3rd Amendment 09/20/2023 GVS COURTq°
o: A Kevin Madok, CPA
-
�o ........ � Clerk of the Circuit Court& Comptroller Monroe County, Florida
�z cooN
DATE: November 10, 2023
TO: William DeSantis, Director
Facilities Maintenance
Chrissy Collins
Executive Administrator
Alice Steryou
Contract Monitor
FROM: Liz Yongue, Deputy Clerk
SUBJECT: September 20, 2023 BOCC Meeting
The following item has been executed and added to the record:
C29 3rd Amendment to Agreement with Siemens Industry, Inc., as a Sole Source
provider for testing, certification, and maintenance of Fire Alarm, Smoke Control, and Building
Automation Systems on Monroe County facilities adjusting the contract amount by a 5.5%
increase effective on October 1, 2023. Funding is Ad Valorem.
Should you have any questions please feel free to contact me at(305) 292-3550.
cc: County Attorney
Finance
File
KEY WEST MARATHON PLANTATION KEY
500 Whitehead Street 3117 Overseas Highway 88770 Overseas Highway
Key West, Florida 33040 Marathon, Florida 33050 Plantation Key, Florida 33070
THIRD AMENDMENT TO SOLE SOURCE AGREEMENT WITH SIEMENS
INDUSTRY, INC.
FOR
TESTING, CERTIFICATION, AND MAINTENANCE OF
ENVIRONMENTAL BUILDING, MANAGEMENT SYSTEMS
MONROE COUNTY, FLORIDA
This Third Amendment to Sole Source Agreement is made and entered into this 20th day
,of Septernber, 2023, by and through MONROE, CIOUN-FY, FLORIDA ("CO1.NTY" or
"OWNER")a political subdivision of the State of Florida,whose address is 11 Simonton Street,
Key West, Florida 40, and SIEMENS INDUnRY, INC. ("CONTRACTOW' or
"SIEMEN'S")) a Delaware corporation, authorized to do business in the State of Florida as a
Foreign-for-Profit Corporation, whose principal address is 100 Technology Drive, Alpharetta,
Georgia 30005, and whose mailing address for the purposes of this Agreement is 3021 M
Commerce Parkway, Miramar, Flofida, 33025, and whose mailing address for payment is 1000
Deerfield Parkway, Buffalo Grove, Illinois 60089-4513, (with each being a "PARTY' and
collectively referred to as the"PARTIES").
WHEREAS,the Board of County Commissioners("BOCC") approved on May 20, 2020,
the replacement of the existing, no longer supported Environmental Building Management
Systems (DBMS) with a, Desigo Enterprise BMS for the amount of $237,583.06 allowing the
County to monitor additional sites remotely and locally in a unified system; and
WHEREAS,the BOCC approved on March, 17,2021,a request for a waiver of the.Monroe
County Purchasing Policy pr visions to designate Siemens Industry,1ric.as a Sole Socar ce.Provider
sothat the expiring Contract with Siemens Industry, Inc. could be negotiated and renewed as a,
sole source contract; and
WtIER]EAS, on April 21, 2021, the BOCC approved a rrionth-to-month renewal
agreement with Siemens Industry, Inc. pending negotiations to take place with Siemens, until a
satisfactory Sole SOUrce Agreement was achieved and than. for it to be placed on an agenda, for
approval by theBOCC; and
WHEREAS, on April 20, 2022, the BOCC approved a negotiated Agreement with
Sieniens Industry, Inc, as a Sole Source provider for testing,certification,and maintenance of Fire
Alarin, Smoke Control, and Environmental Building Mariagenient Systems on Monroe County
facilities ("Original Agreement"); and
WHEREAS, on October 1 , 2022, the BOCC approved a First Amendment to
aniend the Original Agreement to increase payment amounts by five mid five tenths percent(5.5%)
retroactive to October 1, 2022, pursuant to the terins of the Original Agreement and to update the
Federal Required Contract Provisions; and
SicinensTbIrd Amen(fii,,ient Agreement—IrrIffiective October 1,2023
WHEREAS,on March 22,2023,the BOCC approved a Second Amendment to Agreement
t® update certain Federal provisions in order to allow additional necessary upgrades es by Siemens
