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Bilotta~~ ~ ~~ a ~ ~ ~~~ ~~~~ ~ ~ PROPOSAL~OR TOWN OF WAPPINGER. UNITED WAPPINGER WATER DISTRICT WATER MAIN EXTENSION TO CHELSEA- HAMLET CONTRACT NO. 13-006 DIVISION 200 BID FORM PREPARED BY: MORRIS ASSOCIATES ENGINEERING CONSULTANTS, PLLC 9 ELKS LANE POUGHKEEPSIE, NEW YORK 12601 SEPTEMBER 2013 REVISED FEBRUARY 2014 MA#: W21215.11 ~a a~ J J ~. TOWN OF WAPPINGER UNITED WAPPINGER WATER DISTRICT WATER MAIN EXTENSION TO CHELSEA HAMLET CONTRACT NO. 13-006 BID FORM THE TOWN RESERVES TD BY BID SECURETY (AS DESOCR BED IN THE INSTRUCTOION SHALL BE ACCOMPANIE TO BIDDERS). TO THE TOWN BOARD, TOWN OF WAPPINGER, NEW YORK Pursuant to and in compliapce with of r invitatio to bi contained in the Notice to Contractors dated `,~ ~ ~ 1 (month) (day) (year) the undersigned hereby proposes to furnish all labor, machinery, equipment, facilities, tools, transportation, supplies, materials, insurances, permits, certificates, tests, guarantees, protection of equipment and property and life during construction; as well as competent and qualified supervision for all phases of the work, and other facilities and things necessary or proper for or incidental to, Town of Wappinger Water Main Extension to Chelsea Hamlet Project, Town of Wappinger, as required by and in strict accordance with the plans, specifications and all other documents relating to Contract No. 13-006, for the prices stipulated' and as shown on this bid form. Name of Bidder: ~ S~ (Individual, Partne ship, Corporation or L C)* * Circle applicable word The undersigned declares that the bidding and contract documents have been carefully examined and that all things necessary for the completion of the work shall be provided. Receipt of the following addenda is hereby acknowledged: DATE SIGNATURE ADDENDUM NO. 1 ADDENDUM NO. 2 ADDENDUM NO. 3 ADDENDUM NO. 4 2p0 a2 ~r ~r Inconsideration of, and to induce the award of this contract to him/her, the bidder represents and warrants that: (a) If this bid is accepted by the Town Board, Town of Wappinger, as evidenced by issuance of a Notice of Award by the Owner, and mailed by registered ma+I with return receipt requested to the address of the bidder as indicated on his/her bid, the bidder will execute a contract on the form of agreement herein provided and will comply with all provisions of said Notice of Award. (b) This bid is made without any understariding, agreement or connection with any other person, firm or corporation making a bid for the same work, and that it is in all respect fair and without collusion or fraud. (c) The bidder has carefully examined and fully understands all of the parts of the contract documents, and that the bidder will execute the contract and will completely perform it in strict accordance with the provisions thereof for the sum set forth on the bid. Unit Prices have been computed in accordance with the Contract Documents. Bidder acknowledges that estimated quantities are not guaranteed, and are solely for the purpose of comparison of Bids, and final payment for all Unit Price Bid items will be based on actual quantities, determined as provided in the Contract Documents. (d) No officer or employee of the Town Board, Town of Wappinger, or any person whose salary is payable in whole or in part by the Town Board is, shall be, or shall become interested directly or indirectly as a contracting party, partner, stockholder, surety or otherwise in this bid or in the performance of the contract or in the supplies, materials or equipment, or to work or labor to which it relates, or in any portion of the profits thereof. (e) The bidder is not in arrears to the Town Board upon debt or contract and. is not a defaulter as surety, contractor, or otherwise upon any obligation to the Town Board, Town of Wappinger. (f) All work shall be completed within the time allotted, from the date specified in the Notice to Proceed or set by the contract documents, mailed to the undersigned by registered mail with return receipt requested to the legal address of the bidder as indicated on his/her bid. (g) If the bid documents contain any unlawful provision not an essential part of the bid and which shall not appear to have been a controlling or material inducement to the making thereof, the same shall be deemed of no effect and will upon notice by either the Owner or the bidder be deemed stricken from the bid documents without affecting the binding force of the remainder. 