Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
2016-247 Contract - Gerlitz Engineering
Contract for Personal Services less than $35,000.00 CITY O F CONSULTANT: Gerlitz Engineering -A5 H LAND CONTACT: Justin Gerlitz 20 East Main Street Ashland, Oregon 97520 ADDRESS: 1867 Williams HWY, Suite 201, Grants Pass, OR Telephone: 541/488-6002 97527 Fax: 541/488-5311 TELEPHONE: (541) 244-2617 DATE AGREEMENT PREPARED: 8/24/16 EMAIL: justin@gerlitzengineering.com BEGINNING DATE: 9/1/16 COMPLETION DATE: 2/10/17 COMPENSATION: Not to exceed $25,350 SERVICES TO BE PROVIDED: -Engineering for New Do Park (per exhibit C ADDITIONAL TERMS: In the event of conflicts or discrepancies among the contract documents, the City of Ashland Contract for Personal Services will be primary and take precedence, and any exhibits or ancillary contracts or agreements having redundant or contrary provisions will be subordinate to and interpreted in a manner that will not conflict with the said rims City of Ashland Contract. FINDINGS: Pursuant to AMC 2.50.120, after reasonable inquiry and evaluation, the undersigned Department Head finds and determines that: (1) the services to be acquired are personal services; (2) the City does not have adequate personnel nor resources to perform the services; (3) the statement of work represents the department's plan for utilization of such personal services; (4) the undersigned consultant has specialized experience, education, training and capability sufficient to perform the quality, quantity and type of work requested in the scope of work within the time and financial constraints provided; (5) the consultant's proposal will best serve the needs of the City; and (6) the compensation negotiated herein is fair and reasonable. NOW THEREFORE, in consideration of the mutual covenants contained herein the CITY AND CONSULTANT AGREE as follows: 1. Findings / Recitations. The findings and recitations set forth above are true and correct and are incorporated herein by this reference. 2. All Costs by Consultant: Consultant shall, at its own risk and expense, perform the personal services described above and, unless otherwise specified, furnish all labor, equipment and materials required for the proper performance of such service. 3. Qualified Work: Consultant has represented, and by entering into this contract now represents, that all personnel assigned to the work required under this contract are fully qualified to perform the service 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. 4. Completion Date: Consultant shall start performing the service under this contract by the beginning date indicated above and complete the service by the completion date indicated above. 5. Compensation: City shall pay Consultant for service performed, including costs and expenses, the sum specified above. Payments shall be made within 30 days of the date of the invoice. Should the contract be prematurely terminated, payments will be made for work completed and accepted to date of termination. 6. Ownership of Documents: All documents prepared by Consultant pursuant to this contract shall be the property of City. 7. Statutory Requirements: ORS 279C.505, 279C.515, 279C.520 and 279C.530 are made part of this contract. 8. Living Wage Requirements: If the amount of this contract is $20,283.20 or more, Consultant is required to comply with chapter 3.12 of the Ashland Municipal Code by paying a living wage, as defined in this chapter, to all employees performing work under this contract and to any Subcontractor who performs 50% or more of the service work under this contract. Consultant is also required to post the notice attached hereto as Exhibit B predominantly in areas where it will be seen by all employees. 9. Indemnification: Consultant agrees to defend, indemnify and save City, its officers, employees and agents harmless from any and all losses, claims, actions, costs, expenses, judgments, subrogations, or other damages resulting from injury to any person (including injury resulting in death), or damage (including loss or destruction) to property, of whatsoever nature arising out of or incident to the performance of this contract by Consultant (including but not limited to, Consultant's employees, agents, and others designated by Consultant to perform work or services attendant to this contract). Consultant shall not be held responsible for any losses, expenses, claims, subrogations, actions, costs, judgments, or other damages, directly, solely, and proximately caused b the negligence of City. Contract for Personal Services less than $35,000.00, Page 1 of 5 10. Termination: a. Mutual Consent. This contract may be terminated at any time by mutual consent of both parties. b. City's Convenience. This contract may be terminated at any time by City upon 30 days' notice in writing and delivered by certified mail or in person. C. For Cause. City may terminate or modify this contract, in whole or in part, effective upon delivery of written notice to Consultant, or at such later date as may be established by City under any of the following conditions.- i. If City funding from federal, state, county or other sources is not obtained and continued at levels sufficient to allow for the purchase of the indicated quantity of services; ii. If federal or state regulations or guidelines are modified, changed, or interpreted in such a way that the services are no longer allowable or appropriate for purchase under this contract or are no longer eligible for the funding proposed for payments authorized by this contract; or iii. If any license or certificate required by law or regulation to be held by Consultant to provide the services required by this contract is for any reason denied, revoked, suspended, or not renewed. d. For Default or Breach. i. Either City or Consultant may terminate this contract in the event of a breach of the contract by the other. Prior to such termination the party seeking termination shall give to the other party written notice of the breach and intent to terminate. If the party committing the breach has not entirely cured the breach within 15 days of the date of the notice, or within such other period as the party giving the notice may authorize or require, then the contract may be terminated at any time thereafter by a written notice of termination by the party giving notice. ii. Time is of the essence for Consultant's performance of each and every obligation and duty under this contract. City by written notice to Consultant of default or breach may at any time terminate the whole or any part of this contract if Consultant fails to provide services called for by this contract within the time specified herein or in any extension thereof. iii. The rights and remedies of City provided in this subsection (d) are not exclusive and are in addition to any other rights and remedies provided by law or under this contract. e. Obligation/Liability of Parties. Termination or modification of this contract pursuant to subsections a, b, or c above shall be without prejudice to any obligations or liabilities of either party already accrued prior to such termination or modification. However, upon receiving a notice of termination (regardless whether such notice is given pursuant to subsections a, b, c or d of this section, Consultant shall immediately cease all activities under this contract, unless expressly directed otherwise by City in the notice of termination. Further, upon termination, Consultant shall deliver to City all contract documents, information, works-in-progress and other property that are or would be deliverables had the contract been completed. City shall pay Consultant for work performed prior to the termination date if such work was performed in accordance with the Contract. 11. Independent Contractor Status: Consultant is an independent contractor and not an employee of the City. Consultant shall have the complete responsibility for the performance of this contract. Consultant shall provide workers' compensation coverage as required in ORS Ch 656 for all persons employed to perform work pursuant to this contract. Consultant is a subject employer that will comply with ORS 656.017. 12. Assignment and Subcontracts: Consultant shall not assign this contract or subcontract any portion of the work without the written consent of City. Any attempted assignment or subcontract without written consent of City shall be void. Consultant shall be fully responsible for the acts or omissions of any assigns or Subcontractors and of all persons employed by them, and the approval by City of any assignment or subcontract shall not create any contractual relation between the assignee or subcontractor and City. 13. Default. The Consultant shall be in default of this agreement if Consultant: commits any material breach or default of any covenant, warranty, certification, or obligation it owes under the Contract; its QRF status pursuant to the QRF Rules or loses any license, certificate or certification that is required to perform the Services or to qualify as a QRF if consultant has qualified as a QRF for this agreement; institutes an action for relief in bankruptcy or has instituted against it an action for insolvency; makes a general assignment for the benefit of creditors; or ceases doing business on a regular basis of the type identified in its obligations under the Contract; or attempts to assign rights in, or delegate duties under, the Contract. 14. Insurance. Consultant shall at its own expense provide the following insurance: 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 b. Professional Liability insurance with a combined single limit, or the equivalent, of not less than Enter one: $250,000, $500,000, $1,000,000, $2,000,000 or Not Applicable for each claim, incident or occurrence. This is to cover damages caused by error, omission or negligent acts related to the professional services to be provided under this contract. C. General Liability insurance with a combined single limit, or the equivalent, of not less than Enter one: $200,000, $500,000, $1,000,000, $2,000,000 or Not Applicable for each occurrence for Bodily Injury and Property Damage. d. Automobile Liability insurance with a combined single limit, or the equivalent, of not less than Enter one: $100,000, $500,000, $1,000,000, or Not Applicable for each accident for Bodily Injury and Property e, Contract for Personal Services less than $35,000.00, Page 2 of 5 including coverage for owned, hired or non-owned vehicles, as applicable. e. Notice of cancellation or change. There shall be no cancellation, material change, reduction of limits or intent not to renew the insurance coverage(s) without 30 days' written notice from the Consultant or its insurer(s) to the City. f. Additional Insured/Certificates of Insurance. Consultant shall name The City of Ashland, Oregon, and its elected officials, officers and employees as Additional Insureds on any insurance policies, excluding Professional Liability and Workers' Compensation, required herein, but only with respect to Consultant's services to be provided under this Contract. The consultant's insurance is primary and non-contributory. As evidence of the insurance coverages required by this Contract, the Consultant shall furnish acceptable insurance certificates prior to commencing work under this contract. The certificate will specify all of the parties who are Additional Insureds. Insuring companies or entities are subject to the City's acceptance. If requested, complete copies of insurance policies; trust agreements, etc. shall be provided to the City. The Consultant shall be financially responsible for all pertinent deductibles, self-insured retentions and/or self-insurance. 