Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
2025-002 PO 20250316 - Rogue Retreat
B City of Ashland L ATTN: Accounts Payable L 20 E. Main Ashland, OR 97520 T Phone:541/552-2010 O Email: payable -_ashland.or.us V E ROGUE RETREAT N 711 E MAIN ST. #25 D MEDFORD, OR 97504 O R 20250435 Purchase Order S C/O Administration H 20 East Main St P Ashland, OR 97520 Email: kelly.burns@ashlandoregon.gov T Phone: 541 /488-6002 O Fax: 541 /488-5311 03/05/2025 1 4384 1 1 1 Administration De Severe Weather Shelter Services 1 Severe weather shelter operation services through April 1, 2025 1.0 EACH $120,000.00 Project Account: E-000839-999 *************** GL SUMMARY *************** 017200 - 604100 $120,000.00 t $120,000.00 By: Date: Authorized Signature $120,000.00 AGREEMENT FOR COORDINATING SERVICESAND OF SEVERE WEATHER SHELTER BETWEEN CITY OFASHLAND AND ROGUE RETREAT This Agreement by and between THE CITY OF ASHLAND, a municipal corporation (hereinafter "City"), and of ROGUE RETREAT. ("RR"), a 501(c)(3) corporation registered in Oregon, shall be effective upon the date of the last signature. WHEREAS, City and RR enter into this agreement to identify their roles and responsibilities for providing Severe Weather Shelter o v e r n i g h t s to vulnerable persons and families at risk who require safety and protection from exposure to extreme weather conditions. WHEREAS, the City recognizes its budget constraints and the urgent need to provide shelter for its most vulnerable community members during extreme or hazardous weather conditions. Additionally, the City acknowledges the necessity of providing institutional support to the shelter to ensure efficient and safe management, In partnership with RR, the City recognizes the business continuity needs of RR for the operation of the shelter located at 2200 Ashland Street, Ashland, OR 97520 (the "Severe Weather Shelter") over consecutive nights. WHEREAS, this agreement outlines the public policy of the Council to provide emergency shelter services, as codified in Resolution 2022-33, highlighting the requirement for consecutive night operations (i.e., RR's operation of the Severe Weather Shelter from the evening of January 1, 2025, through the evening of April 1, 2025), as well as the need for the City of Ashland to cover the beginning of the winter season from November 11, 2024, to December 31, 2024. THERFORE, in consideration for the mutual covenants contained herein, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows: AGREEMENT 1, RECITALS, The recital set forth above is true and correct and is incorporated herein by this reference. 2. DURATION. Except for termination as provided herein, the term of this agreement shall be January 1A 2025 until April 1!1, 2025, unless otherwise agreed, 3. BUDGET LIMITS, The cost to the City shall not exceed $120,000.0.0 unless otherwise amended. 4. RR SERVICES, FUNCTIONS AND RESPONSIBILITIES, 4.1 During the term of this Agreement, beginning on January 15, 2025, RR shall make all arrangements and commitments necessary and sufficient Page 1 of 6 to have paid and volunteer persons at a location designated for Severe Weather Shelter use. RR will provide adequately trained staffing for authorized, safe, and lawful operation of the Severe Weather Shelter. 4.2 RR will provide communication and distribution of notices for shelter nights at the Severe Weather Shelter. 4.3 RR will hire and train temporary shelter staff. 4.4 For each night the Severe Weather Shelter is open, RR will ensure the provision of Fire Watch duties are performed, by any combination of paid overnight shelter staff and trained volunteers to operate Severe Weather Shelter with oversight by a Shelter Coordinator and the Director of Program Services. RR ensures training on the emergency plan, first aid, abuse prevention, de-escalation, trauma -informed care, safety, and emergency communications for the Severe Weather Shelter, and execution of waivers, in a form reviewed by the City. 4.5 RR shall comply with the Ashland Municipal Code by paying a living wage, as defined in AMC 3.12, to all persons paid to perform work under this Agreement and to any subcontractor paid to perform 50% or more of the service work under this Agreement as detailed in Exhibit B, budget for Severe Weather Shelter activity, attached to this contract. In the event of a conflict between the responsibilities of RR in this Agreement and Exhibit B, the terms of Exhibit B shall govern, RR is also required to post the living wage notice prominently in areas where all its employees will see it. 5. CITY OBLIGATIONS. The City shall declare a Severe Weather Emergency from January 1st, 2025until April 111, 2025 and uponforecasted conditions set forth under the City's Resolution 2022-33; 5.1 The Severe Weather Shelter will operate consecutive nights beginning January 1st 2025, until April 1st 2025, 5.2 Per the City's Resolution 2022-33, any forecasted Ashland temperatures at or below 32 degrees is the threshold at which the City may declare the Severe Weather Shelter open as resources allow. 