200 03 i J (h) Each and every provision of any law and clause required by law to be uments shall be deemed to be inserted herein and the bid d h oc e inserted in t bid documents shall be read and enforced as though it were included herein; and if through mistake or otherwise any such provision is not inserted or is not correctly inserted, then upon the application of either party, the bid documents shall forthwith be physically amended to make such insertion. .. (i) The bidder is financially solvent and sufficiently experienced and competent to perform the work. ~. (j) The work can be performed as called for by the proposal and that the plans and specifications are in all respects suitable and adequate for the work. .. (k) The facts stated in his/her bid and the information given by him/her are true and correct in all respects. (I) The bidder is fully informed regarding all the conditions affecting the work to s be done and labor and materials to be furnished for the completion of this ti ti on ga contract, and that his/her information was secured by personal inves and research. (m) In the event of a lawsuit, the bidder agrees that said suit shall be filed in the same county as the location of the project. BID FOR CONTRACT WORK: Base Bid Install water distribution improvements and related items in accordance with the Contract Documents, not including Bid Alternate 1. The signatory to this bid, for all work proposed, items furnished and strict compliance with all provisions of each and every Contract Document relating to Contract 13-006, agrees to accept (unless modified pursuant to the terms of the General Conditions) a total, final and fixed contract price not to exceed: (Words) -.----- ~~~~~~~ ~ (Figures) BAR 31 2014 ~, TOWN OF WAPPINGER TpW N~ RK-- Z00 04 i i i~. Add Alternate 1 Bid For Add Alternate 1: Overlay paving of Entire Stenger Court, the signatory to this bid, for all work proposed, items furnished and strict compliance with all provisions of each and every Contract Document relating to Contract 13-006, agrees to accept (unless modified pursuant to the terms of the General Conditions) a total, final and fixed contract price not to exceed: (Words) (Figures) Add Alternate 2 Bid For Add Alternate 2: Electrical Service for Pressure Reducing ~ bid, for all work proposed, items furnished and strict compliance and every Contract Document relating to Contract 13-006, modified pursuant to the terms of the General Conditions) a tot price not to exceed: ult ith ions of each rees to ~~~~~ l~l~ss final an ed contract W N ~~ ~ APpINGER To TOw N CLERK _ . (Words) (Figures) Also made a part of this bid is the attached documentation per Division 100, Article C.3. Sign Bid Here ~. SI fl~m~- ~~ Print Name Title ~~ I `~~ ~ ~~ ^' ` Official Company Name ~ ~- ~ (It-at, P._aXtga~,ship orporation, LLC)* '` Circle applicable rd Company Qi ~ ~~ Mailing Address _ ` ST ET r' CITY S TE ZIP CODE Federal Employer ~ ~ ~ ~ -~ Identification No. ~~ ~ ~ 0~ Telephone N~. i 200 05 ~. A 1 ~I (If bidder is a corporation, fill in the following blanks.) ws of the State of: "~' `~ Organized under the la Name and Address of President: ~~ I~,Cr~- ~J ~- l~ ~~ Name and Address of Secretary: -~ (If bidder is a Limited Liability~mpany, fill in the following blanks.) Organized under the laws of the Stat~ot: Name of Manager or Managing Member: Agent for Service of Process: Address for Service of Process: /pd~~° ~ ~~~~ MPS 9~ 10\4 GAR Sows ~FN ~~'~~K~ -~pW 200 06 l~ Name and Address of Treasurer: 3 J _-~ Mr STATE OF NEW YORK ) ss: COUNTY OF On the _____~l_ day of ~ ~l`J ,before me, the ota Public in and for said State, personally appeared 1'~- ~I~ undersigned, a N ry personally known to me or proved to me on the basis of satisfactory evidence o be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the '~ instrument. PATRICIA A. CONDON Notary Public, State of New York NOTARY PUBLIC No. 01004974019 Qualffied In Westchester County L Commission Expires November S, ~ d ~ L 200 07 L J ~_ 0 a p ~ ~ p p ~ p 0 p o ~ ~ ~ ;' 0 0 0 O `~ ~ ~ ~ ~ ~ ~ O ~ ~ O O ~' ~ ~ T ~ ~ Q 00 ~ `~ ~ ~ O ~ 't7 `~ o ~ `J M '9 ~ ~ ° o f~ ` ~ ~ ~ ~ ~~ ~~ J fir, ~ `~ ~. 9 ~ ~ ~ ~, ~ ~ ~ c~ o ~ ~ O~ O ~ ~ \.r M c? o w ~ © O ~ ~ p ~ O ~ o ° ~~ r ~ 9 \~ ~ J p ~ 1n ~ L, ~ ~ O Q ~n ~ ~ `~ J r c? ~ ~ ~ ~ -- ~ o ~ ,J ~ - __`` ~J ~ ~ _ w U ~ ~ `~, O ~ ~ ~ 'a ~ ~ ~ ~ ~ ~ ~~ ~ ,y` k ~- Z ~ ~ `1` ~W~ r .N ~ ~~~. V ~ ~ ~~~ w ~ ~ ~ ~ ~ ~ ~ ~ ~ ~;~, c - ~ ~ - ~~ p ~ °~ 0 1 ~_~, ~ m '" t~J/J~ W ~ ~ ~ ~ ~ ~ ~ ~ ~ ~'^ W W W W W W ~:.. W ~ w ~ V/ V/ VJ VJ V/ VJ VJ VJ V/ VJ a~ ~ Z d W ~ d ~.. 0.. a. ~- a W W W ~ >.- ~ ~ ~ ~ ~ ~ ~ ~ ~~1 ~ LL! 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No other form may be used except with prior approval by the Owner after review by the Town Attorney which approval may be granted or withheld, in the Owner's discretion. 