15. Governing Law; Jurisdiction; Venue: This contract shall be governed and construed in accordance with the laws of the State of Oregon without resort to any jurisdiction's conflict of laws, rules or doctrines. Any claim, action, suit or proceeding (collectively, "the claim") between the City (and/or any other or department of the State of Oregon) and the Consultant that arises from or relates to this contract shall be brought and conducted solely and exclusively within the Circuit Court of Jackson County for the State of Oregon. If, however, the claim must be brought in a federal forum, then it shall be brought and conducted solely and exclusively within the United States District Court for the District of Oregon filed in Jackson County, Oregon. Consultant, by the signature herein of its authorized representative, hereby consents to the in personam jurisdiction of said courts. In no event shall this section be construed as a waiver by City of any form of defense or immunity, based on the Eleventh Amendment to the United States Constitution, or otherwise, from any claim or from the jurisdiction. 16. 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. SUCH WAIVER, CONSENT, MODIFICATION OR CHANGE, IF MADE, SHALL BE EFFECTIVE ONLY IN THE SPECIFIC INSTANCE AND FOR THE SPECIFIC PURPOSE GIVEN. THERE ARE NO UNDERSTANDINGS, AGREEMENTS, OR REPRESENTATIONS, ORAL OR WRITTEN, NOT SPECIFIED HEREIN REGARDING THIS CONTRACT. CONSULTANT, BY SIGNATURE OF ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES THAT HE/SHE HAS READ THIS CONTRACT, UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND CONDITIONS. 17. Nona ppropriations Clause. Funds Available and Authorized: City has sufficient funds currently available and authorized for expenditure to finance the costs of this contract within the City's fiscal year budget. Consultant understands and agrees that City's payment of amounts under this contract attributable to work performed after the last day of the current fiscal year is contingent on City appropriations, or other expenditure authority sufficient to allow City in the exercise of its reasonable administrative discretion, to continue to make payments under this contract. In the event City has insufficient appropriations, limitations or other expenditure authority, City may terminate this contract without penalty or liability to City, effective upon the delivery of written notice to Consultant, with no further liability to Consultant. Certification. Consultant shall sign the certification attached hereto as Exhibit A and herein incorporated b reference. Consultant: City of Ashlan 14- By By S Department Head Print Name ,,pp Print Name Z-.)t Title Date W-9 One copy of a W-9 is to be submitted with the signed contract. Purchase Order No. Contract for Personal Services less than $35,000.00, Page 3 of 5 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: ✓ (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. (3) Telephone listing is used for the business separate from the personal residence listing. (4) Labor or services are performed only pursuant to written contracts. - v1 (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. C n or (Date) Contract for Personal Services less than $35,000.00, Page 4 of 5 CITY OF ASHLAND, OREGON EXHIBIT B City of Ash land LIVING 1 0 1 1. Sol W A F= per hour effective June 30, 2016 (Increases annually every June 30 by the Consumer Price Index) Irma portion of business of their 401 K and IRS eligible employer, if the employer has cafeteria plans (including ten or more employees, and childcare) benefits to the has received financial amount of wages received by assistance for the projector the employee. ➢ For all hours worked under a business from the City of service contract between their Ashland in excess of ➢ Note: "Employee" does not employer and the City of $20,283.20. include temporary or part-time Ashland if the contract employees hired for less than exceeds $20,283.20 or more, ➢ If their employer is the City of 1040 hours in any twelve- Ashland including the Parks month period. For more ➢ For all hours worked in a and Recreation Department. details on applicability of this month if the employee spends policy, please see Ashland 50% or more of the ➢ In calculating the living wage, Municipal Code Section employee's time in that month employers may add the value 3.12.020. working on a project or of health care, retirement, For additional information: Call the Ashland City Administrator's office at 541-488-6002 or write to the City Administrator, City Hall, 20 East Main Street, Ashland, OR 97520 or visit the city's website at www.ashland.or.us. Notice to Employers: This notice must be posted predominantly in areas where it can be seen by all employees. CITY OF ASHLAND Contract for Personal Services less than $35,000.00, Page 5 of 5 W 4 1 ,s < I n-Inc rinc, Consultant" August 19, 2o16 Jason Minica, Planning and Development Manager Ashland Parks & Recreation 1195 E. Main Street Ashland, OR 97520 RE: Planning/ Engineering Services Proposal - Clay Street Dog Park Jason, Per our recent discussions and site meeting, I have prepared the following planning and engineering services proposal for the new Clay Street Dog Park located off of Engle Street in Ashland, Oregon. The main development site is approximately 2.1 acres in size and is located east of Engle Street, north of an existing housing development, and west of the YMCA City Park fields. At this time, it is our understanding that Ashland Parks (Owner) will be improving the vacant property with a dog park, including an area for large dogs, small dogs, and a separate non-dog park area. In addition to this, you will be installing frontage improvements along Engle Street (park row and sidewalk) as well as a pedestrian path between the dog park and existing parking lot in YMCA City Park. Prior to the new park improvements, the City will be making an alley connection on the south side of the park to Villard Street and it is assumed they will be providing us with electronic design drawings of these improvements for our use. It appears that adequate utility infrastructure exists adjacent to the site to serve the new improvements. Based on City standards and the pre-application review comments, we are anticipating that both storm water detention and treatment will be required prior to connecting into the existing off-site storm system at the north end of Engle Street. This system will be sized for all new improvement areas per City standards. It is possible that we may need to get some infiltration testing completed for the proposed storm detention system based on our ability to drain across the property to the north. Per our conversations, we are anticipating the planning submittal occurring in October, construction document completion for agency review around late winter, bidding in the late winter/early spring, and construction commencement in early Spring (weather dependent). Below is the anticipated overall scope/fee for the individual project phases associated with the planning, design, and construction of the new facility: Task "A" - Site Plan Application/Submittal: • Project administration (meetings, site/infrastructure research, design coordination, etc.) • Site inspection of development area. • Survey coordination and review. • Prepare schematic site plan drawings, grading/utility plan, and associated details to comply with City planning application standards. • Prepare schematic landscape/irrigation plan. Ashland Parks to provide redline markup/review of our site layout to identify tree/plant species and locations, irrigation type, and connection location. We will then draft the markups for a formal submittal. 1867 Williams Highway, Suite 201, Grants Pass, OR 97527 Office: 541-244-2617 www.gerlitzengineering.com Page 1 Task "D" - Construction Administration: • Coordinate with the selected contractor to answer RFI's. • Review any necessary material submittals. • Review pay requests and change orders after Owner review. • Attend (4) site visit/inspection during construction activities. • Prepare as-built construction drawings Task "D" Estimated Fee: $3,900 Total Design/Services Fee: $25,~r,0 Exclusions: • Application fees, System Development Charges, Permit Fees, etc. • Consultation associated with a planning appeal and/or associated land use hearings. • Surveying services and construction staking (by others) • Environmental studies, mitigation, etc. (not anticipated) • Geotechnical soils infiltration testing (to be completed by others if necessary based on allowable storm connection) • Final landscape and irrigation design (by City or Design-Build Landscape Contractor) • Formal traffic study above and beyond scope identified above (not anticipated) • Any significant changes made to previously completed design/construction documents based on budgetary limitations and associated Owner revisions. Please review this information and let us know if you have any questions or comments. Based our long standing history of completing similar projects in the local area and strong working relationships with Ashland Parks and City of Ashland Staff, we are confident that we can complete this project efficiently within the schedule provided. We look forward to the opportunity of working with you on this project. Sincerely, Justin Gerlitz, P.E. 1867 Williams Highway, Suite 201, Grants Pass, OR 97527 Office: 541-244-2617 www.gerlitzengineering.com Page 3 saff corpora ion Information Page Carrier No: 20001 Policy No: 862187 Employer Identification No: 81-1188082 NCCI Risk ID No: Item 1. The Insured: Entity Type: GERLITZ ENGINEERING CONSULTANTS, LLC. LIMITED LIABILITY COMPANY Mailing address: Agency: GERLITZ ENGINEERING CONSULTANTS, LLC. MARK O'HARA 1867 WILLIAMS HWY., SUITE 201 HART INSURANCE AGENCY GRANTS PASS, OR 97527 PO BOX 1240 GRANTS PASS, OR 97528 Other workplaces not shown above: NONE Item 2. The policy period is from 05-19-2016, 12:01 A.M. to 06-01-2017, 12:01 A.M. at the insured's mailing address Item 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: OREGON B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $500,000 each accident Bodily Injury by Disease $500,000 each employee Bodily Injury by Disease $500,000 policy limit C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: NONE D. This policy includes these endorsements and schedules: WC360601 E Oregon Cancellation Endorsement WC000421 D Catastrophe (other than Certified Acts of Terrorism) Premium End W0000422B Terrorism Risk Insurance Prog Reauthorization Act Disclosure End WC000414 Notification of Change in Ownership Endorsement WC000406A Premium Discount Endorsement WC360406 Premium Due Date Endorsement WC990309C SAIFPlus Endorsement WC360301 Oregon Unsafe Equipment Exclusion Endorsement WC990616 Confidentiality Endorsement Item 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. The premium and rates and the experience rating modification factor, if any, may change on your anniversary rating date of 06-01-2017. All Information required below is subject to verification and change by audit. i F t Policy No., 862187 saffcorporation Page 2 Information Page Estimated Rate Per Policy Period $100 of Estimated Class w_ Description__ Payroll Pa roll Premium Period: 05/1912016 - 0613112017 Gerilitz Engineering Consultants, Llc. 8601 14 Architect Or Engineer Firm-Sales/Dr $49,7'10. 