5.3 City will pay RR for costs as identified in the budget for Severe Weather Shelter activity, all costs will be paid on an actual or per event basis. 5.4 RR will invoice one to four times per month for actual nightly and operational costs of the Severe Weather Shelter as identified in attached Exhibit A. The City will reimburse weekly for invoices submitted, provided that in no event shall the total amount owed to RR from City exceed the $120,000.00 budget set forth in paragraph 3 above unless the budget is otherwise amended, 6. PAYMENT. This agreement involves the payment of money from the City of Ashland to RR for Severe Weather Shelter Services. 6.1 All payments made to RR under this Agreement should be sent to the following address; Page 2 of 6 Rogue Retreat 711 East Main Street 425 Medford, OR 97504 7. PERSONNEL. RR shall be solely responsible for wages and benefits paid to any employees or contractors working for RR. 8. REAL OR PERSONAL PROPERTY. There shall be no transfer of title or possession to any real or personal property pursuant to this Agreement. 9. TERMINATION, 9.1 All or part of this Agreement may be terminated by mutual consent by both parties; or by either party at any time, upon thirty (30) days' notice in writing and delivered by certified mail. In the event of termination of the Agreement, each party shall be responsible for its own costs and expenses in complying with the Agreement. 9.2 This Agreement may be terminated by either party if the other party commits any material breach of any of the terms or conditions of this Agreement and fails or neglects to correct the same within 10 days after written notice of such breach. if the breach is of such nature that it cannot be completely remedied within the 10- day period, this provision shall be complied with if correction of the breach begins within the 10-day period and thereafter proceeds with reasonable diligence and in good faith to affect the remedy as soon as is practicable. 10. ASSIGNMENT. RR shall not assign or transfer any interest in this Agreement without prior written consent of the City, provided, however, that RR may subcontract the performance of any provision or obligation required by this Agreement, so long as RR remains primarily responsible to the City for the performance of such provision or obligation. 11. INSPECTION RECORDS. 11.1 RR shall maintain books, records, documents, and other evidence and accounting procedures and practices sufficient to properly reflect all costs of whatever nature claimed to have been incurred and anticipated in the performance of the Agreement. The City and its duly authorized representatives shall have access to the books documents, papers, and records of RR which are directly pertinent to the Agreement for the purpose of making audit, examination, excerpts, and transcripts. Such books and records shall be maintained by RR for three years from the date of the completion of work unless a shorter period is authorized in writing. RR is responsible for any RR audit discrepancies involving deviation from the terms of the Agreement. 12. HOLD HARMLESS AND INDEMNIFICATION. Page 3 of 6 12.1 The City of Ashland is not providing services but rather purchasing services from RR. Accordingly, to the extent permitted by the Oregon Constitution and the Oregon Tort Claims Act, the parties both shall hold each other harmless, defend and indemnify the other from any and all claims, demands, damages or injuries, liability of damage, including injury resulting in death or damage to property, that anyone may have or assert by reasons of any negligence or willful misconduct of the other, its officers, employees or agents. The City of Ashland shall not be held responsible for any claims, actions, costs, judgments, or other damages, directly and injury proximately caused by any negligence or willful misconduct by RR, its employees, or agents, or its volunteers. If any aspect of this indemnity shall be found to be illegal or invalid for any reason whatsoever, such illegality or invalidity shall not affect the validity of the remainder of this indemnification. 13. INDEPENDENT CONTRACTOR STATUS. RR is an independent contractor and neither RR nor anyone performing work pursuant to this Agreement and under RR's auspices is an employee of the City. RR shall have complete responsibility for performance of its obligations under this Agreement. Except as provided for in this Agreement, the City shall not be liable for any obligations incurred by RR. RR shall not represent to any person that the City is liable for RR's obligations. 