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HomeMy WebLinkAbout2020-061 PO 20200419-Design Source r R&M Purchase Order ,aa Fiscal Year 2020 Page: 1 of: 1 B City of Ashland ATTN:Accounts Payable 20200419 L 20 E.Main � � Purchase Ashland,OR 97520 Order# T Phone:541/552-2010 O Email:payable@ashland.or.us • V H CIO Facilities Maintenance Div E DESIGN SOURCE I 90 North Mountain Ave 1319 HARRISBURG DR p Ashland, OR 97520 MEDFORD, OR 97501 Phone:541/488-5358 R TFax:541/552-2304 (541)821-6823 David Arnold =}4 -_- 05/11/2020 1886 FOB ASHLAND OR/NET30 City Accounts Payable -:- --- ,_ e�r�l_ _ �r�rt=, l);t=it _-�_��t - - —:- __ _..— _ �•� !—I'!� <it�m'����i-1 s l��_=� Furniture Sale&Installation 1 MODIFIED: Interior design and office furniture sales and 1 $4,995.0000 $4,995.00 installation for FY21 Goods&Services Agreement Completion date: June 30,2021 Project Account: • ***************GL SUMMARY*************** - 082400-602400 $4,995.00 • • I ' By: Date: Authorized Signature '7'71 4 995.00 >d<6,2 e I:--':4-'4 6, • FORM #3 CITY OF ASHLAND - A request for a Purchase Order REQUISITION 7--a frO 0 '1' Date of request: 5/1/2020 Required date for delivery: ry: • Vendor Name Design Source Address,City,State,Zip 1319 Harrisburg Drive.Medford,OR 97501 - Contact Name&Telephone Number Molly Williams 541-821-6823 mollyatdesignsource aC�,hotmail.com Email Email address SOURCING METHOD ❑ Exempt from Competitive Bidding ❑ Emergency ❑ Reason for exemption: ❑ Invitation to Bid ❑ Form#13,Written findings and Authorization ❑ AMC 2.50 Date approved by Council: ❑ Written quote or proposal attached ❑ Written quote or proposal attached (Attach copy of council communication) If council a..roval re•uired,attach co 6 of CC ® Small Procurement 0 Request for Proposal Cooperative Procurement Not exceeding$5,000 Date approved by Council: ❑ State of Oregon ® Direct Award _(Attach copy of council communication) Contract# ❑ Verbal/Written quote(s)or proposal(s) 0 Request for Qualifications(Public Works) ❑ State of Washington Date approved by Council: Contract# (Attach copy of council communication) ❑ Other government agency contract Intermediate Procurement 0 Sole Source Agency GOODS&SERVICES 0 Applicable Form(#5,6,7 or 8) Contract# Greater than$5,000 and less than$100,000 0 Written quote or proposal attached Intergovernmental Agreement 0 (3)Written quotes and solicitation attached 0 Form#4,Personal Services>$5K&<$75K Agency PERSONAL SERVICES 0 Special Procurement 0 Annual cost to City does not exceed$25,000. Greater than$5,000 and less than$75,000 ❑ Form#9,Request for Approval Agreement approved by Legal and approved/signed by ❑ Direct appointment not to exceed$35,000 0 Written quote or proposal attached City Administrator.AMC 2.50.070(4) ❑ (3)Written proposals/written solicitation Date approved by Council: . ❑ Annual cost to City exceeds$25,000,Council ❑ Form#4,Personal Services>$5K&<$75K Valid until: (Date) approval required.(Attach copy of council communication) Description of SERVICES Total.Cost Interior Design and Office Furniture Sales and Installation for FY20 $:4,995:00' Item# Quantity Unit Description of MATERIALS. Unit Price Total Cost ❑ Per attached quotelproposal -1 'TOTAL+COST Project Number. _ _ _ Account Number 082400-602400 , _� _F . *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 a proveall hardware and software purchases: IT Director Date Support-Yes/No By signing this requisition form,/I certify that the City' ublic contracting requirements have been satisfied. Employee: J Department Head: .ICN " 51-* w _ 4/Sr i to o .rooter than$5, 00) Department ManagerlSupervisor: City Administrator: - (Equal to or greater than$25,000) Funds appropriated for current fiscal year: YES /NO Deputy Finance Director-(Equal to or greater than$5,000) Date Comments: ' • Form#3-Requisition GOODS& SERVICES AGREEMENT PROVIDER: Design Source CITY OF PROVIDER'S ASHLAND CONTACT: Molly Williams 20 East Main Street Ashland,Oregon 97520 ADDRESS: 1319 Harrisburg Drive Telephone: 541/488-5587 Medford,OR 97501 Fax: 541/488-6006 PHONE: 541-821-6823 This Goods and Services Agreement (hereinafter "Agreement") is entered into by and between the City of Ashland, an Oregon municipal corporation (hereinafter "City") and Design Source, a domestic business corporation("hereinafter"Provider"),for interior design,office furniture sales and installation. 