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HomeMy WebLinkAboutC22-257 Sun-Up SealcoatsAGREEMENT FOR SERVICES
BETWEEN EAGLE COUNTY, COLORADO
AND
SUN-UP SEALCOATS LLC
THIS AGREEMENT (“Agreement”) is effective as of ______________ by and between Sun-Up
Sealcoats LLC, a Colorado limited liability company (hereinafter “Contractor”), and Eagle
County, Colorado, a body corporate and politic (hereinafter “County”).
RECITALS
WHEREAS, Eagle County requires parking lot maintenance services to include single-coat seal
coat, crack cleaning and filling, striping, and special pavement markings for County-owned
parking lots and pavement at the following locations: 715 Broadway, Eagle, CO; 500 Broadway,
Eagle, CO; and 3989 Cooley Mesa Road, Gypsum, CO (the “Properties”); and
WHEREAS, Contractor is authorized to do business in the State of Colorado and has the time,
skill, expertise, and experience necessary to provide the Services as defined below in paragraph 1
hereof; and
WHEREAS, this Agreement shall govern the relationship between Contractor and County in
connection with the Services.
AGREEMENT
NOW, THEREFORE, in consideration of the foregoing and the following promises Contractor
and County agree as follows:
1. Services or Work. Contractor agrees to diligently provide all services, labor, personnel
and materials necessary to perform and complete the services or work described in Exhibit A
(“Services” or “Work”) which is attached hereto and incorporated herein by reference. The areas
of the Properties to receive the Services are highlighted in Exhibit A. The Services shall be
performed in accordance with the provisions and conditions of this Agreement.
a. Contractor agrees to furnish the Services no later than November 15, 2022, and in
accordance with the schedule established in Exhibit A. Contractor agrees to furnish the Services
in a timely and expeditious manner consistent with the applicable standard of care. By signing
below Contractor represents that it has the expertise and personnel necessary to properly and
timely perform the Services.
b. In the event of any conflict or inconsistency between the terms and conditions set
forth in Exhibit A and the terms and conditions set forth in this Agreement, the terms and
conditions set forth in this Agreement shall prevail.
2. County’s Representative. The Engineering Department’s designee shall be the
Contractor's contact with respect to this Agreement and performance of the Services.
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3. Term of the Agreement. This Agreement shall commence upon the date first written
above, and subject to the provisions of paragraph 11 hereof, shall continue in full force and effect
through the 15 day of November, 2022.
4. Extension or Modification. This Agreement may be extended for up to three additional
one-year terms upon written agreement of the parties. Any amendments or modifications shall be
in writing signed by both parties. No additional services or work performed by Contractor shall
be the basis for additional compensation unless and until Contractor has obtained written
authorization and acknowledgement by County for such additional services in accordance with
County’s internal policies. Accordingly, no course of conduct or dealings between the parties,
nor verbal change orders, express or implied acceptance of alterations or additions to the
Services, and no claim that County has been unjustly enriched by any additional services,
whether or not there is in fact any such unjust enrichment, shall be the basis of any increase in
the compensation payable hereunder. In the event that written authorization and acknowledgment
by County for such additional services is not timely executed and issued in strict accordance with
this Agreement, Contractor’s rights with respect to such additional services shall be deemed
waived and such failure shall result in non-payment for such additional services or work
performed.
5. Compensation. The County shall compensate Contractor for the performance of the
Services at the unit pricing computed and payable as set forth in Exhibit A. The Contractor is
responsible for notifying the County of field discrepancies to the Estimated Quantities set forth
in Exhibit A. Otherwise, it shall be assumed the Actual Unit is equal to the Estimated Unit. The
performance of the Services under this Agreement shall not exceed $69,246.00 pursuant to
Exhibit A, plus 12,754.00 in contingency funds only to be utilized if approved in writing by
the Engineering Department’s designee if the Actual Unit exceeds the Estimated Unity
price, for a total of $82,000.00. Contractor shall not be entitled to bill at overtime and/or double
time rates for work done outside of normal business hours unless specifically authorized in
writing by County.
a. Payment will be made for Services satisfactorily performed within thirty (30)
days of receipt of a proper and accurate invoice from Contractor. All invoices shall include
detail regarding the hours spent, tasks performed, who performed each task, and such other detail
as County may request.
b. If, at any time during the term or after termination or expiration of this
Agreement, County reasonably determines that any payment made by County to Contractor was
improper because the Services for which payment was made were not performed as set forth in
this Agreement, then upon written notice of such determination and request for reimbursement
from County, Contractor shall forthwith return such payment(s) to County. Upon termination or
expiration of this Agreement, unexpended funds advanced by County, if any, shall forthwith be
returned to County.
