HomeMy WebLinkAbout2016-044 Contract - Donald H Ferguson
Contract for GOODS AND SERVICES Small Procurement Less than $5,000
CITY OF INDEPENDENT CONTRACTOR: Don Ferguson
ASHLAND CONTACT: Don Ferguson
20 East Main Street ADDRESS: 440 Helman St Ashland, OR 97520
Ashland, Oregon 97520
Telephone: 541/488-6002
Fax: 541/488-5311 TELEPHONE: 541-778-2679 FAX:
BEGINNING DATE: 2/9/2016 COMPLETION DATE: 2/29/2016
COMPENSATION: $50.00 per hour not to exceed a total of $500
GOODS AND SERVICES TO BE PROVIDED: Facilitation Services: Wildfire Mitigation Commission Retreat Meeting
Contractor will facilitate a six hour meeting on February 24, 2016 preceded by one or two planning sessions with City staff to establish the meeting
agenda, background information, expectations, and roles. The purpose of the meeting is to establish an action plan for continuing community
engagement for the update of the City's Community Wildfire Protection Plan, or CWPP. The meeting will also go over the CWPP draft outline and
identify roles that Commissioners can play in writing the updated plan.
NOW THEREFORE, pursuant to AMC 2.50.090 and after consideration of the mutual covenants contained herein the CITY AND CONTRACTOR AGREE
as follows:
1. All Costs by Contractor: Contractor shall, provide all goods as specified above and shall at its own risk and expense, perform any work
described above and, unless otherwise specified, furnish all labor, equipment and materials required for the proper performance of such work.
2. Qualified Work: Contractor has represented, and by entering into this contract now represents, that any personnel assigned to the work required
under this contract are fully qualified to perform the work to which they will be assigned in a skilled and worker-like manner and, if required to be
registered, licensed or bonded by the State of Oregon, are so registered, licensed and bonded. Contractor must also maintain a current City
business license.
3. Ownership of Production: All documents, materials or items produced by Contractor pursuant to this contract shall be the property of City.
4. Statutory Requirements: ORS 279B.220, 279B.225, 279B.230, 279B.235, ORS Chapter 244 and ORS 670.600 are made part of this contract.
5. Indemnification: Contractor agrees to defend, indemnify and save City, its officers, employees and agents harmless from those losses, expenses,
or other damages resulting from injury to any person or damage to property arising out of or incident to the negligent performance of this contract
by Contractor its employees, or agents. Contractor shall not be held responsible for any losses, expenses, or other damages, directly, solely, and
proximately caused by the negligence of City.
6. Termination: City's Convenience. This contract may be terminated at any time by the City.
7. Independent Contractor Status: Contractor is an independent Contractor and not an employee of the City. Contractor shall have the complete
responsibility for the performance of this contract.
8. Non-discrimination Certification: The undersigned certifies that the undersigned Contractor has not discriminated against minority, women or
emerging small businesses enterprises in obtaining any required subcontracts. Contractor further certifies that it shall not discriminate in the award
of such subcontracts, if any.
9. Asbestos Abatement License: If required under ORS 468A.710, Contractor or Subcontractor shall possess an asbestos abatement license.
10. Assignment and Subcontracts: Contractor shall not assign this contract or subcontract any portion of the work.
11. Use of Recyclable Products: Contractor shall use recyclable products to the maximum extent economically feasible in the performance of the
contract work set forth in this document.
12. Default. The Contractor shall be in default of this agreement if Contractor commits any material breach or default of any covenant, warranty,
certification, or obligation it owes under the Contract.
13. Insurance. Contractor shall at its own expense provide the following insurance:
a. a. Worker's Compensation insurance in compliance with ORS 656.017, which requires subject employers to provide Oregon workers'
compensation coverage for all their subject workers. Worker's compensation insurance is required if work is performed by employees,
subcontractors, or volunteers.
BY INITIALING THIS SENTENCE, CONTRACTOR CERTIFIES UNDER PENALTY OF LAW THAT THE WORK REQUIRED BY THIS
CONTRACT SHALL BE PERFORMED SOLELY BY THE UNDERSIGNED: gap .
b. General Liability insurance with a combined single limit, or the equivalent, of not less than $ N/A for each occurrence for Bodily
Injury and Property Damage. 60 C,
c. Automobile Liability insurance with a combined single limit, or the equivalent, of not less than $ -for each accident for Bodily
Injury and Property Damage, including coverage for owned, hired or non-owned vehicles, as applicable.
