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PREVIOUS CONTRACT NO. H-9-03-242-B1 BID NO. H-Z-05-376-B1
ATTACHMENT "L"
CERTIFICATION OF VENDORS PROVIDING
BENEFITS FOR DOMESTIC PARTNERS
The undersigned vendor hereby certifies that its employee benefits policies are in compliance with Broward County Ordinance #1999-03, as
amended by Broward County Ordinance #1999-18, as follows:
A. Vendor's employee benefits program includes the following minimum standards:
1. Any vendor's employee who is a party to a domestic partnership relationship is entitled to elect insurance coverage for his
or her domestic partner or a dependent of such domestic partner on the same basis in which any other vendor's employee
may elect insurance coverage for his or her spouse or dependents. A vendors employee's right to elect insurance
coverage for his or her domestic partner, or the partner's dependent, extends to all forms of insurance provided by the
vendor to the spouses and dependents of vendor's employees.
2. Any vendor's employee who is a party to a domestic partnership relationship is entitled to use all forms of leave provided
by the vendor including, but not limited to sick leave and annual leave to care for his or her domestic partner or the
dependent of the domestic partner as applicable.
3. All other benefits available to the spouses and dependents of vendor's employees are made available on the same basis
to the domestic partner, or dependent of such domestic partner, of a vendor's employee who is party to a domestic
partnership relationship.
4. It is within the vendor's discretion as to what benefits are provided to its employees and whether vendor's employees who
are party to a domestic partnership relationship must be registered in accordance with Broward County Ordinance No.
1999-03, as amended, in order to be eligible for access to employee benefits.
The vendor's domestic partnership eligibility criteria are substantially equivalent to the following:
1. Each domestic partner is at least 18 years old and competent to contract.
2. Neither domestic partner is married nor a partner to another domestic partnership relationship.
3. The domestic partners are not related by blood.
4. Consent of either domestic partner to the domestic partnership relationship has not been obtained by force, duress, or
fraud.
5. Each domestic partner agrees to be jointly responsible for each other's basic food and shelter.
(Vendor signature)
(Print vendor name)
STATE OF
COUNTY OF
The foregoing instrument was acknowledged before me this day of
by as
(Name of person whose signature is being notarized) (Title)
of , known to me to be the person described
(Name of corporation/entity)
herein, or who produced as identification, and who did/did not take an oath.
(Type of identification)
NOTARY PUBLIC:
(Signature)
(Print name)
State of at Large (SEAL)
My commission expires:
GRMC-PB 12-2005
2/16/06
Page 82 of 84
PREVIOUS CONTRACT NO. H-9-03-242-B1 BID NO. H-Z-05-376-B1
•
ATTACHMENT "M"
SUPPLEMENTAL TO BID/TENDER FORM
TRENCH SAFETY ACT
THIS FORM MUST BE SUBMITTED WITH BID FOR BID TO BE DEEMED
RESPONSIVE
On October 1, 1990 House Bill 3181, known as the Trench Safety Act became law. This incorporates the Occupational
Safety & Health Administration (OSHA) revised excavation safety standards, citation 29 CFR.S.1926.650, as Florida's own
standards.
The Bidder, by virtue of the signature below, affirms that the Bidder is aware of this Act, and will comply with all applicable
trench safety standards. Such assurance shall be legally binding on all persons employed by the Bidder and
subcontractors.
The Bidder is also obligated to identify the anticipated method and cost of compliance with the applicable trench safety
standards.
BIDDER ACKNOWLEDGES THAT INCLUDED IN THE VARIOUS ITEMS OF THE PROPOSAL AND IN THE TOTAL BID
PRICE ARE COSTS FOR COMPLYING WITH THE FLORIDA TRENCH SAFETY ACT. THESE ITEMS ARE A
BREAKOUT OF THE RESPECTIVE ITEMS INVOLVING TRENCHING AND WILL NOT BE PAID SEPARATELY. THEY
ARE NOT TO BE CONFUSED WITH BID ITEMS IN THE SCHEDULE OF PRICES, NOR BE CONSIDERED
ADDITIONAL WORK.
The Bidder further identified the costs and methods summarized below:
Description
Unit
Quantity Unit Price Extended Method
Total
$ 1 ccc> )-
IN ORDER TO BE CONSIDERED RESPONSIVE. THE BIDDER MUST COMPLETE* THIS FORM, SIGN AND SUBMIT
IT WITH THEIR BID DOCUMENT.