200 08 J J BID BOND KNOW ALL MEN BY THESE PRESENTS: that as Principal; and ** as Surety, are hereby held and firmly bound unto the Town Board, Town of Wappinger, New York in the amount of: Dollars $ for the payment whereof Principal and Surety bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. Signed this day of 20 WHEREAS, the condition of the above obligation is such that, whereas the Principal has submitted to the Town Board a certain bid, attached hereto and hereby made a part hereof, to enter into a contract in writing for the Water Main Extension to Chelsea Hamlet for the Town of Wappinger, New York, as shown and specified in Contract No. 13-006. ~ NOW THEREFORE, (a) If said Bid shall be rejected, or in the alternate (b) If said Bid shall be accepted and the Principal shall execute and deliver a it contract in the Form of an Agreement attached hereto (properly completed in accordance with said Bid) and shall in all respects perform the agreement created by the acceptance of said Bid, then this obligation shall be void. Otherwise, the same shall remain in force and effect, it being expressly understood and agreed that the {lability of the Surety for any and all claims hereunder shall, in no event, exceed the amount of this obligation as herein +^ stated. The Surety, for value received, hereby stipulates and agrees that the obligations of said ~"" Surety and .its bond shall in no way be impaired or affected by any extension of the time within which the Principal may accept such bid; and said Surety does hereby waive notice of any such extension. ~r. IN WITNESS WHEREOF, the Principal and the Surety have hereunto set their hands and seals, and such of them as are Corporations have caused their Corporate seals to be hereto affixed and these presents to be signed by their proper officers, the day and year first set forth above. (SEAL) PRINCIPAL *Insert Bidder's Name **Insert Surety's Name ~ BY 200 09 r it Signed, sealed and delivered in the presence of (Corporate seal of Contractor if a corporation) Contractor By By _ (Title of Officer) (Corporate seal of Surety) Attest (Title of Officer) 200 010 il~r ~` STATE OF NEW YORK ) ss: COUNTY OF ) On the day of ,before me, the undersigned, a Notary Public in and for said State, personally appeared ~. personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. NOTARY PUBLIC .. 200 11 iw CERTIFICATION OF NON-COLLUSION BY BIDDER No bid will be considered unless this Certification remains attached to and is submitted with the Bid u By submission of this bid, each bidder and each person signing on behalf of any bidder certifies, and in the case of a joint bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of his knowledge and belief: (1) The prices in this bid have been arrived at independently, without collusion, consultation, communication, or agreement for the purpose of restricting competition as to any matter relating to such prices, with any other bidder or with any competitor. (2) Unless otherwise required bylaw the prices which have been quoted in this bid have not knowingly been disclosed by the bidder and will not knowingly be disclosed by the it bidder, directly or indirectly, to any other bidder or to any competitor, before the time of the bid opening. (3) No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit or not to submit a bid. for the purpose of restricting competition. A bid shall not be considered for award nor shall any award be made where (1) (2) and (3) abo~ce have not been complied with; provided however, that if in any case the bidder ,,, cannot make the foregoing certification, the bidder shall so state and shall furnish with the bid a signed statement which sets forth in detail the reasons therefore. Where (1) (2) and (3) above have not been complied with, the bid shall not be considered for award nor shall any award be made unless the head of the purchasing unit of the State, public department or agency to which the bid is made, or his designee, determines that such disclosure was not made for the purpose of restricting competition. (4) The fact that a bidder (a) has published price lists, rates, or tariffs, covering items being procured, (b) has informed prospective customers of proposed or pending publication of new or revised price lists for such items, or (c) has sold the same items to other customers at the same prices being bid, does not constitute, without more, a disclosure within the meaning of subparagraph (1). (5) Any bid hereafter made to any public authority or to any official of any public authority created by the State or any political subdivision, by a corporate bidder for work of services performed or to be performed or goods sold or to be sold where competitive bidding is required