14. Governing Law; Jurisdiction; Venue: This contract shall be governed and construed in accordance with the laws of the State of Oregon
15. THIS CONTRACT AND ATTACHED EXHIBITS CONSTITUTE THE ENTIRE AGREEMENT BETWEEN THE PARTIES. NO WAIVER, CONSENT,
MODIFICATION OR CHANGE OF TERMS OF THIS CONTRACT SHALL BIND EITHER PARTY UNLESS IN WRITING AND SIGNED BY BOTH
PARTIES.
Certification. Contractor shall sign the certification attached hereto as Exhibit A and herein incorporated by reference.
Contractor: City of Ashla d:
By C~0~ By G-~,-
ignat a epartmen Head
Don Fergu n John arns
rint Name_ Print Name
o r 401(-
Title Date f J
W-9 One copy of a W-9 is to be submitted with the signed contract. Purchase Order NQ.~
L.W
As land City Attorney
Revised 10-28-14 Page 1 of 2 1
Data.
EXHIBIT A
CERTIFICATIONS/REPRESENTATIONS: Contractor, under penalty of perjury, certifies that (a) the number shown on
the attached W-9 form is its correct taxpayer ID (or is waiting for the number to be issued to it and (b) Contractor is not
subject to backup withholding because (i) it is exempt from backup withholding or (ii) it has not been notified by the
Internal Revenue Service (IRS) that it is subject to backup withholding as a result of a failure to report all interest or
dividends, or (iii) the IRS has notified it that it is no longer subject to backup withholding. Contractor further represents
and warrants to City that (a) it has the power and authority to enter into and perform the work, (b) the Contract, when
executed and delivered, shall be a valid and binding obligation of Contractor enforceable in accordance with its terms, (c)
the work under the Contract shall be performed in accordance with the highest professional standards, and (d) Contractor
is qualified, professionally competent and duly licensed to perform the work. Contractor also certifies under penalty of
perjury that its business is not in violation of any Oregon tax laws, and it is a corporation authorized to act on behalf of the
entity designated above and authorized to do business in Oregon or is an independent Contractor as defined in the
contract documents, and has checked four or more of the following criteria:
X (1) 1 carry out the labor or services at a location separate from my residence or is in a specific portion of my
residence, set aside as the location of the business.
(2) Commercial advertising or business cards or a trade association membership are purchased for the
business.
X (3) Telephone listing is used for the business separate from the personal residence listing.
X (4) Labor or services are performed only pursuant to written contracts.
X (5) Labor or services are performed for two or more different persons within a period of one year.
(6) 1 assume financial responsibility for defective workmanship or for service not provided as evidenced by
the ownership of performance bonds, warranties, errors and omission insurance or liability insurance relating
to the labor or services to be provided.
Contractor (Date)
Revised 10-28-14 Page 2 of 2
Community Wildfire Protection Plan (CWPP) Development Facilitation
Contract Proposal
I propose to act as meeting facilitator- for a six-hour workshop hosted by the City on
February 24, 2016 to continue work on the City's Community Wildfire Protection Plan.
I estimate that there will be approximately two hours of meeting with Ashland Fire and
Rescue and the Wildfire Mitigation Commission in advance of the workshop to establish
the meeting agenda, background information, expectations, and roles, also requiring my
services as facilitator.
The maximum time I will bill under this proposal is eight hours. My fee for this service
would be $50.00/hour, for a maximum cost to the City of $500.00.
Thank you for considering this proposal.
Don Ferguson
Kris Bechtold
From: Dave Kanner
Sent: Wednesday, February 10, 2016 5:02 PM
To: Kris Bechtold
Subject: RE: Insurance Q - Don Ferguson Contract
Kris -
The lower amount is fine.
Dave
From: Kris Bechtold
Sent: Wednesday, February 10, 2016 4:56 PM
To: Dave Kanner
Subject: Insurance Q- Don Ferguson Contract
Hi Dave K.... Legal received a small contract for goods and services (NTE $500) for Don Ferguson, who will be
facilitating the Wildfire Mitigation Commission Retreat Meeting for AF&R. I'm attaching the 2015 contract
used last year for your review and the contract for 2016. Dave L. asked that we bring your attention to the
$350,000 Auto Liability Insurance noted on the contract in relation to the AAA Insurance information
$100/$300; and requests a responsive email as to whether you approve of this lower amount of insurance?
