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R-12-11-08-H11 - 11/8/2012RESOLUTION NO. R -12-11-08-H11 WHEREAS, the Area Agency on Aging offers funding for transportation services which provides nutrition bus trips for seniors, and WHEREAS, the Demand Response Bus Service transports seniors to the Baca Center on a daily basis, and the City would like to make application for nutrition funding for this service, Now Therefore BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK, TEXAS, That the Mayor is hereby authorized and directed to execute on behalf of the City various documents in the Vendor Application/Renewal Updated package entitled "Direct Purchase of Services Fiscal Years 2013" relative to applying for nutrition funding for Demand Bus Response Bus Service, a copy of said application being attached hereto as Exhibit "A" and incorporated herein for all purposes. The City Council hereby finds and declares that written notice of the date, hour, place and subject of the meeting at which this Resolution was adopted was posted and that such meeting was open to the public as required by law at all times during which this Resolution and the subject matter hereof were discussed, considered and formally acted upon, all as required by the Open Meetings Act, Chapter 551, Texas Government Code, as amended. RESOLVED this 8th day of November, 2012. ALAN MCGRAW, Mayor City of Round Rock, Texas Ai' 0, Ak' _ T rU fl; � 0:\wdox\SCCIn[s\0112\ 1204\ML NIC1PAL\00261314.DOC EXHIBIT „A„//Agency Area DIRECT PURCHASE OF SERVICES )Wo_i:1kging FISCAL YEAR 2013 VENDOR APPLICATION / RENEWAL UPDATE of the Capital Area Please type or clearly print application information. Vendor Name/Legal Entity City of Round Rock DBA (if applicable) not applicable Physical Address Street: 221 E. Main Street City: Round Rock State: Texas ZIP: 78664 Mailing Address Street or PO Box: 221 E. Main Street City: Round Rock State: Texas ZIP: 78664 Tax Identification Number (SSN or Federal ID): 74-6017485 Type of Provider ❑ Government Agency ❑ Private Non -Profit ❑ Private For Profit ® City Government ❑ County Government ❑ Other: ❑ Rural Provider ❑ Minority Provider Authorizing Official Name: Alan McGraw Title: Mayor Email Address: mayormcgraw@roundrocktexas.gov Telephone: 512-218-5403 Fax: Billing Contact Person and Address: Name: Caren Lee Title: Administrative Assistant Street or PO Box: 2008 Enterprise Dr. City: Round Rock State: Texas ZIP: 78664 Email Address: clee@roundrocktexas.qov Telephone: 512-671-2869 Fax: 512-218-5563 Number of Years Organization has been in business: 100 years Is Agency Bonded? ® Yes: Attach certificate of bonding insurance ❑ No Has Anyone in Agency been convicted of a felony? ❑ Yes ® No If yes, explain (attach additional sheets if necessary): Does Agency have liability insurance? ® Yes: Attach certificate of all insurances ❑ No Revised 09/08 DPS Application Page 2 Service and t3idcUna intormation: 1. Proposed Service: Demand Response Bus Service Define your unit of service: per person Service Any origin and destination within the city limits of Area: Round Rock Proposed service cost per unit: current fare structures is $2.00 per person each way $1.00 per person each way for persons over 60 or with a disability Revised 09/08 2 DPS Application Page 3 Attach a copy of all applicable State and Federal license and/or certifications that regulate your business. Conflicts of Interest: Attach information of applicable names and relationship of any employee(s) or officers of your organization that may have a conflict of interest with an Area Agency on Aging of the Capital Area staff person or Advisory Council member. Additional Attachments: Affirmative Action Plan Signed Statement indicating compliance with the Civil Rights Act of 1964 Signed Certification Regarding Debarment I certify that the information provided in this application is true and correct to the best of my knowledge. Mayor Alan McGraw Print Name Date Authorized Signature Revised 09/08 3 ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES REGULATION UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 City of Round Rock (hereinafter called the "Applicant") Name of Applicant (Type or Print) HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L. 880352) and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45C.F.R. Part 80) issued pursuant to that title, to the end that, in accordance with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement. If any real property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the Applicant by the Department, this Assurance shall obligate the Applicant, or in the case of any transfer of such property, and transferee, for the period during which the real property or structure is used for a purpose for which the Federal Financial assistance is extended or for another purpose involving the provision of similar services or benefits. If any personal property is so provided, this Assurance shall obligate the Applicant for the period during which it retains ownership or possession of the property. In all other cases, this Assurance shall obligate the Applicant for the period during which the Federal financial assistance is extended to it by the Department. THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all Federal grants, loans, contracts, property, discounts or other Federal financial assistance extended after the date hereof to the Applicant by the Department, including installment payments after such a date on account of applications for Federal financial assistance which were approved before such date. The Applicant recognizes and agrees that such Federal financial assistance will be extended in reliance on the representations and agreements made in the Assurance, and that the United States shall have the right to seek judicial enforcement of this Assurance. This Assurance is binding on the Applicant, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this Assurance on behalf of the Applicant. Date 221 E. Main Street Round Rock, Texas 78664 Applicant's Mailing Address City of Round Rock Applicant (Type or Print) Authorized Signature CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS Federal Executive Order 12549 requires the Texas Department of Aging and Disability Services (DADS) to screen each covered potential contractor/grantee to determine whether each has a right to obtain a contract/grant in accordance with federal regulations on debarment, suspension, ineligibility, and voluntary exclusion. Each covered contractor/grantee must also screen each of its covered subcontractors/providers. In this certification "contractor/grantee" refers to both contractor/grantee and subcontractor/subgrantee; "contract/grant" refers to both contract/grant and subcontract/subgrant. By signing and submitting this certification the potential contractor/grantee accepts the following terms: 1. The certification herein below is a material representation of fact upon which reliance was placed when this contract/grant was entered into. If it is later determined that the potential contractor/grantee knowingly rendered an erroneous certification, in addition to other remedies available to the federal government, the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, or the Texas Department of Aging and Disability Services may pursue available remedies, including suspension and/or debarment. 2. The potential contractor/grantee shall provide immediate written notice to the person to which this certification is submitted if at any time the potential contractor/grantee learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. The words "covered contract," "debarred," "suspended; "ineligible," "participant," "person," "principal," "proposal," and "voluntarily excluded," as used in this certification have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. Usage is as defined in the attachment. 