by statute, rule, regulation, or local law, and where such bid contains the certification referred to in the lead paragraph of this section, shall be deemed to have been authorized by the board of directors of the bidder and such authorization shall be deemed to include the signing and submission of the bid and the inclusion therein of the certifrcate as to'non-collusion as the act and deed of the corporation. I affirm these statements under penalty of perjury. BIDDER'S SIGNATURE: . ~' ~ DATE: 1 ~~ ~ ~ ~o ~~ B' ~? Bt~Nt3 itNaW ALL MEN BY THESE PRESEf~T'S: that Bilotta Construction Co ., 296 Purchase Street, R e, New York 10580 as:Principal; and Fidelity and Deposit Company of Maryland ** 1400 American Lane, Schaumburg, IL 60196-1056 as Surety,. are hereby -held and firmly bound unto the Town Board, Town of Wappinger, New Yaric in the amotant af. Five Percent of Bid Amount Clollars 5°~ of Bid Amount for the payment whereof Principal acrd Surety bind ourselves, our' heirs, executors,.. administrators, successors snd assigns:, jointly and severally, firmly by these presents.. Signed this` 24th day of March 2014 , WHEREAS, the condition of the above. obligation is such that, whereas the Principal has submitted to the Town Board a certain bid, attached hereto and hereby made a part hereof, to enter into a cr,ntract in writing far the Nltater Main Extension to Chelsea Hamlet for the Town of Wappinger, iUew York, as shown and specified in Contract No. 1 -008. NQW THEREFORE, {a) If said Bid shall be rejected, ar in the alternate {b) If said Bid shall be accepted and the Principal shall execute and deliver a contract in the Form of an Agreement attached hereto {properly completed in .accordance with said Enid} and shall in all respects perform the agreement created by ~e acceptance of said Bid, then this obligation shall be void:. Otherwise, the same shall remain in force and effect, it being expressly understand and agreed that the li~bilit}r of the: Surety far any and all claims hereunder shall, in no event, exceed the amount of this obligation as herein stated. The Surety:, for value received, hereby stipulates and agrees that the obligations of said Surety and its band shall in no way be impaired or affected by any extension of the time within which the Principal may accept such bid; and said Surety does hereby waive notice of any such extension... IN WITNESS WHEREOF, the Principal and the Surety have hereunto set their hands and seals, and such of them as are Corporations have caused their Corporate seals to be hereto affixed and these presents to be signed by their proper officers, the day and year first set forth above. (SFA,,L) Bilotta Construction Corp. PRINCIPAL *Insert Bidders Name *`lnsert Surety's Name By `~ i(~ ~~~' L 200 (79 o ~ ' PATRICIA A. CONDON ' \ Notary Public, State of New York No. 01004974019 Qualified in Westchester Count o1 Commission Expires November S, Signed, sealed ar~d de(iverec! . in the presence of ~,~uc.c,e~~ - r----- {Cvr~rate seal of CQntractar if a rporation) Bilotta Construction Corp. ,"~ Contractor By ~~ Fidelity and Deposit Company of Maryland Bjl i (Ta e o ices Annette Leuschner, Attorney-In-Fact (COrporate seal t~f Surety) Attest / ~ (Tit # C)ffic~r) Beverly A. Woo €o ,Attorney-In-Fact zoa ~~ ~ {~, U S7AfiE OF NEW YORK } C~7UNTY C)F ..Nassau Can the 24th day of March . ____14 before me, the undersigned, a Notary Public in and fot' said State, per~or'ralty app~ered Annette Leuschner personally known to me or proved to me on ~e basis of satisfact$~ry evidence to be the individual whose name is subscribed to the vrithir- instrurrient and a~knowleciged to me that he executed the same in his capacity, .and that by his signature Ian the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. NC3fiAfitY UBLIC DENISE CUCURULLO Notary Public, State Of New York No. 01 CU4783740 Qualified In Nassau County Commission Expires September 30, 20 2(10 11 ACKNOWLEDGEMENT OF CONTRACTOR, IF A CORPORATION STATE OF New York ,) COUNTY OF ,) ON T E al~~ DA OF , arch 2014, BEFORE BE PERSONALLY CAME _____~IZ~_ _~.,~~ _____________ TO ME KNOWN, WHO, BEING BY ME DULY SWORN, . DID DEPOSE AND SAY THAT ;~ E ESIDES AT ______ __ __ ..