier's check, a bid bond in the same amount, executed by a surety company satisfactory to the District and duly authorized to transact business in Missouri as evidenced by a Certificate of Authority granted by the Insurance Commissioner, Department of Insurance, State of Missouri, may be furnished. The surety company must have a financial strength rating of "A" or better and a financial size category of Class V or higher per AM Best Company. If the bidder fails or refuses to enter into a contract pursuant to such bid within the allotted time, the principal sum of such bond or such checks shall be immediately forfeited to the District. CONTRACT BOND: For projects where the Engineer’s Estimate is $50,000.00 or greater a contract bond (combination performance, labor and material payment bond) will be required for the full amount of the contract price on forms as approved by the District and only from a surety or insurance company satisfactory to the District with the following qualifications: •Duly authorized to transact business in Missouri as evidenced by a Certificate of Authority granted by the Insurance Commissioner, Department of Insurance, State of Missouri. •Having a financial strength rating of "A" or better and a financial size category of Class V or higher in per AM Best Company. •If applicable, listed in the most recent issue of the Federal Register, Circular 570 and possessing a financial limit equal to or greater than the value of the contract to be bonded. The contract bond shall be conditioned that the principal therein will faithfully and properly perform the contract according to all of the terms thereof, that the principal will guarantee the workmanship and materials for a period of one year after the date of final acceptance of the work, and that the principal will, as soon as the work contemplated by the contract shall have been completed, pay to the proper parties all sums due for materials, labor and services used and employed in the performance thereof. The contract bond shall be executed in quintuplicate, be on a District approved form, and submitted to the District within fifteen (15) days after written notification that the bid proposal has been accepted and the contract awarded. INDEMNIFICATION The Contractor shall defend, indemnify and hold harmless the District, its Trustees, directors, officers, agents and employees (the District), from and against any and all claims (including but not limited to attorneys’ fees), suits, causes of action, judgments or damages on account of any liability, including personal injuries or bodily injury, including death or property damage, sustained by the District or sustained or claimed to be sustained by any person or persons, to the extent caused by, to the extent arising out of, or to the extent resulting from, any act or omission of the Contractor or its subcontractors, their agents or employees, related to the work, or due, in whole or part, to any negligent act or omission on the part of the Contractor or its subcontractors, their agents or employees. This indemnity shall continue not only during the time period in which the Contractor performs the work but shall continue thereafter for a period of five (5) years after final acceptance. PAGE 30 OF 42 PAGE 31 OF 42 INSURANCE REQUIREMENTS: a.Within fifteen (15) days after written notification by the District that the bid proposal has been accepted and receipt of the contract for signature, the Contractor must provide executed Certificate(s) of Insurance on the ISO ACORD 25 Form or current equivalent with the District, indicating that the bidder is carrying commercial general liability, business auto liability, workers compensation/employers’ liability, excess (umbrella) liability, professional liability and pollution liability as required. The initial and renewal Certificates of Insurance must identify the MSD Project and Contract by name and reference number. The Certificate shall reference the retroactive date as applicable to the particular coverage(s). A sample Certificate of Insurance Form in the format required is attached to these specifications. b.The Contractor shall carry and maintain adequate liability insurance as required by this Contract with a company or companies satisfactory to the District and which are: Licensed to do business in the State of Missouri (Admitted) with a financial strength rating of “A-” or better and a financial size category of Class VI or higher per AM Best Company; or Not licensed in the State of Missouri (Non-admitted) with a financial strength rating of “A” or better and a financial size category of Class IX or higher per AM Best Company; or If no AM Best rating is available (i.e., captive underwriting), then demonstrating acceptable proof of financial responsibility as determined by MSD. In individual cases as approved by the District, the insurance policy/policies will be acceptable regardless of the above requirements if the insurance company furnishes a bond guarantee or policy containing a provision (commonly referred to as a “cut-through” endorsement) giving all claimants thereunder a direct right of recovery against the company’s reinsurer, provided the reinsurer meets one of the qualifications listed above. c.The amounts of coverage required herein shall not be construed to limit the liability of the Contractor. d.The District (including its Trustees, directors, officers, agents and employees), shall be included as “Additional Insured(s)” for all required insurance coverage (with the exception of professional liability and workers compensation coverage) with respect to the work covered by the contract. The Contractor shall require that its sub-contractors name the District and the Contractor as “Additional Insured(s)”. The additional insured coverage must be sufficiently broad to afford the District coverage as required by the indemnification provision of the Contract and must include products and completed operations coverage within the commercial general liability policy. e.Waivers of subrogation shall be required in the following coverages: Commercial General Liability, Business Auto Liability, Workers Compensation and Employers’ liability Insurance (to the extent the work does not fall within the construction trade class) and Excess (Umbrella) Coverage. f.In the event the Contractor is a joint venture, the following additional requirements shall apply: 1.If the joint venture secures separate stand-alone coverage in the name of the joint venture for one or more of the required lines of coverage, each of the requirements set forth below shall apply to that coverage and the certificate of insurance shall so indicate. PAGE 32 OF 42 The District may request copies of the endorsements &/or policies of insurance to verify that coverage is in the name of the joint venture. 