14. INSURANCE. Each party is responsible for its own insurance and coverage relating to claims arising from providing or staffing a Severe Weather Shelter. No City coverage is extended to the other parties or volunteers; however, the City will maintain existing property coverage of the facility. RR shall hold the following liability insurance limits and name the City of Ashland as an additional insured party: general liability Insurance with a combined single limit, or the equivalent, of not less than $2,000,000 (two million dollars) per occurrence and for bodily injury, death, and property damage and professional liability with a combined single limit, or the equivalent, of not less than $2,000,000 (two million dollars) per occurrence. This is to cover any damage caused by error, omission or negligent acts related to the services provided under this Agreement. 15. DISPUTE RESOLUTION. City and RR shall attempt to resolve all disputes through staff discussions at the lowest possible level. Both parties to this Agreement agree to provide other resources and personnel to negotiate and find resolution to disputes that cannot be resolved at the staff level. Disputes shall be initially submitted to mediation by a mediator chosen by the parties. The cost of mediation shall be borne equally by the parties. If the parties are unable to agree upon a mediator within 5 days or if mediation fails to resolve the dispute and if either party wants to further pursue the dispute, all parties waive Page 4 of 6 their right to a trial by jury. 16. NOTICE AND REPRESENTATIVES. All notices, certificates, or communications shall be delivered or mailed postage prepaid to the parties at their respective places of business as set forth below or at a place designated hereafter in waiting by the parties. City Manager 20 East Main Ashland, OR 97520 711 East Main Street #25 Ashland, OR 97520 And when so addressed, shall be deemed given upon deposit in the United States Mail, postage prepaid. In all other instances, notices: bills, and payments shall be deemed given at the time of actual delivery. Changes may be made in the names and addresses of the person to whom notices, bills, and payments are to be given by giving notice pursuant to this paragraph. MERGER. THIS AGREEMENTCONSTITUTES THE ENTIRE AGREEMENT BETWEEN THE PARTIES. THERE ARE NO UNDERSTANDINGS, AGREEMENTS, OR REPRESENTATIONS, ORAL OR WRITTEN, NOT SPECIFIED HEREIN REGARDING THIS AGREEMENT. NO AMENDMENT, CONSENT, OR WAIVER OR TERMS OF THIS AGREEMENT SHALL BIND EITHER PARTY UNLESS IN WRITING AND SIGNED BY ALL PARTIES, ANY SUCH AMENDMENT, CONSENT OR WAIVER SHALL BE EFFECTIVE ONLY IN THE SPECIFIC INSTANCE AND FOR THE SPECIFIC PURPOSE GIVEN. THE PARTIES, BY THE SIGNATURES BELOW OR THEIR AUTHORIZED REPRESENTATIVES, ACKNOWLEDGE HAVING READ AND UNDERSTOOD THE AGREEMENT AND THE PARTIES AGREE TO BE BOUND BY ITS TERMS AND IN WITNESS WHEREOF, the parties hereto have caused this instrument to be executed in two (2) duplicate originals, either as individuals, or by their officers thereunto duly authorized. CITY OF ASHLAND BY: Sabrina Cotta1 Title: City Manager Dated: Page 5 of 6 Approved as to form Doug a�s-I cGea Acting City Attorney ROGUE RETREAT: By: Sam Engel ..._.� "Title: Executive Director Dated .... IZI) Page 6 of 6 A� " CERTIFICATE OF LIABILITY INSURANCE DATE Y) 01/09/025 09/2025 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 Tom Hart NAME: Redwoods Leavitt Insurance Agency (541) 479-2669 HCNN (541) 479-2667 a/c, o Ext : No): 822 NE E St E-MAIL tom-hart@leavitt.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Suite A Grants Pass OR 97526 INSURERA: Philadelphia Insurance Companies R18667 INSURED INSURER B : SAIF Corporation 36196 Rogue Retreat INSURER C : 711 E Main St STE 25 INSURER D : INSURER E: Medford OR 97504 INSURER F : COVERAGES CERTIFICATE NUMBER: 24-25 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 INSURANCEAUULbUBK INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE FX OCCUR PREM SDA AGES Ea oNcurDrence $ 100'000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 A Y PHPK2603726 09/15/2024 09/15/2025 LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY ❑ PRO ❑ LOC JECT: MOTHER PRODUCTS-COMP/OP AGG $ 3'000'000 Professional Services $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ ANYAUTO A OWNED SCHEDULED AUTOS ONLY AUTOS PHPK2603726 09/15/2024 09/15/2025 BODILY INJURY (Pe r accide nt) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Medical payments $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 HCLAIMS-MADE AGGREGATE $ 1,000,000 A EXCESS LAB PHUB882033 09/15/2024 09/15/2025 DED I X1 RETENTION $ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N/A 743109 07/01/2024 07/01/2025 PER OTH- STATUTE ER E.L. EACH ACCIDENT 500, 000 $ E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 500,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Additional Insured per endorsement PIG LDHS 10-11 attached CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. 