1. PROVIDER'S OBLIGATIONS 1.1 Provide interior design, office furniture sales and installation for FY21 as set forth in the "SUPPORTING DOCUMENTS" attached hereto and,by this reference, incorporated herein. Provider expressly acknowledges that time is of the essence of any completion date set forth in the SUPPORTING DOCUMENTS,and that no waiver or extension of such deadline may be authorized except in the same manner as herein provided for authority to exceed the maximum compensation. The goods and services defined and described in the"SUPPORTING DOCUMENTS"shall hereinafter be collectively referred to as"Work." 1.2 Provider shall obtain and maintain during the term of this Agreement and until City's final acceptance of all Work received hereunder,a policy or policies of liability insurance including commercial general liability insurance with a combined single limit, or the equivalent, of not less than_x27660;000-(two million dollars)per occurrence for Bodily Injury and Property Damage. d)I1QV i�3DO 1.2.1 The insurance required in this Article shall include the following coverages: X • Comprehensive General or Commercial General Liability, including personal injury, contractual liability, and products/completed operations coverage; and • • Automobile Liability. 1.2.2 Each policy of such insurance shall be on an "occurrence" and not a"claims made" form,and shall: • Name as additional insured "the City of Ashland, Oregon, its officers, agents and employees" with respect to claims arising out of the provision of Work under this Agreement; • Apply to each named and additional named insured as though a separate policy had been issued to each,provided that the policy limits shall not be increased thereby; • Apply as primary coverage for each additional named insured except to the extent that two or more such policies are intended to "layer" coverage and, taken together, they provide total coverage from the first dollar of liability; • Provider shall immediately notify the City of any change in insurance coverage • Provider shall supply an endorsement naming the City, its officers,employees and agents as additional insureds by the Effective Date of this Agreement; and • Be evidenced by a certificate or certificates of such insurance approved by the City. Page 1 of 5: Agreement between the City of Ashland and Design Source 1.3 All subject employers working under this Agreement are either employers that will comply with ORS 656.017 or employers that are exempt under ORS 656.126. 1.4 Provider agrees that no person shall, on the grounds of race, color, religion, creed, sex, marital status, familial status or domestic partnership, national origin, age, mental or physical disability, sexual orientation, gender identity or source of income, suffer discrimination in the performance of this Agreement when employed by Provider. Provider agrees to comply with all applicable requirements of federal and state civil rights and rehabilitation statutes,rules and regulations. Further, Provider agrees not to discriminate against a disadvantaged business enterprise,minority-owned business,woman-owned business, a business that a service-disabled veteran owns or an emerging small business enterprise certified under ORS 200.055, in awarding subcontracts as required by ORS 279A.110. 1.5 In all solicitations either by competitive bidding or negotiation made by Provider for work to be performed under a subcontract, including procurements of materials or leases of equipment, each potential subcontractor or supplier shall be notified by the Providers of the Provider's obligations under this Agreement and Title VI of the Civil Rights Act of 1964 and other federal nondiscrimination laws. 2. CITY'S OBLIGATIONS 2.1 City shall pay Provider for its Work at the hourly rates and charges as set forth in Exhibit"X",entitled "Rate Schedule," which is attached hereto and incorporated herein by this reference, as full compensation for Provider's performance of all Work under this Agreement. 