If you'd rather review a hard copy of the contract, let me know!
Thanks for the assist!
Kris Bechtold
Paralegal to City Attorney
City of Ashland / Legal Dept.
20 East Main Street, Ashland, OR 97520
541-488-5350
TTY 1-800-735-2900
541-552-2092 fax
kris.bechtold@ashland.or.us
This email transmission is official business of the City of Ashland, and it is subject to Oregon Public Records Law for disclosure and
retention. If you have received this message in error, please contact me at (541) 488-5350.
1
OREGON AUTO INSURANCE APPLICATION
AAA Insurance underwritten bye'
CSAA Fire & Casualty Insurance Company -
Insurance PO Box 24511 Oakland, CA 94623-9865
For underwriting call (800) 207-3618, underwriting fax (877) 489-5696
Program Selection: AAA Select Policy Type: STANDARD
Named Insured (First MI Last) Primary/Garaging Address: Producer Code: 500016191 Phone (541) 618-4083
DON FERGUSON o Agency Name, Address:
DENISE KESTER = AAA Oregon
440 HELMAN ST E 1777 E Barnett Rd
c ASHLAND, OR 97520-1142 Q 0- Medford, OR 97504
.2 -
E Residence: Own Home Producer: David Buck
,o E-mail: david.buck@aaaoregon.com
Mailing Address:
M SAME AS PRIMARY/GARAGING ADDRESS
c Policy Number: ORSS - 203924937
Policy Effective Date: 09/12/15 Time: 12:01 AM
Phone Number: E Policy Bound Date: 09/11/15 Time: 04:58 PM
E-mail: o Policy Term: 12 Months
SS#: Member E Previous AAA Policy Number: N/A
Occupation: Employed
0
a
All residents and family members of your household permit age and older must be listed on this application. Also, any other
regular drivers must be listed. Any person may be excluded from coverage except the named insured or spouse, or an
individual requesting an SR22 filin .
c DR Driver Name Relation to DOB Sex Marital Driver's License
# Exact/ as Shown on License Applicant Status State/Number
c4 1. DON FERGUSON Insured 08/10/1950 Male Married OR / 3580150
E
0 2. DENISE KESTER Spouse 01/13/1955 Female Married OR / 3580210
4-
3.
C 4.
m
a 5.
N
6.
7.
C
8.
9.
E DR License Age First Prev SR22 ADB Driver Discounts Driver
M # Driver Status Status Licensed Lic Surcharges
_T 1. Rated US Lic 16 N/A No No
E 2. Rated US Lic 16 N/A No No
M
U_ 3.
> 4.
C 5.
6.
7.
8.
i
9.
The following is a complete list of all ACCIDENTS, COMP CLAIMS GREATER THAN $1000, AND TRAFFIC CONVICTIONS for
all drivers in the past 60 months. All accidents are considered "At Fault" unless proof is provided showing "Not At Fault" (Police
Report, CLUE Report or other Carrier's payment).
o DR
N # Incident DT ate Incident Date Incident Date Incident Date
T__
= 1. CMP 03/07/2011
E
U
c
L
0
Policy Number: ORSS - 203924937 Applicant Name: Don Ferguson Page: 1 of 4
Veh Year Make Model ~Vehicle VIN Salvage/ Ue
# e Damage
1. 05 TOYOTA TUNDRA 4 DOOR Automobile 5TBBT44165S464854 None Commute
2. 09 SUBARU FORESTER Automobile JF2SH64639H781700 None Commute
3.
Veh Garage Geog. Stat Phys Damage Stated Amount Vehicle Discounts Vehicle
# Zip Code Factor Code Symbol Surcharges
c
0- 1. 97520 97520 AO 36 A132
w
0 2. 97520 97520 AZ 24 AB4
0
c
3.
V#h Loss Payee or Additional Insured Name & Address (Financial Institution Only) or Certificate Holder LP Al CH
L0 ❑ ❑ ❑
c ❑ ❑ ❑
M
❑ ❑ ❑
El D_ _0
F~ _E1
c Prior Carrier: Farmers Prior Policy 189201266 Months w/Prior Carrier: 58
0
Days Lapse: 0 Prior Liability Limits: 100000/300000
v E
L
O 0
w
a c
Affinity Group:
AAA HO/Renters/Condo policy H059999999
AAA Motorcycle policy M
L
in c AAA Life policy
o
Policy Discounts Policy Surcharges
E
0 0
N Loyalty Discount, Membership Discount, Multi-Car Discount, Multi-Policy Discount
5 - (Home), and Payment Plan Discount
0
a
Policy Number ORSS - 203924937 Applicant Name: Don Ferguson Pa e: 2 of 4
AA11OR 07 14
Underwriting Comments or Remarks
E o
E
-00
c c
Coverages Limit of Liability Premiums
Vehicle 1 Vehicle 2 Vehicle 3
Bodily Injury: 1000001300000 $132.00 $107.00
Prop Damage: 100000 $66.00 $54.00
UM/UIM - BI: 100,000'300,000 $10.00 $12.00
UM-PD (less ded) 1: $20,000 2: $20,000 3: $4.00 $5.00
PIP $28.00 $42.00
o Medical Expenses 15,000 /accident
o ($0 ded)
E Income Loss 3,000 per montlYmax 52weeks
Essential Services 30 per day/max 52 weeks
= Funeral Expenses Up to 5,000
M Childcare Exp. 25 per day/max $750
0 -
Comp Ded: 1:100 2:100 3: $46.00 $42.00
d Safety Glass: 1: 2: 3: NO COV NO COV
Coll Ded: 1:500 2:500 3: $88.00 $125.00
M Spec Equip: 1: 2: 3: NO COV NO COV
Rental Reimb: 1: 2: 3: NO COV NO COV
c
M Towing & Labor: 1: 2: 3: NO COV NO COV
a NO COV NO COV
E Veh Loan/Lease:
New Car Prot:
E Auto Death Ben: $15,000 [Drivers- D) NO COV
p, All Vehicles $374.00 $387.00
Total Vehicle Premiums : $761.00
SR22 Fee(s): $0.00
R
CD
V Total Policy Premium: $761.00
Pay Plan Information Payment Plan: Annual Down Pay Method: CREDIT CARD
Down Pay Required: $ 761(100%) Down Pay Remitted: $761.00
# Payments Required: 0 Payment Excluding Installment Fee : $0.00
Down Payment Information
CREDIT CARD:
Credit Card Holder Name: XXXXXXX
Credit Card Number: XXXXXXXXXXXX0583
Authorization Number:
Credit Card Type: VISA
Expiration Date: 04-30-2017
Authorization Date: 09-11-2015
~ngQ':)daq7 Aenlicant Name: DON FERGUSON Page: 3 of 4
Oregon Fraud Statement
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false
information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions, or concealments on your part, we must
show that: The information is material to the content of the policy; we relied upon the misinformation; and the information was either
material to the risk assumed by us; or provided fraudulently.
For remedies other than the denial of a claim, misstatements, misrepresentations, omissions, or concealments on your part must either
be fraudulent or material to our interests.
Applicant's Statement; Company Practices
Read carefully before signing.
I reviewed the information in this Application. This includes information filled in by my agent. I represent that this
information is true and complete to the best of my knowledge and belief. I agree to inform the Company of any changes
in this information such as my address, drivers, vehicles, and/or use within 10 days of the change and acknowledge that
changes in this information may change the premium or eligibility.
I acknowledge the following practices of the Company and agree to them:
• This Application will be used by the Company to rate the policy and to decide whether to issue the applied for
policy. Inaccurate information in this Application may result in an increase in the premium. In addition, if any of
the information in this Application is false, or a material fact was omitted or misrepresented, the policy may be
cancelled by the Company upon written notice to you and claims may be denied at the sole option of Company.
• Coverage is bound no earlier than the time and date the application is electronically bound in Company's system
and the application is signed by both me and an agent or is bound over the telephone by my voice signature.
• If the initial premium is paid by check, coverage is conditioned on the check being honored. If the check is not
honored, no coverage will have been or be provided at any time.
• A service charge of $20.00 will be imposed on any check or electronic draft not honored. This applies to both
the initial payment and to future premium payments.
• The Company may obtain and use consumer reports (which may include credit information) concerning all
persons named on the application and the vehicles listed on the application. Subsequent reports may be used
for an update, renewal or extension of my insurance.
Signature of Named Insured-Appiican% N rF Date -1 s
Signature of Parent or Legal Guardian X Date
Signature of Producing Agent X _ ~ Date
F
Policy Number: ORSS - 203924937 Applicant Name: DON FERGUSON Page: 4 of 4
W I OR 07 14
AAA Insurance
underwritten by CSAA Fire & Casualty Insurance Company
Insurance PO Box 24511 Oakland, CA 94623-9865 (800) 207-3618
PERSONAL INFORMATION PRIVACY NOTICE
Our Information Practices and Privacy Notice
Federal and state law requires us to tell you how we collect, share, and protect your Personal Information.
This Personal Information Privacy Notice applies to all Personal Information that we collect about you.
Please read this notice carefully to understand what we do.
Please note that, when you apply for insurance, you may be providing information to us, as well as to your AAA club
insurance agency. Your agency may have its own separate privacy notice and data security practices. Please contact
your agency if you have any questions about its policies and practices.
Definitions
"Personal Information" is information that identifies you as an individual, such as: Name, Postal address, Telephone
number and Email address.
'We," "us," and "our" refer to your insurance carrier which is named at the top of this page.
What Personal Information We Collect
The types of Personal Information we collect and share depend on the product or service you have with us. This
information can include your name and address, Social Security number, credit history, and insurance claims history. We
collect information from you (including from your transactions with us) and outside sources.
We collect Personal Information from you, for example, when you request a quote for insurance, apply for insurance, pay
insurance premiums, file an insurance claim, or give us your contact information. We also collect Personal Information
about you from others, such as affiliates or other companies. We also may obtain information from the American
Automobile Association and your AAA club relating to your AAA membership.
We also obtain information from consumer reporting agencies. It may include your driving record, claims history with other
insurers, credit report information and insurance credit score. A consumer reporting agency that gathers information about
you may share this information with others who are authorized to use consumer reports, as allowed by law.
What Personal Information We Share
All financial companies need to share customers' Personal Information to run their everyday business.
We may share all of the Personal Information about you that we collect with affiliated and unaffiliated companies, as
allowed by law. For example,
• We may share your Personal Information for our everyday business purposes-such as to process your
transactions, maintain your account(s), respond to court orders and legal or regulatory investigations, or report to
credit bureaus. Recipients may include, for example, our family of insurance companies, claims representatives,
service providers, consumer reporting agencies, insurance agents, law enforcement, courts and governmental
agencies,
• We may share your Personal Information for our marketing purposes-for example, we may share information
with our agents and service providers to offer our products and services to you more effectively.
• Unless you are a California resident, we also may share your Personal Information for joint marketing with other
financial companies. "Joint marketing" refers to a formal agreement between nonaffiliated financial companies
that together market financial products or services to you.
In addition, we may share Personal Information about our former customers in the manner described above.
Federal and state laws do not allow you to limit the data sharing described above.
AHPNXX 07 14 Page 1 of 2
Protectinq Your Personal Information
To protect Personal Information from unauthorized access and use, we use security measures that comply with federal
law. These measures include computer safeguards and secured files and buildings. We review the data security
practices of companies with whom we share data. We authorize only those personnel who need Personal Information to
perform their duties to access such data.
Your Rights
You can stop unwanted offers of our goods and services.