0.36 $178.96 Total Payroll $49,710 Manual Premium $178,9$ Estimated Premium $178,96 Total Estimated Premium $178,96 SAIFPIus Credit (2% to a $600 maximum) - $3.68 Balance of Policy Minimum Premium (excludes Part Two Premium) + $50.62 Estimated Standard Premium $226.40 Terrorism Premium + $4.97 Catastrophe Premium + $4.97 Estimated Policy Period Premium $235.94 DCBS Assessment @ 6.20% on $235.94 (excludes Part Two & Federal Premium) + $14.63 Total Estimated Policy Premium Including DCBS Assessment $250.57 Policy Minimum Premium: $226 Your policy premium is based on your current estimated premium and may be prorated for policies in effect for less than a full year or adjusted based on actual payroll by classification. The SAIFPIus discount applies only to premium paid prior to the end of the policy period. Terrorism Premium is in addition to Policy Minimum Premium. Catastrophe Premium is in addition to Policy Minimum Premium, Payroll Reporting Frequency: Annual This information page is part of your policy. Countersigned on 05-18-2016 at Salem, Oregon Ker arnett, Pr sident c W0000001A and Chief Executive Officer Y, x i It s' n 5 i i I ' www.salf.com saif corporation RECEJVEJY~, May 18, 2016 1 SAY 2 3 2016 MARK O'HARA J GERLITZ ENGINEERING CONSULTANTS, LLC. HART INSURANCE AGEN P 1867 WILLIAMS HWY., SUITE 201 PO BOX 1240 GRANTS PASS, OR 97527 GRANTS PASS, OR 97528 Policy Number: 862187 Effective Date of Coverage: May 19, 2016 Dear Policyholder: Thank you for selecting SAIF Corporation as your workers' compensation provider. As the leading workers' compensation insurance company in Oregon, our goals are to provide you exceptional service at an affordable price, and to help you make your workplace as safe as possible. Included with this letter is a policy information page that shows your estimated payroll, premium modifiers, and estimated premium amount. You also will find an explanation of your classifications and the endorsements that apply to your policy. We've also provided some key information below. You'll find everything else you need to know about your policy, workplace safety, filing and managing a claim, and more in the easy-to-use Employer Guide on our website. Just go to saif.com and click "Employer Guide." You can request printed information on topics of interest to you and your workers by calling us at 503.373.8000 or 800.285.8525, or by emailing uwpayroll@saif.com. Payroll reporting I At the end of each annual reporting period, we'll send you a form to report the actual payroll for your covered workers for that period. For more on a roll reporting, see these key pages on saif.com: - Learn how to complete your payroll report: saif.com/instructions - View details on the requirements for reporting your payroll by class: saif.com/class - See an explanation of who is covered (also called "subject workers") and who is not: salf.com/whomiscovered - Learn when to report a worker in multiple classifications: saif.com/vtr For your convenience, you can report your payroll and make your payments online. Go to the Employer Guide on saif.com and log into (or register for) Business Online. Your premium Payment options based on your estimated premium of $250.57 are. listed below. r. Installment Payment Plan Due Date Amount 05/18/2016 $250.57 i! s 400 High St SE 1 Salem, OR 97312 I P: 800.285.8525 s 3 E 3 Policy No: 862187 saffcorporation Page 2 Important: Changes in your payroll, classifications, or number of locations during the policy year can result in an adjustment to your installment amounts. Please notify us right away of any changes in your business. Premium audits I Our goal is to ensure accurate payroll reporting we want you to pay only what you're required to pay. Premium auditors verify that you have reported the correct payroll in the proper classification. Learn more about the premium audit process at saif.com/premiumaudit. Nondisabling claim reimbursement I This program could help you reduce or eliminate costs that are considered when determining your future experience rating modification factors. Learn more about the program and billing options at saif.com/ndr. Managed care organizations (MCOs) I Majoris Health Systems is the registered managed care provider in your area. If you need to fin a doctor or medical facility for an injured worker, you'll find MCO directories at saif.com/supportingworker. Workplace safety and health I You may request workplace safety and industrial hygiene assistance by contacting our team of safety and health experts at 877.242.5211 or by email at SafetyServices@saif.com. Safety professionals will assist you in analyzing your operations, hazards, injury records, and management controls. In addition, they will help you. - Learn how to conduct onsite health and safety surveys - Assess your safety and health programs - Learn to identify and evaluate safety training requirements, best practices, and available resources - Understand your responsibilities and the rules which pertain to your workplace under the Oregon Safe Employment Act (OSEA) and the Oregon Occupational Safety and Health Division. (OR-OSHA). OSEA and OR-OSHA require employers to provide a safe and healthful workplace and to do everything reasonably necessary to protect the life, health, and safety of their employees. Learn more at www.orosha.org or 800.922.2689. You also can find expert workplace safety information in the comprehensive safety section on our website by going to saif.com and clicking "Safety and health." Note: You have the right to contact OR-OSHA if we fail to provide loss prevention services as offered or requested. If you have any questions or need assistance, please contact MARK O'HARA at 541.479.5521. We look forward to working with you. Sincerely, i Service Center P: 971.242.5001 or 888.598.5880 F: 971.242.5353 servicecenter@saif.com Enclosures s c: MARK O'HARA - HART INSURANCE AGENCY Y NBL 400 High St SE I Salem, OR 97312 P: 800.285.8525 l HAnover Insurance Group. OZ2 AOM251 0901604 BUSINESSOWNERS LIABILITY SPECIAL BROADENING ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies Insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SUMMARY OF COVERAGES Limits Page 1. Additional Insured by Contract, Agreement or Permit 1 2. Additional Insured - Broad Form Vendors 2 3. Alienated Premises 2 4. Bodily Injury Redefined 2 5. Broad Form Property Damage - Borrowed Equipment, Customers 2 Goods and Use of Elevators 6. Incidental Malpractice (Employed Nurses, EMT's and Paramedics) 3 7. Personal and Advertising Injury - Broad Form 3 8. Product Recall Expense $25,004 Occurrence $50,000 Aggregate 3 9. Unintentional Failure to Disclose Hazards 5 10. Unintentional Failure to Notify 5 This endorsement amends coverages provided under the Businessowners Coverage Form through new coverages and broader coverage grants. This coverage Is subject to the provisions applicable to the Businessowners Coverage Form, except as provided below. I. Additional Insured by Contract, Agreement or This insurance applies on a primary basis if Permit that Is required by the written contract, Under SECTION 11 - LIABILITY, C. Who Is An agreement or permit. Insurad, Paragraph 4. 1s added as follows: b. This provision does not apply: a. Any person or organization for whom you (1) Unless the written contract or written are performing operations when you and agreement has been executed or permit such person or organization have agreed in has been issued prior to the "bodily writing in a contract, agreement or permit injury", "property damage" or "personal that such person or organization be added and advertising injury`; as an additional Insured on your policy. Such (2) To any person or organization Included person or organization is an additional as an insured by an endorsement insured only with respect to liability for issued by us and made part of this "bodily Injury", "property damage" or Policy; "personal and advertising injury" caused, In whole or in part, by: (3) To any person or organization included as an insured under Item 1.a.2. of this (1) Your acts or omissions; or endorsement; (2) The acts or omissions of those acting (4) To any lessor of equipment: on your behalf, (a) After the equipment lease expires; but only with respect to-, or (3) "Your work" for the additional Insureds) (b) If the "bodily injury", "property at the location designated In the damage" or "personal and contract, agreement or permit; or advertising injury" arises out of the A (4) Premises you own, rent, lease, control or sale negligence of the lessor; occupy. 391-1006 06 019 Includes copyrighted material of Insurance Services Off Ice, Inc. Page 1 of 6 13,1113 9GERLEN . OP ID: MO CERTIFICATE OF LIABILITY INSURANCE 06110/2016M) 0THIS 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 pot€cy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s . PRODUCER Phone: 541.479-5521 NAME CT Hart Insurance - P. O, Box '1240 Fax: 541-47'4-1890 P N r< A!C No ; Grants Pass, OR 97628 E AL Mark O'Hara Ms: ~ INSURER S AFFORDING COVERAGE NAIC Il INSURER A: Hanover American IrlsuRSO Gerlltz Engineering INSURER B : AIX S ecial Consultants, LLC. INSURER c~ SAIF Co oration 1867 Williams Hwy., Suite 201 Grants Pass, OR 97527 INSURER D : INSURER I-: IN URER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 13EEN 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 APPORDED 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. IL R TYPE OF INSURANCE ~ ~y WV1 POLICY NUMBER I4lOfOD EF POLICY Y ^MT~ LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,00 TO RE A COMMERCIAL GENERAL LIABILITY X OZ2A83625100 0210812016 0210812017 PREMI§ E§ (Ea atcunenoeL S 300,00 CLAIMS-MADE 0 OCCUR MED EXP (An one parson) S 5,00 X Business Owners PERSONAL B ADV INJURY $ 2,000,00 GENERAL AGGREGATE $ 4,000,00 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG S 4,000,00 POLICY PRO LOC S AUTOMOBILE LIABILITY COMBI ED E LIMIT Ee accident ANY AUTO BODILY INJURY (Per person) S ALLOWNED SCHEDULED BODILY INJURY (Per aocident) S AUTOS AUTOS X HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per acct 9 S UMBRELLA LIA8 OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ J DEG RETENTION $ WORKERS COMPENSATION X WC STATU OTH- AND EMPLOYERS' LIABILITY YIN TORY LIMITS R C ANY PRO RIETOR &xC UDERIEXECUTIVE N 1 A 862187 05119/2016 0511912097 E.L. EACH ACCIDENT S 600,00 OFFtCERIMEMBE (Mandatory In NH) E.L. DISEASE- EA EMPLOYEE $ 600,00 If yes, describe under DESCRIPTION OF OPERATIONS Wow E.L. DISEASE - POLICY LIMIT S 500,00 B Architects & Eng. LH2 A83e262 00 02108/2016 02108/2017 Per Claim 2,000,00 Professional Llab. Aggregate 2,000,00 1 DESCRIPTION OF OPERATIONS i LOCATIONS 1 VEHICLES {Attach ACORD 101, Additional Remarks Schedule, If more space Is required) The City of Ashland, Oregon, its elected officials, officers and employees are included as Additional Insured with reapect to Consultant's service provided by written contract. Coverage is Primary & Non Contributory. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ashland Parks and Recreation ACCORDANCE WITH THE POLICY P VISIONS Commission 340 S. Pioneer Street AUTHORIZED REPRESENTATIVE Ashland, OR 97520 Mark O'Hara ©1988.2010 ACORD CORPORATION, All rights reserved. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD (5) To any: demonstration, testing, or the (a) Owners or other interests from substitution of parts under instruction whom land has been leased which from the manufacturer, and then takes place after the lease for that repackaged in the original container; land expires; or e. Any failure to make such inspection. (b) Managers or lessors of premises if. adjustments, tests or servicing as the vendor has agreed to make or normally G) The occurrence takes place after undertakes to make in the usual course you cease to be a tenant in that of business in connection with the premises; or distribution or sale of the product, (0) The "bodily injury". "property f, Demonstration, installation, servicing or damage" or "personal and repair operations, except such advertising injury' arises out of operations performed at the vendor's structural alterations, new premises In connection with the sale of construction or demolition the product; operations performed by or on products which, after distribution or sale behalf of the manager or lessor; g• or by you, have been labeled or relabeled or used as a container, part or (6) To "bodily injury", "property damage" or Ingredient of any thing or substance by "personal and advertising Injury" arising or for the vendor., or out of the rendering of or the failure to h. "Bodily injury" or "property damage" render any professional services. arising out of the sole negligence of the c. Additional Insured coverage provided by vendor for Its own acts or omissions or this provision will not be broader than those of its employees or anyone else coverage provided to any other Insured, acting on its behalf. However, this d. All other insuring agreements, exclusions, exclusion does not apply to: and conditions of the policy apply. (1) The- exceptions contained in 2. Additional Insured - Broad Form Vendors paragraphs 5.d. or 51; or Under SECTION 11 - LIABILITY, C. Who It, An (2) Such inspections, adjustments, test Insured, paragraph S. is added as follows; or servicing as the vendor has 5. Any person or organization with whom you agreed to make or normally agreed, because of a written contract or undertakes to make In the usual written agreement to provide insurance, but course of business, In connection only with respect to "bodily injury" or with the distribution or sale of the "property damage" arising out of "your products- products" which are distributed or sold In This insurance does not apply to any the regular course of the vendor's business. Insured person or organization, from whom The insurance afforded the vendor does not you have acquired such products, or any apply to: ingredient, part or container, entering into, accompanying or containing such products. a. "Bodily injury" or "property damage" for Alienated Premises which the vendor is obligated to pay damages by reason of the assumption of tinder SECTION tl - UABILITY, 13, Exclusions, liability in a contract or agreement, This paragraph 1.t V) is replaced in its entirety with exclusion does not apply to liability for the following: damages that the vendor would have in (2) premises you sell, give away or abandon. If the absence of the contract or the "property damage" arises out of any part agreement; of those premises and occurred from b. Any express warranter unauthorized by hazards that were known by you, or should you; have reasonably been known by you, at the time the property was transferred or c. Any physical or chemical change in the abandoned. product made intentionally by the vendor; 4. Bodily Injury Redefined d. Repackaging, unless unpacked solely Under SECTION 11 - LIABILITY, F. Liability and for the purpose of inspection, Medical Expenses Definitions, definition 4. Is replaced in its entirety by the following: 391-1006 06 09 Includes copyrighted material of Insurance Services Office, Inc, Page 2 of 5 nn SCR H TIWno~rer Insurance t~roup- OZ2 A835251 0901601 4. "Bodily injury" means bodily Injury, (a) The insured; or disability, sickness or disease sustained by (b) Any officer of the corporation, a person, including death resulting from any poratton, of these at any time. "Bo_ _dily Injury" includes director, stockholder, partner or mental anguish or other mental iniurv member of the insured; and resulting from "bodily Iniury". (2) Not directly or indirectly related to an 5. Broad Form Property Damage - Borrowed "employee", nor to the employment, Equiptrrertf, Customers Goods, Use of Elevators prospective employment or termination of a. Under SECTION Il - LIABILITY, B. any person or persons by an insured. Exclusions, paragraph 1.k., the following Is S' Product Recall Expense added: a. Under SECTION li - LIABILITY, B. Paragraph (4) does not apply to "property Exclusions, Paragraph 1. o. Is replaced In Its damage" to borrowed equipment while at a entirety by the following: jobelte and not being used to perform o. Recall of Products, Work or Impaired operations. Property Paragraph (3), (4) and (6) do not apply to Damages claimed for any loss, cost or "property damage" to "customers goods" expense Incurred by you or others for while on your premises nor to the use of the loss of use, withdrawal, recall, elevators. inspection, repair, replacement, b. Under SECTION 11 - LIABILITY, F. Liability adjustment, removal or disposal of: and MeaBcal Expenses Definitions„ the (1) "Your product"; following additional definition is added: (2) "Your work"; or "Customers goods" means property of your (3) "impaired property'; customer on your premises for the purpose If such product work or property Is of being; withdrawn or recalled from the market a. Worked on: or or from use by any person or b. Used in your manufacturing process. organization because of a known or c. The Insurance afforded under this provision suspected defect, deficiency, inadequacy is excess over any other valid and or dangerous condition in It, but this collectible property Insurance (including exclusion does "not apply to "product deductible) available to the Insured whether recall expenses that you Incur for the primary, excess, contingent or on any other covered recall" of "your product", The basis_ exception to the exclusion does not G. Incidental Malpractice Employed apply to "produc( recall expenses" Nurses, resulting from: EMT's and Paramedics (1) Failure of an Under SECTION II - LIABILITY, C. products to Wha Is An accomplish their intended purpose; Insured, paragraph 2.a.0)(d) does not apply to a nurse, emergency medical technician or (2) Breach of warranties of fitnes$, paramedic employed by you if you are not quality, durability or performance; engaged in the business or occupation of (3) Loss of customer approval, or any providing medical, paramedical, surgical, cost incurred to regain customer dental, x-ray or nursing services, approval; 7. Personal and Actverllsing Injury - Broad Form (4) Redistribution or replacement of Under SECTION 11 - LIABILITY, F. Liability and "your product" which has been Medical Expenses Definidons, definition 15, recalled by like products or "Personal and Adve substitutes; rtisin9 I n1'u ~ paragraph h. is added as follows: (5) Caprice or whim of the insured; y h. Discrimination or humiliation (unless (6) A condition likely to cause loss of insurance thereof is prohibited by law) that which any Insured knew or had results in injury to the feelings or reputation reason to know at the inception of of a natural person, but only if such this insurance; discrimination or humiliation is: (7) Asbestos, including loss, damage (1) Not done intentionally by or at the or clean up resulting from asbestos direction of: or asbestos containing materials; or 5914006 06 09 Includes copyrighted material of Insurance Services Office, Inc. Page 3 of 5 13,185 (8) Recall of "your products" that have printed advertisements including no known or suspected defect stationary, envelopes and solely because a known or postage; suspected defect in another of (2) Shipping the recalled products "your products" has been found. from any purchaser, distributor b. Under SECTION II - LIABILITY, C. Who or user to the place or places Is Are Insured, paragraph 4.c. is added designated by you; as follows: (3) Remuneration paid to your c. "Bodily Injury" or "property damage" regular "employees" for do not apply to "product recall necessary overtime; expense" arising out of any (4) Hiring additional persons, other withdrawal or recall that occurred than your regular "employees"; before you acquired or formed the organization. (5) Expenses incurred by employees" including c. Under SECTION 11 - LIABILITY, E. transportation and Uability and Medical Expense General accommodations; Conditions, 2. Duties in the Event of Occurrence, Offense, Claim or Suit. (S) Expenses to rent additional paragraph e. is added as follows: warehouse or storage space; e. You must see to it that the following (7) disposal of "your product", but are done in the event of an actual or only to the extent that specific anticipated "covered recall" that methods of destruction other may result In "product recall than those employed for trash expense": discarding or disposal are required to avoid "bodily Injury" (1) Give us prompt notice of any or "property damage" as a result discovery or notification that of such disposal. "your product" must be withdrawn or recalled. Include a you incur exclusively for the purpose description of "your product" of recalling your product"; and and the reason for the b. Your lost profit resulting from such withdrawal or recall; "covered recall". (2) Cease any further release, e. Under SECTION It - LIABILITY, D. shipment, consignment or any Uability and Medical Expenses Umits of other method of distribution of Insurance, the following is added: like or similar products until it 5. The Limits of Insurance and rules has been determined that all stated below fix the most that we such products are free from will pay under this Product Recall defects that could be a cause of Expense Coverage. loss under this insurance. (1) The Aggregate Limit Is the most d. Under SECTION It - LIABILITY, F. that we will reimburse you for Liability and Medical Expenses the sum of all "product recall Deftnitfons, the following additional expenses" incurred for all definitions are added: "product recall expenses" "Covered recall" means a recall made Initiated during the policy period. necessary because you or a government (2) The occurrence Limit shown on body has determined that a known or the Summary of Coverages is suspected defect deficiency, the most we will pay in Inadequacy, or dangerous condition in connection with any one defect "your product" has resulted or will result or deficiency. In "bodily injury" or "property damage". f (ai) All "product recall "Product recall expense(s)" means: expenses" In connection with substantially the same a. Necessary and reasonable expenses general harmful condition for: will be deemed to arise out (1) Communications, including radio of the same defect or or television announcements or deficiency and considered one "occurrence". 