20 East Main AUTHORIZED REPRESENTATIVE Ashland OR 97520 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Additional Named Insureds Other Named Insureds Rogue Retreat Doing Business As OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC ADDITIONAL COVERAGES Ref # Description Abuse & Mmolestation Coverage Code Form No. Edition Date Limit 1 1,000,000 Limit 2 3,000,000 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Cyber liability Coverage Code CLIAB Form No. Edition Date Limit 1 Included Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Underinsured motorist BI single limit Coverage Code UNDSG Form No. Edition Date Limit 1 1,000,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Experience Mod Factor 1 Coverage Code EXP01 Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium -$3,380.78 Ref # Description Terrorism Cov Coverage Code TERO Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $148.72 Ref # Description Premium discount Coverage Code PDIS Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium -$2,872.76 Ref # Description Assessment Fund Coverage Code ASMNT Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $2,191.85 Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium rOFADTLCV Copyright 2001, AMS Services, Inc. PI-GLD-HS (10/11) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY DELUXE ENDORSEMENT: HUMAN SERVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposure is provided under this policy. If such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy, unless otherwise noted on this endorsement. The following is a summary of the Limits of Insurance and additional coverages provided by this endorsement. For complete details on specific coverages, consult the policy contract wording. Coverage Applicable Limit of Insurance Page # Extended Property Damage Included 2 Limited Rental Lease Agreement Contractual Liability $50,000 limit 2 Non -Owned Watercraft Less than 58 feet 2 Damage to Property You Own, Rent, or Occupy $30,000 limit 2 Damage to Premises Rented to You $1,000,000 3 HIPAA Clarification 4 Medical Payments $20,000 5 Medical Payments — Extended Reporting Period 3 years 5 Athletic Activities Amended 5 Supplementary Payments — Bail Bonds $5,000 5 Supplementary Payment— Loss of Earnings $1,000 per day 5 Employee Indemnification Defense Coverage $25,000 5 Key and Lock Replacement — Janitorial Services Client Coverage $10,000 limit 6 Additional Insured — Newly Acquired Time Period Amended 6 Additional Insured — Medical Directors and Administrators Included 7 Additional Insured — Managers and Supervisors (with Fellow Employee Coverage) Included 7 Additional Insured — Broadened Named Insured Included 7 Additional Insured — Funding Source Included 7 Additional Insured — Home Care Providers Included 7 Additional Insured — Managers, Landlords, or Lessors of Premises Included 7 Additional Insured — Lessor of Leased Equipment Included 7 Additional Insured — Grantor of Permits Included 8 Additional Insured — Vendor Included 8 Additional Insured — Franchisor Included 9 Additional Insured —When Required by Contract Included 9 Additional Insured — Owners, Lessees, or Contractors Included 9 Additional Insured — State or Political Subdivisions Included 10 Page 1 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) K. Key and Lock Replacement —Janitorial Services Client Coverage SECTION I — COVERAGES, SUPPLEMENTARY PAYMENTS — COVERAGES A AND B is amended to include the following: We will pay for the cost to replace keys and locks at the "clients" premises due to theft or other loss to keys entrusted to you by your "client," up to a $10,000 limit per occurrence and $10,000 policy aggregate. We will not pay for loss or damage resulting from theft or any other dishonest or criminal act that you or any of your partners, members, officers, "employees", "managers", directors, trustees, authorized representatives or any one to whom you entrust the keys of a "client' for any purpose commit, whether acting alone or in collusion with other persons. The following, when used on this coverage, are defined as follows: a. "Client' means an individual, company or organization with whom you have a written contract or work order for your services for a described premises and have billed for your services. b. "Employee" means: (1) Any natural person: (a) While in your service or for 30 days after termination of service; (b) Who you compensate directly by salary, wages or commissions; and (c) Who you have the right to direct and control while performing services for you; or (2) Any natural person who is furnished temporarily to you: (a) To substitute for a permanent "employee" as defined in Paragraph (1) above, who is on leave; or (b) To meet seasonal or