2.If separate stand-alone coverage in the name of the joint venture is not provided for one or more of the required lines of coverage, then for each such line of required coverage, the following requirements shall apply: (i) the coverages of each of the joint venture members must provide specific endorsements to each such line of required coverage; (ii) The joint venture shall be endorsed to each such line of coverage; (iii) The joint venture and each member of the joint venture must be “named insureds” for each such line of coverage; and (iv) The certificates of insurance for each such joint venture member shall be provided and shall reflect compliance with these requirements. It is anticipated that business auto and workers compensation/employers’ liability coverage will not be secured in the name of the joint venture, and will fall in this category. g.The coverage and minimum limits of liability shall be in accordance with the specifications below except as may be specifically modified by the Project specifications: COVERAGES & LIMITS COMMERCIAL GENERAL LIABILITY Limits $1,000,000 Each Occurrence $2,000,000 Aggregate/Per Project* *The aggregate limits must be provided on a per project basis. Aggregate limits not provided on a per project basis must be noted on the Certificate of Insurance and the District must approve in advance. The Commercial General Liability (CGL) policy shall be in accordance with the standard ISO CG0001 policy form. No restrictive endorsements are allowed that would remove or limit the coverages provided by the standard form, including the following: 1. Premises – Operations Liability 2.Products & Completed Operations Liability 3.Advertising & Personal Injury Liability 4.Coverage for explosion, collapse and underground hazards (XCU) (to the extent applicable in connection with the work) 5.Blasting (provided that blasting coverage may be excluded if not to be performed in connection with the work). If any restrictions or exclusions have been made to the standard CGL Policy, the restrictions and exclusions must be specifically listed and identified in the Description of Operations section of the Certificate of Insurance and must be submitted to the District for approval. If not using a standard policy form (such as Form CG 00 01 04 13 or equivalent), then additional endorsements may be required and the form must be provided for District approval. The commercial general liability policy must provide primary and non-contributory coverage that is equivalent to the terms of ISO Form CG 20 01 04 13, Primary and PAGE 33 OF 42 Noncontributory Other Insurance Conditions (or current equivalent). If equivalent, must provide form for District approval. Any punitive damages exclusion must be specifically set forth and submitted to the District for approval. The commercial general liability coverage including products and completed operations shall be maintained for a minimum period of five (5) years following final payment. BUSINESS AUTOMOBILE LIABILITY Limits $1,000,000 Combined Single Limit Insurance shall apply to all owned, non-owned and hired vehicles. An MCS-90 endorsement shall be included on the Policy when required by law. WORKERS COMPENSATION & EMPLOYERS’ LIABILITY INSURANCE Workers Compensation Insurance shall comply with all applicable State and Federal laws, including but not limited to U.S. Longshore & Harbor Workers (USL&H) Act and Jones Act (to the extent applicable to the work covered by the contract). $1,000,000 Each Accident $1,000,000 Disease Each Employee $1,000,000 Disease Policy Limit EXCESS (UMBRELLA) COVERAGE – Applies to Commercial General, Business Auto & Employers Liability Excess coverage must be provided and with the following limits for each of the Commercial General Liability, Business Auto & Employers’ Liability coverages. These limits are in addition to the primary limits set forth above. Limits For Contracts between $50,000 and $5 million: $ 2 million Per Occurrence $ 2 million Aggregate/Per Project* Limits For Contracts between $5 million and $30 million: $ 5 million Per Occurrence $ 5 million Aggregate/Per Project* Limits For Contracts over $30 million: $ 10 million Per Occurrence $ 10 million Aggregate/Per Project* PAGE 34 OF 42 * The aggregate limits must be provided on a per project basis. Aggregate limits not provided on a per project basis must be noted on the certificate of insurance and the District must approve. The required provisions for the General Liability coverage (such as additional insured for products and completed operations, primary and noncontributory, etc.) will be following form on the excess over the GL coverages. POLLUTION LIABILITY The Contractor shall maintain in force for the full period of the Contract, pollution liability insurance coverage in the minimum amount set forth below for losses caused by sudden and accidental pollution conditions that arise from the operations of the Contractor. Such insurance shall apply to bodily injury and property damage, including loss of use of the damaged property or property that has not been physically injured, and shall cover cleanup, transportation, disposal, remediation and defense costs, including all expenses incurred in the investigation, defense, payment or settlement of claims. Limits for Contracts up to $30 million: $ 2 million Per Claim/Occurrence $ 2 million Aggregate Limits For Contracts Over $30 million: $ 5 million Per Claim/Occurrence $ 5 million Aggregate/Per