to current equipment with funding from American Rescue Plan Act(" • PA")funds; and
WHEREAS,Pam graph 10. G..onfthe Original Agreement provides that commencing after
one (1) fill year from the effective date of October 1, 2021, and annually thereafter, the contract
amount shall be adjusted In accordance ce with the percentage change in the U.S. Department of
Commerce Consumer price Index for all Urban Consumers(CPI-U)for all items and services for
all U.S. Cities, not seasonally adjusted, as reported by the U.S. Bureau of Labor Statistics at
December 31 of the previous year using the most recently published indicator, or adjusted by an
increase of five and five tenths percent(.5.5%), whichever is less; a nd
WHEREAS, theCPI- U as of December 30 of 2022 was six and five tenths percent
( °5%). Therefore, pursuant to Paragraph 10. G. of the Original Agreement, the contract amount
shall be increased by five and five tenths percent(5.5%), which is less than theCPI.-[J of six and
five tenths percent(6.5%)as of December 31, 2022; d
WHEREAS,this Third Amendment is for amend the Original Agreement, as amended, to
increase payment amounts by five and five tenths percent(5°5%), effective as of October 1,2023,
pursuant to the terms of the Original Agreement; and
WHEREAS, the parties find that it would be mutually beneficial to amend its Original
Agreement, as amended, and enter into this Third Amendment to Agreement;
NOW, THEREFORE, IN ("ONSIDERATION of the mutual promises and covenants
contained herein, It is agreed as follows:
I® In accordance with Paragraph 10. G. of die Original Agreement,the Contract amount shall
be increased by five and fire tenths percent( °5%),which is less than the P1U of six and
five tenths percent( . %)as of December 31.,2022°
2° The Contract amounts for Maintenance ce d 'besting Services, excluding Additional
Services,based on the five and five tenths percent(5°5%)CPI.-U increase,in Paragraph 10.
E. of the Original Agreement, shall be increased with an effective date of October 1,2023,
In the total annual amount of Two HundredSixty-six Thousand, Twelve and 98/100
( , 12aDollars, and arnended for each location as follows-,
Monroe County Detention Center 98,424.80 per year
Plantation Key Detention Center and Courtliouse 7,9 0.39 per year
Sheriffs Administration Building 21,281.04 per year
Monroe County Juvenile Justice Building 37,241.82 per year
Monroe County Government Center(Marathon) 1 , 20°91 per year
2
iemeus'fishd Amendment Agreement. fTective October 1.,2023
Medical Examiner's Office $ 7,980.39, per year
Gato Building $ 7,980.39 per year,
Harvey Government Center S 7,980�.39 per year
Murray Nelson Government Center $ 7,980.39 per year
Jackson Square Key West Courthouse Annex $, 18,620.91 per year
Jefferson B. Browne Building $ 7,980.39 per year
Historic Courthouse $ 7,98039 per year
Lester Building $ 7,98039 per year
Freeman Justice Center $ 7,98039 per year
TOTAL $266,012.99 Annual
3. Except as set forth in Paragraphs I through 2 of this Third Amendment to Sole Source
Agreement, in all other respects, the terms and conditions set forth in the Original
Agreement, as amended, remain in fall force and effect.
[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]
[SIGNATURE PAGE TO FOLLOW]
3
Siemens Third Amendment Agreement—Effective October 1.,2023
IN WITNESS WHEREOF, COUNTY and CONTRACTOR. hereto have set their hands
and seals the day and year first above written.
10 u�-i ,,, `BAIL) -E BOARD OF COUNTY COMMISSIONERS
i�4`-7� C,} ,wYa ' v� k
F`,'� A s?i , VIN MADOK, CLERK OF MONRO '�frjrIUNTY FL I RIDA
a ray-`�C - .1 .st:g a il .,4, ..+,-r �/
qn + c�''�sa
'' — Gkk19 14141 or- .
As peputy Clerk Mayor
Date:
1120i 3
Witnesses for CONTRACTOR: CONTRACTOR:
SIEMENS INDUSTRY,INC.
