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HomeMy WebLinkAbout604016 SHACHTMAN STUDIOS INC - CONTRACT - AGREEMENT MISC - SHACHTMAN STUDIOS INC (2)1 ART IN PUBLIC PLACES CONSTRUCTION AGREEMENT Fossil Creek Trail Project THIS AGREEMENT is made and entered into this 3rd day of December, 2018, by and between THE CITY OF FORT COLLINS, COLORADO, a municipal corporation (hereinafter referred to as “the City”), and SHACHTMAN STUDIOS INC., (hereinafter referred to as “Artist.”) In consideration of the mutual covenants and obligations described below, the parties agree as follows: 1. Scope of the Work. The Artist must furnish all of the materials and perform all of the work for the Fossil Creek Trail Project as shown on the drawings and described in the specifications attached as Exhibit “A” and incorporated by reference into this Agreement (the “Project”). The Project generally consists of the design, fabrication, signage, and installation of a stone sculpture. The Artist’s work must be of high quality, in compliance with generally accepted standards of workmanship, and in conformity with this Agreement. 2. Time of Completion. The City will issue a Notice to Proceed. Artist must begin the Project promptly upon receiving the Notice to Proceed and must fully complete the Project by May 20, 2019. Any extensions of this time limit must be agreed to in writing by the parties. The City will grant the Artist a reasonable extension of time if the City is delayed in performing its obligations or if conditions beyond the Artist’s control or Acts of God make it impossible for the Artist to perform on schedule. 3. Capital Project Management Control System. To insure the Project is consistent with its authorized scope and schedule, the Artist must provide an approximate schedule for completing all unit work items covered by the Agreement. The schedule must show the anticipated percentage completion of each unit work item for each week of the Project. The Artist must submit the initial schedule to the City prior to beginning the work. 4. City Representative. On or before the date the City issues its Notice to Proceed the City will designate its project representative who will make all necessary and proper decisions regarding the Project within the scope of his or her authority. The Artist must direct all requests for contract interpretations, change orders, or other clarification or instruction to the City representative. 5. Changes to Scope of Work. A. Changes by Artist. The Artist cannot change the Project specifications and drawings in Exhibit “A” without advance written approval from the City. B. Changes by the City. The City may request changes in the design and construction of the Project through written Change Order Requests. The Artist and the City will then negotiate in good faith to reach agreement on any necessary changes in price or scheduling. Once the parties have reached agreement, the City will issue a written Change Order documenting the agreed upon terms. The Artist must not proceed with work related to the requested change until the City issues the Change Order. 6. Formal Acceptance and Ownership of the Project. The Artist must notify the City when the Project is fully installed and complete. No more than thirty (30) days after receiving such notice, the City will provide the Artist a written response, informing the Artist that either: DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 2 (1) the City agrees the Project is fully installed and is complete consistent with the terms of this Agreement, all other related work is completed in accordance with this Agreement, and the City formally accepts the Project as completed (“Letter of Acceptance”); or (2) the City does not consider the Project to be completed due to unresolved issues or defects that remain, and describing the outstanding issues or defects that the Artist must cure before the City will issue a Letter of Acceptance. The Project is not finally complete for purposes of this Agreement until the City has issued a Letter of Acceptance. Once the City has issued a Letter of Acceptance the City will be the sole owner of the Project, and the Artist will have no further obligations under this Agreement, except as set forth in paragraphs 8, 9, 12, and 26. 7. Ownership of Works Created. A. Assignment of Copyright. The Artist hereby assigns, transfers, and conveys to the City all right, title and interest in and to the Project together with the copyright therein and the right to secure copyright registration therefore, in accordance with Sections 101, 204, and 205 of Title 17 of the United States Code, the Copyright Law of the United States. This assignment, transfer and conveyance includes, without limitation, any and all features, sections, and components of the Project, any substantially similar works, the United States and worldwide copyrights therein, and any renewals or extensions thereof, and any and all other rights that the Artist now has or to which the Artist may become entitled under existing or subsequently enacted federal, state, or foreign laws, including, but not limited to the following rights: to reproduce, publish, and display the Project publicly, to prepare derivative works of and from the Project, to combine the Project with other materials, and to otherwise exploit and control the use of the artwork. As additional consideration for this assignment, the City agrees that all reproductions of the artwork by the City shall credit the