2.2 In no event shall Provider's total of all compensation and reimbursement under this Agreement exceed the sum of$4,995 without express, written approval from the City official whose signature appears below,or such official's successor in office. Provider expressly acknowledges that no other person has authority to order or authorize additional Work which would cause this maximum sum to be exceeded and that any authorization from the responsible official must be in writing. Provider further acknowledges that any Work delivered or expenses incurred without authorization. 3. GENERAL PROVISIONS 3.1 This is a non-exclusive Agreement. City is not obligated to procure any specific amount of Work from Provider and is free to procure similar types of goods and services from other providers in its sole discretion. 3.2 Provider is an independent contractor and not an employee or agent of the City for any purpose. 3.3 Provider is not entitled to,and expressly waives all claims to City benefits such as health and disability insurance,paid leave, and retirement. 3.4 This Agreement embodies the full and complete understanding of the parties respecting the subject matter hereof. It supersedes all prior agreements,negotiations,and representations between the parties, whether written or oral. 3.5 This Agreement may be amended only by written instrument executed with the same formalities as this Agreement. 3.6 The following laws of the State of Oregon are hereby incorporated by reference into this Agreement: ORS 279B.220,279B.230 and 279B.235. Page 2 of 5: Agreement between the City of Ashland and Design Source 3.7 This Agreement shall be governed by the laws of the State of Oregon without regard to conflict of laws principles. Exclusive venue for litigation of any action arising under this Agreement shall be in the Circuit Court of the State of Oregon for Jackson County unless exclusive jurisdiction is in federal court, in which case exclusive venue shall be in the federal district court for the district of Oregon. Each party expressly waives any and all rights to maintain an action under this Agreement in any other venue,and expressly consents that, upon motion of the other party, any case may be dismissed or its venue transferred,as appropriate,so as to effectuate this choice of venue. 3.8 Provider shall defend,save,hold harmless and indemnify the City and its officers,employees and agents from and against any and all claims, suits, actions, losses, damages, liabilities, costs, and expenses of any nature resulting from, arising out of, or relating to the activities of Provider or its officers, employees,contractors,or agents under this Agreement. 3.9 Neither party to this Agreement shall hold the other responsible for damages or delay in performance caused by acts of God,strikes,lockouts,accidents,or other events beyond the control of the other or the other's officers, employees or agents. 3.10 If any provision of this Agreement is found by a court of competent jurisdiction to be unenforceable, such provision shall not affect the other provisions, but such unenforceable provision shall be deemed modified to the extent necessary to render it enforceable, preserving to the fullest extent permitted the intent of Provider and the City set forth in this Agreement. 4. SUPPORTING DOCUMENTS The following documents are,by this reference,expressly incorporated in this Agreement,and are collectively referred to in this Agreement as the "SUPPORTING DOCUMENTS:" • The Provider's complete written Rate Schedule for July 1,2020-June 30,2021 5. REMEDIES 5.1 In the event Provider is in default of this Agreement, City may, at its option, pursue any or all of the remedies available to it under this Agreement and at law or in equity, including,but not limited to: 5.1.1 Termination of this Agreement; 5.1.2 Withholding all monies due for the Work that Provider has failed to deliver within any scheduled completion dates or any Work that have been delivered inadequately or defectively; 5.1.3 Initiation of an action or proceeding for damages, specific performance, or declaratory or injunctive relief; 5.1.4 These remedies are cumulative to the extent the remedies are not inconsistent,and City may pursue any remedy or remedies singly,collectively, successively or in any order whatsoever. 