Common use of LANCASTER COUNTY, NEBRASKA Clause in Contracts

LANCASTER COUNTY, NEBRASKA. Contract Approved as to Form: The Board of County Commissioners of Lancaster, Nebraska Deputy Lancaster County Attorney dated FIRST INITIATIVES INSURANCE, LTD Governor’s Square, Suite 4-213-4 00 Xxxx Xxxx Xxx Xxx., P.O. Box 10073 Grand Cayman, KY1-1001, Cayman Islands (000) 000-0000, Fax (000) 000-0000 Email: xxxxxxxxxxxxxxxx@xxxxxxxxxxxxxx.xxx THIS IS TO CERTIFY TO DATE OF CERTIFICATE ISSUANCE: October 5, 2017 NAME AND ADDRESS OF CERTIFICATE HOLDER: ORIGINAL DATE OF ISSUANCE October 5, 2017 CITY OF LINCOLN/AND OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION 000 XXXXX 00XX XXXXXX LINCOLN, NE 68508 CERTIFICATE OF SELF-INSURANCE That the described self-insurance coverages as provided by the indicated policy and issued by the company has been issued to: Named Insured: TPN - COMPANY CARE Address: 0000 XXXXX 00XX XXXXXX, XXXXX 000 XXXXXXX, XX 00000 The Policy identified below by a policy number is in force on the date of Certificate issuance. Self-Insurance is afforded only with respect to those coverages for which a specific limit of liability has been entered and is subject to all the terms of the Policy having reference thereto. This Certificate of Self-Insurance neither affirmatively nor negatively amends, extends or alters the coverage afforded under any policy identified herein. POLICY NUMBER POLICY PERIOD EFF. 07/01/17 EXP. 07/01/18 FIPR00717 TYPE OF SELF-INSURANCE DESIGNATED BELOW COVERAGES LIMITS OF LIABILITY COMMERCIAL GENERAL LIABILITY BODILY INJURY, PROPERTY DAMAGE, PERSONAL INJURY LIABILITY & MISCELLANEOUS PROFESSIONAL LIABILITY $10,000,000 Each claim HEALTHCARE PROFESSIONAL LIABILITY AS DESCRIBED $10,000,000 Each claim $85,000,000 Shared Aggregate Claims made coverage. Policy retroactive date is: July 1, 2002 SPECIAL CONDITIONS/OTHER COVERAGES SITE CODE: 2611F20 CITY OF LINCOLN AND/OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION ARE ADDED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY, SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY, ATIMA, AS REQUIRED PER RFP #: 13-197. 2611F - NE Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing company will endeavor to mail 30 days written notice to the above named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the company.

LANCASTER COUNTY, NEBRASKA. Contract Approved as to Form: The Board of County Commissioners of Lancaster, Nebraska Deputy Lancaster County Attorney dated FIRST INITIATIVES INSURANCEXxxxxxx-Xxxxxxxxx County Public Building Commission Signature Page CONTRACT Annual Service Offset Printing, LTD Governor’s SquareDesign Services, Suite 4and Related Services Bid No. 19-213141 City of Lincoln, Nebraska, Lancaster County, City of Xxxxxxx - Xxxxxxxxx County Public Building Commission Firespring EXECUTION BY XXXXXXX-4 00 Xxxx Xxxx Xxx Xxx.XXXXXXXXX COUNTY PUBLIC BUILDING COMMISSION ATTEST: Public Building Commission Attorney Chairperson, P.O. Box 10073 Grand Cayman, KY1-1001, Cayman Islands Public Building Commission dated City of Lincoln/Lancaster County (Lincoln Purchasing) Supplier Response Bid Information Contact Information Ship to Information Bid Creator Xxxxxx Xxxxx Purchasing Address Purchasing\City & Address Agent County Email xxxxxx@xxxxxxx.xx.xxx 000 X. 0xx Xx. Phone 0 (000) 000-00000000 Lincoln, NE 68508 Contact Fax 0 (000) 000-0000 Contact Xxxxxx Xxxxx Asst. Purchasing Agent Department Bid Number 19-141 Building Title Annual Requirements - Department Offset Printing, Design Building Floor/Room Serices, and Related Telephone