Artist. B. Exceptions. Notwithstanding the assignment of rights described in paragraph A., the City agrees that it may not alter the artwork and represent it as the Artist’s work without the Artist’s permission. In addition, the City will not, nor will it license others to, make three dimensional reproductions of the artwork without obtaining the consent of the Artist, and negotiating additional compensation to the Artist in good faith. C. License Back to Artist of Certain Rights. The City hereby grants to Artist the following rights in and to the Project: the non-exclusive right to make two-dimensional reproductions of the artwork for any promotional purpose, provided that any such reproduction clearly states the location of the Project, acknowledges the City and the Art in Public Places Program, and contains a copyright notice. With the exception of publicity pieces, the Artist must not knowingly permit others to make reproductions of the artwork for commercial purposes without the written permission of the City. D. Rights under the Visual Artists’ Rights Act. To the extent the uses or removal of the Project under this Contract affect any rights Artist may have under the provisions of federal or state law, including the 1990 Visual Artists’ Rights Act, the Artist hereby knowingly waives any rights of preservation of the Project provided by those laws DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 3 8. Guarantee of Workmanship and Material. For a period of three (3) years from the date of the City's Letter of Acceptance, Artist agrees to replace or correct any material defects in the Project, whether caused by defects in the design, workmanship or materials used in the Project. If Artist fails to replace or correct any such defects, or to make arrangements to do so within a reasonable time satisfactory to the City, the City has the right to arrange for such replacement or correction, and Artist must reimburse the City for the costs of any such replacement or correction. If the City asks Artist to repair damage caused to the Project by vandalism, collision, extreme environmental conditions, or other unforeseeable causes, the City will reimburse Artist for reasonable material and labor costs for such repairs, except to the extent such damage is due to a defect in design, workmanship or materials used in the Project. 9. Maintenance. Artist must provide to the City written instructions for maintenance of the Project, including detailed information on the operation, care, maintenance and repair of the Project, as well as a digital images depicting a total of at least eight views of the completed Project. Artist will also provide, at no charge to the City, continuing advice regarding the operation, care, maintenance and repair of the Project, as needed. Additional services above and beyond this amount will be negotiated and agreed to in writing by the parties. 10. Contract Sum. The City will pay Artist for the performance of this Contract, subject to additions and deletions provided herein, Forty-Six Thousand, Five Hundred and Forty-Six Dollars ($46,546) for time, materials, Artist’s commission and related project costs, on the following schedule: A. $23,275 upon full execution of this Agreement; B. $11,636 upon completion of half of the sculptural sphere on site; C. $6,981 upon delivery and installation of all art components; C. $4,654 or any remaining amounts due under this Agreement, upon the City's final approval and acceptance of the Project as complete and receipt of a lien waiver from the Artist in substantially the form shown on Exhibit B. City will not make final payment until it has received satisfactory maintenance instructions and photographs as described in Section 9 and lien waivers in a form acceptable to the City from any and all subcontractors that have performed work or provided materials in connection with the Project. 11. Failure to Complete. If Artist becomes ill, dies, or is otherwise unable or unwilling to complete the Project in accordance with the Agreement, any work already done on the Project will be the City’s property. The City will be entitled to withhold any sums not yet paid to Artist and may use any such sums toward completion of the Project in any manner the City deems appropriate. 12. Project as Unique. Artist represents and warrants that the Project is artistically unique and agrees not to create or be involved in the creation of an identical or substantially similar artwork within 150 miles of Fort Collins, Colorado. 13. Liquidated Damages. The parties agree the City will suffer certain unspecified damages if the Project is not completed within the time set forth above, as adjusted for any delays DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 4 agreed upon by the parties pursuant to Section 2. Recognizing the difficulty of ascertaining the actual damages sustained by the City, the parties agree that the assessment of liquidated damages is appropriate. If the Project is not completed within the specified time, Artist authorizes the City to retain from any monies due the Artist, the sum of Two Hundred and Fifty Dollars ($250) per day for each and every calendar day the Project remains unfinished. Liquidated damages will be capped at Five Thousand Dollars ($5,000). 14. Governing Law. This Agreement is governed by the laws of the State of Colorado. 