391.1006 06 09 Includes copyrighted material of Insurance Services Office, Inc. Page 4 of 6 44 400 Harter Insurance C,roup_ OZ2 A835251 0901641 (h) Any amount reimbursed for "product recall expenses" in connection with any one "occurrence" will reduce the amount of the Aggregate Limit available for reimbursement of "product recall expenses" In connection with any other defect or deficiency. (c) If the Aggregate Limit has been reduced by reimbursement of "product recall expenses" to an amount that is less than the Occurrence Limit, the remaining Aggregate Limit is the most that will be available for reimbursement of "product recall expenses" in connection with any other defect or deficiency. 6. A deductible of M applies per each "Occurrence". 9. Unintentional Failure to Disclose Hazards Under SECTION If - LIABILITY, E. Liabifity and Medical Expenses General Conditions, paragraph 6. is added as follows: 6. Representations We will not disclaim coverage under this Coverage Dorm if you fail to disclose all hazards existing as of the Inception date of the policy provided such failure Is not intentional. 10. Unintentional Failure to Notify Under SECTION fl - LIABILITY, E. Lrabiiity and Medical Expenses General Conditions, 2. Duties in they Event of Occurrence, Offense, Claim or Suit, paragraph L is added as follows: f Your rights afforded under this Coverage Form shall not be prejudiced if you fail to give us notice of an "occurrence", offense, claim or "suit", solely due to your reasonable and documented belief that the "bodily Injury" or "property damage" is not covered under this Policy. 391-1006 06 09 includes copyrighted material of Insurance Services Office, Inc. Page 5 of 6 13,187 Q)Allstate,., You're in goad hands. Information as of May 6, 2016 Three Rivers Policyholder(s) Page 1 of 2 822 Ne E St Suite A Justin and Michele Gerlitz Grants Pass OR 97526 Policy number 964 338 546 Your Allstate agency is Three Rivers II~IIII~~I~I~IIIII~II~I~III'III~~~II~I~I~~I~~II"III~I~~~I~~~~I~I (541) 474-2071 KarenTownsend2@allstate.com JUSTIN AND MICHELE GERLITZ 3375 WHITE HORSE DR GRANTS PASS OR 97527-7469 Thank you for being a loyal Allstate customer-we're happy to have you with us! Here's your automobile insurance renewal offer for the next six months. We've also included a guide to what's in this package and answers to some common questions. Renewing your policy is easy Keep an eye out for your bill, which should arrive in a couple weeks. Just send your payment by the due date on your bill. If you're enrolled in the Allstate@ Easy Pay Plan, you won't receive a bill-we'll send you a statement with your payment withdrawal schedule. How to contact us Give your Allstate Agent a call at (541) 474-2071 if you have any questions. It's our job to make sure you're in good hands. (ed. 2) Sincerely, Steven P. Sorenson President, Allstate Fire and Casualty Insurance Company RA719-1 Policy number: 964 338 546 Page 2 of 2 Policy effective date: June 12, 2016 Your Allstate agency is Three Rivers (541) 474-2071 Your Insurance Coverage Checklist We're happy to have you as an Allstate customer! This checklist outlines what's in this package and provides answers to some basic questions, as well as any "next steps" you may need to take. ❑ What's in this package? ❑ What about my bill? See the guide below for the documents that are included. Unless you've already paid your premium in full, we'll send Next steps: review your Policy Declarations to confirm you your bill separately. Next steps: please pay the minimum have the coverages, coverage limits, premiums and amount by the due date listed on it. savings that you requested and expected. Read any You can also pay your bill online at allstate.com or by Endorsements or Important Notices to learn about new calling 1-800-ALLSTATE (1-800-255-7828). Para policy changes, topics of special interest, as well as espanol, Ilamar al 1-800-979-4285. If you're enrolled in required communications. Keep all of these documents the Allstate) Easy Pay Plan, we'll send you a statement with your other important insurance papers. detailing your payment withdrawal schedule. ❑ Am I getting all the discounts I should? ❑ What if I have questions? Confirm with your Allstate Agent that you're benefiting You can either contact your Allstate Agent or call us 24/7 from all the discounts you're eligible to receive. at 1-800-ALLSTATE (1-800-255-7828) - para espanol, Ilamar al 1-800-979-4285 - with questions about your coverage, or to update your coverages, limits, or deductibles. Or visit us online at allstate.com. A guide to your renewal package ...-..-...H.., c;aai~ae< _;•_u C°s3a~+ce ...,,w.,,.. (~3aiaah`^"' a,... 6#~awne made simple Proof of Policy Policy Important Insurance Made o Insurance Declarations* Endorsements Notices Simple N ID Cards The Policy If changes are We use these Insurance seem o Your insurance Declarations made to your notices to call complicated? o cards are legally lists policy policy, these attention to Our online required, so details, such as documents will particularly guides explain S please keep your specific include your new important coverage terms them in your drivers, vehicles contract coverages, policy and features: vehicle at all and coverages. language. changes and www.allstate.com/ S times. discounts. madesimple o Espanol.allstate.com o /facildeentender o 0 r N * To make it easier to see where you may have gaps in your protection, we've highlighted any coverages you do not have in the m Coverage Detail section in the enclosed Policy Declarations. ° o 0 0 00 °0 U) o ono Thank you for choosing Allstate WAllstate.1" You're in good hands. Proof of Insurance Card Page 1 of 2 For your convenience, two insurance cards have been included for each vehicle. State law requires that one of these cards be kept in each vehicle. Please place them in your vehicles by the effective date. . t (c:u`ri in good hands, YoiAe in good hands. O 0 Please use the printed Insurance Cards below. Please use the printed Insurance Cards below. state. You're in and hands. You're in stood fends. Please use the printed Insurance Cards below. Please use the printed Insurance Cards below. Oregon Auto Liability Oregon Auto Liability Insurance Identification Card Insurance Identification Card Y,,u're in good hands, You're in good hands. Allstate Fire and Casualty Insurance Company Allstate Fire and Casualty Insurance Company Justin and Michele Gerlitz Justin and Michele Gerlitz 3375 White Horse Drive E 3375 White Horse Drive Grants Pass OR 97527.7469 Grants Pass 0i-9752 -7469 POLICY NUMBER YEAR / MAKE / MODEL i POLICY NUMBER YEAR / MAKE / MODEL 964 338 546 2010 Toy. Truck Tundra 964 338 546 2010 Toy. Truck Tundra EFFECTIVE DATE VEHICLE ID NUMBER EFFECTIVE DATE VEHICLE ID NUMBER 06/12/16 5TFDY51F12AX124349 06/12/16 5TFDYSF12AX124349 EXPIRATION DATE EXPIRATION DATE 12/12/16 12/12/16 This card must be carried in the vehicle at all times as evidence of insurance. This card must be carried in the vehicle at all times as evidence of insurance. Oregon Auto Liability Oregon Auto Liability Insurance Identification Card Insurance Identification Card Allstate You', e in go,-)d hands. You're in good hands. Allstate Fire and Casualty Insurance Company Allstate Fire and Casualty Insurance Company Justin and Michele Gerlitz Justin and Michele Gerlitz 3375 White Horse Drive 3375 White Horse Drive Grants Pass OR 97527-7469 Grants Pass OR 97527-7469 POLICY NUMBER YEAR / MAKE / MODEL ; POLICY NUMBER YEAR / MAKE / MODEL 964 338 546 2015 Jeep Grnd Cheroke ; 964 338 546 2015 Jeep Grnd Cheroke EFFECTIVE DATE VEHICLE ID NUMBER EFFECTIVE DATE VEHICLE ID NUMBER 06/12/16 1C4RJFBG4FC699917 06/12/16 1C4RJFBG4FC699917 EXPIRATION DATE EXPIRATION DATE 12/12/16 12/12/16 This card must be carried in the vehicle at all times as evidence of insurance. This card must be carried in the vehicle at all times as evidence of insurance. Policy number: 964 338 546 Page 2 of 2 Policy effective date: June 12, 2016 Your Allstate agency is Three Rivers (541) 474-2071 Please use the printed Insurance Cards below. Please use the printed Insurance Cards below. Please use the printed Insurance Cards below. Please use the printed Insurance Cards below. If you have an accident or loss: If you have an accident or loss: • Get medical attention if needed. • Get medical attention if needed. • Notify the police immediately. • Notify the police immediately. • Obtain names, addresses, phone numbers (work & home) and • Obtain names, addresses, phone numbers (work & home) and license plate numbers of all persons involved, including license plate numbers of all persons involved, including passengers and witnesses. passengers and witnesses. • Call 1-800-ALLSTATE (1-800-255-7828), • Call 1-800-ALLSTATE (1-800-255-7828), N logon to allstate.com or contact your Allstate agent logon to allstate.com or contact your Allstate agent o as soon as possible. as soon as possible. o Three Rivers Three Rivers o (541) 474-2071 (541) 474-2071 822 Ne E St Suite A 822 Ne E St Suite A 0 Grants Pass, OR 97526 Grants Pass, OR 97526 0 0 r rn v If you have an accident or loss: If you have an accident or loss: o • Get medical attention if needed. ' • Get medical attention if needed. o Notify the police immediately. • Notify the police immediately. o ' • Obtain names, addresses, phone numbers (work & home) and • Obtain names, addresses, phone numbers (work & home) and N license plate numbers of all persons involved, including license plate numbers of all persons involved, including 0 passengers and witnesses. passengers and witnesses. m o o • Call 1-800-ALLSTATE (1-800-255-7828), • Call 1-800-ALLSTATE (1-800-255-7828), 0 o m logon to allstate.com or contact your Allstate agent logon to allstate.com or contact your Allstate agent o ~ g as soon as possible. as soon as possible. 0 o o Three Rivers Three Rivers r (541) 474-2071 (541) 474-2071 822 Ne E St Suite A 822 Ne E St Suite A Grants Pass, OR 97526 Grants Pass, OR 97526 Renewal auto policy declarations a)/Ustate,. Your effective date is June 12, 2016 Platinum Gold Standard Value Plan policy You're in good hands. Page 1 of 5 Information as of May 6, 2016 Total Premium for the Policy Period Please review your insured vehicles and verify their VINs are correct. Summary Vehicles covered Identification Number (VIN) Premium Named Insured(s) 2015 Jeep Grnd Cheroke 1C4RJFBG4FC699917 $516.62 Justin and Michele Gerlitz 2010 Toy. Truck Tundra 5TFDY5F12AX124349 315.96 Mailing address If you pay in installments* $832.58 3375 White Horse Drive Grants Pass OR 97527-7469 If you pay in full (includes FullPay® Discount) $754.54 Policy number 964 338 546 *if you pay less than the Pay in Full amount, you will be charged an installment fee(s). Your policy provided by See the Important payment and coverage information section for details about Allstate Fire and Casualty Insurance installment fees. Company Policy period Beginning June 12, 2016 through DISCOUntS (included in your total premium) December 12, 2016 at 12:01 a.m. Allstate Easy Pay $33.41 Safe Driving Club® $106.58 standard time Plan Your Allstate agency is Multiple Policy $41.10 The Good Hands $6.33 Three Rivers People® Program 822 Ne E St Suite A Responsible Payer $75.91 Homeowner $37.10 Grants Pass OR 97526 Allstate Auto/Life $16.21 Allstate eSmart® $33.35 (541) 474-2071 Passive Restraint $36.84 Antilock Brakes $23.02 KarenTownsend2@allstate.com New Car $39.79 Electronic Stability $40.70 Some or all of the information on your Control Policy Declarations is used in the rating Total discounts $490.34 of your policy or it could affect your eligibility for certain coverages. Please notify us immediately if you believe that any information on your Policy (policy discounts $349.99 Declarations is incorrect. We will make Allstate Easy Pay $33.41 Responsible Payer $75.91 corrections once you have notified us, Plan and any resulting rate adjustments, will Safe Driving Club® $106.58 Homeowner $37.10 be made only for the current policy Multiple Policy $41.10 Allstate Auto/Life $16.21 period or for future policy periods. The Good Hands $6.33 Allstate eSmart® $33.35 Please also notify us immediately if you People® Program believe any coverages are not listed or are inaccurately listed. 2015 Jeep Grnd Cheroke discounts $95.30 Passive Restraint $18.63 Antilock Brakes $13.09 New Car $39.79 Electronic Stability $23.79 Control (continued) o 0 m 0 0 0 x Renewal auto policy declarations Page 2 of 5 Policy number: 964 338 546 Policy effective date: June 12, 2016 Your Allstate agency is Three Rivers (541) 474-2071 2010 Toy. Truck Tundra discounts $45.05 Passive Restraint $18.21 Antilock Brakes $9.93 Electronic Stability $16.91 Control Listed drivers on your policy Justin Gerlitz - Married male driver, age 39 Michele Gerlitz - Married female driver, age 39, Safe Driving Club Excluded drivers from your policy None Coverage detail for 2015 Jeep Grnd Cheroke Coverage Limits Deductible Premium Automobile Liability Insurance Not applicable $229.13 Bodily Injury $100,000 each person $300,000 each occurrence ` Property Damage $100,000 each occurrence Basic Personal Injury Protection $43.45 (Please see the attached Supplement to Policy Declarations for complete coverage, limits and deductible.) °W Auto Collision Insurance Actual cash value $500 $128.47 M*k Auto Comprehensive Insurance Actual cash value $100 $66.02 top Rental Reimbursement Not purchased* Towing and Labor Costs $50 each disablement Not applicable $5.80 ON M Uninsured Motorists Insurance $43.75 0 Bodily Injury $100,000 each person Not applicable o $300,000 each accident i Of } Property Damage $20,000 each accident As Stated In Policy N Sound System Not purchased* °g O Tape Not purchased* o N Total premium for 2015 Jeep Grnd Cheroke $516.62 0 0 0 * This coverage can provide you with valuable protection. To help you stay current with your insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can help protect you. VIN 1C4RJFBG4FC699917 Lienholder o Northwest Comm CU of N O M m ~o ID O O O p m m O ~O O E-) ON O O O O ~ 0 Renewal auto policy declarations Policy number: 964 338 QA11sta1Lt!,,. Policy effective date: June 12, 2016 Your Allstate agency is Three Rivers You're in goad hands' (541) 474-2071 Page 3 of 5 Coverage detail for 2010 Toy. Truck Tundra Coverage Limits' Deductible Premium Automobile Liability Insurance Not applicable $106.69 Bodily Injury $100,000 each person $300,000 each occurrence Property Damage $100,000 each occurrence Basic Personal Injury Protection $42.49 (Please see the attached Supplement to Policy Declarations for complete coverage, limits and deductible.) Auto Collision Insurance Actual cash value $500 $82.05 Auto Comprehensive Insurance Actual cash value $100 $46.27 Rental Reimbursement Not purchased* O Towing and Labor Costs $50 each disablement Not applicable $5.80 Uninsured Motorists Insurance $32.66 Bodily Injury $100,000 each person Not applicable $300,000 each accident Property Damage $20,000 each accident As Stated In Policy Sound System Not purchased* Tape Not purchased* Total premium for 2010 Toy. Truck Tundra $315.96 * This coverage can provide you with valuable protection. To help you stay current with your insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can help protect you. VIN 5TFDY5F12AX124349 Your policy documents Your automobile policy consists of this Policy Declarations and the documents in the following list. Please keep these together. • Oregon Allstate Fire and Casualty Insurance Company Auto Amendatory Endorsement-Oregon - AU14223-5 Insurance Policy - AFA18 ■ Claim Satisfaction Guarantee Amendatory Endorsement - AP4878 0 0 m 0 0 O Renewal auto policy declarations Page 4 of 5 Policy number: 964 338 546 Policy effective date: June 12, 2016 Your Allstate agency is Three Rivers (541) 474-2071 Important payment and coverage information Here is some additional, helpful information related to your coverage and paying your bill: ►Your policy reflects Allstate's Preferred Package Savings. We have applied this savings to your policy because you own a residential property and insure more than one vehicle. ►If you decide to pay your premium in installments, there will be a $3.50 installment fee charge for each payment due. If you make 6 installment payments during the policy period, and do not change your payment plan method, then the total amount of installment fees during the policy period will be $21.00. If you are on the Allstate® Easy Pay Plan, there will be a $1.00 installment fee charge for each payment due. If you make 6 installment payments during the policy period, and remain on the Allstate® Easy Pay Plan, then the total amount of installment fees during the policy period will be $6.00. If you change payment plan methods or make additional payments, your installment'fee charge for each payment due and the total amount of installment fees during the policy period may change or even increase. Please note that the Allstate® Easy Pay Plan allows you to have your insurance payments automatically deducted from your checking or savings account. Oregon required communications ► The insurance provided by this policy contains insurance coverage in accordance with the ORS 806.070 and 806.080 or in accordance with ORS 806.270, as appropriate. Oregon Financial Responsibility Law ►The Oregon Financial Responsibility Law requires Oregon drivers to maintain at least a minimum amount of liability o insurance coverage. This policy enables you to satisfy the requirements of this law. CM) 0 110-The minimum limits of liability coverage required by the Oregon Financial Responsibility Law are: o a) $25,000 because of bodily injury to or death of one person in any one accident; or b) subject to that limit for one person, $50,000 because of bodily injury to or death of two more persons in any one accident; and o c) $20,000 because of injury to or destruction of the property of others in any one accident. o 0 0 ►The limits described above may be amended by the Oregon Legislature. m 0 0 0 00 M Allstate Fire and Casualty Insurance Company's Secretary and President have signed this policy with legal authority at Northbrook, Illinois. 0 Lr) Jf^nj 0 0 I 0 O Steven P. Sorenson Susan L. Lees N 0 President Secretary m ~o 00°0 0 000 o a Renewal auto policy declarations Policy number: 964 338 546 W/m ffs Policy effective date: June 12, 2016 Illstate., Your Allstate agency is Three Rivers You're in good hands (541) 474-2071 Page 5 of 5 Supplement to Policy Declarations The following is a complete description of Personal Injury Protection Benefits for vehicles: Coverage Limits Deductible Basic Personal Injury Protection • Auto Medical Expenses $15,000 each person $0 • Income Continuation $3,000 each person $0 • Loss of Services $30 per day $0 • Funeral Benefits $5,000 each person $0 • Child Care Expenses $25 per day $0 to a maximum of $750 each occurrence $0 0 0 m 0 0 0 Policy'Endorsement Policy number: 964 338 546 WAllstate,. Policy effective date: June 12, 2016 You're in good hands Your Allstate agency is Three Rivers (541) 474-2071 Page 1 of 4 The following endorsement changes your policy. ambulance, prosthetic services, X-ray and Please read this document carefully and keep it with professional nursing services. your policy. B. Under Definitions, item (6) is replaced by the Amendatory Endorsement-Oregon - following: AU14223-5 (6) You or Your means the policyholder named in the Policy Declarations and that policyholder's 1. In the General section, the Fraud Or Misrepresentation resident spouse or resident partner as defined by provision is replaced by the following: the Oregon Family Fairness Act of 2007. Fraud Or Misrepresentation C. The Proof Of Claim; Medical Reports provision is We may not provide coverage for any insured who has replaced by the following: made fraudulent statements or engaged in fraudulent Proof Of Claim; Medical Reports conduct in connection with any accident or loss for which As soon as possible, the injured person or someone coverage is sought under this policy. on that person's behalf, must give us written notice II. In Part I-Automobile Liability Insurance the following and proof of claim. It must include all details changes are made: reasonably required by us to determine the amounts payable. We may also require any person making A. Under Definitions, item (5) is replaced by the claim to submit to examinations under oath, following: separately and apart from others, and to sign the transcript. The injured person must take medical (5) You or Your means the policyholder named in the examinations by physicians selected by us when and Policy Declarations and that policyholder's as often as we may reasonably require. resident spouse or resident partner as defined by the Oregon Family Fairness Act of 2007. If an injured person or someone on that person's behalf sues a third party to recover damages from B. Under Exclusions-What Is Not Covered, exclusion anyone believed responsible for the bodily injury, a (6) is deleted. copy of the summons, complaint or other documents pertaining to the lawsuit shall be sent to us as soon as C. The Proof Of Claim provision is added. possible. Proof Of Claim Upon our request, the injured person, or someone on As soon as possible, any person making claim must that person's behalf shall give us the necessary give us written proof of claim. It must include all authorization to obtain medical reports, copies of details we may need to determine the amounts records, and information with respect to loss of payable. We may also require any person making income. Prior to payment of Income Continuation claim to submit to examinations under oath, benefits, we may require that an injured person separately and apart from others, and to sign the cooperate in furnishing us reasonable proof of that transcript. person's inability to work. III. In Part 11-Automobile Personal Injury Protection- IV. In Part III-Uninsured Motorists Insurance-Coverage SS Coverage VA, the following changes are made: the following changes are made: A. The Medical And Hospital Expenses provision is A. Under An Uninsured Auto Is:, item (6) is replaced by replaced by the following: the following: (1) Medical And Hospital Expenses (6) an underinsured motor vehicle which has liability All reasonable and necessary expenses incurred protection, or a plan of self-insurance approved within two years from the date of the accident. pursuant to Oregon Revised Statutes (ORS) This covers medical, hospital, dental, surgical, 806.130, in effect and applicable at the time of the lly~ Policy endorsement Page 2 of 4 Policy number: 964 338 546 Policy effective date: June 12, 2016 Your Allstate agency is Three Rivers (541) 474-2071 accident, but which provides recovery in an The Uninsured Motorists Coverage limits apply to amount less than the sums that the insured each insured motor vehicle as shown on the person or the heirs or legal representative of the Policy Declarations. This means the insuring of insured person is legally entitled to recover as more than one person or auto under this or other damages for bodily injury. auto policies will not increase our uninsured motorists limit of liability beyond the amount B. Under An Uninsured Auto Is Not:, items (1) and (2) shown for any one auto even though a separate are replaced by the following: premium is charged for each auto. (1) a motor vehicle owned by any federal government (3) We are not obligated to make any payment for or agency. bodily injury or property damage under this (2) a motor vehicle owned by any state or local coverage which arises out of the use of an government or agency. Coverage does apply underinsured motor vehicle until after the limits when a motor vehicle is owned by a public body of liability for all liability protection in effect and or owned or operated by its officers, employees or applicable at the time of the accident have been agents acting within the scope of their exhausted by payments of judgments or employment or duties and recovery is limited settlements to an insured person or any other pursuant to Oregon Revised Statutes (ORS) injured person. 30.260 to 30.300 as amended. (4) No one will be entitled to receive duplicate C. The Limits Of Liability provision is replaced by the payments for the same elements of loss under following: this coverage. Limits Of Liability Subject to the above limits of liability, damages (1) The coverage limit shown on the Policy payable will be reduced by: Declarations for: (a) all amounts paid by or on behalf of the owner (a) "each person" is the maximum that we will or operator of an uninsured auto, including an pay for all damages arising out of bodily underinsured motor vehicle, or anyone else injury to one person in any one motor vehicle responsible. This includes all sums paid under accident, including all damages sustained by the bodily injury liability coverage of this or anyone else as a result of that bodily injury. any other policy. (b) "each accident" is the maximum that we will (b) all amounts paid under any worker's pay for all damages arising out of bodily compensation law, disability benefits law, or injury to two or more persons in any one similar law, Automobile Personal Injury motor vehicle accident. This limit is subject to Protection or any similar coverage. the limit for "each person." (c) "each accident" is the total limit for all Any reduction to the amount of damages payable damages arising out of injury to or under this provision will not reduce the insured destruction of all property insured under this person's limits of liability under this coverage. coverage in any one motor vehicle accident. o D. Under Definitions, item (6) is replaced by the o (2) These limits are the maximum we will pay for any following: o one motor vehicle accident regardless of the number of: (6) You or Your means the policyholder named in the o (a) claims made; Policy Declarations and that policyholder's 00 (b) vehicles or persons shown on the Policy resident spouse or resident partner as defined by 1* Declarations; or the Oregon Family Fairness Act of 2007. (c) vehicles involved in the accident. o 0 0 0 0 N O r- M M O 0 O p O O M O O 00 Z O 000 O O N O 0 Policy endorsement Policy number: 964 338 546 (PAVIstate, Policy effective date: June 12, 2016 Your Allstate agency is Three Rivers You're an goad hands. (541) 474-2071 Page 3 of 4 E. The Proof Of Claim; Medical Reports provision is If the final appraisal decision exceeds the amount of replaced by the following: our last offer prior to your incurrence of the appraisal costs, we will reimburse you for your reasonable Proof Of Claim; Medical Reports appraisal costs. As soon as possible, you or any other person making claim must give us written proof of claim including all C. The Limits Of Liability provision is replaced with the details reasonably required by us to determine the following: amounts payable. We may also require any person making claim to submit to examinations under oath, Limits Of Liability separately and apart from others, and to sign the Our limit of liability is the least of: transcript. (1) the actual cash value of the property or damaged part of the property at the time of loss, which may The injured person may be required to take medical include a deduction for depreciation; examinations by physicians selected by us, as often as we reasonably require. The injured person or his (2) the cost to repair or replace the property or part representative must authorize us to obtain medical to its physical condition at the time of loss using reports and copies of records. parts produced by or for the vehicle's manufacturer, or parts from other sources, F. The Payment Of Loss By Us provision is replaced by including, but not limited to, nonoriginal the following: equipment manufacturers, subject to applicable state laws and regulations; Payment Of Loss By Us Any amount due is payable to the injured person, to (3) the limit of liability shown on the Policy the parent or the guardian of an injured minor, or to Declarations applicable to the damaged property; the spouse or resident partner of any insured person or who dies. However, we may pay any other person or (4) $500, if the loss is to a covered trailer not estates lawfully entitled to recover the damages. described on the Policy Declarations. V. In Part IV-Protection Against Loss To The Auto the Any applicable deductible amount is then subtracted. following changes are made: LIMITATION: If we, at our option, elect to pay for the A. Under Definitions, item (8) is replaced by the cost to repair or replace the property or part, our following: liability does not include any decrease in the (8) You or Your means the policyholder named in the property's value, however measured, resulting from Policy Declarations and that policyholder's the loss and/or repair or replacement. resident spouse or resident partner as defined by If repair or replacement results in the betterment of the Oregon Family Fairness Act of 2007. the property or part, you may be responsible, subject B. The Right To Appraisal provision is replaced by the to applicable state laws and regulations, for the following: amount of the betterment. Right To Appraisal The maximum we will pay for a covered loss to any Upon mutual consent, you and we have a right to custom parts or equipment is $1,000. demand an appraisal of the loss. Each will appoint and pay a qualified appraiser. Other appraisal expenses An auto and attached trailer are considered separate will be shared equally. The two appraisers, or a judge autos, and you must pay the deductible, if any, on of a court of record, will choose an umpire. Each each. Only one deductible will apply to an auto with a appraiser will state the actual cash value and the mounted camper unit. If unmounted, a separate amount of the loss. If they disagree, they'll submit deductible will apply to the auto and camper unit. their differences to the umpire. A written decision by any two of these persons will determine the amount of the loss. Policy endorsement Page 4 of 4 Policy number: 964 338 546 Policy effective date: June 12, 2016 Your Allstate agency is Three Rivers (541) 474-2071 D. In the What You Must Do If There Is A Loss provision, item (1) is replaced by the following: (1) As soon as possible any person making claim must give us written proof of loss, including all details reasonably required by us. We may also require that person to submit to examinations under oath, separately and apart from others, and to sign the transcript. We have the right to inspect the damaged property. All other policy terms and conditions apply. N O O O O 00 O O N M O O O CO M rn lzr Ln O 0 0 0 0 O N O m M D '000 M O 0 Dom 0m0 'D O 000 0 000 Important notices Policy number: 964 338 546 (QA"11state,,,,. Policy effective date: June 12, 2016 You're in goad hands. Your Allstate agency is Three Rivers (541) 474-2071 Page 1 of 2 Notice of Changes to Your Auto Policy vehicle, including partial payments made by an insolvent insurer." From time to time Allstate will revise your coverage. We've . Under "Limits Of Liability" item 4 has been revised. No one included an Amendatory Endorsement in this mailing package will be entitled to receive duplicate payments for the same that changes parts of your contract. Please read this elements of loss under Uninsured Motorists Insurance, endorsement and keep it with your auto policy. and any reduction to the amount of damages payable We're also providing you with the following summary. We under