short-term workload conditions; while that person is subject to your direction and control and performing services for you. (3) "Employee" does not mean: (a) Any agent, broker, person leased to you by a labor leasing firm, factor, commission merchant, consignee, independent contractor or representative of the same general character; or (b) Any "manager," director or trustee except while performing acts coming within the scope of the usual duties of an "employee." c. "Manager" means a person serving in a directorial capacity for a limited liability company. L. Additional Insureds SECTION II — WHO IS AN INSURED is amended as follows: 1. If coverage for newly acquired or formed organizations is not otherwise excluded from this Page 6 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) Coverage Part, Paragraph 3.a. is deleted in its entirely and replaced by the following: a. Coverage under this provision is afforded until the end of the policy period. 2. Each of the following is also an insured: a. Medical Directors and Administrators — Your medical directors and administrators, but only while acting within the scope of and during the course of their duties as such. Such duties do not include the furnishing or failure to furnish professional services of any physician or psychiatrist in the treatment of a patient. b. Managers and Supervisors — Your managers and supervisors are also insureds, but only with respect to their duties as your managers and supervisors. Managers and supervisors who are your "employees" are also insureds for "bodily injury" to a co - "employee" while in the course of his or her employment by you or performing duties related to the conduct of your business. This provision does not change Item 2.a.(1)(a) as it applies to managers of a limited liability company. c. Broadened Named Insured — Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage Part. However, coverage does not apply to any organization or subsidiary not named in the Declarations as Named Insured, if they are also insured under another similar policy, but for its termination or the exhaustion of its limits of insurance. d. Funding Source — Any person or organization with respect to their liability arising out of: (1) Their financial control of you; or (2) Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. e. Home Care Providers — At the first Named Insured's option, any person or organization under your direct supervision and control while providing for you private home respite or foster home care for the developmentally disabled. f. Managers, Landlords, or Lessors of Premises — Any person or organization with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased or rented to you subject to the following additional exclusions: This insurance does not apply to: (1) Any "occurrence" which takes place after you cease to be a tenant in that premises; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization. g. Lessor of Leased Equipment— Automatic Status When Required in Lease Agreement With You — Any person or organization from whom you lease equipment when you and such person or organization have agreed in writing in a contract or agreement that such person or organization is to be added as an additional insured on your policy. Such person or Page 7 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) organization is an insured only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person or organization. A person's or organization's status as an additional insured under this endorsement ends when their contract or agreement with you for such leased equipment ends. With respect to the insurance afforded to these additional insureds, this insurance does not apply to any "occurrence" which takes place after the equipment lease expires. h. Grantors of Permits — Any state or political subdivision granting you a permit in connection with your premises subject to the following additional provision: (1) This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit in connection with the premises you own, rent or control and to which this insurance applies: (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners or decorations and similar exposures; (b) The construction, erection, or removal of elevators; or (c) The ownership, maintenance, or use of any elevators covered by this insurance. i. Vendors — Only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business, subject to the following additional exclusions: (1) The insurance afforded the vendor does not apply to: (a) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; (b) Any express warranty unauthorized by you; (c) Any physical or chemical change in the product made intentionally by the vendor; (d) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; (e) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; (f) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; Page 