WEEKLEY ASPHALT PAVING, INtr
Name of Bidder
Au
DANIEL D.
*COMPLETION REQUIRES FILLING IN THE APPROPRIATE DETAILS UNDER THE HEADI
ature of Bidder
stoNT
UNIT, QUANTITY, UNIT PRICE, EXTENDED, AND METHOD.
GRMC-PB12-2005
2/16/06 Page 83 of 84
•
PREVIOUS CONTRACT NO. H-9-03-242-B1
ATTACHMENT "N'
BID NO. H-Z-05-376-B1
Insurance Request to provide Maintenance, Installation, and Repair Services for Roadway Systems
The following coverages are deemed appropriate for minimum insurance requirements for this project and will be required of the selected
firm and identified in the negotiated agreement. Any deviation or change during the contract negotiation period shall be approved by Risk
Management.
TYPE OF INSURANCE Urafts aril.labffity, in Thousands of i:iolifarfi
Each Occurrence Aggregate
GENERAL LIABILITY
[x ] Commercial General Liability
[x ] Premises -Operations
[x J Explosion & Collapse Hazard
[x) Underground Hazard
(x ] Products/Completed Operations Hazard
[x j Contractual Insurance
[x ] Broad Form Property Damage
(x j Independent Contractors
[ j Personal Injury
Bodily Injury
Property Damage
Bodily Injury and
Property Damage
Combined
$1,000K
$1,000K
Personal Injury
AUTO LIABILITY
[X ] Comprehensive Form
(X j Owned
[X 1 Hired
[X j Non -owned
[X ] Any Auto If applicable
Bodily Injury (each
person)
Bodily Injury (each
accident)
Property Damage
Bodily Injury and
Property Damage
Combined
$500K
EXCESS LIABILITY/UMBRELLA
[ ] Umbrella Form
[ j Other than Umbrella Form
Bodily Injury and
Property Damage
Combined
$
[ x] WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY (NOTE ")
jx) STATUTORY
(each accident)
$10OK MIN
[) PROFESSIONAL LIABILITY - E6tO
Max. Ded. $
VENDOR RESPONSIBLE
FOR DEDUCTIBLE
[ ] PROPERTY COVERAGE J BUILDERS RISK
INCLUDE WIND AND FLOOD INS.
Max. Ded. $
VENDOR RESPONSIBLE
FOR DEDUCTIBLE
Applicable to construction
Agreed value
Replacement Cost
[X) If project greater than $1 Ok - installation
floater required for replacement of material,
equipment, installation. All risk, agreed
value. Otherwise, contractor will be
responsible for tools, materials, equipment,
machinery etc, until completion, acceptance
by County and County takes possession.
Maximum Deductible
$ 1OK deductible
Agreed value
Each Claim
VENDOR RESPONSIBLE
FOR DEDUCTIBLE
DoscrvIon or Operations/LocationsNeniUes Certificate must show on general liability and excess liability Additiona Insured: Broward
County Board of County Commissioners, Broward County, Florida. Also when applicable certificate should show
B.C.B.C.0 as a named insured for property and builders risk and as a Toss payee for installation floater when
coverage's are required. Certificate Must be Signed and All applicable Deductibles shown. Indicate bid number, RLI,RFp,
and project manager nn COI.
NOTE' - If the Company is exempt from Workers' Compensation Coverage, please provide a letter on company letterhead or a copy of the
State's exemption which documents this status and attache to the Certificate of Insurance for approval. If any operations are to be
undertaken on or about navigable waters, coverage must be included for U.S. Longshoremen & Harbor Workers' Act/ & Jones Act
CANCELLATION: Thirty (30) Day written notice of cancellation required to the Certificate Holder:
Darlene S. George / Daniel F. Clark
Risk Manage nt Division
1 /26/
Narm a Addrersv of Certlticata Molder
Broward County•Board of. County COMMissioners
Pur.ctiastng Dtvisio , RM 2.12
115: SotutkAndrews Avec(lae;
Fort:Laucierdale:'FL 3 3O1
RE: (Bid MZ 78=B.14:`AA: Potter..:: Purchasing) ...
insurence.imtivForm.03 Ravisetl ceni!vateormsrevised2005. DOC COI
Date Issued
GRMC-PB12-2005
2/16/06
Page 84 of 84