5.2 In no event shall City be liable to Provider for any expenses related to termination of this Agreement or for anticipated profits.If previous amounts paid to Provider exceed the amount due,Provider shall pay immediately any excess to City upon written demand provided. 6. TERM AND TERMINATION 6.1 Term This Agreement shall be effective from the date of execution on behalf of the City as set forth below (the "Effective Date"), and shall continue in full force and effect until June 30, 2021, unless sooner terminated as provided in Subsection 6.2. Page 3 of 5: Agreement between the City of Ashland and Design Source 6.2 Termination 6.2.1 The City and Provider may terminate this Agreement by mutual agreement at any time. 6.2.2 The City may,upon not less than thirty (30) days' prior written notice,terminate this Agreement for any reason deemed appropriate in its sole discretion. 6.2.3 Either party may terminate this Agreement,with cause, by not less than fourteen(14)days' prior written notice if the cause is not cured within that fourteen (14) day period after written notice. Such termination is in addition to and not in lieu of any other remedy at law or equity. 7. NOTICE Whenever notice is required or permitted to be given under this Agreement, such notice shall be given in writing to the other party by personal delivery,by sending via a reputable commercial overnight courier,or by mailing using registered or certified United States mail, return receipt requested, postage prepaid, to the address set forth below: If to the City: City of Ashland—Facilities Maintenance Department Attn: David Arnold 90 North Mountain Avenue Ashland, Oregon 97520 Phone: (541) 552-2292 With a copy to: City of Ashland—Legal Department 20 E.Main Street Ashland,OR 97520 Phone: (541)488-5350 If to Provider: Design Source Attn:Molly Williams 1319 Harrisburg Drive Medford,OR 97501 541-821-6823 8. WAIVER OF BREACH One or more waivers or failures to object by either party to the other's breach of any provision,term,condition, or covenant contained in this Agreement shall not be construed as a waiver of any subsequent breach,whether or not of the same nature. 9. PROVIDER'S COMPLIANCE WITH TAX LAWS 9.1 Provider represents and warrants to the City that: 9.1.1 Provider shall, throughout the term of this Agreement, including any extensions hereof, comply with: (i) All tax laws of the State of Oregon, including but not limited to ORS 305.620 and ORS chapters 316,317,and 318; (ii) Any tax provisions imposed by a political subdivision of the State of Oregon applicable to Provider;and (iii) Any rules, regulations,charter provisions, or ordinances that implement or enforce any of the foregoing tax laws or provisions. Page 4 of 5: Agreement between the City of Ashland and Design Source 9.1.2 Provider, for a period of no fewer than six(6)calendar years preceding the Effective Date of this Agreement, has faithfully complied with: (i) All tax laws of the State of Oregon, including but not limited to ORS 305.620 and ORS chapters 316, 317, and 318; (ii) Any tax provisions imposed by a political subdivision of the State of Oregon applicable to Provider;and (iii) Any rules,regulations, charter provisions, or ordinances that implement or enforce any of the foregoing tax laws or provisions. 9.2 Provider's failure to comply with the tax laws of the State of Oregon and all applicable tax laws of any political subdivision of the State of Oregon shall constitute a material breach of this Agreement. Further, any violation of Provider's warranty, as set forth in this Article 9, shall constitute a material breach of this Agreement. Any material breach of this Agreement shall entitle the City to terminate this Agreement and to seek damages and any other relief available under this Agreement,at law,or in equity. IN WITNESS WHEREOF the parties have caused this Agreement to be signed in their respective names by their duly authorized representatives as of the dates set forth below. CITY OF ASHLAND: Design Source(PROVIDER): By: � By: LU gnature L8igiature cb. co- r Fumy M d L( J (A (lQ,M s Printed Name Printed Name Title Title Ito 5- /1 / 2ow