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c. County will not withhold any taxes from monies paid to the Contractor hereunder
and Contractor agrees to be solely responsible for the accurate reporting and payment of any
taxes related to payments made pursuant to the terms of this Agreement.
d. Notwithstanding anything to the contrary contained in this Agreement, County
shall have no obligations under this Agreement after, nor shall any payments be made to
Contractor in respect of any period after December 31 of any year, without an appropriation
therefor by County in accordance with a budget adopted by the Board of County Commissioners
in compliance with Article 25, title 30 of the Colorado Revised Statutes, the Local Government
Budget Law (C.R.S. 29-1-101 et. seq.) and the TABOR Amendment (Colorado Constitution,
Article X, Sec. 20).
6. Subcontractors. Contractor acknowledges that County has entered into this Agreement in
reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter
into any subcontractor agreements for the performance of any of the Services or additional
services without County’s prior written consent, which may be withheld in County’s sole
discretion. County shall have the right in its reasonable discretion to approve all personnel
assigned to the subject Project during the performance of this Agreement and no personnel to
whom County has an objection, in its reasonable discretion, shall be assigned to the
Project. Contractor shall require each subcontractor, as approved by County and to the extent of
the Services to be performed by the subcontractor, to be bound to Contractor by the terms of this
Agreement, and to assume toward Contractor all the obligations and responsibilities which
Contractor, by this Agreement, assumes toward County. County shall have the right (but not the
obligation) to enforce the provisions of this Agreement against any subcontractor hired by
Contractor and Contractor shall cooperate in such process. The Contractor shall be responsible
for the acts and omissions of its agents, employees and subcontractors.
7. Insurance. Contractor agrees to provide and maintain at Contractor’s sole cost and
expense, the following insurance coverage with limits of liability not less than those stated
below:
a. Types of Insurance.
i. Workers’ Compensation insurance as required by law.
ii. Auto coverage with limits of liability not less than $1,000,000 each
accident combined bodily injury and property damage liability insurance, including coverage for
owned, hired, and non-owned vehicles.
iii. Commercial General Liability coverage to include premises and
operations, personal/advertising injury, products/completed operations, broad form property
damage with limits of liability not less than $500,000 per occurrence and $850,000 aggregate
limits.
b. Other Requirements.
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i. The automobile and commercial general liability coverage shall be
endorsed to include Eagle County, its associated or affiliated entities, its successors and assigns,
elected officials, employees, agents and volunteers as additional insureds. A certificate of
insurance consistent with the foregoing requirements is attached hereto as Exhibit B.
ii. Contractor’s certificates of insurance shall include subcontractors, if any
as additional insureds under its policies or Contractor shall furnish to County separate certificates
and endorsements for each subcontractor.
iii. The insurance provisions of this Agreement shall survive expiration or
termination hereof.
iv. The parties hereto understand and agree that the County is relying on, and does
not waive or intend to waive by any provision of this Agreement, the monetary limitations or
rights, immunities and protections provided by the Colorado Governmental Immunity Act, as
from time to time amended, or otherwise available to County, its affiliated entities, successors or
assigns, its elected officials, employees, agents and volunteers.
v. Contractor is not entitled to workers’ compensation benefits except as
provided by the Contractor, nor to unemployment insurance benefits unless unemployment
compensation coverage is provided by Contractor or some other entity. The Contractor is
obligated to pay all federal and state income tax on any moneys paid pursuant to this
Agreement.
8. Indemnification. The Contractor shall indemnify and hold harmless County, and any of
its officers, agents, and employees against any losses, claims, damages, or liabilities for which
County may become subject to insofar as any such losses, claims, damages, or liabilities arise out
of, directly or indirectly, this Agreement, or are based upon any performance or nonperformance
by Contractor or any of its subcontractors hereunder; and Contractor shall reimburse County for
reasonable attorney fees and costs, legal, and other expenses incurred by County in connection
with investigating or defending any such loss, claim, damage, liability, or action. This
indemnification shall not apply to claims by third parties against the County to the extent that
County is liable to such third party for such claims without regard to the involvement of the
Contractor. This paragraph shall survive expiration or termination hereof.
9. Ownership of Documents. All documents (including electronic files) and materials
obtained during, purchased or prepared in the performance of the Services shall remain the
property of the County and are to be delivered to County before final payment is made to
Contractor or upon earlier termination of this Agreement.