} ~__ _ THAT HE IS THE _________~ _ _ . ___ __________________ OF Bilotta Construction Corp., THE CORPOR ION DESCRIBED IN AND WHICH EXECUTED THE ABOVE INSTRUMENT; AND THAT SIGNE~/-~ NAME THERETO BY ORDER OF THE BOARD OF DIRECTORS OF SAID CORPORATION. PATRICIA A. CONDON Notary Public, State of New York - No.01C04974019 _ _______ _ ______________ Qualified in Westchester County -- Commission Expires November 5,/~' ~( Notary Pu b I i c ZURICH AMERICAN INSURANCE COMPANY COLONIAL AMERLCAN CASUALTY AND SURF,TY COMPANY FIDELITY AND DEPOSIT COMPANY OF MARYLAND POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That the ZURICH AMERICAN INSURANCE COMPANY, a corporation of the State of New York, the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, a corporation of the State of Maryland, and the FIDELITY AND DEPOSIT COMPANY OF MARYLAND a corporation of the State of Maryland (herein collectively called the "Companies"), by THOMAS O. MCCLELLAN, Vice President, in pursuance of authority granted by Article V, Section 8, of the By-Laws of said Companies, which are set forth on the reverse side hereof and are hereby certified to be in full force and effect on the date hereof, do hereby nominate, constitute, and appoint David W. ROSEHILL, Nancy SCHNEE, Andrea E. GORBERT; Annette LEUSCHNER, Valorie SPATES, Beverly A. WOOLFORD and Anne POTTER, all of Jericho, New York, EACH its true and lawful agent. and Attorney-in- Fact, to make, execute, seal and deliver, for, and on its behalf as surety, and as its act and deed: any and all bonds and undertakings, and the execution of such bonds or undertakings in pursuance of these presents, shall be as binding upon said Companies, as fully and amply, to all intents and purposes, as if they had been duly executed and acknowledged by the regularly elected officers of the ZURICH AMERICAN INSURANCE COMPANY at its office in New York, New York., the regularly elected officers of the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY at its office in Owings Mills, Maryland., and the regularly elected officers of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND at its office in Owings Mills, Maryland., in their own proper persons. The said Vice President does hereby certify that the extract set forth on the reverse side hereof is a true copy of Article V, Section 8, of the By-Laws of said Companies, and is now in force. IN WITNESS WHEREOF, the said Vice-President has hereunto subscribed his/her names and affixed the Corporate Seals of the said ZURICH AMERICAN INSURANCE COMPANY, COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, and FIDELITY AND DEPOSIT COMPANY OF MARYLAND, this 10th day of December, A.D. 2013. ATTEST: ZURICH AMERICAN INSURANCE COMPANY COLONIAL AMERICAN CASUALTY AND SURETY COMPANY FIDELITY AND DEPOSIT COMPANY OF MARYLAND «r ~ ~ It00 ~ s b ;~ 1oD8 r ~~3 ~,Itt ~Lnl ••~•Nq~~ u~N*~f '.'7' Assistant Secretary Eric D. Barnes f~. Vice President Thomas O. McClellan State of Maryland City of Baltimore On this 10th day of December, A.D. 2013, before the subscriber, a Notary Public of the State of Maryland, duly commissioned and qualified, THOMAS O. MCCLELLAN, Vice President, and ERIC D. BARNES, Assistant Secretary, of the Companies, to me personally known to be the individuals and officers described in and who executed the preceding instrument, and acknowledged the execution of same, and being by me duly sworn, deposeth and with, that he/she is the said officer of the Company aforesaid, and that the seals affixed to the preceding instrument aze the Corporate Seals of said Companies, and that the said Corporate Seals and the signature as such officer were duly affixed and subscribed to the said instrument by the authority and direction of the said Corporations. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my Official Seal the day and year first above written. ,,~ ~, ~ q~n nfuPP Constance A. Dunn, Notary Public My Conunission Expires: July 14, 2015 POA-F 093-7185C EXTRACT FROM BY-LAWS OF THE COMPANIES "Article V, Section S, Attorneys-in-Fact. The Chief Executive Officer, the President, or any Executive Vice President or Vice President may, by written instrument under the attested corporate seal, appoint attorneys-in-fact with authority to execute bonds, policies, recognizances, stipulations, undertakings, or other like instruments on behalf of the Company, and may authorize any officer or any such attorney-in-fact to affix the corporate seal thereto; and may with or without cause modify of revoke any such appointment or authority at any time." CERTIFICATE I, the undersigned, Vice President of the ZURICH AMERICAN INSURANCE COMPANY, the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, and the FIDELITY AND llEPOSIT COMPANY OF MARYLAND, do hereby certify that the foregoing Power of Attorney is still in full force and effect on the date of this certificate; and I do further certify that Article V, Section 8, of the By-Laws of the Companies is still in force. This Power of Attorney and Certificate may be signed by facsimile under and by authority of the following resolution of the Board of Directors of the ZURICH AMERICAN INSURANCE COMPANY at a meeting