Digitally signed by Quiceno Bryam
Digital y signed by F ussel DN;:CN=Qulceno Bryam,O=Siemens,
mussei,. Deborah c n rn SN=-Qukeno,G.,,,,,,
a rr� DN:cn--ftus.dDe6oruh,o= Quiceno �ry�'a 1_SERIAWUMBEFi=Z00351W
Deborah - &eme s:com'kdetrblesussei@ By: . .. nafn^:an?ankal hAh5'�3.04'00'
Date:2023.08.3108A9:20-01,00' Signature of person authorized to
Signature Debbie Russel legally bind Corporation
Branch FBA Manager
Date: Bryam Quiceno
Sales Manager Miami
Date Print Name Print Name and Title
Sunnmerlin Jr Ot Myd sdey5unserunkHew".. „ line,;
Howard giver ,no•lbvwrd,..dumr eren k
Signature °�` °°"„°"."°�
-
rn
Date Print Name . `...:' 7.3
C
7,73
-;. :1: r
MONROE COUNTY A3TORNEY'S OFF9t c
' �VEDAS TO f OFRM
PATRICIA FABLES
ASSISTANT
8 30UNTY ATTORNEY
,
DATE: -
4
Siemens Third Amendment Agreement—Effective October 1,2023
A��" CERTIFICATE OF LIABILITY INSURANCE °;ppg1 23°"r"`
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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 CONTACT
MARSH USA.L-C. NAME:
445 SOUTH STREET PHONE A Ne
MORRiSTOWN,NJ 07960-6454 E4AaL
ADDRESSi
INSURERS AFFORDING COVERAGE NAIC 0
CN102147003•RAM-23R4 4433 MANGO NOC60 INSURER A:HDI Global Insurance Company 41343
INSURED SIEMENS INDUSTRY,INC. INSURERS Travelers Prope5y Casua Co of America 25674
1000 DEERFIELD PARKWAY INSURER C:Travelers CaskiaiN d SurSty ComQanX 19038
BUFFALO GROVE,IL 9-4513 INSURER D s
INSURER E:
INSURER F;
COVERAGES CERTIFICATE NUMBER: NYC-011722700.01 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.
IITR ADDTYPE OF INSURANCE L S B POLICY NUMBER MMI°D_12606Y EFF- PM�EXP �EACH
LIMITS
LTR
A X COMMERCIAL GENERAL LIABILITY IGLW110115 10101)2023 ;:1010112024 OCCURRENCE $ 1,000„00O
CL4IMS-MADE ...,, OCCUR MED EXP(Any one Person) __... ,
x_ .�.._ L .. $ .. 1,0110 0d�
.� _ XP $ 100 000
x1,,000,000
�..m.. AGGREGATE $ 10„00O,O0D
POLICY AGGREGATE LIMIT APPLIES PER: 1 GENERALAGG N'L.AGGREGA���� �..,_ G $ INCL
X LOD PRODUCTS-COMPIOP AG
OTHER: $
AUTOMOBILE LIABILITY TC2J-CRP-7440L34A-TIL-23 %Q112023 10101I2024 COMBINED SINGLE LIMIT 0
B Au TO BODILY
-a t.Y_
ANY BOD
..mm 000 00
acdolA
!.. OWNED ... SCHEDULED BIY INJURY(Per psrsoawd r NI$
AUTOS ONLY ALTOS de 19 $ NIA
AAUTOS ONLY X AUTOS ONLD II p CYPERTY�aMAfaE $ NIA
P g,er acadenl
UMBRELLALIAR11 CUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
B WORKERS COMPENSATION LIB-8P839 -23.51-K(ADS) 110101,7023 10101024 X PER ITH-
ANDEMPLOYERS'LIABILITY ,STATUTE . „ER w,,,,,,,,,,,,, ,,,,�_.
C YIN UB-6P79233A-23-51-RQAZ,MA,WI) 10�1P2023 10r01c2024 EACH ACCIDENT $ �_ ,000000
OFFICERIMEMBE1
Mandatory in NHREXCLUDED7 N N r A E.L. „„....
ANYPROPRIETORfPARTNERIEXECUTIVE E.L
® TWXJ-UB7440L33823(OH 10r012023 10J()192024 DISEASE-EA EMPLOYE $ 1„000,000
IIyam.daaraiba under k, __._..._.m ..................................................„.........................
DE RIPTION OF OPERATIONS Wrawr $500K LIMIT 1$50DK 51R °"" E.L.DISEASE-POLICY LIMIT $ 1„000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached H mote space is required)
RE:006MZ000DD6M2KXAS tl BFL2 BAU ES MONROE COUNTY SA RENEWAL
144P RISK=i6,,
SEE ATTACHED ..,,�i1,„
w!! i w
CERTIFICATE HOLDER CANCELLATION
MONROE COUNTY BOCC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
1100 SIMONTON STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
KEY WEST,FL 33040 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA LLC
1988 2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CN102147003
LOC#: Morristown
ACCM0 ADDITIONAL REMARKS SCHEDULE Page 2 of 2
III.,
AGENCY NAMED INSURED
MARSH USA,LLC- SIEMENS INDUSTRY,INC.