Services Floor/Room Fax Bid Type Bid Telephone 0 (000) 000-0000 Email Issue Date 4/22/2019 02:46 PM (CT) Fax 0 (000) 000-0000 Close Date 5/10/2019 01:25:00 PM (CT) Email xxxxxx@xxxxxxx.xx.xxx Supplier Information Company Firespring Address 0000 Xxxxxxxx Xxxxx Lincoln, NE 68512 Contact Xxxxx Xxxxxx Department Building Floor/Room Telephone (000) 000-0000 Fax (000) 000-0000 EmailEmail xxxxx.xxxxxx@xxxxxxxxxx.xxx Submitted 5/6/2019 08:33:18 AM (CT) Total $7,787.22 By submitting your response, you certify that you are authorized to represent and bind your company. Signature Xxxxx Xxxxxx Email xxxxx.xxxxxx@xxxxxxxxxx.xxx Supplier Notes Bid Notes Bid Activities Bid Messages Bid Attributes Please review the following and respond where necessary # Name Note Response 1 Insurance Requirements I acknowledge reading and understanding the Insurance Requirements. Yes 2 Specifications I acknowledge reading and understanding the specifications. Yes 3 Electronic Signature Please check here for your electronic signature. Yes 4 Instructions to Bidders I acknowledge reading and understanding the Instructions to Bidders. Yes 5 Contact Name of person submitting this bid: xxxxxxxxxxxxxxxx@xxxxxxxxxxxxxx.xxx THIS IS TO CERTIFY TO DATE OF CERTIFICATE ISSUANCE: October 5, 2017 NAME AND ADDRESS OF CERTIFICATE HOLDER: ORIGINAL DATE OF ISSUANCE October 5, 2017 CITY OF LINCOLN/AND OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION 000 XXXXX 00XX XXXXXX LINCOLN, NE 68508 CERTIFICATE OF SELF-INSURANCE That Xxxxx Xxxxxx 6 Annual Requirements I acknowledge reading and understanding the described self-insurance coverages as provided by the indicated policy and issued by the company has been issued to: Named Insured: TPN - COMPANY CARE Address: 0000 XXXXX 00XX XXXXXX, XXXXX 000 XXXXXXX, XX 00000 The Policy identified below by a policy number is in force on the date of Certificate issuanceAnnual Requirements. Self-Insurance is afforded only with respect to those coverages for which a specific limit of liability has been entered and is subject to all the terms of the Policy having reference thereto. This Certificate of Self-Insurance neither affirmatively nor negatively amends, extends or alters the coverage afforded under any policy identified herein. POLICY NUMBER POLICY PERIOD EFF. 07/01/17 EXP. 07/01/18 FIPR00717 TYPE OF SELF-INSURANCE DESIGNATED BELOW COVERAGES LIMITS OF LIABILITY COMMERCIAL GENERAL LIABILITY BODILY INJURY, PROPERTY DAMAGE, PERSONAL INJURY LIABILITY & MISCELLANEOUS PROFESSIONAL LIABILITY $10,000,000 Each claim HEALTHCARE PROFESSIONAL LIABILITY AS DESCRIBED $10,000,000 Each claim $85,000,000 Shared Aggregate Claims made coverage. Policy retroactive date is: July 1, 2002 SPECIAL CONDITIONS/OTHER COVERAGES SITE CODE: 2611F20 CITY OF LINCOLN AND/OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION ARE ADDED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY, SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY, ATIMA, AS REQUIRED PER RFP #: 13-197. 2611F - NE Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing company will endeavor to mail 30 days written notice to the above named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the company.Yes