duly called and held on the 15th day of December 1998. RESOLVED: "That the signature of the President or a Vice President and the attesting signature of a Secretary or an Assistant Secretary and the Seal of the Company may he affixed by facsimile on any Power of Attorney...Any such Power or any certificate thereof bearing such facsimile signature and seal shall be valid and binding on the Company." This Power of Attorney and Certificate may be signed by facsimile under and by authority of the following resolution of the Board of Directors of the COLONIAL AMERICAN CASUALTY ANll SURETY COMPANY at a meeting duly called and held on the 5th day of May, 1994, and the following resolution of the Board of Directors of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND at a meeting duly called and held on the 10th day of May, 1990. RESOLVED: "That the facsimile or mechanically reproduced seal of the company and facsimile or mechanically reproduced signature of any Vice-President, Secretary, or Assistant Secretary of the Company, whether made heretofore or hereafter, wherever appearing upon a certified copy of any power of attorney issued by the Company, shall be valid and binding upon the Company with the same force and effect as though manually affixed. IN TESTIMONY WHEREOF, I have hereunto subscribed my name and affixed the corporate seals of the said Companies, this day of , 20_, W~ s ~~j.3~p":01Yrg Sniff TS •rw O n+. ; ~~. ~ooe ~~= 86AL tb•, ~ ~~ "4 rx~W~N •~ Geoffrey Delisio, Vice President FIDELITY AND DEPOSIT COMPANY OF MARYLAND 600 Red Brook Blvd., Suite 600, Owings Mitis, MD 21117 Statement of I+~nanciai Condition As Of December 31, 2012 ASSETS $onds ............................................................................................................................................... $ 157,177,826 Stocks ...................... .................................................... 23,000,311 ..................................................................... Cash and Short Term Investments .................................................................................................... 119,155 Reinsurance Recoverable ................................................................................................................. 17,923,564 Other Accounts Receivable .............................................................................................................. 35,473,256 TOTAL ADMI'Pl'ED ASSE'I'S ........................................................................................................ $ 233,694,113 LIABILITIES, SURPLUS AND OTHER )iU1~IDS Reserve for Taxes and Expenses ...................................................................................................... $ 74,782 Ceded Reinsurance Premiums Payable ............................................................................................ 48,323,524 Securities Lending Collateral Liability ............................................................................................ 1,716,240 TOTALI.dAB1LITIES .................................................................................................................... $ 50,114,546 Capital Stock, Paid Up ........................................................................................ $ 5,000,000 Sutplus ................................................................................................................ 178,579,567 Surplus as regards Policyltolders ...................................................................................................... 183,579,567 To'I'AL ....................................................................................................................................... $ 233,694,113 Securities carried at $59,468,002 in the above statement are deposited as required by law. Securities carried on the basis prescribed by the National Association of Insurance Commissioners. On the basis of December 31, 2012 market quotations for all bonds and stocks owned, the Company's total admitted assets would be $243,518,971 and surplus as regards policyholders $193,404,425. I, DENN15 F. KERRIGAN, Corporate Secretary of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND, do hereby certify that the foregoing statement is a correct exhibit of the assets and Iiabilities of the said Company on the 31st day of December, 2012. State of Illinois City of Schaumburg SS: Subscribed and sworn to, before me, a Notary Public of the State of Illinois, ur ftte City of 5cltauntlxtrg, this 15th day of March, 2013. '•` 1 r t n'o~ary Prrblrc OFFICIAL SEAL DARRYL JOINER Notary Public -Stale of Illinois My Commission Expires May 3, 2014