15. Notice. Any notice or other communication given by either party to the other related to this Agreement must be hand delivered; sent by a commercial carrier; or sent by mail, addressed to the party at its address as set forth below. The notice or other communication will be effective on the date it is delivered or on the third business day after being sent, whichever comes first. If to the Artist: If to the City: SHACHTMAN STUDIOS INC., Ellen Martin STEPHEN SHACHTMAN Lincoln Center 1025 Cimmeron Dr. 417 West Magnolia Loveland, CO 80537 Fort Collins, CO 80521 16. Termination/Default. A. Termination. The City may terminate this Agreement on no less than seven (7) days written notice to the Artist. The City will compensate Artist for all services performed to the date Artist receives the notice of termination, together with reasonable expenses then due, unless the parties agree otherwise in writing. B. Default. Each and every term and condition of this Agreement is deemed to be a material element of this Agreement. If either party fails or refuses to perform according to the terms of this Agreement, it may be declared in default thereof. If Artist defaults or neglects to carry out the work in accordance with this Agreement, the City may elect to make good such deficiencies and charge Artist therefor. C. Remedies Upon Default. If one party declares the other in default of this Agreement and performance is possible within the completion time established herein, the defaulting party has a period of five (5) days within which to cure the default. If the defaulting party fails to correct the default (or timely performance is not possible), the party declaring default may elect to: (1) immediately terminate the Agreement; (2) treat the Agreement as continuing and require specific performance; and/or (3) avail itself of any other remedy at law or equity. If either party elects to terminate the agreement for default, termination will be effective upon the mailing, by the terminating party, of written notice of termination to the defaulting party. D. Attorneys Fees. If the non-defaulting party must commence legal or equitable action against the defaulting party to enforce the terms of this Agreement, the defaulting party is liable to the non-defaulting party for the non-defaulting party’s reasonable legal fees, including attorney’s fees, incurred because of the default. DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 5 17. Assignment. Artist understands that the City enters into this Agreement based on the special abilities of Artist and that the City considers this Agreement to be an agreement for personal services. Accordingly, Artist must neither assign any responsibilities nor delegate any duties arising under this Agreement without the prior written consent of the City. 18. Artist -- Independent Agent. The Artist performs all work under this Agreement as an independent agent and is not an agent of the City, nor are the Artist's Subcontractors or employees subagents of the City. 19. License and Business. The Artist must hold, in the Artist's name, all necessary licenses and permits to perform the work. The Artist must have full authority to do business in the State of Colorado, and have a designated place of business for making and accepting communications with or from the City. The Artist must maintain a current address and telephone number with the City throughout the term of this Agreement. 20. Superintendence. Before starting work the Artist must designate an authorized representative who has complete authority to represent and act for the Artist. The Artist must keep competent supervisory personnel on the work during its progress and provide efficient supervision of the work, using Artist’s best skill and attention. The Artist is solely responsible for all construction means, methods, techniques, and procedures, and for providing adequate safety precautions and coordinating all portions of the work. 21. Employees. The Artist must employ only competent, skillful workers to do the work. Whenever any person employed by the Artist appears to be incompetent or acts in a disorderly or improper manner, the Artist must promptly remove such person from the work. 22. Subcontractors. The Artist may use subcontractors to complete the fabrication, transportation and/or installation of the Project, under Artist’s direction and supervision. The Artist must, within fifteen (15) days of the effective date of this Agreement, submit to the City the names of all subcontractors Artist intends to use for the work. The Artist must not employ any subcontractors that the City, in its discretion, objects to as lacking the capability to properly perform work of the type and scope intended for the Project. The Artist is as fully responsible to the City for the acts and omissions of Artist’s subcontractors and of persons either directly or indirectly employed by them as for the acts and omissions of persons directly employed by Artist. Nothing contained in the contract documents creates any contractual relation between any subcontractor and the City, except to the extent the City is indemnified or insured through requirements upon said subcontractor. If Artist uses subcontractors, the City may, in its discretion, require the submission of lien waivers in a form reasonably acceptable to the City by any such subcontractors prior to final payment to the Artist. 23. Prosecution of the Work. The time of beginning, rate of progress, and time of completion of the work are the essence of this Agreement. The Artist must do the work at such time, and in such order, as will result in successful completion of the Project during the time specified in the Agreement and the approved construction schedule. The Artist must furnish tools and equipment for the Project in sufficient quantity and of a capacity and type that will safely perform the work specified without delay in the progress of the work. DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 6 24. Safety. The Artist is solely responsible for maintaining a safe work area and protecting the safety and welfare of Artist’s employees and subcontractors, and the general public, including without limitation area residents, motorists, bicyclists, pedestrians, and children, from work area hazards. The Artist must provide all work area safety control devices, at Artist’s cost, including, for example, barricades and safety fences around excavations and drop-offs. The Artist’s safety precautions must be in compliance with all applicable laws, rules and regulations. 25. Work and Property. The Artist must use best efforts at all times during Artist’s work on the Project to safely guard the Project, the City's property and adjacent property, including underground utilities, from damage, injury or loss in connection with the Project. The Artist must provide and maintain all passageways, guard fences, lights, and other facilities required for property protection by state or municipal laws and regulations and location conditions during Artist’s work on the Project. The Artist must protect the Project and related materials from damage due to the nature of the work, the elements, carelessness of the Artist, or from any foreseeable cause whatever until the completion and acceptance of the Project by the City. The Artist assumes all risk of loss or damages arising out of the nature of the work to be done under this Agreement, or from any unforeseen obstructions or defects that may be encountered in the prosecution of the work, or from the action of the elements or other damage, except damage proximately caused by the City, its employees, agents or other contractors, until final acceptance of the Project by the City 26. Indemnity. The Artist indemnifies and holds harmless the City, its officers, agents and employees, from and against all claims, damages, losses, expenses, and legal fees including attorney’s fees, arising out of or resulting from the negligence or fault of Artist, its subcontractors, agents or employees in the performance of this Agreement. In any and all claims against the City, or any of its officers, agents, or employees by any employee, subcontractor or agent of the Artist, the Artist’s indemnification obligation are not limited in any way by any limitation on the amount or type of damages, compensation, or benefits payable by or for the Artist or any subcontractor under Workmen's Compensation laws, Disability Benefit laws, or other employee benefit laws. 27. Insurance and Liability. The Artist must provide or, in lieu of personally providing, must require all Subcontractors providing services in connection with this Agreement to provide, from insurance companies acceptable to the City, the insurance coverage designated below, and pay all costs for such coverage, before commencing work under this Agreement. The Artist must furnish the City with certificates of insurance as specified herein showing the type, amount, class of operations covered, effective dates, and date of expiration of policies, and containing substantially the following statement: “The insurance covered by this Certificate will not be canceled or materially altered, except after ten (10) days written notice has been received by the Owner, the City of Fort Collins.” In case of the breach of any provision of this Section, the City, at its option, may take out and maintain such insurance at the Artist’s expense. DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 7 The Artist must not commence work under this Agreement until all the insurance required hereunder has been reviewed by the City and the Artist has provided an acceptable certificate of insurance to the City. The Artist, or in lieu thereof, all Subcontractors of Artist, must maintain during the life of this Agreement the Worker's Compensation Insurance required by state statute and, in addition, Employer’s Liability Insurance in an amount not less than $400,000 for each occurrence, for all of Artist’s employees, if any, to be engaged in work on the Project under this Agreement. The Artist and all Subcontractors of Artist must maintain during the life of this Agreement commercial general liability insurance sufficient to provide coverage for claims for damages for personal injury, including accidental death, as well as for claims for property damage, which may arise directly or indirectly from performance of the work under this Agreement. Coverage for property damage must be on a “broad form” basis. Amount of insurance to be provided must be not less than $300,000 combined single limits for bodily injury and property damage. The Artist is responsible for any liability directly or indirectly arising out of the work performed under this Agreement by a subcontractor, to the extent that liability is not covered by the Subcontractor's insurance. The Artist's and any subcontractor’s insurance policies required under this Agreement must name the City as an additional insured for any claims arising out of work performed under this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year first above written. THE CITY OF FORT COLLINS, COLORADO, A municipal corporation BY: _______________________________ Gerry Paul Purchasing Director ATTEST: ______________________________ APPROVED AS TO FORM: ______________________________ ARTIST: SHACHTMAN STUDIOS INC., A Colorado corporation BY: ____________________________________ Stephen Shachtman, President DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 Senior Assistant City Attorney City Clerk 8 EXHIBIT “A” DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 9 DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 10 DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 11 DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 12 The City of Fort Collins will install the foundation for the sculpture. DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 13 DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 14 Budget: Engineering: $3,000.00 30hours, engineered drawings and calculations Cad design for Templates $1,250.00 Design of the templates for stone sections Design of the templates for all foundation, barring, inner rings & top plate Material $33,000.00 23,000lbs of stone, Steel plate, Concrete 10,000lbs of Pea gravel, Fasteners, Epoxy, epoxy dispenser, consumables, infrastructure Renting equipment, tools. Miscellanies Labor $9,046.00 Shop work/prep, Site prep, site work, unloading stone by hand, stone stacking by hand, stone grinding, welding, steel grinding, drilling, shoveling gravel, fastening, site teardown Insurance $250.00 Total $46,546 Artist will need APP approval on access to the site prior to start of the installation. DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 15 EXHIBIT B SAMPLE LIEN WAIVER RELEASE (ARTIST) TO: City of Fort Collins, Colorado (OWNER) FROM: SHACHTMAN STUDIOS INC., PROJECT: Fossil Creek Trail Project 1. The ARTIST acknowledges having received payment, except final payment, from the OWNER for all work, labor, skill and material furnished, delivered and performed by the ARTIST for the OWNER or for anyone in the construction, design, improvement, alteration, addition or repair of the above described project. 2. In consideration of such payment and upon receipt of full and final payment, the ARTIST voluntarily waives all rights, claims and liens, including but not limited to, mechanic’s notices, equitable liens and labor and material bond rights which the ARTIST may now or may afterward have, claim or assert for all and any work, labor, skill or materials furnished, delivered or performed for the construction, design, improvement, alteration, addition or repair of the above described project, against the OWNER or its officers, agents, employees or assigns, against any fund of or in the possession or control of the OWNER, against the project or against all land and the buildings on and appurtenances to the land improved by the project. 3. The ARTIST affirms that all work, labor and materials, furnished, delivered or performed to or for the construction, design, improvement, alteration, addition or repair of the project were furnished, delivered or performed by the ARTIST or ARTIST’s agents, employees, and servants, or by and through the ARTIST by various Subcontractors or material men or their agents, employees and servants and further affirms the same have been paid in full and have released in full any and all existing or possible future mechanic’s liens or rights or claims against the project or any funds in the OWNER’S rights or control concerning the project or against the OWNER or its officers, agents, employees or assigns arising out of the project. 4. The ARTIST agrees to defend and hold harmless the OWNER, the lender, if any, and the Surety on the project against and from any claim hereinafter made by the ARTIST’S Subcontractors, material men, employees, servants agents or assigns against the project or against the OWNER or its officers, employees, agents or assigns arising out of the project for all loss, damage and costs, including reasonable attorneys fees, incurred as a result of such claims. 5. The parties acknowledge that the description of the project set forth above constitutes an adequate description of the property and improvements to which this Lien Waiver Release pertains. It is further acknowledged that this Lien Waiver Release is for the benefit of and may be relied upon by the OWNER, the LENDER, if any, and Surety on any labor and material bonds for the project. DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 16 Signed this __________ day of __________, 20___. ______________________________ ARTIST STATE OF COLORADO ) ) ss. COUNTY OF LARIMER ) Subscribed and sworn to before me this __________ day of __________, 20__, by ___________________________________ Witness my hand and official seal. My Commission Expires: ______________________________ ______________________________ Notary Public DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 WLTR005 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 November 5, 2018 Ellen Martin City of Fort Collins PO BOX 580 FORT COLLINS CO 80522-0580 Account Information: Policy Holder Details : STEVE SHACHTMAN STUDIOS INC Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (888) 242-1430 Fax: (888) 443-6112 Email: agency.services@thehartford.com Website: https://business.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 11/05/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS 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 USAA INSURANCE AGENCY INC/PHS 65812846 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO, TX 78265 CONTACT NAME: PHONE (A/C, No, Ext): (888) 242-1430 FAX (A/C, No): (888) 443-6112 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED STEVE SHACHTMAN STUDIOS INC 1025 CIMMERON DR LOVELAND CO 80537-4315 INSURER A : The Hartford Casualty Insurance Company 29424 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A COMMERCIAL GENERAL LIABILITY 65 SBA IL2832 09/18/2018 09/18/2019 EACH OCCURRENCE $2,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $300,000 X General Liability X MED EXP (Any one person) $10,000 COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION REJECTION OF COYERAGE BY CORPORATE OFFICERS OR MEMBERS OF A LIMITED LIABILITY COMPANY (LLC) PART A 1. Type of Entity f; Corporation O Limited Liability Company (LLC) 2.Inc Shachtman Studios J. Name of Corporation or LLC MailingAddress 1025 Cimmeron Dr Street or P.O. Box, UniVSuite Loveland 80537 State 4. Nature of Business Public Art Federal Employer Identification Number 20-8530154 6. Business Phone 585'313'1347 Date of Incorporation or Organization March 1 2007 8. State of Incorporation or Organization CO Corporate Officers or LLC Members RejectingCoverage: City Zip 5. 7. 9. First Middle Name Last Stephen Joseph Shachtman Sufrix (Jr., Sr., III) Percent of Ownership/ Member Interest 100 L;bG) Owner 10. Number of employees of the business other than the offtcers or members listedabove: 11A. Does your company have workers'compensation insurance? O Yes O No 1lB. If you answered ooYes" to Question 11A, please include your workers' compensation policy information below and submit this completed form directly to your carrier. If you answered "No" to Question 1lA, please submit this completed form directly to the Cdlorado Division of Workers' Compensation. a. Insurance carrier name b. PolicyNumber c. Effective Dates F 12. Certification: I, Stephen Shachtman , in my capacity as Corporate Secretary or LLC Managerof Name of Corporate Secretary or LLC and To Inc Name of Corporation is correct and complete. ttf r f t-"tr Signature orLLC Manager Date C.R.S. Section 10-1-128(6Xa) states: clt is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies." COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION REJECTION OF COVERAGE BY CORPORATE OFFICERS OR MEMBERS OF A LIMITED LIABILITY COMPANY (TLC) PART B - Corporate Oflicer or LLC Member Questionnaire IMPORTANT: A separate Part B MUST be completed byegery person listed in Part A. l. 2. Name of Corporation or LLC MailingAddress Shachtman Studios Inc 1025 Cimmeron Dr Loveland Street or P.O. Box, Unit/Suite co 80537 City Joseph Middle State Shachunan zip 3. Officer or MemberName Steohen 4. Corporate Officer Title-.lOwner NohrY Public Stato ol Colorado Notary lD 201140?5310 -^.- utt co*niit-sion irPitet Juffi My commission expire s e74/a. First Last Suffx (Jr., Sr.,III) 585-313-1437 7. 8. 5. Business Phone 6. Date Officer/lvlemberElected March 12007 Duties performed for Corporation or LLC Mark ONE thatApplies: Desiener. fabricator. installation I hereby elect to reject workers' compensation insurance coverage based on C.R.S. $ 8-41-202 (Non- agricultural). By signing this form, you are acknowledging your rejection of all benefits under the Workers' Compensation Act and that if you are hurt on the iob, C.R.S. $ &41-401(3) may limit your recovery to $15,fi)0. You are further acknowledging that you are an owner ofat Ieast 107o ofthe stock ofthe corporation or at least 107o ofthe membership interest of the LLC at all times, and control, supervise or manage the business affairs of the corporation or LLC. The election to rejectworkers'compensation insurance as a corporate officerlLLC member rnust be voluntary and cannot be a condition of your employment E Iherebyrescind filed rejection of coverage. Member Signature 9. Notary: If this form is being filed with the Division of Workers' Compensation, the signature of the individual corporate officer or LLC member completing Part B must be notarized. If this form is beingfiled with your insurance carier, please contact your insurance carrier to determine if they require this form to kfrlaqr In and and C.R.S. Section l0-l-128(6xa) states: "It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages, Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.' WC43 Rev. 10/17 Page 2 of4 DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4 PERSONAL & ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY PRO- JECT X LOC PRODUCTS - COMP/OP AGG $4,000,000 OTHER: A AUTOMOBILE LIABILITY 65 SBA IL2832 09/18/2018 09/18/2019 COMBINED SINGLE LIMIT (Ea accident) $2,000,000 ANY AUTO BODILY INJURY (Per person) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) X HIRED AUTOS X NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS-MADE EACH OCCURRENCE AGGREGATE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/ A PER STATUTE OTH- ER Y/N E.L. EACH ACCIDENT E.L. DISEASE -EA EMPLOYEE E.L. DISEASE - POLICY LIMIT A EMPLOYMENT PRACTICES LIABILITY 65 SBA IL2832 09/18/2018 09/18/2019 Each Claim Limit Aggregate Limit $5,000 $5,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. Certificate holder is an additional insured per the Business Liability Coverage Form SS0008, attached to this policy. CERTIFICATE HOLDER CANCELLATION ELLEN MARTIN CITY OF FORT COLLINS PO BOX 580 FORT COLLINS CO 80522-0580 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 DocuSign Envelope ID: 675E5E8F-5586-489C-8A07-EE8A1E96AFF4