• If you do not wish to receive mail or telephone marketing communications from us, please call us at (800)
207-3618 or write us (and include your name, address and policy number) at:
CSAA Insurance Group
Privacy c/o Legal & Regulatory Affairs
3055 Oak Road, MS W280,
Walnut Creek, CA 94597; or by email at: Privacy@csaa.com
You have the right to see and, if necessary, correct Personal Information about you. This requires a written request, both
to see Personal Information about you and to request correction. We do not have to change our records if we do not
agree with your correction, but we will place your statement in our file. If you would like a copy of Personal Information
about you, please write us (and include your name, address and policy number) at:
CSAA Insurance Group
Attention: Policyholder Endorsement Department
PO Box 24511
Oakland, CA 94623-9865
For Nevada Residents Only:
We are providing you this notice pursuant to state law. You may be placed on our internal Do Not Call List by calling
(800) 207-3618. Nevada law requires that we also provide you with the following contact information:
Bureau of Consumer Protection
Office of the Nevada Attorney General
555 E. Washington St., Suite 3900
Las Vegas, NV 89101
Phone number: (702)486-3132
email: BCPINFO@ag.state.nv.us
Page 2 of 2
AHPNXX 07 14
Payment receipt
AAA Insurance
underwritten by CSAA Fire & Casualty Insurance Company
insurance PO Box 24511 Oakland, CA 94623-9865 (800) 207-3618
September 11, 2015
DON FERGUSON
CUSTOMER INFORMATION
Address 440 HELMAN STASHLAND, R
Thank you for your auto insurance policy payment. It will be 97520-1142
reflected on the next bill we send you. Please keep this receipt Preferred (541) 778-2679
for your records. phone number
Your policy number ORSS - 203924937
Payment information Type of policy auto insurance
Amwnt you paid $761.00
Type of payment Full Payment AGENT INFORMATION
Method of payment Credit/debit card - VISA agent's name David Buck
Cardholder name DON FERGUSON Agency AAA OREGON
Card number XXXXXXXXXXXX0583 Phone number (541) 618-4083
Expiration date 04/2017
Authorization date September 11, 2015 M Address EE BDFOR OR D, OR 975
504
Authorization number 117554134
Date September 11, 2015
Questions Call (800) 207-3618
about your Monday through Saturday, 5:00 am. to 7:00
Please note: Policy or p.m. Pacific Time
bill? Moving? Call to give us your new address.
Payments made by check, credit card, and debit card or electronic funds
transfer only take effect when cleared by your financial institution. If for
any reason your bank does not honor your check, credit card charge or
electronic payment, or they later reverse the amount, this means that you
have not made a payment. If that happens, it could affect the status of
your policy.
AHRCTXX 03 15
Page 1 of 1
KEEP THIS COPY IN YOUR VEHICLE IF YOU HAVE AN ACCIDENT
CSAA Fire & Casualty Insurance Co. / NAIC # 10921
PO Box 24511, Oakland, CA 94623-9865 1. NOTIFY THE POLICE IMMEDIATELY.
Insurance OR INSURANCE IDENTIFICATION CARD
POLICY# EFFECTIVE DATE EXPIRATION DATE 2. Write down names, addresses, telephone
ORSS - 203924937 09/12/15 09/12/16 numbers, and license numbers of persons
NAMED INSURED involved and of witnesses. Also write down the
DON FERGUSON, DENISE KESTER license plate number and state of each vehicle.
440 HELMAN ST
ASHLAND, OR 97520-1142 3. Report all accidents to AAA Claims immediately at
(800) 207-3618.
VEHICLE YEAR / MAKE / MODEL VEHICLE ID #
05 TOYO TUNDRA 5TBBT44165S464854 4. Do not admit fault. Do not discuss the accident
AGENT AAA Oregon /500/David Buck with anyone except your AAA representative or the Police.
AGENTID - 500016191
PHONE (800) 207-3618
IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART IMPORTANT THIS INSURANCE IDENTIFICATION CARD IS NOT PART
OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN
FORCE AND YOUR PREMIUMS ARE PAID. FORCE AND YOUR PREMIUMSARE PAID.
AA10XX 07 14
KEEP THIS COPY IN YOUR VEHICLE F IF YOU HAVE AN ACCIDENT
CSAA Fire & Casualty Insurance Co. / NAIC # 10921
PO Box 24511, Oakland, CA 94623-9865 1. NOTIFY THE POLICE IMMEDIATELY.
Insurance OR INSURANCE IDENTIFICATION CARD
POLICY # EFFECTIVE DATE EXPIRATION DATE 2. Write down names, addresses, telephone
ORSS - 203924937 09/12/15 09/12/16 numbers, and license numbers of persons
NAMED INSURED involved and of witnesses. Also write down the
DON FERGUSON, DENISE KESTER license plate number and state of each vehicle.
440 HELMAN ST
ASHLAND, OR 97520-1142 3. Report all accidents to AAA Claims immediately at
(800) 207-3618.
VEHICLE YEAR / MAKE / MODEL VEHICLE ID #
09 SUBA FORESTER JF2SH64639H781700 4. Do not admit fault. Do not discuss the accident
AGENT AAA Oregon /500/David Buck with anyone except your AAA representative or the Police.
AGENT ID - 500016191
PHONE (800) 207-3618
IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART
OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN
FORCE AND YOUR PREMIUMS ARE PAID. FORCE AND YOUR PREMIUMSARE PAID.
AA10XX 07 14
U-• ti
AAA Insurance
underwritten by CSAA Fire & Casualty Insurance Company
Insurance PO Box 24511 Oakland, CA 94623-9865 (800) 207-3618 La
II~~IIIIIII~II~I~~IIII~~~IIIIi~I~~llis~I~III~I~Ii~I~Ii~Illlliilll
DON FERGUSON Policy Number: ORSS - 203924937
440 HELMAN ST Agent Code: 500016191
ASHLAND, OR 97520-1142
Date: 09/12/15
CREDIT DISCLOSURE NOTICE
AUTO
In connection with this application for insurance, we may review your credit report or obtain or use a credit-
based insurance score based on the information contained in that credit report. We use this information to
predict the probability of future losses and to help rate your insurance policy. By more accurately anticipating
claims, we can better control risk, enabling us to offer insurance coverage to our policy holders at a more
competitive cost. An absence of credit will not affect consideration of an application. We may use a third
party in connection with the development of your insurance score. Please send us a written request at the
address listed above if you would like more information about our use of credit scores.
AACDOR 10 13
Oregon Auto Coverage Authorization Form
My agent has explained Bodily Injury Liability, Property Damage Liability, Uninsured/Underins..
Motorist Coverage, Personal Injury Protection, and Medical Payment Coverage.
I request my coverage be placed with AAA Insurance Company and authorize the policy
limits selected below (as well as on my application) with my signature and initials:
-
Initial
Bodily Injury Liability: Co)$100k/300k C)$250k/500k C) $500k/500k Other Amount
Property Damage Liability: $100k 0$250k 0 $500k Other Amount
Uninsured/Underinsured Motorist: $100k/300k (0$250k/500k (0 $500k/500k (L-) Other Amount
Personal Injury Protection: $15k C)$25k $50k j Other Amount
Medical Payment Coverage: $1k (D$5k $10k Ce) None r`
I rtt6 ~~fy i e.< y . f Ej1 a i G ~~IFI-`f~N_lk}f Initial
UMPD Limit: _ $20k 0$25k r-)$50k Other Amount
Comprehensive Deductible: (E)$100 0$250 0$500 C) Other Amount
Collision Deductible: $100 CJ$250 '$500 Other Amount
Rental Car Reimbursement: $30 per day 0$40 per day Other Amount
Gap Coverage € Accept # Not Eligible (D
In'tial
UMPD Limit: (F)$20k 0$25k C)$50k C) Other Amount
Comprehensive Deductible: 0$100 $250 Q$500 ' Other Amount 0
Collision Deductible: ()$100 C)$250 CD$500 0 Other Amount 0
Rental Car Reimbursement: }$30 per day j$40 per day (L) Other Amount
Gap Coverage D Accept Ce; Not Eligible CI)__ .
Ufa--1i' i}old ~cIto Irittl^al...
UMPD Limit: C $20k $25k (-)$50k (0 Other Amount r
Comprehensive Deductible: C)$100 0$250 Q$500 Q Other Amount 0
Collision Deductible: x;!$100 0)$250 x'$500 Other Amount 01
Rental Car Reimbursement: 0$30 per day $40 per day C Other Amount
Gap Coverage ( Accept C,) Not Eligible
Don Ferguson
Insured's Name / Insured's S gnat e Date signed
AAA Oregon/Idaho and/or its wholly owned subsidiary, Automobile Association Agency KEEP
(collectively "AAA"), will receive a commission from the insurer in connection with the place-
ment of your insurance, and may also receive additional compensation from the insurer as a LIFE
result of our purchase of insurance. In connection with the placement of your insurance, AAA GOING
represents only the insurer, but may provide services to you on behalf of the insurer.