Project* The insurance coverage shall be retroactive to the earlier of the date of the Contract or the commencement of the Contractor’s work on the Project, and Contractor shal l caus e th e same to remai n in effec t for a period of at leas t five (5) years after final acceptance of the Project by the District or such other period as may be set forth in the Contract or in the Project Specifications. PROFESSIONAL LIABILITY For contracts in excess of $30 million or on MSD-Owned Facilities, the Contractor and any sub-contractor providing design services shall maintain in force for the duration of the Contract errors and omissions/professional liability insurance. Coverage as required in this Article shall apply to liability for professional errors, acts or omissions arising out of the scope of the Contractor’s services as set forth in the Contract and the Project S pecifications. Limits for Contracts over $30 million or on MSD-Owned Facilities : $ 2 million Per Claim or Occurrence $ 2 million Aggregate If claims made, the insurance coverage shall be retroactive to the earlier of the date of the Contract or the commencement of the Contractor’s work on the Project, and Contractor shall caus e th e sam e to remai n in effec t fo r a period of at leas t five (5) years after fina l acceptance of the Project by the District or such other period as may be set forth in the Contract or in the Project Specifications. NOTE: If Contractor provides combined Pollution Liability and Professional Liability coverage or if such coverage is shared w/GL or other insurance, separate limits in the amounts required must be provided. If a policy aggregate applies, the policy aggregate must equal at a minimum the sum of the two limits, and the certificate of insurance must so indicate and the amounts must be approved by the District. DEDUCTIBLE/SELF-INSURED RETENTION: For any coverage, a deductible or retention that exceeds $100,000 shall be noted and approved by the District’s Insurance & Safety Division. The District will reserve the right to review the funding for a deductible or retention program. Satisfaction of any such deductible or retention shall be the sole responsibility of the Contractor. If self-insured, the District reserves the right to request acceptable proof of financial responsibility before approval. CAPTIVE UNDERWRITING: If any insurance coverage is provided by or through a captive, the following requirements shall apply: A.The insurance coverage must be written on “A” paper; and B.The use of a captive must be disclosed on the Certificate of Insurance provided to the District. CANCELLATION: All policies of insurance required by these specifications shall include an endorsement that the District must be notified in the event any of the required insurance coverage is cancelled prior to the expiration date. In addition, the Contractor must provide at least sixty (60) days written notice to the District prior to the cancellation. For policy cancellation for non-payment of premium by the Contractor, the Contractor must notify the District at least ten (10) calendar days prior to the cancellation. Cancellation provisions within any coverage shall be in accordance with Missouri Cancellation and Non-Renewal provisions. REPLACEMENT POLICY: Should any of the required insurance coverage be cancelled, terminated or materially altered, the Contractor will send written notice to MSD at least sixty (60) days prior to the effective date of said cancellation, termination or alteration. Upon receipt of any notice of insurance cancellation, termination or alteration, the Contractor shall within thirty (30) days procure other policies of insurance identical in all respects to the policy or policies about to be canceled, terminated or altered and shall provide the District with evidence of coverage before the cancellation or termination date; and if the Contractor fails to provide, procure and deliver acceptable policies of insurance and satisfactory certificates or other evidence thereof, the District may obtain such insurance at the cost and expense of the Contractor without notice to the Contractor, and elect to pursue any other remedy permitted by law or the contract terms, including but not limited to termination of the Contract. PAGE 35 OF 42 Acord9 CERTIFICATE OF LIABILITY INSURANCE COVERAGES CERTIFICATE NUMBER REVISION NUMBER 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 pohcy(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 ABC Insurance Agency 1234 Mam Street Any city, State, ZIP nameACT contact name <a/°Nno. exh. Phone number I (WC. No) address ema|l address of agent INSURER(S) AFFORDING COVERAGE NAIC# insurer a ABC company INSURED Insured Name Address City, State, Zip insurer b DEF company insurer c GHI company insurer d JKL company INSURER E INSURER F CERTIFICATE HOLDER __________ ______________________CANCELLATION 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 INSR SUBR WVP POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY)LIMITS GENERAL LIABILITY X X policy number EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GE NERAL LIABILITY E | X | OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence)$ | CLAIMS-MAC MED EXP (Any one person)$ PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER | POLICY [x] JECT 1 LOC PRODUCTS - COMP/OP AGG $ 1,000,000 $ AUTOMOBILE LIABILITY X X policy number COMBINED SINGLE LIMIT (Ea accident)$ 1,000,000 X ANY AUTO BODILY INJURY (Per person)$ ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON-OWNED AUTOS BODILY INJURY (Per accident)$ X X PROPERTY DAMAGE (Per accident)$ $ X UMBRELLA LIAB OCCUR CLAIMS-MADE X X policy number EACH OCCURRENCE $ 2M-10M EXCESS LIAB AGGREGATE $ 2M-10M DED I I RETENTIONS depending on contract s WORKERS COMPENSATION AND EMPLOYERS’ LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE 1-------1 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A policy number 1 WC STATU- IVlOTH- 1 TORY 1 IMITS 1 1 FR EL EACH ACCIDENT $ 1,000,000 EL DISEASE - EA EMPLOYEE $ 1,000,000 EL DISEASE - POLICY LIMIT $ 1,000,000 Pollution, Professional, Cyber if required by contract X X policy