8 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) (g) Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or (h) 'Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (1) The exceptions contained in Sub -paragraphs (d) or ft or (ii) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. (2) This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing. j. Franchisor — Any person or organization with respect to their liability as the grantor of a franchise to you. k. As Required by Contract — Any person or organization where required by a written contract executed prior to the occurrence of a loss. Such person or organization is an additional insured for "bodily injury," "property damage" or "personal and advertising injury" but only for liability arising out of the negligence of the named insured. The limits of insurance applicable to these additional insureds are the lesser of the policy limits or those limits specified in a contract or agreement. These limits are included within and not in addition to the limits of insurance shown in the Declarations I. Owners, Lessees or Contractors — Any person or organization, but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" caused, in whole or in part, by: (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured when required by a contract. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: (a) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or (b) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Page 9 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company PI-GLD-HS (10/11) m. State or Political Subdivisions — Any state or political subdivision as required, subject to the following provisions: (1) This insurance applies only with respect to operations performed by you or on your behalf for which the state or political subdivision has issued a permit, and is required by contract. (2) This insurance does not apply to: (a) 'Bodily injury," "property damage" or "personal and advertising injury" arising out of operations performed for the state or municipality; or (b) 'Bodily injury" or "property damage" included within the "products -completed operations hazard." M. Duties in the Event of Occurrence, Claim or Suit SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 2. is amended as follows: a. is amended to include: This condition applies only when the `occurrence" or offense is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; or (3) An executive officer or insurance manager, if you are a corporation. b. is amended to include: This condition will not be considered breached unless the breach occurs after such claim or "suit" is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; or (3) An executive officer or insurance manager, if you are a corporation. N. Unintentional Failure To Disclose Hazards SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 6. Representations is amended to include the following: It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. O. Transfer of Rights of Recovery Against Others To Us SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 8. Transfer of Rights of Page 10 of 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. © 2011 Philadelphia Indemnity Insurance Company POLICY CHANGE DOCUMENT POLICY NO.: PHPK2603726-015 Philadelphia Indemnity Insurance Companyl 118028 Redwoods Leavitt Insurance Agency NAMED INSURED Rogue Retreat MAILING ADDRESS 711 E Main St Ste 25 Medford, OR 97504-7139 POLICY PERIOD: FROM 09/15/2024 TO 09/15/2025 at 12:01 A.M. Standard Time at your mailing address shown above. CHANGE EFFECTIVE 01/01/2025 CHANGE # 2 QDUI RHWM" 2 DESCRIPTION In consideration of the premium reflected, the policy is amended as indicated below: Adding Location Added: Loc #14 Bldg #1 2200 Ashland Street, Ashland, OR 97520 Per attached schedule Path ID 18170264 Total Annual Additional/Return Premium $ COUNTERSIGNED (Date) 01 /24/2025 Issue Date Total Prorate 746.00 Additional/Return Premium $ 525.00 ADDITIONAL ADDITIONAL BY (Authorized Representative) Insurance Policy Page 1 of 1 PI-LOC-SCH (08/20) Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2603726-015 Prems. Bldg. 0001 0001 529 N Riverside Ave Medford, OR 97501-4604 0001 0002 525, 529 N Riverside Ave Medford, OR 97501-4604 0002 0001 405, 415 S Grape/131-135 W 11th Medford, OR 97501-4639 0003 0001 1116 N Riverside Ave Medford, OR 97501-4617 0004 0001 726 W 4th St Medford, OR 97501-2654 0005 0001 821 N Columbus Ave Medford, OR 97501-1766 0005 0002 821 N Columbus Ave Medford, OR 97501-1766 0005 0003 821 N Columbus Ave Medford, OR 97501-1766 0005 0004 821 N Columbus Ave Medford, OR 97501-1766 0005 0005 821 N Columbus Ave Medford, OR 97501-1766 0005 0006 821 N Columbus Ave Medford, OR 97501-1766 0005 0007 821 N Columbus Ave Medford, OR 97501-1766 0005 0008 821 N Columbus