Performance and Payment BondsSUPPLEMENTAL CONTRACTOR VERIFICATION OF COMPLIANCE
By signing this document I certify that I am an owner or officer of the company, and I swear under
oath that:
My company meets each of the minimum criteria of Minn. Stat. § 16C.285, subd. 3, the
Responsible Contractor statute.
Pursuant to Stat. § 16C.285, subd. 3(7), my company has obtained from all
subcontractors and motor carriers with which it will have a direct contractual relationship a signed
statement under oath by an owner or officer verifying that they meet all of the minimum criteria in
subdivision 3 prior to execution of a construction contract with each subcontractor or motor
carrier.
The undersigned agrees that, if it retains additional subcontractors on the project after
submitting its verification of compliance, it shall obtain verifications of compliance from each
additional subcontractor with which it has a direct contractual relationship and shall submit a
supplemental verification confirming compliance with Minn. Stat. § 16C.285, subd. 3(7), within 14
days of retaining the additional subcontractors.
Upon request, the undersigned shall submit to the contracting authority copies of the
signed verifications of compliance from all subcontractors of any tier and all motor carriers
providing for -hire transportation of materials, equipment, or supplies for a project.
The undersigned understands that a failure to meet or verify compliance with the
minimum criteria established for a "responsible contractor" as defined in Minn. Stat. § 16C.285,
subd. 3, renders a bidder ineligible to be awarded a construction contract for the Project or to
perform work on the Project.
The undersigned understands that a false statement under oath verifying compliance with
any of the minimum criteria shall make the undersigned, ineligible to be awarded a construction
project and may result in termination of a contract awarded to the undersigned. A contracting
authority shall not be liable for declining to award a contract or terminating a contract based on a
reasonable determination that the contractor failed to verify compliance with the minimum criteria
or falsely stated that it meets the minimum criteria.
Date: 08/02/18
Contractor:
Sir Lines -A -Lot
By Dan Harvey
p 'nf name)
Signature
(please sign name)
Its President
2018 PAVEMENT MARKING PROJECT SUPPLEMENTAL VERIFICATION
CITY OF SHOREWOOD, MN
WSB PROJECT NO.R- 011854 -000
Bond No. 9187512
Executed in Triplicate
PERFORMANCE AND PAYMENT BONDS
PART A: PAYMENT
KNOW ALL MEN BY THESE PRESENTS, that we Sir Lines -A -Lot
7175 Cahill Road, Edina, NfN 55439
Contractor, as Principal, and Washington International Insurance Company
are firmly bound unto theCity of Shorewood , a Minnesota Corporation, (hereinafter referred
to as "Obligee "), for the use and benefit of Obligee and all persons furnishing labor and materials to
perform the Contract, in an amount of Twenty Eight Thousand Five Hundred Forty Six and
70 /100 Dollars, for payment of all claims, costs and charges as hereinafter set forth. For the
payment of this obligation, well and truly made, we jointly and severally bind ourselves, our representatives
and successors firmly by these presents.
The condition of this obligation is such that whereas the Principal has entered into a written
contract with the Obligee dated July 23, 2018 , which contract is on file in the office of
the Obligee, the regularity and validity of which is hereby affirmed;
NOW THEREFORE, if the Principal shall pay as they may come due all just claims for work done;
for furnishing labor and materials, insurance premiums, equipment, or supplies for the purpose of such
contract, and all taxes incurred under Minnesota Statutes, Section 290.92 or Chapter 297A, and supplies
for the completion of the contract in accordance with its terms, and shall pay all costs of enforcement of
the terms of the bond, if action is brought thereon, including reasonable attorney's fees, costs and
disbursements in any case in which such action is successfully maintained, and shall comply with the laws
of the state appertaining to such contract, then this obligation shall be void but otherwise it shall remain in
full force and effect pursuant to Minnesota Statutes, Chapter 574.
PART B: PERFORMANCE
KNOW ALL MEN BY THESE PRESENTS, that the aforesaid Principal and Surety are held and
firmly bound unto the Obligee, for the use and benefit of the Obligee, in the additional amount of
Twenty Eight Thousand Five Hundred Forty Six
and 70 /100 Dollars, for the faithful performance of the Contract pursuant to its terms, as
hereinafter set forth.
For the payment of this well and truly to be made we jointly and severally bind ourselves, our
representatives and successors firmly by these presents.
The condition of this obligation is such that whereas the Principal has entered into the Contract
more particularly described in Part A hereof, the regularity and validity of which is hereby affirmed:
NOW, THEREFORE, if the Principal shall faithfully perform the Contract and shall save the
Obligee harmless from all cost and charges that may accrue on account of the doing of the work specified
and shall pay all costs of enforcement of the terms of the bond, if action is brought thereon, including
reasonable attorney's fees, in any case in which such action is successfully maintained, and shall comply
with the laws of the state pertaining to such Contract, then this obligation shall be void but otherwise it
shall remain in full force and effect pursuant to Minnesota Statutes, Chapter 574.