numbers 2M - 10M as required by contract DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The District and its Trustees, directors, officers, agents and employees, shall be named as Additional Insured(s)” for all required insurance coverage (with the exception of professional liability and workers compensation coverage) with respect to the work covered by the Contract The Contractor shall require that its sub-contractor name the District and the Contractor as Additional Insured(s)” The Contractor shall name any Consultant and Sub-consultant for the Project as Additional Insured(s) on the commercial general liability coverage applicable to the Project The additional insured coverage must be sufficiently broad to afford the District coverage as required by the indemnification provision of the Contract and must include products and completed operations coverage Please name the MSD project name and number ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION All rights reserved Metropolitan St Louis Sewer District 2350 Market St St Louis, Mo 63103 ___________I______________________________________________________ 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 The ACORD name and logo are registered marks of ACORD PAGE 37 OF 42 Metropolitan St. Louis Sewer District 2350 Market Street St. Louis, Missouri 63103 Insurance Requirements for Annual Pre-Qualification (This acknowledgement must be signed by both the Contractor and the Contractor’s Insurance Broker) Metropolitan St Louis Sewer District (MSD) requires contractors to be pre-qualified prior to bidding on Capital Improvement Projects. In the pre-qualification process, contractors must demonstrate their ability to perform in the event they are awarded a contract, including meeting the District’s insurance requirements. MSD has certain contract requirements relating to contractor insurance coverage, including increasing the limits for certain coverage and requiring pollution liability coverage as noted above in the Revised Insurance Provisions, effective 10/15/22, Updated 12/07/22 (pages 30-36). For pre- qualification purposes only, MSD is requiring both the contractor and the contractor’s insurance broker to sign below acknowledging their understanding and agreement to the coverage and minimum limits of Liability in accordance with the specifications noted in the Revised Insurance Provisions above and that the Contractor has been approved for the insurance coverage, with the limits required. Additionally, it is agreed that the policy will be endorsed, and coverage will be in place in the event a contract is awarded. The Contractor acknowledges and agrees that in the event a contract is awarded, and insurance is not secured within the required timeframe, the Contractor will forfeit its bid bond on the project and will be determined non-responsive. Acknowledged and Agreed: Contractor/Company Name:_______________________________________________________ Authorized representative name (Print):______________________________________ Signature:________________________________ Title:____________________________________ Date:________________________ Insurance Broker/Company Name:_______________________________________________________ Authorized representative name (Print):______________________________________ Signature:________________________________ Title:____________________________________ Date:________________________ PAGE 38 OF 42 AFFIDAVIT FOR CORPORATION STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, ____________________, depose and state as follows: 1. I am the _________________(title) of _____________________________________; 2. I am authorized to sign this Affidavit on behalf of the corporation; 3. The foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief; and 4. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name and affixed the official seal of the corporation this day of ____, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20___. Notary Public My commission expires: PAGE 39 OF 42 AFFIDAVIT FOR PARTNERSHIP STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, ____________________, depose and state as follows: 1.I am a partner in the partnership known as ____________________________________________________________; 2. I am authorized to sign this Affidavit on behalf of the partnership; 3. The foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief; and 4. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name this __ day of ________________, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20___. Notary Public My commission expires: PAGE 40 OF 42 AFFIDAVIT FOR JOINT VENTURE STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, ____________________, depose and state as follows: 1.I am a joint venture partner &/or am authorized to sign this Affidavit on behalf of the Joint Venture between _______________________ and _________________________; 2. The foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief; and 3. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name this __ day of ________________, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20___. Notary Public My commission expires: PAGE 41 OF 42 AFFIDAVIT FOR INDIVIDUAL STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, _____________________________________, depose and state under oath that the foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name and affixed my official seal this day of ____, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20__. Notary Public My commission expires: PAGE 42 OF 42 AFFIDAVIT FOR LIMITED LIABILTY COMPANY STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, ____________________, depose and state as follows: 1. I am the _________________(title) of _____________________________________, a limited liability company; 2. I am authorized to sign this Affidavit on behalf of the limited liability company; 3. The foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief; and 4. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name on this day of ____, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20___. Notary Public My commission expires: