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SERVICES AGREEMENT
WORK ORDER TYPE
THIS AGREEMENT made and entered into the day and year set forth below, by and
between THE CITY OF FORT COLLINS, COLORADO, a Municipal Corporation, hereinafter
referred to as the "City" and NORTHERN COLORADO MUD JACKING hereinafter referred
to as "Service Provider".
WITNESSETH:
In consideration of the mutual covenants and obligations herein expressed, it is agreed by
and between the parties hereto as follows:
1. Services to be Performed.
a. This Agreement shall constitute the basic agreement between the parties for services
for 8722 Foam Injection Pavement Lift Project. The conditions set forth herein shall
apply to all services performed by the Service Provider on behalf of the City and
particularly described in Work Orders agreed upon in writing by the parties from time to
time. Such Work Orders, a sample of which is attached hereto as Exhibit A, consisting
of one (1) page and incorporated herein by this reference, shall include a description of
the services to be performed, the location and time for performance, the amount of
payment, any materials to be supplied by the City and any other special circumstances
relating to the performance of services. No Work Order shall exceed $75,000. A
general scope of services is attached hereto as Exhibit C, consisting of three (3)
page(s), and incorporated herein by this reference.
The only services authorized under this Agreement are those which are performed
after receipt of such Work Order, except in emergency circumstances where oral work
requests may be issued. Oral requests for emergency actions will be confirmed by
issuance of a written Work Order within two (2) working days. Irrespective of
references in Exhibit A to certain named third parties, Service Provider shall be solely
responsible for performance of all duties hereunder.
b. The City may, at any time during the term of a particular Work Order and without
invalidating such Work Order, make changes to the scope of the particular services.
Such changes shall be agreed upon in writing by the parties by Change Order, a
sample of which is attached hereto as Exhibit B, consisting of one (1) page and
incorporated herein by this reference.
2. Changes in the Work. The City reserves the right to independently bid any services rather
than issuing work to the Service Provider pursuant to this Agreement. Nothing within this
Agreement shall obligate the City to have any particular service performed by the Service
Provider.
3. Time of Commencement and Completion of Services. The services to be performed
pursuant to this Agreement shall be initiated as specified by each written Work Order or
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oral emergency service request. Oral emergency service requests will be acted upon
without waiting for a written Work Order. Time is of the essence.
4. Contract Period. This Agreement shall commence June 15, 2018 and shall continue in
full force and effect until June 14, 2019, unless sooner terminated as herein provided. In
addition, at the option of the City, the Agreement may be extended for additional one year
periods not to exceed four (4) additional one year periods. Renewals and pricing changes
shall be negotiated by and agreed to by both parties. Written notice of renewal shall be
provided to the Service Provider and mailed no later than thirty (30) days prior to contract
end.
5. Delay. If either party is prevented in whole or in part from performing its obligations by
unforeseeable causes beyond its reasonable control and without is fault or negligence,
then the party so prevented shall be excused from whatever performance is prevented by
such cause. To the extent that the performance is actually prevented, the Service
Provider must provide written notice to the City of such condition within fifteen (15) days
from the onset of such condition.
6. Early Termination by City/Notices. Notwithstanding the time periods contained herein, the
City may terminate this Agreement at any time without cause by providing written notice of
termination to the Service Provider. Such notice shall be mailed at least fifteen (15) days
prior to the termination date contained in said notice unless otherwise agreed in writing by
the parties. All notices provided under this Agreement shall be effective when mailed,
postage prepaid and sent to the following address:
Service Provider: City: Copy to:
Northern Colorado Mud Jacking
Attn: Jeremy Bair
1675 Falcon Ridge Dr.
Fort Collins, CO 80528
City of Fort Collins
Attn: Angel Ontiveros
PO Box 580
Fort Collins, CO 80522
City of Fort Collins
Attn: Purchasing Dept.
PO Box 580
Fort Collins, CO 80522
In the event of early termination by the City, the Service Provider shall be paid for services
rendered to the termination date, subject only to the satisfactory performance of the
Service Provider's obligations under this Agreement. Such payment shall be the Service
Provider's sole right and remedy for such termination.
7. Contract Sum. This is an open-end indefinite quantity Agreement with no fixed price. The
actual amount of work to be performed will be stated on the individual Work Orders. The
City makes no guarantee as to the number of Work Orders that may be issued or the
actual amount of services which will in fact be requested.
8. Payments.
a. The City agrees to pay and the Service Provider agrees to accept as full payment for
all work done and all materials furnished and for all costs and expenses incurred in
performance of the work the sums set forth for the hourly labor rate and material costs,
with markups, stated within the Bid Schedule Proposal Form, attached hereto as
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Exhibit D, consisting of five (5) page(s), and incorporated herein by this reference.
Payment shall be made by the City only upon acceptance of the work by the City and
upon the Service Provider furnishing satisfactory evidence of payment of all wages,
taxes, supplies and materials, and other costs incurred in connection with the
performance of such work.
9. City Representative. The City's representative will be shown on the specific Work Order
and shall make, within the scope of his or her authority, all necessary and proper decisions
with reference to the work requested. All requests concerning this Agreement shall be
directed to the City Representative.
10. Independent Contractor. It is agreed that in the performance of any services hereunder,
the Service Provider is an independent contractor responsible to the City only as to the
results to be obtained in the particular work assignment and to the extent that the work
shall be done in accordance with the terms, plans and specifications furnished by the City.
11. Subcontractors. Service Provider may not subcontract any of the Work set forth in the
Exhibit A, Statement of Work without the prior written consent of the city, which shall not
be unreasonably withheld. If any of the Work is subcontracted hereunder (with the consent
of the City), then the following provisions shall apply: (a) the subcontractor must be a
reputable, qualified firm with an established record of successful performance in its
respective trade performing identical or substantially similar work, (b) the subcontractor will
be required to comply with all applicable terms of this Agreement, (c) the subcontract will
not create any contractual relationship between any such subcontractor and the City, nor
will it obligate the City to pay or see to the payment of any subcontractor, and (d) the work
of the subcontractor will be subject to inspection by the City to the same extent as the
work of the Service Provider.
12. Personal Services. It is understood that the City enters into the Agreement based on the
special abilities of the Service Provider and that this Agreement shall be considered as an
agreement for personal services. Accordingly, the Service Provider shall neither assign
any responsibilities nor delegate any duties arising under the Agreement without the prior
written consent of the city.
13. Acceptance Not Waiver. The City's approval or acceptance of, or payment for any of the
services shall not be construed to operate as a waiver of any rights under the Agreement
or of any cause of action arising out of the performance of this Agreement.
14. Warranty.
a. Service Provider warrants that all work performed hereunder shall be performed with
the highest degree of competence and care in accordance with accepted standards for
work of a similar nature.
b. Unless otherwise provided in the Agreement, all materials and equipment incorporated
into any work shall be new and, where not specified, of the most suitable grade of their
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respective kinds for their intended use, and all workmanship shall be acceptable to
City.
c. Service Provider warrants all equipment, materials, labor and other work, provided
under this Agreement, except City-furnished materials, equipment and labor, against
defects and nonconformances in design, materials and workmanship/workwomanship
for a period beginning with the start of the work and ending twelve (12) months from
and after final acceptance under the Agreement, regardless whether the same were
furnished or performed by Service Provider or by any of its subcontractors of any tier.
Upon receipt of written notice from City of any such defect or nonconformances, the
affected item or part thereof shall be redesigned, repaired or replaced by Service
Provider in a manner and at a time acceptable to City.
15. Default. Each and every term and condition hereof shall be deemed to be a material
element of this Agreement. In the event either party should fail or refuse to perform
according to the terms of this Agreement, such party may be declared in default thereof.
16. Remedies. In the event a party has been declared in default, such defaulting party shall
be allowed a period of ten (10) days within which to cure said default. In the event the
default remains uncorrected, the party declaring default may elect to (a) terminate the
Agreement and seek damages; (b) treat the Agreement as continuing and require specific
performance; or (c) avail himself of any other remedy at law or equity. If the non-
defaulting party commences legal or equitable actions against the defaulting party, the
defaulting party shall be liable to the non-defaulting party for the non-defaulting party's
reasonable attorney fees and costs incurred because of the default.
17. Binding Effect. This writing, together with the exhibits hereto, constitutes the entire
Agreement between the parties and shall be binding upon said parties, their officers,
employees, agents and assigns and shall inure to the benefit of the respective survivors,
heirs, personal representative, successors and assigns of said parties.
18. Indemnity/Insurance.
a. The Service Provider agrees to indemnify and save harmless the City, its officers,
agents and employees against and from any and all actions, suits, claims, demands or
liability of any character whatsoever, brought or asserted for injuries to or death of any
person or persons, or damages to property arising out of, result from or occurring in
connection with the performance of any service hereunder.
b. The Service Provider shall take all necessary precautions in performing the work
hereunder to prevent injury to persons and property.
c. Without limiting any of the Service Provider's obligations hereunder, the Service
Provider shall provide and maintain insurance coverage naming the City as an
additional insured under this Agreement of the type and with the limits specified within
Exhibit E, consisting of one (1) page, attached hereto and incorporated herein by this
reference. The Service Provider before commencing services hereunder shall deliver
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to the City's Purchasing Director, P. O. Box 580, Fort Collins, Colorado 80522 one
copy of a certificate evidencing the insurance coverage required from an insurance
company acceptable to the city.
19. Entire Agreement. This Agreement, along with all Exhibits and other documents
incorporated herein, shall constitute the entire Agreement of the parties. Covenants or
representations not contained in this Agreement shall not be binding on the parties.
20. Law/Severability. This Agreement shall be governed in all respect by the laws of the State
of Colorado. In the event any provision of this Agreement shall be held invalid or
unenforceable by any court of competent jurisdiction such holding shall not invalidate or
render unenforceable any other provision of this Agreement.
21. Prohibition Against Employing Illegal Aliens. Pursuant to Section 8-17.5-101, C.R.S., et.
seq., Service Provider represents and agrees that:
a. As of the date of this Agreement:
1) Service Provider does not knowingly employ or contract with an illegal alien who
will perform work under this Agreement; and
2) Service Provider will participate in either the e-Verify program created in Public
Law 208, 104th Congress, as amended, and expanded in Public Law 156, 108th
Congress, as amended, administered by the United States Department of
Homeland Security (the “e-Verify Program”) or the Department Program (the
“Department Program”), an employment verification program established pursuant
to Section 8-17.5-102(5)(c) C.R.S. in order to confirm the employment eligibility of
all newly hired employees to perform work under this Agreement.
b. Service Provider shall not knowingly employ or contract with an illegal alien to perform
work under this Agreement or knowingly enter into a contract with a subcontractor that
knowingly employs or contracts with an illegal alien to perform work under this
Agreement.
c. Service Provider is prohibited from using the e-Verify Program or Department Program
procedures to undertake pre-employment screening of job applicants while this
Agreement is being performed.
d. If Service Provider obtains actual knowledge that a subcontractor performing work
under this Agreement knowingly employs or contracts with an illegal alien, Service
Provider shall:
1) Notify such subcontractor and the City within three days that Service Provider has
actual knowledge that the subcontractor is employing or contracting with an illegal
alien; and
2) Terminate the subcontract with the subcontractor if within three days of receiving
the notice required pursuant to this section the subcontractor does not cease
employing or contracting with the illegal alien; except that Service Provider shall
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not terminate the contract with the subcontractor if during such three days the
subcontractor provides information to establish that the subcontractor has not
knowingly employed or contracted with an illegal alien.
e. Service Provider shall comply with any reasonable request by the Colorado
Department of Labor and Employment (the “Department”) made in the course of an
investigation that the Department undertakes or is undertaking pursuant to the
authority established in Subsection 8-17.5-102 (5), C.R.S.
f. If Service Provider violates any provision of this Agreement pertaining to the duties
imposed by Subsection 8-17.5-102, C.R.S. the City may terminate this Agreement. If
this Agreement is so terminated, Service Provider shall be liable for actual and
consequential damages to the City arising out of Service Provider’s violation of
Subsection 8-17.5-102, C.R.S.
g. The City will notify the Office of the Secretary of State if Service Provider violates this
provision of this Agreement and the City terminates the Agreement for such breach.
22. Dust Control. The Service Provider shall abide by the City of Fort Collins “Dust Prevention
and Control Manual,” which is available for public download at
https://www.fcgov.com/airquality/pdf/dust-prevention-and-control-manual.pdf, and is
incorporated herein by this reference. The City of Fort Collins has implemented this
manual for all projects performed for the City of Fort Collins or located within the City of
Fort Collins City limits.
23. Haul Routes. All trucks used for work contracted by the City utilizing asphalt from the
asphalt plant located at 1800 North Taft Hill Road may only enter North Taft Hill Road from
the North using CR 54 G and only exit the site on North Taft Hill Road to the North to CR
54G.
24. Special Provisions. Special provisions or conditions relating to the services to be
performed pursuant to this Agreement are set forth in Exhibit F – Certificate of Exemption
from Statutory Workers’ Compensation Law and Acknowledgement of Risk/Hold Harmless
Agreement, consisting of one (1) page, attached hereto and incorporated herein by this
reference.
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THE CITY OF FORT COLLINS, COLORADO
By:
Gerry Paul
Purchasing Director
DATE:
ATTEST:
APPROVED AS TO FORM:
NORTHERN COLORADO MUD JACKING
By:
Printed:
Title:
CORPORATE PRESIDENT OR VICE PRESIDENT
Date:
DocuSign Envelope ID: 1127B7B2-97FF-4C19-857E-373845FD8F97
Jeremy Bair
6/19/2018
corporate president
Assistant City Attorney ll
6/19/2018
City Clerk
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EXHIBIT A
WORK ORDER FORM
PURSUANT TO A MASTER AGREEMENT BETWEEN
THE CITY OF FORT COLLINS
AND
NORTHERN COLORADO MUD JACKING
WORK ORDER NUMBER:
PROJECT TITLE:
ORIGINAL BID/RFP NUMBER & NAME: 8722 Foam Injection Pavement Lift Project
MASTER AGREEMENT EFFECTIVE DATE: Original Contract Date
WORK ORDER COMMENCEMENT DATE:
WORK ORDER COMPLETION DATE:
MAXIMUM FEE: (time and reimbursable direct costs):
PROJECT DESCRIPTION/SCOPE OF SERVICES:
Service Provider agrees to perform the services identified above and on the attached forms in
accordance with the terms and conditions contained herein and in the Master Agreement
between the parties. In the event of a conflict between or ambiguity in the terms of the Master
Agreement and this Work Order (including the attached forms) the Master Agreement shall
control.
The attached forms consisting of ( ) page(s) are hereby accepted and incorporated
herein, by this reference, and Notice to Proceed is hereby given after all parties have signed this
document.
SERVICE PROVIDER: Date:
Name, Title
ACCEPTANCE: Date:
Name, Project Manager
REVIEWED: Date:
Name, Buyer or Senior Buyer
ACCEPTANCE: Date:
Gerry Paul, Purchasing Director
(if greater than $60,000)
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EXHIBIT B
CHANGE ORDER
NO.
PROJECT TITLE:
SERVICE PROVIDER: Northern Colorado Mud Jacking
WORK ORDER NUMBER:
PO NUMBER:
DESCRIPTION:
1. Reason for Change: Why is the change required?
2. Description of Change: Provide details of the changes to the Work
3. Change in Work Order Price:
4. Change in Work Order Time:
ORIGINAL WORK ORDER PRICE $ .00
TOTAL APPROVED CHANGE ORDER .00
TOTAL PENDING CHANGE ORDER .00
TOTAL THIS CHANGE ORDER .00
TOTAL % OF THIS CHANGE ORDER %
TOTAL C.O.% OF ORIGINAL WORK ORDER %
ADJUSTED WORK ORDER COST $ .00
SERVICE PROVIDER: Date:
Name, Title
ACCEPTANCE: Date:
Name, Project Manager
REVIEWED: Date:
Name, Buyer or Senior Buyer
ACCEPTANCE: Date:
Gerry Paul, Purchasing Director
(if greater than $60,000)
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EXHIBIT C
GENERAL SCOPE OF SERVICES
1.0 Description
This work consists of providing any lift as required, and filling any voids around structures,
under sidewalks and in exploratory pot holes, by furnishing and injecting a two-part
polyurethane material beneath the pavement. Examples of repairs to utilize this process
are settlements and dips in roadways, sidewalks, curb and gutter, bridge approaches, inlet
structures and building slabs. The City will identify such repair sites as they are
encountered with a single pink paint dot on the side of the hazard that needs lifting, and
will be shown on the plans and as directed. Locations are collected using a Fulcrum Data
Collection App as described in the Construction Requirements, Section 4.6.
1.5 Traffic Control
When working on arterial roads, the City of Fort Collins will provide Traffic Control as
needed.
2.0 Material Requirements
2.1 Material used for soil densification under these pavements shall be a two-part, one-
to-one ratio by volume, closed cell, hydro-insensitive, high density polyurethane
system. Such as URETEK 486 STAR or equivalent.
2.2 The material shall have a free rise density range of 3.8 – 4.2 lbs./cubic ft.
2.3 The material shall have a minimum compressive strength per ASTM 1621 of 60 psi.
2.4 The material shall have a minimum tensile strength per ASTM 1622 of 60 psi.
2.5 Material shall reach 90% compressive strength in 15 minutes such that traffic may be
returned to roadway within 15 minutes after last injection of material each day.
2.6 The material shall be a high-density polyurethane material, such as URETEK 486
STAR or equivalent, as approved by the engineer. The material shall be a
polyurethane-forming mixture, having a water insoluble diluent, which permits the
formation of polyurethanes in excess water. The presence of these water insoluble
diluents provides polyurethane foam with improved dimensional stability properties.
This formula and these characteristics must be certified by the manufacturer.
3.0 Equipment Requirements
The Service Provider shall provide at a minimum, the following equipment:
3.1 A truck-mounted pumping unit capable of injecting the high density polyurethane
material beneath the pavement through drilled holes and injection tubes to the
depths required. The pumping unit shall be capable of controlling the rate of flow of
material as required to densify soils and prevent pavement blowouts. The unit will be
equipped with a manufacturer’s certified flow meter to measure the amount of high-
density polyurethane injected at each location.
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3.2 Pressure and temperature control devices capable of maintaining proper
temperature and proportionate mixing of the polyurethane component materials.
3.3 Pneumatic or electric drills capable of efficiently drilling 5/8” to 3/4” diameter injection
holes through the pavement without damaging the structural integrity of the existing
pavement.
3.4 Laser levels or dial indicator devices capable of monitoring movement at the surface
of the pavement to verify that the injected base, sub-base, and sub-grade soils have
been properly densified.
3.5 A portable Dynamic Cone Penetrometer (DCP) for on-site soils investigation to assist
in location of weak sub-base soils and determination of injection pattern through
tubes to densify weak soils.
3.6 All necessary light towers, electric generators, compressors, heaters, hoses,
containers, valves and gauges to efficiently conduct and control the work.
4.0 Construction Requirements
4.1 Where applicable and as directed by the engineer, the Service Provider shall provide
a pavement profile from laser level measurements of each area where the pavement
structures require attention. Each profile shall be accepted by the engineer prior to
performing the work at the project location. Target and post-injection profiles shall
also be made part of the work and provided to the engineer upon project completion.
4.2 Dynamic cone penetrometer (DCP) testing may be required as directed by the
engineer on each project lane to confirm existing sub-grade soil conditions.
4.3 For stabilization and lifting of asphalt, concrete, or composite pavement, a series of
5/8” – 3/4” holes shall be drilled through the pavement above the area requiring
lifting. The polyurethane material shall then be injected at the proper locations,
depths, and rate to attain the desired profile. The exact location, spacing, hole size
and depth shall be selected by the Service Provider and approved by the engineer.
The rate and amount of material injected shall be determined by the Service Provider
to obtain proper densification of the base and sub-base soils.
4.4 Continuous laser level or dial indicator micrometer readings shall be in place and
monitored by the Service Provider during injection to determine sufficient material
usage and pavement lifting.
4.5 The Service Provider will be responsible for any pavement blowouts, excessive
pavement lifting or pavement damage that may occur as a result of the Service
Provider’s work. The Service Provider shall repair any subject areas to the
satisfaction of the engineer at the Service Provider’s expense. The Service Provider
shall fill all drilled holes, clean up all work areas and remove any temporary wedges
installed by City crews; the City will accept the asphalt wedge debris at no cost to the
Service Provider.
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4.6 The City has identified over 400 locations in residential neighborhoods that need
leveling and should not require traffic control. The Service Provider will be required to
use the City’s mobile app for viewing and finding needed trip hazard locations
throughout the City, updating the data point status and capturing a photo. All new
data collected will need to be uploaded back to the cloud server including photos.
The cost incurred for using the mobile device and data plan shall be included in the
unit cost and not paid for separately. Only one license for the mobile app will be
provided to the Service Provider. Work shall only occur from 7am to 6pm unless
approved by the City Engineer.
4.7 The Service Provider shall be required to wear the proper Personal Protection
Equipment (PPE) at all times.
5.0 Basis of Payment
The accepted quantities of polyurethane material as displayed by the certified flow meter
will be paid for at the contract unit price.
6.0 Warranty
The Service Provider shall provide a two-year bumper-to-bumper warranty against
movement of more than 1/4” of the pavement. In the event that movement of more than
1/4” in the injected areas occurs, Service Provider shall return to inject the affected area
to lift to proper grade at no cost to the owner. One exception to warranty – if the DCP
tests reveal deeper problems and the owner does not authorize payment to address
these issues; two-year warranty will not be valid.
7.0 Work Order Procedures
The awarded Service Provider will be expected to sign the City’s standard work order
type services agreement, a sample of which is included as Attachment A for reference
purposes. Individual work assignments will be requested and agreed to utilizing the
City’s standard Work Order (included in the agreement). Each work order will include a
start and completion date, total cost and a general summary of work. No work order
over $5,000 will be considered valid until signed, at a minimum, by the Service
Provider, Project Manager and Purchasing Department representative. Depending
on the cost and nature of the work, additional signature authorization may be required.
Any changes to the dates, cost or scope of any Work Order must be agreed upon in
writing utilizing the City’s Change Order (included in the agreement) and will not be
considered valid until signed, at a minimum, by the Service Provider, Project Manager
and Purchasing Department representative
8.0 Cost
Unit pricing is based on per Pound and shall include all costs including but not limited to
labor, equipment and materials. Measurement shall be calculated by the metering device
used to monitor amount of material used at each location each day.
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EXHIBIT D
BID SCHEDULE
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EXHIBIT E
INSURANCE REQUIREMENTS
1. The Service Provider will provide, from insurance companies acceptable to the City, the
insurance coverage designated hereinafter and pay all costs. Before commencing work
under this bid, the Service Provider shall furnish the City with certificates of insurance
showing the type, amount, class of operations covered, effective dates and date of
expiration of policies, and containing substantially the following statement:
“The insurance evidenced by this Certificate will not reduce coverage or limits and
will not be cancelled, except after thirty (30) days written notice has been received
by the City of Fort Collins.”
In case of the breach of any provision of the Insurance Requirements, the City, at its
option, may take out and maintain, at the expense of the Service Provider, such
insurance as the City may deem proper and may deduct the cost of such insurance from
any monies which may be due or become due the Service Provider under this
Agreement. The City, its officers, agents and employees shall be named as additional
insureds on the Service Provider 's general liability and automobile liability insurance
policies for any claims arising out of work performed under this Agreement.
2. Insurance coverages shall be as follows:
A. Workers' Compensation & Employer's Liability. See Exhibit F, Certificate of
Exemption from Statutory Workers’ Compensation Law and Acknowledgement of
Risk/Hold Harmless Agreement.
B. Commercial General & Vehicle Liability. The Service Provider shall maintain
during the life of this Agreement such commercial general liability and automobile
liability insurance as will provide coverage for damage claims of personal injury,
including accidental death, as well as for claims for property damage, which may
arise directly or indirectly from the performance of work under this Agreement.
Coverage for property damage shall be on a "broad form" basis. The amount of
insurance for each coverage, Commercial General and Vehicle, shall not be less
than $1,000,000 combined single limits for bodily injury and property damage.
In the event any work is performed by a subcontractor, the Service Provider shall
be responsible for any liability directly or indirectly arising out of the work
performed under this Agreement by a subcontractor, which liability is not covered
by the subcontractor's insurance.
DocuSign Envelope ID: 1127B7B2-97FF-4C19-857E-373845FD8F97
Official Purchasing Document
Last updated 10/2017
Services Agreement – Work Order Type
8722 Foam Injection Pavement Lifting Project Page 19 of 19
EXHIBIT F
CERTIFICATE OF EXEMPTION FROM STATUTORY WORKERS’
COMPENSATION LAW AND ACKNOWLEDGEMENT OF RISK/HOLD
HARMLESS AGREEMENT
I, Jeremy Bair, as the owner in Northern Colorado Mud Jacking, with a principal
address of 1675 Falcon Ridge Drive, Fort Collins, CO 80528, certify to the City of Fort
Collins, Colorado (the “City”) that the aforementioned business has no employees as
defined by the Workers’ Compensation Act of Colorado, C.R.S. §§ 8-40-101, et seq., (the
“Act”) other than those owners, members, partners, directors or other principals that have
elected to be exempt from Workers’ Compensation coverage in accordance with Colorado
law.
On behalf of said business and its officers, agents, insurers, heirs, legal representatives,
successors and assigns (collectively the “Business”), I warrant that I have full authority to
execute this Exhibit on behalf of the Business. I warrant I understand the requirements of
the Act with respect to providing Workers’ Compensation coverage for any employees of
the Business. If the Business’s status changes in such a manner that requires Workers’
Compensation Insurance, the Business shall provide the City with a Certificate of
Insurance evidencing proof of Workers’ Compensation Insurance coverage and
Employer’s Liability Insurance coverage as required by the Agreement. The Business
shall provide such Certificate of Insurance prior to the employees’ start of work for the
City.
On behalf of the Business, I acknowledge the Business may be contracting to engage in
activities that involve a risk of personal injury, that the Business is capable of performing
the activities, and that the Business shall take all necessary precautions to prevent injury.
The Business does hereby waive, release and forever discharge and hold harmless the
City, its officers, employees, agents and insurers from any and all liability, damages,
claims, causes of action and demands with respect to any bodily injury, personal injury,
illness, or death that may result from the performance of the Agreement, either in law or
equity, whether caused by the negligence or breach of contract of the City its officers,
employees, agents and insurers or otherwise. The Business also understands that the
City, its officers, employees, agents and insurers do not assume any responsibility for, or
obligation to, provide the Business with financial assistance or other assistance, including
but not limited to medical, health, or disability insurance in the event of any bodily injury,
personal injury, illness or death The Business agrees to defend, indemnify, and hold
harmless the City from any and all such claims.
As an independent contractor, the Business acknowledges that neither the Business nor
any person employed by or serving the Business is entitled to workers’ compensation
benefits from the City. The Business hereby waives any rights or claims to workers’
compensation benefits from the City, and agrees to indemnify and hold the City harmless
against any claims for such benefits by any officer, director, owner, employee, or servant
of the Business or any other person claiming through the Business. By signing this
Certificate, the Business acknowledges that it is responsible and liable for all work-related
injuries, and further requests the City waive its requirement for evidence of Workers’
Compensation Insurance.
DocuSign Envelope ID: 1127B7B2-97FF-4C19-857E-373845FD8F97
DocuSign Envelope ID: 1127B7B2-97FF-4C19-857E-373845FD8F97
DocuSign Envelope ID: 1127B7B2-97FF-4C19-857E-373845FD8F97