LANCASTER COUNTY, NEBRASKA. Contract Approved as to Form: The Board of County Commissioners of Lancaster, Nebraska Deputy Lancaster County Attorney dated FIRST INITIATIVES INSURANCEXxxxxxx-Xxxxxxxxx County Public Building Commission Signature Page CONTRACT Annual Service Offset Printing, LTD Governor’s SquareDesign Services, Suite 4and Related Services Bid No. 19-213141 City of Lincoln, Nebraska, Lancaster County, City of Xxxxxxx - Xxxxxxxxx County Public Building Commission Cornhusker State Industries (Department of Corrections) EXECUTION BY XXXXXXX-4 00 Xxxx Xxxx Xxx Xxx.XXXXXXXXX COUNTY PUBLIC BUILDING COMMISSION ATTEST: Public Building Commission Attorney Chairperson, P.O. Box 10073 Grand Cayman, KY1-1001, Cayman Islands Public Building Commission dated City of Lincoln/Lancaster County (Lincoln Purchasing) Supplier Response Bid Information Contact Information Ship to Information Bid Creator Xxxxxx Xxxxx Purchasing Address Purchasing\City & Address Agent County Email xxxxxx@xxxxxxx.xx.xxx 000 X. 0xx Xx. Phone 0 (000) 000-00000000 Lincoln, NE 68508 Contact Fax 0 (000) 000-0000 Contact Xxxxxx Xxxxx Asst. Purchasing Agent Department Bid Number 19-141 Building Title Annual Requirements - Department Offset Printing, Design Building Floor/Room Serices, and Related Telephone Services Floor/Room Fax Bid Type Bid Telephone 0 (000) 000-0000 Email Issue Date 4/22/2019 02:46 PM (CT) Fax 0 (000) 000-0000 Close Date 5/10/2019 01:25:00 PM (CT) Email xxxxxx@xxxxxxx.xx.xxx Supplier Information Company CORNHUSKER STATE INDUSTRIES (DEPARTMENT OF CORRECTIONS) Address NDCS ACCOUNTS PAYABLE PO BOX 94661 LINCOLN, NE 00000-0000 Contact Department Building Floor/Room Telephone (000) 000-0000 Fax (000) 000-0000 EmailEmail Submitted 5/10/2019 10:19:12 AM (CT) Total $2,946.44 By submitting your response, you certify that you are authorized to represent and bind your company. Signature Xxxxxx Xxxx Email xxxxxxx.xxxx@xxxxxxxx.xxx Supplier Notes Bid Notes Bid Activities Bid Messages Bid Attributes Please review the following and respond where necessary # Name Note Response 1 Insurance Requirements I acknowledge reading and understanding the Insurance Requirements. Yes 2 Specifications I acknowledge reading and understanding the specifications. Yes 3 Electronic Signature Please check here for your electronic signature. Yes 4 Instructions to Bidders I acknowledge reading and understanding the Instructions to Bidders. Yes 5 Contact Name of person submitting this bid: xxxxxxxxxxxxxxxx@xxxxxxxxxxxxxx.xxx THIS IS TO CERTIFY TO DATE OF CERTIFICATE ISSUANCE: October 5, 2017 NAME AND ADDRESS OF CERTIFICATE HOLDER: ORIGINAL DATE OF ISSUANCE October 5, 2017 CITY OF LINCOLN/AND OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION 000 XXXXX 00XX XXXXXX LINCOLN, NE 68508 CERTIFICATE OF SELF-INSURANCE That Xxxxxx Xxxx 6 Annual Requirements I acknowledge reading and understanding the described self-insurance coverages as provided by the indicated policy and issued by the company has been issued to: Named Insured: TPN - COMPANY CARE Address: 0000 XXXXX 00XX XXXXXX, XXXXX 000 XXXXXXX, XX 00000 The Policy identified below by a policy number is in force on the date of Certificate issuanceAnnual Requirements. Self-Insurance is afforded only with respect to those coverages for which a specific limit of liability has been entered and is subject to all the terms of the Policy having reference thereto. This Certificate of Self-Insurance neither affirmatively nor negatively amends, extends or alters the coverage afforded under any policy identified herein. POLICY NUMBER POLICY PERIOD EFF. 07/01/17 EXP. 07/01/18 FIPR00717 TYPE OF SELF-INSURANCE DESIGNATED BELOW COVERAGES LIMITS OF LIABILITY COMMERCIAL GENERAL LIABILITY BODILY INJURY, PROPERTY DAMAGE, PERSONAL INJURY LIABILITY & MISCELLANEOUS PROFESSIONAL LIABILITY $10,000,000 Each claim HEALTHCARE PROFESSIONAL LIABILITY AS DESCRIBED $10,000,000 Each claim $85,000,000 Shared Aggregate Claims made coverage. Policy retroactive date is: July 1, 2002 SPECIAL CONDITIONS/OTHER COVERAGES SITE CODE: 2611F20 CITY OF LINCOLN AND/OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION ARE ADDED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY, SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY, ATIMA, AS REQUIRED PER RFP #: 13-197. 