Page 1 / 1
CITY OF
ASHLAND DATE PO NUMBER
1prat 20 E MAIN ST. 2/19/2016 13392
ASHLAND, OR 97520
(541) 488-5300
VENDOR: 019276 SHIP TO: Ashland Fire Department
FERGUSON, DONALD H. (541) 482-2770
440 HELMAN STREET 455 SISKIYOU BLVD
ASHLAND, OR 97520 ASHLAND, OR 97520
FOB Point: Ashland, Oreqon Req. No.:
Terms: Net Dept.:
Req. Del. Date: Contact: Alison Lerch
Special Inst: Confirming? NO
Quantity Unit Description Unit Price Ext. Price
Facilitator for 6-hour meetinq February 500.00
24th preceded by one or two planning
sessions with City staff to establish
the meeitnq agenda, backqround
information, expectations and roles.
The purpose of this meetinq is to
create an action plan for community
enqaqement and outreach for the Citv's
Community Wildfire Protection Plan, or
CWPP.
Contract for Goods and Services Small
Procurement Less than $5,000
Beqinninq date: 02/09/2016
Completion date: 02/29/2016
SUBTOTAL 500.00
BILL TO: Account Payable TAX 0.00
20 EAST MAIN ST FREIGHT 0.00
541-552-2010 TOTAL 500.00
ASHLAND, OR 97520
Account Number Project Number Amount Account Number Project Number Amount
E 110.07.29.00.60416 E 000442.400 500.00
Autho&:ed Signature VENDOR COPY
FORM #3 CITY OF
'l ASHLAND
REQUISITION Date of request: 2/4/2016
Required date for delivery: 2/12/2016
Vendor Name nnn Farrnicnn
Address, City, State, Zip 440 Helman St„ Ashland OR 97520
Contact Name & Telephone Number Don Ferguson, (541) 778-2679
Fax Number
SOURCING METHOD
❑ Exempt from Competitive Bidding ❑ Emergency
❑ Reason for exemption: ❑ Invitation to Bid (Copies on file) ❑ Form #13, Written findings and Authorization
❑ AMC 2.50 Date approved by Council: ❑ Written quote or proposal attached
❑ Written quote or proposal attached Attach co of council communication If council approval required, attach co of CC
® Small Procurement Cooperative Procurement
Less than $5,000 ❑ Request for Proposal (Copies on file) ❑ State of Oregon
® Direct Award Date approved by Council: Contract #
❑ Verbal/Written quote(s) or proposal(s) -(Attach copy of council communication) ❑ State of Washington
Intermediate Procurement ❑ Sole Source Contract #
GOODS & SERVICES ❑ Applicable Form (#5,6, 7 or 8) ❑ Other government agency contract
$5,000 to $100,000 ❑ Written quote or proposal attached Agency
❑ (3) Written quotes and solicitation attached ❑ Form #4, Personal Services $5K to $75K Contract #
PERSONAL SERVICES ❑ Special Procurement Intergovernmental Agreement
$5,000 to $75,000 ❑ Agency
❑ Form #9, Request for Approval
❑ Less than $35,000, by direct appointment ❑ Written quote or proposal attached Date original contract approved by Council:
❑ (3) Written proposals/written solicitation Date approved by Council: (Date)
❑ Form #4, Personal Services $5K to $75K Valid until: Date - (Attach copy of council communication)
Description of SERVICES Total Cost
Contractor will facilitate a 6 hour meeting on February 24th preceded by one or two planning
sessions with City staff to establish the meeting agenda, background information, expectations and
roles. The purpose of this meeting is to create an action plan for community engagement and $ not to exceed $500
outreach for the City's Community Wildfire Protection Plan, or CWPP.
Item # Quantity Unit Description of MATERIALS Unit Price Total Cost
TOTAL
Per attached quotelproposal COST
❑
$500.00
Project Number 000442.400 Account Number 110.07.29.00.604160
Account Number - Account Number--- -
*Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect the actual expenditures.
IT Director in collaboration with department to approve all hardware and software purchases:
IT Director Date Support -Yes /No
By signing this requisition form, I certify that the City's public contracting requirements have been satisfied.
Employee:',, a ~~1 Department Head: 9~(~---
(Equal,t'o or greater than $5,000)
Department Manager/Supervisor: City Administrator:
(Equal to or greater than $25,000)
Funds appropriated for current fiscal year YES / NO
Finance Director- (Equal to orgreaterthan $5,000) Date
Comments:
Form #3 - Requisition