1000 DEERFIELD PARKWAY
POLICY NUMBER BUFFALO GROVE,IL M9-4513
CARRIER NAIC CODE
EFFECTIVE
DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: --25- FORM TITLE: Certificate of Liability Insurance
RE W6MZ0000D6M2KKJAS ,BFL2 BAU ES MONROE COUNTY SA RENEWAL
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS,1100 SIMONTON STREET,KEY WEST,FL 3304015 HEREBY ADDITIONAL INSURED AS OBLIGATED UNDER CONTRACT UNDER THE
REFERENCED GENERAL LIABILITY AND AUTOMOBILE IJABILITY INSURANCE POIUC;ES
SUCH INSURANCE AS IS AFFORDED BY THE ADDITIONAL INSURED ENDORSEMENT SHALL APPLY AS PRIMARY fNSURANCE&OTHER INSURANCE MAiNTAINED BY THE CERTIFICATE HOLDER
SHALL BE EXCESS ONLY&NOT CONTRIBUTING WITH INSURANCE PROVIDED UNDER THIS POLICY.
WAIVER OF S,RROGATION fS EFFECTUA,WHERE REQUIRED BY WRITTEN CONTRACT
COMPLETED OPERATIONS COVERAGE PS INCLUDED IN THE GENERAL LIABILITY POLICY
IF THESE POLICIES ARE CANCELLED FOR ANY REASON OTHER THAN NONPAYMENT OF PREMIUM,THE INSPJRER WILL DELIVER NOTICE OF CANCELLATION TO THE CERTIFICATE HOLDER UP
TO 60 DAYS PRIOR TO THE CANCELLATION OR AS REQU,,,RED BY WRITTEN CONTRACT,WHICHEVER TS tESS
aw
ACORD 101 (2008101) 0 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
COMMERCIAL AUTO
POLICY NUMBER: ISSUE DATE: - -
TC2J-CAP-7440L34A-TIL-23 09 29 23
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi.
fied by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds"for Covered Autos Liability Coverage
under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage pro-
vided in the Coverage Form.
SCHEDULE
Name Of Person(s)Or Organization(s):
ANY PERSON OR ORGANIZATION WHOM YOU HAVE AGREED TO ADD AS
ADDITIONAL INSURED, BUT ONLY TO COVERAGE AND MINIMUM LIMITS
REQUIRED IN A WRITTEN CONTRACT
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Each person or organization shown in the Schedule is ered Autos Liability Coverage in the Business Auto
an "insured"for Covered Autos Liability Coverage, but and Motor Carrier Coverage Forms and Paragraph
only to the extent that person or organization qualifies D.2. of Section I - Covered Autos Coverages of the
as an "insured" under the Who is An Insured provi- Auto Dealers Coverage Form.
sion contained in Paragraph A.1. of Section 11 - Cov-
CA 20 48 10 13 Insurance Services Office, Inc., 2011 Page 1 of 1
COMMERDAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF SUBROGATION
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorse- required of you by a written contract executed
meni, the provisions of the Coverage Form apply prior to any "accident" or "loss", provided that the
unless modified by the endorsement. "accident" or "loss" arises out of the operations
Paragraph 5. Transfer of Rights Of Recovery contemplated by such contract. The waiver ap-
Against Others To Us of the COND@TIONS section plies only to the person or organization desig-
is replaced by the following. Hated in such contract.
5. Transfer Of Rights Of Recovery Against Oth-
ers To Us
We waive any right of recovery we may have
against any person or organization to the extent
CA T3 40 08 08 0 2008 The Travelers Companies,Inc. Page 1 of 1
HDI GLOBAL INSURANCE COMPANY
ENDORSEMENT#31
PolllcyNwrtber Nm ardirtsured
CAD1110115 SIENENSCORPORA"I ON
Pak!►lae tod: E ctln Deband
10-01-2023 10.012024 Thm ofEndor
senout
10401-=12:01 am.Standard Time
atAddf+sasoftho
insMed.
77ds Em*vs=wtCl wWw Tb@ Pb#cy. Phase Read!!Cxdeflydfj►.
This modifies Ir�arece I underthe foNawing:
CenmwddGsrsarai Llisbiity/CaysnW Fw..r
Who Is an Insured Is amended to Include as an adMonal insured any person whom you are required to add as an
addlllonal InsunWI on this policy under a wrben agreement,but only with respect 1>D liability for INW4 Injury', property
damage'or"personal and advertising lnjury caused.In whole or in part, by:1.Your ads or omissions;or 2.The ads
oromissions of those acing on your behalf.The Insurance coverage provided to such addidonel insured applies only to
the efxi ant required wMdn the wrlden agreenserst.