2611F - NE Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing company will endeavor to mail 30 days written notice to the above named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the company.Yes

LANCASTER COUNTY, NEBRASKA. Contract Approved as to Form: The Board of County Commissioners of Lancaster, Nebraska Deputy Lancaster County Attorney dated FIRST INITIATIVES INSURANCECity of Xxxxxxx-Xxxxxxxxx County Public Building Commission Signature Page AMENDMENT TO CONTRACT Unit Price Demolition Services Bid No. 16-279 City of Lincoln, LTD Governor’s Square, Suite 4Lancaster County and City of Xxxxxxx-213Xxxxxxxxx County Public Building Commission Renewal Xxxxxx Excavating Company EXECUTION BY XXXXXXX-4 00 Xxxx Xxxx Xxx Xxx., P.O. Box 10073 Grand Cayman, KY1-1001, Cayman Islands (000) 000-0000, Fax (000) 000-0000 Email: xxxxxxxxxxxxxxxx@xxxxxxxxxxxxxx.xxx THIS IS TO CERTIFY TO DATE OF CERTIFICATE ISSUANCE: October 5, 2017 NAME AND ADDRESS OF CERTIFICATE HOLDER: ORIGINAL DATE OF ISSUANCE October 5, 2017 CITY OF LINCOLN/AND OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER XXXXXXXXX COUNTY PUBLIC BUILDING COMMISSION 000 XXXXX 00XX XXXXXX LINCOLNATTEST: Public Building Commission Attorney Chairperson, NE 68508 CERTIFICATE OF SELFPublic Building Commission dated Certified Statement Pursuant to Neb. Rev. Stat. § 77-INSURANCE That 1323 § 77-1323 Every person, partnership, limited liability company, association, or corporation furnishing labor or material in the described self-insurance coverages as provided by repair, alteration, improvement, erection, or construction of any public improvement shall furnish a certified statement to be attached to the indicated policy and issued by contract that all equipment to be used on the company project, except that acquired since the assessment date, has been issued to: Named Insured: TPN - COMPANY CARE Address: 0000 XXXXX 00XX XXXXXXassessed for taxation for the current year, XXXXX 000 XXXXXXXgiving the county where assessed. Pursuant to Neb. Rev. Stat. § 77-1323, XX 00000 The Policy identified below by a policy number is in force I, , do hereby certify that all equipment to be used on Bid No. 16-279, except that equipment acquired since the date of Certificate issuance. Self-Insurance is afforded only with respect to those coverages for which a specific limit of liability assessment date, has been entered and is subject to all assessed for taxation for the terms current year, in County, Nebraska. DATED this day of the Policy having reference thereto, 2021. This Certificate of Self-Insurance neither affirmatively nor negatively amendsBy: Title: STATE OF NEBRASKA ) )ss. COUNTY OF ) On , extends or alters the coverage afforded under any policy identified herein. POLICY NUMBER POLICY PERIOD EFF. 07/01/17 EXP. 07/01/18 FIPR00717 TYPE OF SELF-INSURANCE DESIGNATED BELOW COVERAGES LIMITS OF LIABILITY COMMERCIAL GENERAL LIABILITY BODILY INJURY2021, PROPERTY DAMAGE, PERSONAL INJURY LIABILITY & MISCELLANEOUS PROFESSIONAL LIABILITY $10,000,000 Each claim HEALTHCARE PROFESSIONAL LIABILITY AS DESCRIBED $10,000,000 Each claim $85,000,000 Shared Aggregate Claims made coverage. Policy retroactive date is: July 1, 2002 SPECIAL CONDITIONS/OTHER COVERAGES SITE CODE: 2611F20 CITY OF LINCOLN AND/OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION ARE ADDED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY, SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY, ATIMA, AS REQUIRED PER RFP #: 13-197. 