2018 PAVEMENT MARKING PROJECT PERFORMANCE AND PAYMENT BONDS
CITY OF SHOREWOOD, MN
WSB PROJECT NO.R- 011854 -000 PAGE 1
The aggregate liability for bonds provided under Part A and Part B hereof is
Fifty Seven Thousoand Ninety Three and 40/100 Dollars ($57,093.40)
(Sum of Parts A and B)
No assignment, modifications, or change in the Contract, or change in the work covered thereby,
nor any extension of time for completion of the Contract, shall release the Surety on this bond.
Sealed with our seals and dated this
Contractor
By
Its President
And (�+
Its General Ma
(Seal of Contractor if a Corporation)
Witnesses to Contractor's Signature:
2018 PAVEMENT MARKING PROJECT
CITY OF SHOREWOOD, MN
WSB PROJECT NO.R- 011854 -000
2nd day of
2018
Washington International Insurance Company
Surety
By
Its William Reidinger, Attorney -in -Fact
Witnesses to Surety's Signature:
a�
PERFORMANCE AND PAYMENT BONDS
PAGE 2
State of ... Illinois ...... „ . .............
County of. cook
. ss.:
On this 2nd ........... day of. August.. . .......2018.., before me
Surety personally appeared...
Company William Reidinger , to be known,
Acknowledgment: whom being by me duly sworn, did depose and say: that he /she resides
at.... W.q1 ? burh. IL ........................... ...............................
that he /she is the. Attorney In Fact .......O f.... Washington International
.................. ..
Insurance Company ............... the corporation described in and which
executed the annexed instrument; that he /she knows the corporate seal of
said corporation that the seal affixed to said instrument is such corporate
seal; that it was so affixed by order of the Board of Directors of said
corporation; that he /she signed his/her name thereto by like order; and
that the liabilities of said corporation do not exceed its assets as
ascertained in the manner provided by law.
OFFICIAL SEAL
JOSEPH HALLERAN
rNOTARy PUBLIC, STATE OF ILLINOIS y Commission Expires Notary u lic in and for the above County and State.
X019
08/30/2019
My commission expires .. ...............................
SWISS RE CORPORATE SOLUTIONS
NORTH AMERICAN SPECIALTY INSURANCE COMPANY
WASHINGTON INTERNATIONAL INSURANCE COMPANY
GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, THAT North American Specialty Insurance Company, a corporation duly organized and existing under
laws of the State of New Hampshire, and having its principal office in the City of Overland Park, Kansas, and Washington International Insurance
Company, a corporation organized and existing under the laws of the State of New Hampshire and having its principal office in the City of Overland
Park, Kansas, each does hereby make, constitute and appoint: William Reidinger
Principal: Sir Lines -A -Lot Bond Number: 9187512.
Obligee: City of Shorewood Bond Amount: See Bond Form
Bond Description: 2018 Pavement Marking Project
Its true and lawful Attomey -in -Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings
obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by
law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the
amount of. FIFTY MILLION ($50,000,000.00) DOLLARS
This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of
Directors of both North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held
on the 91h of May, 2012:
"RESOLVED, that any two of the Presidents, any Managing Director, any Senior Vice President, any Vice President, any Assistant Vice President,
the Secretary or any Assistant Secretary be, and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named
in the given Power of Attorney to execute on behalf of the Company bonds, undertakings and all contracts of surety, and that each or any of them
hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company; and it is
FURTHER RESOLVED, that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any
certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be
binding upon the Company when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached."
`g%,N'{t lrY N
1 -. 9 Steven P. Anderson, Senior Vice President of Washington International Insurance Company �3~ � SEAL'F4?�
% 1973 ep�n1 & Senior Vice President ofNortb American Specialty Insurance Company �F m a
U B
e7
Mic Re X..lto,Semo•�ace President of ' wasnington ntemal ona nsurance ompany roalW pm�p°
& Senior Vice President of North American Specialty Insurance Company
IN WITNESS WHEREOF, North American Specialty Insurance Company and Washington International Insurance Company have caused their
official seals to be hereunto affixed, and these presents to be signed by their authorized officers this 12th day of October , 2017 .
North American Specialty Insurance Company
Washington International Insurance Company
State of Illinois
County of Cook SS:
On this 12th day of October , 2017 , before me, a Notary Public personally appeared Steven P. Anderson ,Senior Vice President of
Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and Michael A. Ito ,
Senior Vice President of Washington International Insurance Company and Senior Vice President of North American Specialty Insurance
Company, personally known to me, who being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and
acknowledged said instrument to be the voluntary act and deed of their respective companies.
OFFICIAL SEAL t j
M. KENNY `../
Notary Public • State of Illinois
MYC°1=roiuoii PI`S M. Kenny, Notary Public
I, Jeffrey Goldberg , the duly elected Assistant Secretary of North American Specialty Insurance Company and Washington
International Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney given by said North
American Specialty Insurance Company and Washington International Insurance Company, which is still in full force and effect.
IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this 2nd day of August , 2018
Jeffrey Goldberg, Vice President & Assistant Secretary of
Washington International Insurance Company & North American Specialty Insurance Company