4. The potential contractor/grantee agrees by submitting this certification that, should the proposed covered contract/grant be entered into, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, and/or the Texas Department of Aging and Disability Services, as applicable. Do you have or do you anticipate having subcontractors/subgrantees under this proposed contract? YES NO 5. The potential contractor/grantee further agrees by submitting this certification that it will include this certification titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants" without modification, in all covered subcontracts and in solicitations for all covered subcontracts. 6. A contractor/grantee may rely upon a certification of a potential subcontractor/subgrantee that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered contract/grant, unless it knows that the certification is erroneous. A contractor/grantee must, at a minimum, obtain certifications from its covered subcontractors/subgrantees upon each subcontracfs/subgranfs initiation and upon each renewal. 7. Nothing contained in all the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this certification document. The knowledge and information of a contractor/grantee is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 8. Except for contracts/grants authorized under paragraph 4 of these terms, if a contractor/grantee in a covered contract/grant knowingly enters into a covered subcontract/subgrant with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in the transaction, in addition to other remedies available to the federal government, Department of Health and Human Services, United State Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Aging and Disability Services may pursue available remedies, including suspension and/or debarment. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS Indicate which statement applies to the covered potential contractor/grantee: _X_ The potential contractor/grantee certifies, by submission of this certification, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this contract/grant by any federal department or agency or by the State of Texas. The potential contractor/grantee is unable to certify to one or more of the terms in this certification. In this instance, the potential contractor/grantee must attach an explanation for each of the above terms to which he is unable to make certification. Attach the explanation(s) to this certification. NAME OF POTENTIAL CONTRACTOR/GRANTEE City of Round Rock VENDOR ID NO./FEDERAL EMPLOYER'S ID NO, 74-6017485 Signature of Authorized Representative Date Alan McGraw Printed/Typed Name of Authorized Representative Mayor Title of Authorized Representative THIS CERTIFICATION IS FOR FY 2013, PERIOD BEGINNING October 1, 2012 and ENDING September 30, 2013. Insurance Documentation From the City's Third -Party Transit Provider, Star Shuttle STARSHU-01 SCDO '4�� O' CERTIFICATE OF LIABILITY INSURANCE DATE(M1201 YYII) 5/1/2012 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER (800) 935-2442 American Highways Insurance Agency, Inc. 3250 Interstate Drive Richfield, OH 44286 CNAOMEACT Customer Service PHONE Exti. 800 935-2442 FAX No : 330 659-8912 a DDDRRESS: customerservice@ahlains.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:National Interstate Insurance Company 32620 INSURED Star Shuttle, Inc. dba Star Shuttle Iii Charter PO Box 17967 San Antonio, TX 78217- INSURER B : INSURER C : INSURERD: 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. ILNTSRR TYPE OF INSURANCEim POLICY NUMBER POLICY EFF POLICY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 5,000,00 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FKOCCUR X X PP2400020-08 '21112012 2/112013 IJAMAUF TO es (Ea NTFL) nee $ 250;00 MED EXP (Any one person) $ 5,0 PERSONAL S ADV INJURY 3 6,000,000 GENERAL AGGREGATE $ 5,000,0 GENT. AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 5,000,00 X I POLICY PRO- LOCECT $ AUTOMOBILE LIABILITY COMBINED�SINGLE LIMIT Et $ 1,000,00 BODILY INJURY (Per person) S A X ANY AUTO X X PP2400020-08 211/2012 2/1/2013 ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) S X HIRED AUTOS X NON -OWNED AUTOS PR PE E $ Per accident $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 4,000,000 AGGREGATE $ A X EXCESS LIAO CLNMS-MADE EX2400020-09 211/2012 2/1/2013 DED I I RETENTION S $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / NTORY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED?ElN (Mandatory In NH) I A LIMITS E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ N yes, deserve under DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ A Phys.Dam. Deductibies:Charters PP2400020-08 2/1/2012 2/112013 Spec. Perils/Collision $2000 A�All Other $5,000 Spec. Perils/ IIPP2400020-08 211/2012 2/1/2013 $10,000 COII;PP/SVC $2,500 Comp/Col DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, U more space is required) $4M X $1M Excess Auto Liability applies to Charter Buses, Charter Minis, Charter Vans, and School Buses (Charter bases are defined with passenger capacity >29, Charter Minis are defined as Charters with passenger capacity >15 and <30, Charter Vans are defined as Charters with passenger capacity <16 City of Round Rock, its officers and employees 221 East Main Round Rock, TX 78664-5299 ACORD 26 (2010105) 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 11 .- / ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I1�TTER��. T�A7'E WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS This endorsement modifies Insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM TRUCKERS COVERAGE FORM Schedule: Name of Person or Organization: City of Round Rock, its officers and employees We waive any right of recovery we may have against the person or organization shown above because of payments we make for injury or damage arising out of the ownership, maintenance or use of automobiles covered by this policy and where such waiver has been included as part of a contract with that person or organization. The waiver applies only to the person or organization shown above. This endorsement changes the policy to which it is attached and is effective on the date Issued unless otherwise stated. The information below is required only when this endorsement is Issued subsequent to preparation of the policy. Endorsement Effective: 51!2012 Policy No.: XPP2400020-08 Insured: Counter. I ENDORSEMENT CHANGES THE POLICY - PLEASE READ IT CAREFULLY ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY COVERAGE — BUSINESS AUTO This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE Name of Persons or O anization s City of Round Rock, its officers and employees A. The following is added to Paragraph c. under A.1. Who Is An Insured, of Section H — Liability Coverage: Any person or organization shown in the above Schedule who is required to be named as an additional insured under a written contract or agreement between you and that person or organization is an "insured" for Liability Coverage, but only for damages to which this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section H. In addition, the written contract or agreement must be signed and executed by you and the person or organization before the "bodily injury" or "property damage" occurs and in effect during the policy period. B. The following is added to Paragraph 5. Other Insurance, under B. General Conditions of Section IV — Business Auto Conditions: If the person or organization in the above Schedule under a written contract or agreement with you requires this insurance to be primary and non contributory, regardless of the provisions under paragraph a. and paragraph d. of part 5. Other Insurance, this insurance will be primary and non contributory to any other insurance where the scheduled person or organization is a Named Insured. The written contract or agreement must be signed and executed by you and the person or organization before the "bodily injury" or "property damage" occurs and in effect during the policy period. NI CA 20 52 0111 THIS ENDORSEMENT CHANGES THE POLICY - PLEASE READ IT CAREFULLY ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Persons or Organization(s) City of Round Rock, its officers and employees A. Section H — Who Is An Insured is amended to include as an insured any person or organization shown in the above Schedule who you are required to add as an additional insured on this policy under a written contract or written agreement. The written contract or agreement must have been signed and executed by you and the additional insured prior to any "bodily injury", `property damage" or "personal and advertising injury" and in effect during the policy period. B. The insurance provided to the additional insured person or organization applies only to "bodily injury', "property damage" or "personal and advertising injury" covered under Section I — Coverage A — Bodily Injury and Property Damage Liability and Section I — Coverage B — Personal and Advertising Injury Liability , but only with respect to liability for "bodily injury" , `property damage" or `personal and advertising injury" caused in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; and resulting directly from: a. Your ongoing operations performed for the additional insured, which is the subject of the written contract or agreement; or b. "Your work" completed as included in the `products -completed operations hazard", performed for the additional insured, which is the subject of the written contract or agreement. C. For the coverage provided by this endorsement: 1. The following paragraph is added to Paragraph 4.a. of the Other Insurance Condition of Section IV — Commercial General Liability Conditions: NI CG 20 54 0111 This insurance is primary insurance as respects our coverage to the additional insured person or organization where the written contract or agreement requires that this insurance be primary and non contributory. In that event, we will not seek contribution from any other insurance policy available to the additional insured where the additional insured person or organization is a Named Insured. NI CG 20 54 01 11 POLICY NUMBER: XPP2400020-08 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS This endorsement modffles Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: City of Round Rock, its officers and employees (If no entry appears above, Information required to complete this endorsement will be shown in the Dederations as applicable to this endorsement.) We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. The waiver applies only to the person or organization shown in the Schedule. CG 24 041185 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 113 IL 02 75 09 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TEXAS CHANGES - CANCELLATION AND NONRENEWAL PROVISIONS FOR CASUALTY LINES AND COMMERCIAL PACKAGE POLICIES This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART EMPLOYMENT-RELATED PRACTICES LIABILITY FARM COVERAGE PART - FARM LIABILITY COVERAGE FORM LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART This endorsement also modifies insurance provided under the following when written as part of a Commercial Package Policy: CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART CRIME AND FIDELITY COVERAGE PART EMPLOYMENT-RELATED PRACTICES LIABILITY EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART - FARM LIABILITY COVERAGE FORM FARM COVERAGE PART - LIVESTOCK COVERAGE FORM FARM COVERAGE PART - MOBILE AGRICULTURAL MACHINERY AND EQUIPMENT COVERAGE FORM GLASS COVERAGE FORM LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Paragraph 2. of the Cancellation Common unit -owner to whom we issued a certificate Policy Condition is replaced by the following: or memorandum of insurance, by mailing or 2. We may cancel this policy by mailing or delivering the notice to each last mailing delivering to the first Named Insured address known to us. written notice of cancellation, stating the The permissible reasons for cancellation are reason for cancellation, at least 10 days as follows: before the effective date of cancellation. a. If this policy has been in effect for 60 However if this policy covers a condo- days or less, we may cancel for any minium association, and the condominium reason- except, that under the pro - property contains at least one residence or visions of the Texas insurance Code, the condominium declarations conform we may not cancel this policy solely with the Texas Uniform Condominium Act, because the policyholder is an elected then the notice of cancellation, as official. described above, will be provided to the First Named Insured 30 days before the b. If this policy has been in effect for effective date of cancellation. We will also more than 60 days, or if it is a renewal provide 30 days' written notice to each or continuation of a policy issued by ILTX 02 75 09 07 ® ISO Properties, Inc., 2006 Page 1 of 2 %Awt .... VM....-. ri--. _i_... i .... .. TM us, we may cancel only for one or more of the fallowing reasons:• .• (1) Fraud in obtaining coverage; (2) Failure to pay premiums when due; (3) An increase in hazard within the control of the insured which would produce an Increase in rate; (4) Loss of our reinsurance covering all or part of the risk covered by the policy; or (5) If we have been placed In supervis- ion, conservatorship or receivership and the cancellation is approved or directed by the supervisor, conser- vator or receiver. B. The following condition is added and super- sedes any provision to the contrary: NONRENEWAL 1. We may elect not to renew this policy except, that under the provisions of the Texas Insurance Code, we may not refuse to renew this policy solely because the policyholder is an elected official. 2. This Paragraph, 2., applies unless the policy qualifies under Paragraph 3. below. If we elect not to renew this policy, we may do so by mailing or delivering to the first Named Insured, at the last mailing address known to us, written notice of nonrenewal, stating the reason for non- renewal, at least 60 days before the expiration date. If notice is mailed or -.- delivered less than. .60 . days .. before_ . the expiration date, this policy will remain in effect until the 61st day after the date on which the notice is mailed or delivered. Earned premium for any period of coverage that extends beyond the expiration date will be computed pro rata based on the previous year's premium. 3. If this policy covers a condominium asso- ciation, and the condominium property contains at least one residence or the condominium declarations conform with the Texas Uniform Condominium Act, then we will mail or deliver written notice of nonrenewal, at least 30 days before the expiration or anniversary date of the policy, to: a. The first Named Insured; and b. Each unit -owner to whom we issued a certificate or memorandum of insurance. We will mail or deliver such notice to each last mailing address known to us. 4. If notice is mailed, proof of mailing will be sufficient proof of notice. 5. The transfer of a policyholder between admitted companies within the same insur- ance group is not considered a refusal to renew. Pam 2 of 2 0 ISO Properties, Inc., 2006 ILTX 02 75 09 07 CravensWarren Insurance - Bonds - Benefits TO CERTIFICATE HOLDER: Our agency is issuing the enclosed certificate of insurance on behalf of STAR SHUTTLE, INC, a client of G&A Partners, a Professional Employer Organization (PEO). G&A and STAR SHUTTLE, INC are co -employer's Of STAR SHUTTLE, INC's leased employees. G&A is the employer of record for Workers Compensation and extends coverage from that policy to STAR SHUTTLE, INC through an Alternate Employer Endorsement, which is shown on your Certificate of Insurance. Effective January 1$t, Texas Senate Bill 425 became law mandating specific requirements regarding Certificates of Insurance. Under this new law Certificate of Insurance forms must be filed and approved by the Texas Department of Insurance before they can be used. In addition, Insurance agents or Certificate Holders that do not follow the new law could incur significant penalties. And any person who willfully violates this law is subject to a civil penalty of not more than $1,000 for each violation. For this reason, we are restricted on what we can state on Certificates of Insurance and can not type any special wording beyond what is allowed by statute. Attached we have included G&A's Blanket Alternate Employer Endorsement which applies to all clients of G&A. We hope you will understand our position and ask that you give us a call if you have any questions or comments. Sincerely, Debbie Preston, CISR, ACSR Account Manager G&AST-1 OP ID: RSG CERTIFICATE OF LIABILITY INSURANCE DATE051015rouDNYYY) ' 12 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 713-690-6000 CravensMMarren & Company P. 0. Box 41328 713-690-6020 Houston, TX 77241-1328 C. Michael Schneider cT NAME; PHONE AIC o E A1C No): E-MAIL ss: INSURERS) AFFORDING COVERAGE NAIL i INSURERA:Texas Mutual Insurance Company 22945 INSURED G&A Partners 4801 Woodway, #210 Houston, TX 77056 INSURERS: 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. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER M MMIDOIYYYY LIMBS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE r_1 OCCUR EACH OCCURRENCE $ PREMISES(Ea occurrence f MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS- COMPIOP AGG f f AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOSHIRED AUTOS NON-OWNEDUT CEO1cadNdTISINGLE LIMIT $ BODILY INJURY (Per person) f BODILY INJURY (Per accident) f PROPERTY PeraccidentDAMAG f s UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE f AGGREGATE f DED RETENTION$ f A WOFtFCERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Ya OFFICERI EMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA TSF0001076234 02/23/12 02/23/13 X WC STATU-LIMITS OTH- ER E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOY f 1,000,0 E.L. DISEASE - POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addldonal Remarks Schedule, Irmore space Is required) Star Shuttle is insured under the referenced policy through an alternate employer endorsement. See form WC 000301 City of Round Rock Assistant City Manager 221 East Main Round Rock, TX 78664-5299 ACORD 26 (2010105) CITYRRI 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 C �� V 1Vtftf-LUTU A%.VKU (.VKYVKAI IVN. /ill ngms reSeFWU. The ACORD name and logo are registered marks of ACORD G&AST-1 OP ID: RSG '41 Rte- CERTIFICATE OF LIABILITY INSURANCE °A'0510112 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 05101/12 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s), PRODUCER 713-690-6000 Cravens/Warren & Company P. O. BOX 41328 713-890-6020 Houston, TX 77241-1328 C. Michael Schneider NA00E;cT P ONE FAR AIC No E AIC No): E AIL ADDRESS: WSURER(S) AFFORDING COVERAGE NAIC GENERAL LIABILITY INSURER A: Texas Mutual Insurance Company 22945 INSURED G&A Partners 4801 Woodway, #210 Houston, TX 77056 INSURER B: INSURER C: INSURER D : PREMISES Ea occurrence i INSURER E COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F] OCCUR INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NIIMR6R- 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. SIRR TYPE OF INSURANCE ADUL SUBF MM POLICY NUMBER POLICY EFF MM POLICY EXP MMIDOIYYYY LIMBS GENERAL LIABILITY EACH OCCURRENCE f PREMISES Ea occurrence i COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F] OCCUR MED EXP (Any one person) f PERSONAL & ADV INJURY f GENERAL AGGREGATE f GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP/OP AGG S POLICY % LOC f AUTOMOBILE LIABILITY CEOM"NE�D,tSiNGLE LIMIT f BODILY INJURY (Per person) f ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) f HIRED AUTOS AUTNON-OWNEDPer accident) A f f UMBRELLA UAB HOCCUR EACH OCCURRENCE i AGGREGATE f EXCESS LIAB CLAIMS -MADE DED I I RETENTION S f A WORKERS COMPENSATIONX AND EMPLOYERS'LIABILITY IELIMITSTH- ANY PROPRIETORIPARTNERearnVE YIN EXCLUDED? (Mandatory In NH) N I A TSF0001076234 02/23/12 02/23113 WC STATU- O E.L. EACH ACCIDENT f 1,000,00 E.L. DISEASE - EA EMPLOYEE f 1,000,00 Ryes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT f 1,000,0 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If mon space is required) Star Shuttle is insured under the referenced policy through an alternate employer endorsement. See form WC 000301 City of Round Rock City Attorney 309 East Main Round Rock, TX 78664 CITYRR2 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 /o ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD ®iNORKERS' COMPENSATION AND EMPLOYERS m, LIABILITY INSURANCE POLICY .TomInsumaceCompany WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENT This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be canceled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the altemate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. Alternate Employer STAR SHUTTLE (1138) -CLIENT Schedule Address 1343 HALLMARK DR SAN ANTONIO, TX 78216-6020 State of Special or Temporary Employment TEXAS This endorsement changes the policy to which it is attached effective on the Inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on February 23, 2012 at 12:01 A.M. standard time, forms a part of Policy No. TSF -0001076234 20120223 of the Texas Mutual Insurance Company Issued to G & A OUTSOURCING INC Endorsement No. 1 DBA: G & A PARTNERS Premium $ 0.00 �0*%�1** Authorized Representative ** WC000301 (ED. 1.94) INSURED'S COPY MXSALAZA 3-02-2012 ** WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC420304A TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Texas Is shown in item 3A. of the Information Page. We have the right to recover our payments from anyone tlable for an injury covered by this policy. We will not enforce oui right against the person or orgaMzatlon named in the Schedule, but this waiver applies only with n;spect to bodily injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or Indirectly to benefit anyone not named In the Schedule. The premium forthis endorsement is shown in the Schedule. Schedule 1. ( ) Spedtic Waiver Name of person or organization ( X ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: ALL TEXAS. OPERAT 1 ONS 3. Premium The premium charge fortlrls endorsement shalt be, 2.00 percent of the premium developed on payroll in connection with work performed for the above person(s) or organizations) arising out of the operations described. 4. Advance Premium 1 NCLUDED . SEE: I NFORMAT 1 ON PAGE. This erdonentierd dwVw itw policy to width a b attached *O*W" on Ow hoVdon date of #* policy wdea. a da'arant dada b kKgc ed blow. (n:e fdMnd lattft daued' need be completed o* when We endorsement to leeued eubeequWd to prepardw of the policy.) Ude wWo wnerd, sKectim on d 1x01 A.M. atendard time, forms a part of PoficyNo. TBF-0001070234 20120223 oftheTexas Mutual Insuranoe Company issued to G & A OUTSOURC i NO 1 NC EndorsernentNo. ORA: 0 et A PARTNERS Premium REPR I NT Authorized Represonti ive WC42030" (ED. 1.01-2000) iNSURED'S COPY OUSER 2-21-2012 ROUND ROCK TEW City Council Agenda Summary Sheet PURPOSE PASSION PROSPERfrY. Agenda Item No. H11. Consider a resolution authorizing the Mayor to execute various relative to applying for Agenda Caption: nutrition funding for Demand Response Bus Service. Date: November 8, 2012 rtment: Transportation Staff Person making presentation: Gary Hudder Transportation Director Item Summary: The Area Agency on Aging offers funding for transportation services which provides nutrition bus trips for seniors. The Demand Response Bus Service transports seniors, on a daily basis, to the Baca Center and AGE to participate in their low cost meal programs. The funding will provide reimbursement for the nutrition trips the Demand Response Bus Service makes. The amount of the funding will be dependent on the number of those trips. The exact amount will not be calculated until execution of the Vendor Agreement, which will happen after this Vendor Application is processed and accepted. The execution of this Vendor Application is step one in the process of obtaining funding. After the application is accepted the Area Agency on Aging will provide a Vendor Agreement which will need to be executed before obtaining the funding. Cost: N/A Source of Funds: N/A Recommended Action: Approval t' k S; d 3 5 44 is S S` a x a 3 i Fa i' is i 3 n: f 4` { AreaAgency DIRECT PURCHASE OF SERVICES on Aging FISCAL YEAR 2013 VENDOR APPLICATION / RENEWAL UPDATE of the Capital Area Please type or clearly print application information. Vendor Name/Legal Entity City of Round Rock DBA (if applicable) not applicable Physical Address Street: 221 E. Main Street City: Round Rock State: Texas ZIP: 78664 Mailing Address Street or PO Box: 221 E. Main Street City: Round Rock State: Texas ZIP: 78664 Tax Identification Number (SSN or Federal ID): 74-6017485 Type of Provider ❑ Government Agency ❑ Private Non -Profit ❑ Private For Profit ® City Government ❑ County Government ❑ Other: ❑ Rural Provider ❑ Minority Provider Authorizing Official Name: Alan McGraw Title: Mayor Email Address: mayormcgraw@roundrocktexas.gov Telephone: 512-218-5403 Fax: Billing Contact Person and Address: Name: Caren Lee Title: Administrative Assistant Street or PO Box: 2008 Enterprise Dr. City: Round Rock State: Texas ZIP: 78664 Email Address: clee@roundrocktexas.gov Telephone: 512-671-2869 Fax: 512-218-5563 Number of Years Organization has been in business: 100 years Is Agency Bonded? ® Yes: Attach certificate of bonding insurance ❑ No Has Anyone in Agency been convicted of a felony? ❑ Yes ® No If yes, explain (attach additional sheets if necessary): Does Agency have liability insurance? ® Yes: Attach certificate of all insurances ❑ No Revised 09/08 DPS Application Page 2 service and Bidding Information: 1. Proposed Service: Demand Response Bus Service Define your unit of service: per person Service Any origin and destination within the city limits of Area: Round Rock Proposed service cost per unit: current fare structures is $2.00 per person each way $1.00 per person each way for persons over 60 or with a disability Revised 09/08 2 DPS Application Page 3 Attach a copy of all applicable State and Federal license and/or certifications that regulate your business. Conflicts of Interest: Attach information of applicable names and relationship of any employee(s) or officers of your organization that may have a conflict of interest with an Area Agency on Aging of the Capital Area staff person or Advisory Council member. Additional Attachments: Affirmative Action Plan Signed Statement indicating compliance with the Civil Rights Act of 1964 Signed Certification Regarding Debarment I certify that the information provided in this application is true and correct to the best of my knowledge. Mayor Alan McGraw Print Name Date Authorized Signature Revised 09/08 3 ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES REGULATION UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 City of Round Rock (hereinafter called the "Applicant") Name of Applicant (Type or Print) HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L. 880352) and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45C.F.R. Part 80) issued pursuant to that title, to the end that, in accordance with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement. If any real property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the Applicant by the Department, this Assurance shall obligate the Applicant, or in the case of any transfer of such property, and transferee, for the period during which the real property or structure is used for a purpose for which the Federal Financial assistance is extended or for another purpose involving the provision of similar services or benefits. If any personal property is so provided, this Assurance shall obligate the Applicant for the period during which it retains ownership or possession of the property. In all other cases, this Assurance shall obligate the Applicant for the period during which the Federal financial assistance is extended to it by the Department. THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all Federal grants, loans, contracts, property, discounts or other Federal financial assistance extended after the date hereof to the Applicant by the Department, including installment payments after such a date on account of applications for Federal financial assistance which were approved before such date. The Applicant recognizes and agrees that such Federal financial assistance will be extended in reliance on the representations and agreements made in the Assurance, and that the United States shall have the right to seek judicial enforcement of this Assurance. This Assurance is binding on the Applicant, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this Assurance on behalf of the Applicant. Date 221 E. Main Street Round Rock, Texas 78664 Applicant's Mailing Address Vt7-- 11-0% - fl 11 (1) City of Round Rock Applicant (Type or Print) Authorized Signature CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS Federal Executive Order 12549 requires the Texas Department of Aging and Disability Services (DADS) to screen each covered potential contractor/grantee to determine whether each has a right to obtain a contract/grant in accordance with federal regulations on debarment, suspension, ineligibility, and voluntary exclusion. Each covered contractor/grantee must also screen each of its covered subcontractors/providers. In this certification "contractor/grantee" refers to both contractor/grantee and subcontractor/subgrantee; "contract/grant" refers to both contract/grant and subcontract/subgrant. By signing and submitting this certification the potential contractor/grantee accepts the following terms: 1. The certification herein below is a material representation of fact upon which reliance was placed when this contract/grant was entered into. If it is later determined that the potential contractor/grantee knowingly rendered an erroneous certification, in addition to other remedies available to the federal government, the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, or the Texas Department of Aging and Disability Services may pursue available remedies, including suspension and/or debarment. 2. The potential contractor/grantee shall provide immediate written notice to the person to which this certification is submitted if at any time the potential contractor/grantee learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. The words "covered contract," "debarred," "suspended," "ineligible," "participant," "person," "principal," "proposal," and "voluntarily excluded," as used in this certification have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. Usage is as defined in the attachment. 4. The potential contractor/grantee agrees by submitting this certification that, should the proposed covered contract/grant he entered into, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, and/or the Texas Department of Aging and Disability Services, as applicable. Do you have or do you anticipate having subcontractors/subgrantees under this proposed contract? YES NO 5. The potential contractor/grantee further agrees by submitting this certification that it will include this certification titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants" without modification, in all covered subcontracts and in solicitations for all covered subcontracts. 6. A contractor/grantee may rely upon a certification of a potential subcontractor/subgrantee that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered contract/grant, unless it knows that the certification is erroneous. A contractor/grantee must, at a minimum, obtain certifications from its covered subcontractors/subgrantees upon each subcontract's/subgrant's initiation and upon each renewal. 7. Nothing contained in all the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this certification document. The knowledge and information of a contractor/grantee is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 8. Except for contracts/grants authorized under paragraph 4 of these terms, if a contractor/grantee in a covered contract/grant knowingly enters into a covered subcontract/subgrant with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in the transaction, in addition to other remedies available to the federal government, Department of Health and Human Services, United State Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Aging and Disability Services may pursue available remedies, including suspension and/or debarment. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS Indicate which statement applies to the covered potential contractor/grantee: _X_ The potential contractor/grantee certifies, by submission of this certification, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this contract/grant by any federal department or agency or by the State of Texas. The potential contractor/grantee is unable to certify to one or more of the terms in this certification. In this instance, the potential contractor/grantee must attach an explanation for each of the above terms to which he is unable to make certification. Attach the explanation(s) to this certification. NAME OF POTENTIAL CONTRACTOR/GRANTEE City of Round Rock VENDOR ID NO./FEDERAL EMPLOYER'S ID NO. /' Signature of Authorized Representative // �/ Z Date Alan McGraw Printed/Typed Name of Authorized Representative Title of Authorized Representative THIS CERTIFICATION IS FOR FY 2013, PERIOD BEGINNING October 1, 2012 and ENDING September 30, 2013. W-12-11- 000i` -b 1 (3) Insurance Documentation From the City's Third -Party Transit Provider, Star Shuttle STARSHU-01 SCDO H CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) TYPE OF INSURANCE 611/2 5/1/2012 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: ff the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. H SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER (800) 935-2442 American Highways Insurance Agency, Inc. 3250 Interstate Drive Richfield, OH 44286 NAME Customer Service PHONE (FAX,No : 330 659-8912 Arc No Ext): 800 935-2442AIC ADD�RELSS: CUStomemerviC ahiains.com INSURE S AFFORDING COVERAGE NAIC ■ INSURED Star Shuttle, Inc. dba Star Shuttle & Charter PO Box 17967 San Antonio, TX 78217- INSURERA:National Interstate Insurance Company 32620 INSURER B INSURER C : INSURER D : INSURER E EACH OCCURRENCE $ 5,000,0 00 INSURER F MED EXP (Any one person) $ 5,004 ---- ----�— a.cn i irn.ia t r- NUMOCK: REVISION NUMBER: Twe m TA ^co- r ,,, . r" rvuvlw Ur IlvtlUKANGt 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. R LTR TYPE OF INSURANCE WVDPOLICY NUMBER MMIDDIYYYY POLICY EXP MMIDONYYY LIMITS A GENERAL EDIBILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX -1 OCCUR X X PP2400020-08 2/1/2012 2/1/2013 EACH OCCURRENCE $ 5,000,0 00 PREMISES Ea occurrence $ 2500 MED EXP (Any one person) $ 5,004 PERSONAL 6 ADV INJURY $ 5,000,04 GENERAL AGGREGATE $ 5,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRO - X POLICY F LOC PRODUCTS - COMPIOP AGG $ 5,000,0 S A AUTOMOBILE LIABILITY JX ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X X PP2400020-08 211/2012 211/2013 Ea accident) INGLE LIMIT S 1,0110, 00( BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ HIRED AUTOS X ANON-OWNED P P DAMAGE$ Per accident S A X UMBRELLA L IAB EXCESS UAB X OCCUR CLAIM MADE EX2400020-09 21112012 21112013 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ DED RETENTION $ S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ (Mandatory in NH) N yyss deeerlee under DESG�RIPTION OF OPERATIONS bebw N / A WC STATU- OTH TORY LIMITS E.L.EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT I $ A Phys.Dam. Deductibles:Charters PP2400020-08 21112012 2/1/2013 Spec. Perils/Collision $2000( A All Other $6,000 Spec. Perils/ PP2400020-08 211/2012 2/1/2013 $10,000 COII;PP/SVC $2,500 Comp/Col DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) $4M X $1M Excess Auto Liability applies to Charter Buses, Charter Minis, Charter Vans, and School Buses (Charter beses are defined with passenger capacity >29, Charter Minis are defined as Charters with passenger capacity >15 and <30, Charter Vans are defined as Charters with passenger capacity <16 City of Round Rock, its officers and employees 221 East Main Round Rock, TX 78664-5299 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 vc IVOO-ZUTU Acuru) cORPVRATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS This endorsement modifies Insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM TRUCKERS COVERAGE FORM Schedule: Name of Person or Organization: City of Round Rock, its officers and employees We waive any right of recovery we may have against the person or organization shown above because of payments we make for injury or damage arising out or the ownership. maintenance or use of automobiles covered by this policy and where such waiver has been included as part of a contract with that person or organization. The waiver applies only to the person or organization shown above. This endorsement changes the policy to which It is attached and is effective on the date issued unless otherwise stated. The Information below Is required only when this endorsement Is Issued subsequent to preparation of the policy. Endorsement Effective: 5/1/1012 Policy No.: XPP2400020-08 Insured: Counters THIS ENDORSEMENT CHANGES THE POLICY - PLEASE READ IT CAREFULLY ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY COVERAGE — BUSINESS AUTO This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE Name ofPerso s or OrganizatiLmUs City of Round Rock, its officers and employees A. The following is added to Paragraph c. under A.1. Who Is An Insured, of Section 11 — Liability Coverage: Any person or organization shown in the above Schedule who is required to be named as an additional insured under a written contract or agreement between you and that person or organization is an "insured" for Liability Coverage, but only for damages to which this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section H. In addition, the written contract or agreement must be signed and executed by you and the person or organization before the "bodily injury" or `property damage" occurs and in effect during the policy period. B. The following is added to Paragraph S. Other Insurance, under B. General Conditions of Section IV — Business Auto Conditions: If the person or organization in the above Schedule under a written contract or agreement with you requires this insurance to be primary and non contributory, regardless of the provisions under paragraph a. and paragraph d. of part 5. Other Insurance, this insurance will be primary and non contributory to any other insurance where the scheduled person or organization is a Named Insured. The written contract or agreement must be signed and executed by you and the person or organization before the "bodily injury" or "property damage" occurs and in effect during the policy period. NI CA 20 52 01 11 THIS ENDORSEMENT CHANGES THE POLICY - PLEASE READ IT CAREFULLY ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Persons or do s City of Round Rock, its officers and employees A. Section II — Who Is An Insured is amended to include as an insured any person or organization shown in the above Schedule who you are required to add as an additional insured on this policy under a written contract or written agreement. The written contract or agreement must have been signed and executed by you and the additional insured prior to any "bodily injury", "property damage" or "personal and advertising injury" and in effect during the policy period. B. The insurance provided to the additional insured person or organization applies only to "bodily injury", "property damage" or `personal and advertising injury" covered under Section I — Coverage A — Bodily Injury and Property Damage Liability and Section I — Coverage B — Personal and Advertising Injury Liability , but only with respect to liability for "bodily injury" , `property damage" or `personal and advertising injury" caused in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, and resulting directly from: a. Your ongoing operations performed for the additional insured, which is the subject of the written contract or agreement; or b. "Your work" completed as included in the `products -completed operations hazard", performed for the additional insured, which is the subject of the written contract or agreement. C. For the coverage provided by this endorsement: 1. The following paragraph is added to Paragraph 4.a. of the Other Insurance Condition of Section IV — Commercial General Liability Conditions: NI CG 20 54 0111 This insurance is primary insurance as respects our coverage to the additional insured person or organization where the written contract or agreement requires that this insurance be primary and non contributory. In that event, we will not seek contribution from any other insurance policy available to the additional insured where the additional insured person or organization is a Named Insured. NI CG 20 54 01 11 POLICY NUMBER: XPP2400020-08 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART SCHEDULE Name of Penson or Organization: City of Round Rock, its officers and employees (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. The waiver applies orgy to the person or organization shown in the Schedule. CG 24 041185 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 10 IL 02 75 09 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ & CAREFULLY. TEXAS CHANGES - CANCELLATION AND NONRENEWAL PROVISIONS FOR CASUALTY LINES AND COMMERCIAL PACKAGE POLICIES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART EMPLOYMENT-RELATED PRACTICES LIABILITY FARM COVERAGE PART - FARM LIABILITY COVERAGE FORM LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART This endorsement also modifies Insurance provided under the following when written as part of a Commercial Package Policy: CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART CRIME AND FIDELITY COVERAGE PART EMPLOYMENT-RELATED PRACTICES LIABILITY EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART - FARM LIABILITY COVERAGE FORM FARM COVERAGE PART - LIVESTOCK COVERAGE FORM FARM COVERAGE PART - MOBILE AGRICULTURAL MACHINERY AND EQUIPMENT COVERAGE FORM GLASS COVERAGE FORM LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Paragraph 2. of the CwwWlatlon Common Policy Condition is replaced by the following: unit -owner to whom we issued a certificate 2. We may cancel this policy by mailing or or memorandum of insurance, by mail'mg or delivering the notice to each last mailing delivering to the first Named Insured address known to us. written notice of cancellation, stating the reason for The permissible reasons for cancellation are cancellation, at least 10 days before the effective date of cancellation. as follows: However if this policy covers a condo- a. If this policy has been in effect for 60 days less, minium association, and the condominium or we may cancel for any Property contains at least one residence or the reason except, that under the pro - visions of the Texas Insurance Code, condominium declarations conform with the Taxes Uniform Condominium Act. we may not cancel this solely then the notice of cancellation, as because the policyholder is an s an elea cted official. described above, will be provided to the Rrst Named Insured 30 days before the b, If this policy has been in effect for effective date of cancellation. We will also more than 60 days, or if it is renewal provide 30 days' written notice to each or continuation of a policy issued by s ILTX 02 75 09 07 0 ISO Properties, Inc., 2006 Page 1 of 2 W..M..... VI.....-- r% ---teTM us, we may cancel only for one or more of the following reasons. (1) Fraud in obtaining coverage; (2) Failure to pay premiums when due; (3) An increase in hazard within the control of the Insured which would produce an Increase in rate; (4) Loss of our reinsurance covering all or part of the risk covered by the policy; or (5) If we have been placed in supervis- ion, conservatorship or receivership and the cancellation is approved or directed by the supervisor, conser- vator or receiver. B. The following condition is added and super- sedes any provision to the contrary: NONRENEWAL 1. We may elect not to renew this policy except, that under the provisions of the Texas Insurance Code, we may not refuse to renew this poric:y solely because the policyholder is an elected official. 2. This Paragraph, 2., applies unless the policy qualifies under Paragraph 3. below. If we elect not to renew this policy, we may do so by mairing or derivering to the first Named Insured, at the last mailing address known to us, written notice of nonrenewal, stating the reason for non- renewal, at least 60 days before the expiration date. If notice is mailed or delivered less than 60 . days. before. the expiration date, this policy will remain in effect until the 61 at day after the date on which the notice is mailed or delivered. Earned premium for any period of coverage that extends beyond the expiration date will be computed pro rata based on the previous year's premium. 3. If this policy covers a condominium asso- ciation, and the condominium property contains at least one residence or the condominium declarations conform with the Texas Uniform Condominium Act, then we will mail or deriver written notice of nonrenewal, at least 30 days before the expiration or anniversary date of the policy, to: a. The first Named insured; and b. Each unit -owner to whom we issued a certificate or memorandum of insurance. We will mail or deriver such notice to each last maPring address known to us. 4. If notice is mailed, proof of mairing will be sufficient proof of notice. S. The transfer of a policyholder between admitted companies within the same Insur- ance group is not considered a refusal to renew. Paas 2 of 2 0 ISO Properties, Inc., 2006 ILTX 02 75 09 07 CravensWaerren Insurance - Bonds - Benefits TO CERTIFICATE HOLDER: Our agency is issuing the enclosed certificate of insurance on behalf of STAR SHUTTLE, INC, a client of G&A Partners, a Professional Employer Organization (PEO). G&A and STAR SHUTTLE, INC are co -employer's of STAR SHUTTLE, INC's leased employees. G&A is the employer of record for Workers Compensation and extends coverage from that policy to STAR SHUTTLE, INC through an Alternate Employer Endorsement, which is shown on your Certificate of Insurance. Effective January la, Texas Senate Bill 425 became law