2611F - NE Cancellation: Should any of the above described policies be cancelled before the expiration date thereofme, the issuing company will endeavor undersigned Notary Public duly commissioned for and qualified in said County, personally came , to mail 30 days written notice me known to be the identical person, whose name is affixed to the foregoing instrument and acknowledged the execution thereof to be his voluntary act and deed. Witness my hand and notarial seal the day and year last above named certificate holderwritten. Notary Public 15 | P a g e EMPLOYEE CLASSIFICATION ACT AFFIDAVIT For the purposes of complying with THE NEBRASKA EMPLOYEE CLASSIFICATION ACT, but failure Nebraska Revised Statutes 48-2901 to mail such notice shall impose no obligation or liability 48-2912 and City of any kind upon Lincoln Executive Order 083319, I, , herein below known as the company.Contractor, state under oath and swear as follows:

LANCASTER COUNTY, NEBRASKA. Contract Approved as to Form: The Board of County Commissioners of Lancaster, Nebraska Deputy Lancaster County Attorney dated FIRST INITIATIVES INSURANCE, LTD Governor’s Square, Suite 4-213-4 00 Xxxx Xxxx Xxx Xxx., P.O. Box 10073 Grand Cayman, KY1-1001, Cayman Islands City of Lincoln/Lancaster County (Lincoln Purchasing) Supplier Response Bid Information Contact Information Ship to Information Bid Creator Email Xxxxxxxx Xxxxx Buyer xxxxxx@xxxxxxx.xx.xxx Address Purchasing 000 X. 0xx St. Address Phone 0 (000) 000-00000000 Lincoln, NE 68508 Fax 0 (000) 000-0000 Contact Xxxxxxxx Xxxxx, Buyer Contact Bid Number 18-048 Department Department Title Bid Type Issue Date Annual Supply of Grass Seed Bid 2/26/2018 03:38 PM (CT) Building Suite 200 Floor/Room Building Floor/Room Close Date 3/9/2018 12:00:00 PM (CT) Telephone 0 (000) 000-0000 Fax 0 (000) 000-0000 Email xxxxxx@xxxxxxx.xx.xxx Telephone Fax Email Supplier Information Company Xxxxxx Seed Company Address P.O. Box 81823 0000 Xxxxxxxxxx Xxx Lincoln, NE 68501 Contact Xxxxx Xxxxxx Department Building Floor/Room Telephone (000) 000-0000 Fax (000) 000-0000 EmailEmail xxxxx@xxxxxxxxxx.xxx Submitted 3/7/2018 02:59:39 PM (CT) Total $51,510.00 By submitting your response, you certify that you are authorized to represent and bind your company. Signature Xxxxx X Xxxxxx Email xxxxx@xxxxxxxxxx.xxx Supplier Notes Bid Notes Bid Activities Bid Messages Bid Attributes Please review the following and respond where necessary # Name Note Response 1 U.S. Citizenship Attestation Is your company legally considered an Individual or Sole Proprietor: xxxxxxxxxxxxxxxx@xxxxxxxxxxxxxx.xxx THIS IS TO CERTIFY TO DATE OF CERTIFICATE ISSUANCE: October 5, 2017 NAME AND ADDRESS OF CERTIFICATE HOLDER: ORIGINAL DATE OF ISSUANCE October 5, 2017 CITY OF LINCOLN/AND OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION 000 XXXXX 00XX XXXXXX LINCOLN, NE 68508 CERTIFICATE OF SELF-INSURANCE That YES or NO YES As a Vendor who is legally considered an Individual or a Sole Proprietor I hereby understand and agree to comply with the described self-insurance coverages as provided by the indicated policy and issued by the company has been issued to: Named Insured: TPN - COMPANY CARE Address: 0000 XXXXX 00XX XXXXXX, XXXXX 000 XXXXXXX, XX 00000 The Policy identified below by a policy number is in force on the date of Certificate