10. Notice. Any notice required by this Agreement shall be deemed properly delivered when
(i) personally delivered, or (ii) when mailed in the United States mail, first class postage prepaid,
or (iii) when delivered by FedEx or other comparable courier service, charges prepaid, to the
parties at their respective addresses listed below, or (iv) when sent via facsimile so long as the
sending party can provide facsimile machine or other confirmation showing the date, time and
receiving facsimile number for the transmission, or (v) when transmitted via e-mail with
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confirmation of receipt. Either party may change its address for purposes of this paragraph by
giving five (5) days prior written notice of such change to the other party.
COUNTY:
Eagle County, Colorado
Attention: Julie Pranger, PE, CFM
500 Broadway
Post Office Box 850
Eagle, CO 81631
Telephone: 970-328-3563
E-Mail: julie.pranger@eaglecounty.us
With a copy to:
Eagle County Attorney
500 Broadway
Post Office Box 850
Eagle, Co 81631
Telephone: 970-328-8685
Facsimile: 970-328-8699
E-Mail: atty@eaglecounty.us
CONTRACTOR:
Sun-Up Sealcoats LLC
Ben Barron, Owner
PO Box 1267
Vail, CO 81658
(970)-376-7621
services@sunupsealcoats.com
11. Termination. County may terminate this Agreement, in whole or in part, at any time and
for any reason, with or without cause, and without penalty therefor with seven (7) calendar days’
prior written notice to the Contractor. Upon termination of this Agreement, Contractor shall
immediately provide County with all documents as defined in paragraph 9 hereof, in such format
as County shall direct and shall return all County owned materials and documents. County shall
pay Contractor for the Services satisfactorily performed to the date of termination.
12. Venue, Jurisdiction, and Applicable Law. Any and all claims, disputes, or controversies
related to this Agreement, or breach thereof, shall be litigated in the District Court for Eagle
County, Colorado, which shall be the sole and exclusive forum for such litigation. This
Agreement shall be construed and interpreted under and shall be governed by the laws of the
State of Colorado.
13. Execution by Counterparts; Electronic Signatures. This Agreement may be executed in
two or more counterparts, each of which shall be deemed an original, but all of which shall
constitute one and the same instrument. The parties approve the use of electronic signatures for
execution of this Agreement. Only the following two forms of electronic signatures shall be
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permitted to bind the parties to this Agreement: (i) Electronic or facsimile delivery of a fully
executed copy of the signature page; (ii) the image of the signature of an authorized signer
inserted onto PDF format documents. All documents must be properly notarized, if
applicable. All use of electronic signatures shall be governed by the Uniform Electronic
Transactions Act, C.R.S. 24-71.3-101 to 121.
14. Other Contract Requirements and Contractor Representations.
a. Contractor has familiarized itself with the nature and extent of the Services to be
provided hereunder and the Properties, and with all local conditions, federal, state and local laws,
ordinances, rules, and regulations that in any manner affect cost, progress, or performance of the
Services.
b. Contractor will make, or cause to be made, examinations, investigations, and tests
as it deems necessary for the performance of the Services.
c. To the extent possible, Contractor has correlated the results of such observations,
examinations, investigations, tests, reports, and data with the terms and conditions of this
Agreement.
d. To the extent possible, Contractor has given County written notice of all conflicts,
errors, or discrepancies.
e. Contractor shall be responsible for the completeness and accuracy of the Services
and shall correct, at its sole expense, all significant errors and omissions in performance of the
Services. The fact that the County has accepted or approved the Services shall not relieve
Contractor of any of its responsibilities. Contractor shall perform the Services in a skillful,
professional, and competent manner and in accordance with the standard of care, skill, and
diligence applicable to contractors performing similar services. Contractor represents and
warrants that it has the expertise and personnel necessary to properly perform the Services and
shall comply with the highest standards of customer service to the public. Contractor shall
provide appropriate supervision to its employees to ensure the Services are performed in
accordance with this Agreement. This paragraph shall survive termination of this Agreement.
f. Contractor agrees to work in an expeditious manner, within the sound exercise of
its judgment and professional standards, in the performance of this Agreement. Time is of the
essence with respect to this Agreement.
g. This Agreement constitutes an agreement for performance of the Services by
Contractor as an independent contractor and not as an employee of County. Nothing contained
in this Agreement shall be deemed to create a relationship of employer-employee, master-
servant, partnership, joint venture, or any other relationship between County and Contractor
except that of independent contractor. Contractor shall have no authority to bind County.
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h. Contractor represents and warrants that at all times in the performance of the
Services, Contractor shall comply with any and all applicable laws, codes, rules, and
regulations.
i. This Agreement contains the entire agreement between the parties with respect to
the subject matter hereof and supersedes all other agreements or understanding between the
parties with respect thereto.
j. Contractor shall not assign any portion of this Agreement without the prior
written consent of the County. Any attempt to assign this Agreement without such consent shall
be void.
k. This Agreement shall be binding upon and shall inure to the benefit of the parties
hereto and their respective permitted assigns and successors in interest. Enforcement of this
Agreement and all rights and obligations hereunder are reserved solely for the parties, and not to
any third party.
l. No failure or delay by either party in the exercise of any right hereunder shall
constitute a waiver thereof. No waiver of any breach shall be deemed a waiver of any preceding
or succeeding breach.
m. The invalidity, illegality, or unenforceability of any provision of this Agreement
shall not affect the validity or enforceability of any other provision hereof.
n. The signatories to this Agreement aver to their knowledge no employee of the
County has any personal or beneficial interest whatsoever in the Services or Properties described
in this Agreement. The Contractor has no beneficial interest, direct or indirect, that would
conflict in any manner or degree with the performance of the Services and Contractor shall not
employ any person having such known interests.
o. The Contractor, if a natural person eighteen (18) years of age or older, hereby
swears and affirms under penalty of perjury that he or she (i) is a citizen or otherwise lawfully
present in the United States pursuant to federal law, (ii) to the extent applicable shall comply
with C.R.S. 24-76.5-103 prior to the effective date of this Agreement.
15. Prohibitions on Government Contracts. As used in this Section 15, the term
undocumented individual will refer to those individuals from foreign countries not legally within
the United States as set forth in C.R.S. 8-17.5-101, et. seq. If Contractor has any employees or
subcontractors, Contractor shall comply with C.R.S. 8-17.5-101, et. seq., and this
Agreement. By execution of this Agreement, Contractor certifies that it does not knowingly
employ or contract with an undocumented individual who will perform under this Agreement
and that Contractor will participate in the E-verify Program or other Department of Labor and
Employment program (“Department Program”) in order to confirm the eligibility of all
employees who are newly hired for employment to perform Services under this Agreement.
a. Contractor shall not:
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i. Knowingly employ or contract with an undocumented individual to
perform Services under this Agreement; or
ii. Enter into a subcontract that fails to certify to Contractor that the
subcontractor shall not knowingly employ or contract with an undocumented individual to
perform work under the public contract for services.
b. Contractor has confirmed the employment eligibility of all employees who are
newly hired for employment to perform Services under this Agreement through participation in
the E-Verify Program or Department Program, as administered by the United States Department
of Homeland Security. Information on applying for the E-verify program can be found at:
https://www.uscis.gov/e-verify
c. Contractor shall not use either the E-verify program or other Department Program
procedures to undertake pre-employment screening of job applicants while the public contract for
services is being performed.
d. If Contractor obtains actual knowledge that a subcontractor performing work under
the public contract for services knowingly employs or contracts with an undocumented individual,
Contractor shall be required to:
i. Notify the subcontractor and County within three (3) days that Contractor
has actual knowledge that the subcontractor is employing or contracting with an undocumented
individual; and
ii. Terminate the subcontract with the subcontractor if within three days of
receiving the notice required pursuant to subparagraph (i) of the paragraph (d) the subcontractor
does not stop employing or contracting with the undocumented individual; except that Contractor
shall not terminate the contract with the subcontractor if during such three (3) days the
subcontractor provides information to establish that the subcontractor has not knowingly employed
or contracted with an undocumented individual.
e. Contractor shall comply with any reasonable request by the Department of Labor
and Employment made in the course of an investigation that the department is undertaking
pursuant to its authority established in C.R.S. 8-17.5-102(5).
f. If Contractor violates these prohibitions, County may terminate the Agreement for
breach of contract. If the Agreement is so terminated specifically for breach of this provision of
this Agreement, Contractor shall be liable for actual and consequential damages to County as
required by law.
g. County will notify the Colorado Secretary of State if Contractor violates this
provision of this Agreement and County terminates the Agreement for such breach.
[REST OF PAGE INTENTIONALLY LEFT BLANK]
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IN WITNESS WHEREOF, the parties have executed this Agreement the day and year first set
forth above.