The Insuranoscoverege pvAded to the addidonal Insured person shall not provide any broader cover4e thanyou are
taqukedl pmvldeto the addlMonal Insured pennon in the written agreamentoW shall nut provide Ilmllss of InsuranostM
exceed the lower of the IUnft of Insurerm pry dedl to you in this po6cy,orthe limits of Insurance you are reqLdred to
provide in ttowritten gIreement.
The Insuramw provided to the additional insured by this endorsement Is wtcess over any valid and colledlble other
insurance,whether .eowess,amlinpK or an anyatherbasis,that Is avellableto the addi&md Insured for a loss
we cover under this enclareernent However,If to writ m agreerserd speciftelly requires that this Insurance apply on a
primary basis,this Insurance is primary.If the rrr[t en agreement specilkaly requires ft Inaumnce apply on a primary
and r4rHxwdftj1wy basis this hssuranceIs prlmaryto other insurance available b the additional Insured and we will not
share with thatother Insurance.
This endorsementshall prevall over additional Insured endorsernerds do may apply underthis policy unless required
otherwise In thewrittennmernent.
Auuxdwd I' eser>ks i ve
All terms and conditlor►s of the policy remain unchmWed.
THIS ENDORSEMENT MUST BE ATTACHED TO A CHANGE ENDORSEMENT WHEN ISSUED AFTER THE POLICY
IS WRITTEN.
PW-
POLICY NUMBER GLDI IIO115 COMMERCIAL.GENERALLIABRITY
CG 24 04 0509
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance pro u irisd under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTSICOMPLETED OPERATIONS LIABILITYCOVERAGE PART
SCHEDULE
Nara Of Pera m OrOrganta®tion:
ANY PERSON OR ORGANIZATION TO THE EXTENT REQUIRED BY WRITTEN CONTRACT
Irdiormafion nmulred to co eta this Schedule,If not shown above will be shown In,the Declarations.
The following Is added to &17 an I r Of
Rlghft Of Rimmery Against To Us of
Secllon IV—Condillons:
We waive any right of recovery we may have against
the person or organbMm shown in the Schedule
above because of payment we make for Injury or
damage arising out of your ongoing operations or
'your woW done under a contract with Mat person or
organization and included in the Wuc ts-completed
operations hazarT. This waiver applies any to the
person or or+gani¢allon shown In the Schedule above.
CO 24 04 05 09 0 Insurance Services Office, Ina,2W8 Pap 1 *(I 0
NAMED INS D: SIFUMNS CORPORATION
POLICY EFFECTIVE: 10/01/2023 TO 10/01/2024
TRAVELERS J� WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 00 03 13 (00)-
POLICY NUMBER: UB-SP83929A-23-51-K
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy_ We will not
enforce our right against the person or organization named iin the Schedule. (This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule.
SCHEDULE
DESIGNATED PERSON:
DESIGNATED ORGANIZATION:
ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY
WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER.
DATE OF ISSUE: 08-03 23 ST ASSIGN:
POLICY NUMBEk GLD1110115 IL SU 4004(1a1Dy
HDI GLOBAL INSURANCE COMPANY
THIS PENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION AMENDMENT
SCHEDULE
Name,Address and EaNall Address ofOther
gan Number of Days Notice:
s)t Or - - 1(s):
Par schedule on file with the Company. 60 Days.or as required by contrack
whiclw4w is lass
(lf no entry appears above,the inforrnatlon required to complete this endorsement wll be shown In the Declarations as
applicable to thiserKicmnrent:)
I. If we cancel this policy by notice to you for any sWh t dy permitted reason other than nonpayment of premium,we
shall endeavor to mall,email or deliver a copy of such written notice of canoella Lion to the person(s)or
organization(s)shown in the Schedvieabove.
IL A copy of the notice,per paragraph I.above,wig be mailed,e-malled or delivered:
1. To the appropriate addresses corresponding to the person(s)or orgsnhatlon(s)shown in the Schedulsabove;
and
2. The number of days required for notice of canoeliation,as provided in paragraph AZ of the Common Policy
Condbone or as amended by an applicable state cancellation endonwnent or by the data as shown in the
Schedule above
III. Our failure to provide such advance notiflcatlon to the pwson(s)or organizations)shown in the Schedule ofthis
endorsement will not odend any policy cancellation date nor negate any cancellation of the policy.
All curer berms and conditions of this policy remain unchanged.
Page 1 of 1 IL SU 4004(10.10)