issuance. Self-Insurance is afforded only with respect to those coverages for which a specific limit of liability has been entered and is subject to all the terms requirements of the Policy having reference theretoUnited States Citizenship Attestation Form, available at: xxxx://xxx.xxx.xx.xxx/business/notary/citizenforminfo.html All awarded Vendors who are legally considered an Individual or a Sole Proprietor must complete the form and submit it with contract documents at time of execution. This Certificate of Self-Insurance neither affirmatively nor negatively amends, extends If a Vendor indicates on such attestation form that he or alters the coverage afforded under any policy identified herein. POLICY NUMBER POLICY PERIOD EFF. 07/01/17 EXP. 07/01/18 FIPR00717 TYPE OF SELF-INSURANCE DESIGNATED BELOW COVERAGES LIMITS OF LIABILITY COMMERCIAL GENERAL LIABILITY BODILY INJURY, PROPERTY DAMAGE, PERSONAL INJURY LIABILITY & MISCELLANEOUS PROFESSIONAL LIABILITY $10,000,000 Each claim HEALTHCARE PROFESSIONAL LIABILITY AS DESCRIBED $10,000,000 Each claim $85,000,000 Shared Aggregate Claims made coverage. Policy retroactive date is: July 1, 2002 SPECIAL CONDITIONS/OTHER COVERAGES SITE CODE: 2611F20 CITY OF LINCOLN AND/OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION ARE ADDED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY, SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY, ATIMA, AS REQUIRED PER RFP #: 13-197. 2611F - NE Cancellation: Should any of the above described policies be cancelled before the expiration date thereofshe is a qualified alien, the issuing company will endeavor Vendor agrees to mail 30 days written notice provide the US Citizenship and Immigration Services documentation required to verify the above named certificate holder, but failure Vendor’s lawful presence in the United States using the Systematic Alien Verification for Entitlements (SAVE) Program. Vendor further understands and agrees that lawful presence in the United States is required and the Vendor may be disqualified or the Contract terminated if such lawful presence cannot be verified as required by Neb. Rev. Stat. 4-108. 2 Instructions to mail such notice shall impose no obligation or liability of any kind upon Bidders I acknowledge reading and understanding the company.Instructions to Bidders. Yes

LANCASTER COUNTY, NEBRASKA. Contract Approved as to Form: The Board of County Commissioners of Lancaster, Nebraska Deputy Lancaster County Attorney dated FIRST INITIATIVES INSURANCE6152 MICROFILM IMAGING SYSTEMS, LTD Governor’s SquareINC Supplier Response Event Information Number: 6152 Title: Annual Supply - Microfilming Supplies Type: Quotation Request Issue Date: 2/6/2020 Deadline: 2/21/2020 11:00 AM (CT) Contact Information Contact: Xxxxxxxx Xxxxx Buyer Address: Suite 200 Purchasing 000 X. 0xx Xx. Lincoln, Suite 4-213-4 00 Xxxx Xxxx Xxx Xxx., P.O. Box 10073 Grand Cayman, KY1-1001, Cayman Islands NE 68508 Phone: 0 (000) 000-0000, Fax 0000 Fax: 0 (000) 000-0000 Email: xxxxxxxxxxxxxxxx@xxxxxxxxxxxxxx.xxx THIS IS TO CERTIFY TO DATE OF CERTIFICATE ISSUANCE: October 5xxxxxx@xxxxxxx.xx.xxx MICROFILM IMAGING SYSTEMS, 2017 NAME AND ADDRESS OF CERTIFICATE HOLDER: ORIGINAL DATE OF ISSUANCE October 5, 2017 CITY OF LINCOLN/AND OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION 000 XXXXX 00XX XXXXXX LINCOLN, NE 68508 CERTIFICATE OF SELF-INSURANCE That the described self-insurance coverages as provided by the indicated policy and issued by the company has been issued to: Named Insured: TPN - COMPANY CARE INC Information Address: 0000 XXXXX 00XX XXXXXXXXXXXX