Date Date (W-9 is to be submitted with this signed Agreement) Purchase Order No. v 'et°i Page 5 of 5: Agreement between the City of Ashland and Design Source DESIGN SOURCE 1319 Harrisburg Dr. Medford, OR 97501 Phone: 541-821-6823 Mollyatdesignsource@hotmail.com Rate Schedule July 1, 2020-June 30, 2021 Service labor for assembly of furniture items new or existing $50 per hour per person Non-BOLI assignments DESIGN SOURCE I�T>d 1319 Harrisburg Dr. Medford, OR 97501 Phone: 541-821-6823 Mollyatdesignsource@hotmail.com April, 29 2020 To:City of Ashland To whom it concerns, Regarding the City of Ashland's Service Agreement General Liability Insurance requirement, I would like to request an exception. As the owner of Design Source, my company currently carries$1,000,000 per occurrence and $2,000,000 for general aggregate and products worth of Liability Insurance while providing the assembly of office furnishings. During the process of performing these services, incidents are extremely rare and personal injury or property damage is almost unheard of. Please contact me if you have any questions or would like more information as you consider my request, Thank you, MollyWilliams, �o�wner alC) Design Source CERTIFICATION OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE REQUIREMENTS Contractor is exempt from the requirement to obtain workers compensation insurance under ORS Chapter 656 for the following reason.Contractor is to initial the appropriate box as follows: ._.U ) SOLE PROPRIETOR (Initials) ■ Contractor is a sole proprietor,and • Contractor has no employees,and • Contractor will not hire employees or subcontractors to perform this contract. CORPORATION—FOR PROFIT (Initials) to Contractor's business is incorporated;and • All employees of the corporation are officers and directors and have a substantial ownership interest*in the corporation,and • All work will be performed by the officers and directors;Contractor will not hire other employees or subcontractors to perform this contract. CORPORATION-NONPROFIT (Initials) • Contractor's business is incorporated as a nonprofit corporation,and • Contractor has no employees;all work is performed by volunteers,and • Contractor will not hire employees or subcontractors to perform this contract. PARTNERSHIP (Initials) ■ Contractor is a partnership,and • Contractor has no employees,and • All work will be performed by the partners;Contractor will not hire employees or subcontractors to perform this contract,and • Contractor is not engaged in work performed in direct connection with the construction,alteration,repair, improvement,moving or demolition of an improvement to real property or appurtenances thereto.** LIMITED LIABILITY COMPANY (Initials) ■ Contractor is a limited liability company,and • Contractor has no employees,and • All work will be performed by the members;Contractor will not hire employees or subcontractors to perform this contract,and • If Contractor has more than one member,Contractor is not engaged in work performed in direct connection with the construction,alteration,repair,improvement,moving or demolition of an improvement to real property or appurtenances thereto.** � ! (Sign f uthorized Signer) /2020+(Date) (Signer'sTitle *NOTE: Under 0AR436-50-050 a shareholder has a"substantial ownership"interest if the shareholder owns 10%of the corporation,or if less than 10%is owned,the shareholder has ownership that is at least equal to or greater than the average percentage of ownership of all shareholders. **NOTE: Under certain circumstances partnerships and limited liability companies can claim an exemption even when performing 'construction work. The requirements for this exemption are complicated. Consult with City Attorney's Office before an exemption request is accepted from a contractor who will perform construction work. ,eco OINSURANCE 4.---- ® CERTIFICATE OF LIABILITY DATE(MM/DDIYYYY) 04/29/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Tanis Harber NAME: Ashland Insurance Inc (A/C,No,Ext): (541)857-0679 FAX No): (541)857-9883 801 O'Hare Parkway,Ste 101 E-MAIL tharber@ashlandinsurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Medford OR 97504 INSURERA: Ohio Security Insurance Co. 24082 INSURED INSURER B: Design Source INSURER C: 1319 Harrisburg Dr INSURER D: INSURER E: Medford OR 97501 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 Cert REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSD WVD_ POLICY NUMBER DDL AMR POLICY EFF POLICY EXP (MMIDD/YYYY) (MM/DDM/YY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 DAMAGE TO RENTED 1,000,000 CLAIMS-MADE OCCUR PREMISES(En occurrence) $ _ MED EXP(Any one person) $ 15,000 A Y Y BLS58165091 07/24/2019 07/24/2020 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY n SM: [1 Loc2,000,000 PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILYNJURYeracc Pident $ AUTOS ONLY AUTOS ( ) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY IPer accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/NSTATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE n N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if mare apace Is required) Certficate holder is included as Additional Insured for General Liability coverages with written contract.This form is subject to policy terms,conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. 20 E.Main St. AUTHORIZED REPRESENTATNE [�/� Ashland OR 97520 I �+ d 74 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) A3 Ro® VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE DATE( M THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. This form is used to report coverages provided to a single specific vehicle or equipment.Do not use this form to report liability coverage provided to multiple vehicles under a single policy.Use ACORD 25 for that purpose. PRODUCER NAME CT Russell P Brown StateFarm Russell P Brown Ins Agcy Inc (arc°,No,Exq: 541-776-8466FAX lAIC No); 541-776-8473 2581 W Main St AIL ADDRESS: russell@nissellbrown.biz 00 Medford.Or 97501 PRODUCER CUSTOMER ID M: INSURER(S)AFFORDING COVERAGE NAIC I INSURED INSURER A:State Farm Mutual Automobile Insurance Company 25178 Williams,Molly INSURER B: 1319 Harrisburg Dr INSURER C: Medford.Or 97501 INSURER D: INSURER E: DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR MAKE I MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER 2012 Ford Escape Utility 1FMCUOE72CKC19053 DESCRIPTION VEHICLE/EQUIPMENT VALUE SERIAL NUMBER $ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICY(IES)OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S)INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICY(IES)DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR ADPL POLICY EFFECTIVE POLICY EXPIRATION _ LTR Immo TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YYTY) DATE(MMIDD/YYYY) LIMITS X I VEHICLE LIABILITY COMBINED SINGLE LIMIT $ , BODILY INJURY(Per person) $ 100000 A 155 6519-C22-37F 03/22/2020 09/22/2020 BODILY INJURY(Per accident) S 300000 PROPERTY DAMAGE $ 100000 GENERAL UABIUTY EACH OCCURENCE $ OCCURRENCE GENERAL AGGREGATE $ CLAIMS MADE $ INSR LOSS POLICY EFFECTIVE POUCY EXPIRATION LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YYYY) DATE(MM/DD/YYYY) UNITS I DEDUCTIBLE VEH COLLISION LOSS ❑ACV ❑AGREED AMT $ OMIT 0 ❑STATED AMT $ DED VEH COMP I I VEH OTC 0 ACV ❑AGREED AMT $ LIMIT ❑ ❑STATED AMT $ DED EQUIPMENT 0 ACV 0 AGREED AMT $ LIMIT BASIC BROAD IDRC ❑STATED AMT SPECIAL 0 $ DED REMARKS(INCLUDING SPECIAL CONDITIONS(OTHER COVERAGES)(Attach ACORD 101,Additional Remarks Schedule,It more space Is required) ADDITIONAL.INTEREST CANCELLATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED The additional interest described below has been added to the policy(ies)listed herein by policy number(s). BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE A reqquest has been eubmibed to add the additional interest described below to the policy(ies) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. toted herein by policy number(s). _ VEHICLE!EQUIPMENT INTEREST: LEASED FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST ADDITIONAL INSURED LOSS PAYEE Certificate Holder: LENDER'S\LOSS PAYEE City of Ashland LOAN/LEASE UMBER fi r / 20 E Main St Ashland,OR 97520 AUTH REP• ATIVE Ai` I d� 1l41 J , if ©1997-2015 ACORD C•- -- •TION.All rights reserved. ACORD 23(2016/03) The ACORD name and logo are registered marks of ACORD 1004381 142987.3 01-26-2016