COUNTY OF EAGLE, STATE OF COLORADO,
By and Through Its COUNTY MANAGER
By: ______________________________
Jeff Shroll, County Manager
CONTRACTOR:
By:________________________________
Print Name: _________________________
Title: ______________________________
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Owner
Benjamin Barron
10
EXHIBIT A
SCOPE OF SERVICES AND FEES
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Eagle County Building/Old Court House/Attorney Annex
500 Broadway
Eagle, CO 81631
Exhibt A - Scope of Services and Fees
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MSC Complex
3289 Cooley Mesa
Gypsum, CO 81637
Exhibt A - Scope of Services and Fees
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Senior Center/Golden Eagle Apartments/Seniors on Broadway
715 Broadway Street
Eagle, Co 81631
Exhibt A - Scope of Services and Fees
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Special Pavement Marking Examples
1. Handicap Accessible Symbols
2. Pedestrian Symbol
Exhibt A - Scope of Services and Fees
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3. Crosswalk
Exhibt A - Scope of Services and Fees
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2022 Parking Lot Asphalt Pavement Maintenance Estimated Quantities
Parking Lot Location Number of Phases Seal Coat Surface (square feet) Crack Seal (linear feet) Striping (linear feet)
Special Pavement Markings
Seniors on Broadway Eagle 2 18,000 1,000 2,000 5 handicap accessible symbols
Maintenance S Complex Gypsum 4-5 219,200 10,000 5,000 5 handicap accessible symbols
Old Court House
Eagle 1-2 55,400 2,000 5,000 6 handicap accessible symbols
4 pedestrian symbols
4 crosswalks
Eagle County Building
Attorney Annex
Unit Pricing
Item
Lump Sum based
on Estimated
Quantities Unit Price Unit
Seal Coat (single coat)$51,823.00 $0.189 square foot
Crack Seal $9,629.00 $0.802 linear foot
Striping/Special Markings $7,794.00 $0.779 linear foot
Note: Seniors on Broadway is to be completed as warranty work and is not included in lump sum estimate or unit pricing.
Exhibt A - Scope of Services and Fees
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EXHIBIT B
INSURANCE CERTIFICATE
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1001486 132849.13 04-22-2020
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
INSURER(S) AFFORDING COVERAGE
INSURER F :
INSURER E :
INSURER D :
INSURER C :
INSURER B :
INSURER A :
NAIC #
NAME:
CONTACT
(A/C, No):
FAX
E-MAIL
ADDRESS:
PRODUCER
(A/C, No, Ext):
PHONE
INSURED
REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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).
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.
OTHER:
(Per accident)
(Ea accident)
$
$
N / A
SUBR
WVD
ADDL
INSD
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.
$
$
$
$PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person)
COMBINED SINGLE LIMIT
AUTOS ONLY
AUTOSAUTOS ONLY
NON-OWNED
SCHEDULEDOWNED
ANY AUTO
AUTOMOBILE LIABILITY
Y / N
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below
If yes, describe under
ANY PROPRIETOR/PARTNER/EXECUTIVE
$
$
$
E.L. DISEASE - POLICY LIMIT
E.L. DISEASE - EA EMPLOYEE
E.L. EACH ACCIDENT
ER
OTH-
STATUTE
PER
LIMITS(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
POLICY EFF
POLICY NUMBERTYPE OF INSURANCELTR
INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EXCESS LIAB
UMBRELLA LIAB $EACH OCCURRENCE
$AGGREGATE
$
OCCUR
CLAIMS-MADE
DED RETENTION $
$PRODUCTS - COMP/OP AGG
$GENERAL AGGREGATE
$PERSONAL & ADV INJURY
$MED EXP (Any one person)
$EACH OCCURRENCE
DAMAGE TO RENTED
$PREMISES (Ea occurrence)
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
JECT LOC
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
06/03/2022
Randy Bales State Farm
6452 S Quebec St.
Centennial, CO 80111
Randy Bales
303-985-3276
Randy.bales.twuk@statefarm.com
Sun-Up Sealcoats, LLC
2802 Shepherd Rdg
Avon, CO 81620
25143
A
1,000,000
300,000
5,000
2,000,000
2,000,000
2,000,000
A
496 3776-E17-06 05/17/2022 11/17/2022
250,000
500,000
100,000
A Y 96-EL-R932-6 11/17/2021 11/17/2022 100,000
100,000
500,000
The automobile and general liability policies endorsed to include Eagle County, its associated or affiliated entities, ISAOA, elected officials, employees,
agents and volunteers as additional insureds.
Eagle County Government
500 Broadway
Eagle, CO 81631
State Farm Fire and Casualty Company
96-EL-R936-5 11/17/2021 11/17/2022
496 3777-E17-06
525 5086-E17-06
525 5087-E17-06
05/17/2022
05/17/2022
05/17/2022
11/17/2022
11/17/2022
11/17/2022
Completed by an authorized State Farm representative. If signature
is required, please contact a State Farm agent.
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