XXXXXX OMAHA, XXXXX 000 XXXXXXXNE 68131 Phone: (000) 000-0000 Fax: (000) 000-0000 By submitting your response, XX 00000 The Policy identified below you certify that you are authorized to represent and bind your company. Xxxxxx X Xxxxxx xxxx@xxxxxxxxxxxxxxxx.xxx Signature Email Submitted at 2/20/2020 3:20:54 PM Bid Attributes U.S. Citizenship Attestation Is your company legally considered an Individual or Sole Proprietor: YES or NO As a Vendor who is legally considered an Individual or a Sole Proprietor I hereby understand and agree to comply w ith the requirements of the United States Citizenship Attestation Form, available at: xxxx://xxx.xxx.xx.xxx/business/ notary/citizenforminfo.html All awarded Vendors who are legally considered an Individual or a Sole Proprietor must complete the form and sub mit it with contract documents at time of execution. If a Vendor indicates on such attestation form that he or she is a qualified alien, the Vendor agrees to provide the U S Citizenship and Immigration Services documentation required to verify the Vendor’s lawful presence in the United States using the Systematic Alien Verification for Entitlements (SAVE) Program. Vendor further understands and agrees that lawful presence in the United States is required and the Vendor may b e disqualified or the Contract terminated if such lawful presence cannot be verified as required by Neb. Rev. Stat. 4- 108. No Instructions to Bidders I acknowledge reading and understanding the Instructions to Bidders. Yes Specifications I acknowledge reading and understanding the specifications. Yes Bid Documents I acknowledge and accept that it is my responsibility as a policy number Bidder to promptly notify the Purchasing Department Staff prior to the close of the bid of any ambiguity, inconsistency or error which I may discover upon examination of the bi d documents including, but not limited to the Specifications. Yes Sample Contract I acknowledge reading and understanding the sample contract. 5 Yes Term Clause of Contract with Escalation/De-Escalation - 1 year I acknowledge that the term of the contract is in force on for a one (1) year term with the option for three (3) additional one (1) year terms from the date of Certificate issuance. Self-Insurance is afforded only with respect to those coverages for which a specific limit of liability has been entered and is subject to all the terms of the Policy having reference thereto. This Certificate of Self-Insurance neither affirmatively nor negatively amends, extends or alters the coverage afforded under any policy identified herein. POLICY NUMBER POLICY PERIOD EFF. 07/01/17 EXP. 07/01/18 FIPR00717 TYPE OF SELF-INSURANCE DESIGNATED BELOW COVERAGES LIMITS OF LIABILITY COMMERCIAL GENERAL LIABILITY BODILY INJURY, PROPERTY DAMAGE, PERSONAL INJURY LIABILITY & MISCELLANEOUS PROFESSIONAL LIABILITY $10,000,000 Each claim HEALTHCARE PROFESSIONAL LIABILITY AS DESCRIBED $10,000,000 Each claim $85,000,000 Shared Aggregate Claims made coverage. Policy retroactive date is: July 1, 2002 SPECIAL CONDITIONS/OTHER COVERAGES SITE CODE: 2611F20 CITY OF LINCOLN AND/OR LANCASTER COUNTY AND/OR CITY OF LINCOLN/LANCASTER COUNTY PUBLIC BUILDING COMMISSION ARE ADDED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY, SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY, ATIMA, AS REQUIRED PER RFP #: 13-197. 2611F - NE Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing company will endeavor to mail 30 days written notice to the above named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the companyexecuted contract.