mandating specific requirements regarding Certificates of Insurance. Under this new law Certificate of Insurance forms must be filed and approved by the Texas Department of Insurance before they can be used. In addition, Insurance agents or Certificate Hoklers that do not follow the new law could incur significant penalties. And any person who willfully violates this law is subiect to a civil penalty of not more than $1,000 for each violation. For this reason, we are restricted on what we can state on Certificates of Insurance and can not type any special wording beyond what is allowed by statute. Attached we have included G&A's Blanket Alternate Employer Endorsement which applies to all clients of G&A. We hope you will understand our position and ask that you give us a call if you have any questions or comments. Sincerely, Debbie Preston, CLSR, ACSR Account Manager G&AST-1 OP ID: RSG � CERTIFICATE OF LIABILITY INSURANCE DATE 10111IYYyY) o5rov12 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 CONS71TUTE 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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 713-690-6000 Cravens/Warren & Company P. O. Box 41328 713-690-6020 Houston, TX 77241-1328 C. Michael Schneider NCONTACT AME: PHONE MC No �DARESS. AD INSU S) AFFORDING COVERAGENAIC I INSURED G&A Partners 4801 Woodway, #210 Houston, TX 77056 INStxtERA:Texas Mutual Insurance Com an 22945 INSURERS: INSURER C : INSURER D: INSURER E INSURER F r[CYIWIVn MILIPMOCK. 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE7F ADMI POLICY NUMBER MM ro EXP MMOONYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE f COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FlOCCUR PREMISES Ea occurrence f MED EXP (Any one person) f PERSONAL & ADV INJURY f GENERAL AGGREGATE f GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT F-1 PRO LOC PRODUCTS- COMP/OP AGG f S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident f BODILY INJURY (Per person) S ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) f HIRED AUTOS AUTOSOWNED 0 TY AMAGE f Per accident f UMBRELLA LA" HCOL CCUR EACH OCCURRENCE f EXCESS LIAR AIMS MADE AGGREGATE f DED RETENTION f S A WORXERS COMPENSATION AND EMPLOYERS' LIABILITY �PR� �LLUDDR�CUTIVE Y� NIA SF0001076234 02/23/12 02/23/13 X WC S A OETR A0O0, E.L. EACH ACCIDENT f E.L. DISEASE - EA EMPLOYEES (Mandatory ti NH) yes, describe under E.L. DISEASE - POLICY LIMIT 1 f 1,000, DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If mon spats Is requlred) Star Shuttle is insured under the referenced policy through an alternate employer endorsement. See form WC 000301 City of Round Rock Assistant City Manager 221 East Main Round Rock, TX 78664-5299 CITYRR1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD G&AST-1 OP ID: RSG CERTIFICATE OF LIABILITY INSURANCE AT 0510110111YYY1� 012 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement s PRODUCER 713-690-6000 Cravens/Warren & Company P. O. Box 41328 713-690-6020 Houston, TX 77241-1328 C. Michael Schneider CONTACT NAME: PHONE No : E-MALarc INSURE S) AFFORDING COVERAGE NAIO d I G&A Palmers 4801 Woodway, #210 Houston, TX 77056 INMutual Insurance Com an 22945 INSURER 6: INSURERc: INSURER D: INSURER E: INSURER F : RCVIOIVN NUNItitK: 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. TR I TYPE OF INSURANCE ma POLICY NUMBER POLICY IWIF MM POLICY EXP_ M LIMBS GENERAL LIABILITY EACH OCCURRENCE f COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR PREMISES Ea occurrence f MED EXP (Any one person) f PERSONAL& ADV INJURY f GENERAL AGGREGATE f GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC PRODUCTS- COMPIOP AGG s f AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee accident f ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS AUTOSWNED BODILY INJURY (Per person) s BODILY INJURY (Per accident) $ R Y A f Per accident s UMBRELLA LY18 EXCESS LIAR IOCCUR CLAIMS -MADE EACH OCCURRENCE f AGGREGATE f DED I I RETENTION f f A WORKERSCOMPENSATION AND �PR CERAYIEMBER �1UDE� cunvE Ya NIA TSF0001076234 02123M2 02Q3/13 X W A _U LIMITS I IFR E.L. EACH ACCIDENT s 1,000, E.L. DISEASE - EA EMPLOYEE f 1,000 (M�Mory in NH) I yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT f 11000, DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If mon spas Is required) : Star Shuttle is insured under the referenced policy through an alternate employer endorsement. See form WC 000301 CERTIFICATE HOLDER CANCELLATION City of Round Rock CITYRR2 City Attomey 309 East Main SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Round Rock, TX 78664 AUTHORIZED REPRESENTATIVE ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD iexasmuta ®IIVORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY LtstlraaceCo "ay WC 00 03 01 ALTERNATE EMPLOYER ENDORSEMENT This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the altemate employer in the state named in the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the altemate employer is insured. Under Part One (Workers Compensation Insurance) we will reimburse the altemate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the altemate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be canceled according to its terms without sending notice to the altemate employer. Part Four (Your Duties If Injury Occurs) applies to you and the altemate employer. The altemate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. Alternate Emolover STAR SHUTTLE (1138) -CLIENT Schedule Address 1343 HALLMARK OR SAN ANTONIO, TX 7821 &6020 State of Special or Temporary Employment TEXAS This endorsement changes the policy to which it Is attached effective on the inception date of the policy unless a different date is indicated below. (The Wowing "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on February 23, 2012 at 1201 A.M. standard time, forms a part of Policy No. TSF -0001076234 20120223 of the Texas Mutual Insurance Company Issued to G & A OUTSOURCING INC Endorsement No. 1 ORA: G & A PARTNERS Premium $ 0.00 Authorized Representative *• WC000301 (ED. 1.94) INSURED'S COPY MXSALAZA 3-02-2012 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC420304A TEXAS WAIM OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement apples only to the Insurance provided by the policy because Texas Is shown In item 3A. of the Information Page. We have the right to recover our payments from anyone liable for an injury covered by this poncy. We WU not enforce ow fight against the person or organization named in the Schedule, but this waiver apples only with respect to bodly InJuq arising out of the operations described In the Schedule where you are required by a written contract to obtain this waterer from us. This endorsement shad not operate directly or Indirectly to benefit anyone not named in the Schedule. The premium for this endorsement Is shown in the Schedule. Schedule 1. ( ) Spedlc Waterer Name of pemon or organization ( X ) Blantcet Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: ALL TEXAS. OPERAT I ONS 3. Premium The premium charge for this endorsement shall be 2.00 perraent of the premium developed on payroll in connection with work perfumed for the above person(s) or organization(s) arising out of the operations described. 4. Advance Premium INCLUDED, SEE INFORMATION PAGE. rnW erulWS wd dtt ow fie pricy fb which It M affadwd a(Iedlw on #w hoWUm data ortlr pofrcy aria. n r-61 1 rrt dice Y idWW bWow. . (ro+ 1dkW g tithed ft dwW novel be aomphted 0* when thh Mdonw:wx Is hared *Wxoqwrt Io pr pwdm, of ON poNq.) TW o mdoaa:wit. WIrMa on d 12;01 A.M. standard fxwk fwn a pert of PoftNo. TSF -0001076234 20120223 of am Texas Mutual lnstuanoeCompany Issued to 0 G A OUTS"C I NO I NC ORA: O Q A PARTNERS; Prowurn $ REPRINT WC4ff MA tED.141-2008) ErAorsement No. Av--4 i NSURED' S COPY OUSER 2-21-2012