this provision will not reduce the insured person's hope you find it informative and useful, but keep in mind that limits of liability under Uninsured Motorists Insurance. it's not part of your contract. Always reference your policy XC3825 documents for your exact coverage details. If you have any questions about this notice or your policy coverage, you can contact your Allstate Agent or Important Information About Your Auto representative at 1-800-ALLSTATE'm (1-800-255-7828), or Policy visit www.allstate.com. We're here to help! The enclosed Policy Declarations lists important information about your policy, such as your address, the vehicles you've Summary of Changes insured, the vehicle identification numbers (VIN) assigned to your insured vehicles, the drivers insured, and the coverages In Part II-Automobile Personal Injury Protection-Coverage and coverage limits you've chosen. Your Policy Declarations VA, the "Medical and Hospital Expenses" provision has been also lists any discounts and surcharges applied to your policy. revised. We will pay all reasonable and necessary expenses Because much of the information found on your Policy incurred within two years from the date of the accident. Declarations is used to help us determine your premium, In Part III-Uninsured Motorists Insurance-Coverage SS, the please be sure to review your Policy Declarations carefully following changes have been made: each time you receive one. You may want to add coverage, delete coverage or change your coverage limits, or you may • Under "An Uninsured Auto Is:" item 6 has been revised. want to change the information concerning the vehicles or An underinsured motor vehicle is one which has liability drivers your policy insures. protection in effect and applicable at the time of the accident, but which provides recovery in an amount less Another thing to keep in mind is that you may now qualify for than the sums that the insured person or the heirs or legal discounts that you were not eligible to receive previously. For representative of the insured person is legally entitled to instance, Allstate offers discounts for: recover as damages for bodily injury. • Unmarried young drivers, including students under the age • Under "An Uninsured Auto Is Not:" item 2 has been of 25 revised. An uninsured motor vehicle is not a motor vehicle • Drivers who have completed approved driver training owned by any state or local government or agency. courses However, coverage will apply when a motor vehicle is • Drivers who also own a home, townhouse, condominium, owned by a public body or owned or operated by its or mobilehome officers, employees or agents acting within the scope of their employment or duties. Recovery will be limited Please contact your Allstate agent for additional information pursuant to Oregon Revised Statutes (ORS) 30.260 to about discount qualifications, as well as other discounts that 30.300 as amended. may be available to you. • The "Limits Of Liability" provision has been revised. We Making Changes to Your Policy have removed the following limitation: "The limits for If you need to make a change to any of the information listed on Coverage SS will be reduced by all amounts paid by or on your Policy Declarations, please notify your Allstate agent as behalf of the owner or operator of the underinsured motor Important` notices Page 2 of 2 Policy number: 964 338 546 Policy effective date: June 12, 2016 Your Allstate agency is Three Rivers (541) 474-2071 soon as possible. With a few exceptions, any changes will be following the directions below, we will be able to expedite the effective as of the date you notify us. processing of your claim if you ever file one. If you have any questions about this notice, or if you need to When an accident or loss occurs, we ask that you please notify update any of the information listed on the enclosed Policy us or one of our agents in writing about it as soon as reasonably Declarations, please contact your Allstate agent or possible. We also ask that you take the following actions: 1-800-ALLSTATE (1-800-255-7828). X72910-1 • Report the loss to the police when it is the result of theft or larceny; • Protect the damaged vehicle (we will pay any reasonable expense to do so); Higher Uninsured Motorists Bodily • Allow us to see the vehicle damage if we make this Injury Liability Limits May Be Available request; and • Work with us to help resolve your claim. Oregon law requires all vehicle owners to comply with financial Please remember that when you have your damaged vehicle responsibility requirements. As you may know, Uninsured fixed, you have the right to choose the repair shop that fixes Motorists Insurance can provide you with protection for bodily your damaged vehicle and pay reasonable repair costs for injuries sustained in a covered accident that a legally liable claims your policy covers. Oregon law states: uninsured motorist caused. You can purchase Uninsured Motorists Insurance for bodily injury at minimum limits of "Oregon law prohibits us from requiring you get repairs to your $25,000 for one person in one accident and $50,000 for two vehicle at a particular motor vehicle repair shop. You have the or more people in one accident. You may, however, purchase right to select the motor vehicle repair shop of your choice." Uninsured Motorists Insurance limits equal to your Bodily You can review the complete statement of your rights and Injury Liability Insurance limits. responsibilities, as well as ours, in the policy contract. If your Uninsured Motorists Insurance bodily injury limits are If you have any questions about this reminder or about your equal to your limits for Bodily Injury Liability, but you would like insurance coverage in general, please feel free to contact your to increase your Uninsured Motorists Insurance limits, you Allstate representative-or call the Allstate Customer may do so by increasing your Bodily Injury Liability limits. Information Center at 1-800-ALLSTATE (1-800-255-7828). If your Uninsured Motorists Insurance bodily injury limits are X72337 lower than your Bodily Injury Liability limits, you may, if you wish, purchase Uninsured Motorists Insurance bodily injury limits equal to the Bodily Injury Liability limits for a relatively You Now Have the Allstate eSmart 5M modest increase in premium. Discount! If you want to increase your coverage limits, please contact your Allstate agent, or call the Allstate Customer Information Thank you for enrolling in our ePolicy program. With your Center at 1-800-ALLSTATE (1-800-255-7828). enrollment, you now also have the Allstate eSmarts" discount o X72336 on your policy. °g O rn In addition to the convenience of an electronic policy and o knowing that you're helping the environment, you're benefiting o Remember These Steps When Filing a from the savings that the Allstate eSmartsm discount provides. 00 Claim Important Reminder about This Discount: Please remember that to keep the Allstate eSmarts' discount on your policy, you o We'd like to take this opportunity to remind you of your rights need to remain enrolled in our ePolicy program. If you were to and responsibilities when submitting a vehicle damage claim. un-enroll from ePolicy, you would lose the discount. o Our goal is to handle all claims quickly and fairly, and, by X73345 0 N O M M ~D O p O m O D O O O O O 0 O F'~S#fe~ Purchase Order 'Vk Fiscal Year 2017 Page: 1 of: 1 ~ v o= _8011 ft B Ashland Parks Commission I ATTN: Accounts Payable L 20 E. Main Purchase 151 L L Ashland, OR 97520 Order # T Phone: 541/552-2010 O Email: payable@ashland.or.us V S C/O Parks Department E GERLITZ ENGINEERING H Admin Office N 1867 WILLIAMS HWY SUITE 201 I 340 South Pioneer D GRANTS,PASS, OR 97527 P Ashland, OR 97520 O T Phone: 541/488-5340 R O Fax: 541/488-5314 ~~n_dQr eh n JUmbQf GFE 174 NO - - _ - Jason Minica 09/08/2016 2368 Parks Accounts Pa able _r ''I I'll `lt - - 1tm# - Q- Engineering - New Dog Park 1 Provide engineering services for new dog park per attached 1 $25,350.0000 $25,350.00 contract and proposal. Project #000071 Contract for Personal Services less than $35,000 Beginning date: 09/01/2016 Completion date: 02/10/2017 GL SUMMARY************** 123000 704200 $25,350.00 By: ;~-r- Date: Authorized Signature - $25,350.00 FORM #3 CITY OF ASHLAND REQUISITION Date of request: 8/24/16 Required date for delivery: 8/25/16 Vendor Name C,,r1it7 Fnninjprinn ~ansidtant.; Address, City, State, Zip 1867 H'jqbwqV, Stjitp- 201, Grants Pass, OR 97527 Contact Name & Telephone Number Justin Gerlitz: 541-244-2617 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 # El 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 ❑ Form #9, Request for Approval ❑ Agency ® 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 Provide engineering (per proposal) for New Do Park $ 25,350 Item # Quantity Unit Description of MATERIALS Unit Price Total Cost TOTAL COST ® Per attached quote/proposal-'' Project Number 000071 Account Number 411.12.00.00.704200 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: T Director Date Support -Yes /No By signing this requisition form, I certify that the City's public contracting requirements have been satisfied. Employee: Department Head: (Equal to or greater than $5,000) Department Manager/Supervisor: City Administrator. (Equal to or greater.than $25,000) Funds appropriated for current fiscal year: YES i NO r' Finance Director- (Equal to or greathan S5, 0001', Date Comments: Form #3 - Requisition CITY OF ASHLAND FORM #4 DETERMINATIONS TO PROCURE PERSONAL SERVICES $5,000 to $75,000 To: Dave Kanner, Public Contracting Officer From: Michael Black, Ashland Parks and Recreation Director Date: August 24, 2016 Re: DETERMINATIONS TO PROCURE PERSONAL SERVICES In accordance with AMC 2.50.120(A), for personal services contracts greater than $5,000, but less than $75,000, the Department Head shall make findings that City personnel are not available to perform the services, and that the City does not have the personnel or resources to perform the services required under the proposed contract. However, the City Attorney, the Public Contracting Officer, or Local Contract Review Board, can require a formal solicitation for bids to ensure that the purposes of this chapter are upheld. Background The Parks Commission intent is to hire professional engineering services for the new Dog Park on the corner or Villard and Engle St. Gerlitz Engineering will provide a bid packet that is listed in the attached scope of work. Estimated cost for this service is $25,350. Pursuant to AMC 2.50.120(A), has a reasonable inquiry been conducted as to the availability of City personnel to perform the services, and that the City does not have the personnel and resources to perform the services required under the proposed contract? Ashland Parks and Recreation Commission does not have personnel to perform the duties as outlines above. Form #4 - Department Head Determinations to Procure Personal Services, Page 1 of 1, 8/24/2016