Ave Medford, OR 97501-1766 0005 0009 821 N Columbus Ave Medford, OR 97501-1766 0005 0010 821 N Columbus Ave Medford, OR 97501-1766 0005 0011 821 N Columbus Ave Medford, OR 97501-1766 PI-LOC-SCH (08/20) Page 1 of 4 PI-LOC-SCH (08/20) Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2603726-015 Prems. Bldg. 0006 0001 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0002 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0003 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0004 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0005 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0006 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0007 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0008 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0009 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0010 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0011 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0012 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0013 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0014 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0015 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0016 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 PI-LOC-SCH (08/20) Page 2 of 4 PI-LOC-SCH (08/20) Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2603726-015 Prems. Bldg. 0006 0017 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0018 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0019 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0020 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0021 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0022 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0023 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0024 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0025 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0007 0001 711 E Main St, Ste 20,22,23,24,25,28 Medford, OR 97504-7139 0008 0001 35 N Orange St Medford, OR 97501-2637 0009 0001 722 N Riverside Ave Medford, OR 97501-4609 0010 0001 685-691 Market St Medford, OR 97504-6125 0011 0001 848 W McAndrews Rd Medford, OR 97501-2360 0011 0002 848 W McAndrews Rd Medford, OR 97501-2360 0011 0003 848 W McAndrews Rd Medford, OR 97501-2360 PI-LOC-SCH (08/20) Page 3 of 4 PI-LOC-SCH (08/20) Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2603726-015 Prems. Bldg. 0011 0004 848 W McAndrews Rd Medford, OR 97501-2360 0011 0005 848 W McAndrews Rd Medford, OR 97501-2360 0011 0006 848 W McAndrews Rd Medford, OR 97501-2360 0012 0001 1130 N Riverside Ave (Welcome Center) Medford, OR 97501-4617 0012 0002 1130 N Riverside Ave Maintenance Building Medford, OR 97501-4617 0013 0001 2555 Brookside Dr Medford, OR 97504-5162 0014 0001 2200 Ashland St Ashland, OR 97520-1406 PI-LOC-SCH (08/20) Page 4 of 4 Philadelphia Indemnity Insurance Company C S F G C S F G F G C S F G C S C S F G C S F G COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK2603726-015 Agent # 118028 Classifications Code No. Premium Basis Rates Prem./ Prod./ O s. Comp. O s. Advance Premiums Prem./ Prod./ O s. Comp. O s. R PREM NO. 001 3ELTER/MISSION/STTLMNT/HALF H 67017 14,680 105.746 INCL 1,552 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 001 HELTER/MISSION/STTLMNT/HALF H 67017 750 105.746 INCL 79 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 001 DNSULTANT-NOC 41677 20,000 0.892 INCL 18 INCL PAYROLL ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 002 HELTER/MISSION/STTLMNT/HALF H 67017 3,612 105.746 INCL 382 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 003 ECONDHAND/SALVAGE DEAL/DISTR 16881 156,500 5.307 1.359 831 213 GROSS SALES R PREM NO. 004 1,930 105.746 INCL 204 INCL HELTER/MISSION/STTLMNT/HALF H 67017 AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 005 1,100 105.746 INCL 116 INCL HELTER/MISSION/STTLMNT/HALF H 67017 AREA ROD/COMP OP SUBJ TO EN AGO LIMIT Philadelphia Indemnity Insurance Company C S F G C E F G C L F G C S F G C S F G C S F G E F G COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK2603726-015 Agent # 118028 Classifications Code No. Premium Basis Rates Prem./ Prod./ O s. Comp. O s. Advance Premiums Prem./ Prod./ O s. Comp. O s. R PREM NO. 006 3ELTER/MISSION/STTLMNT/HALF H 67017 1,900 105.746 INCL 201 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 007 LDG/PREMS-OFFICE-NOC-NFP 61227 7,424 144.380 INCL 1,072 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 007 D,NDSCAPE GARDENING 97047 120,710 9.636 INCL 1,163 INCL PAYROLL ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 008 3ELTER/MISSION/STTLMNT/HALF H 67017 2,264 105.746 INCL 239 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 009 3ELTER/MISSION/STTLMNT/HALF H 67017 18,500 105.746 INCL 1,956 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 010 12,765 105.746 INCL 1,350 INCL 3ELTER/MISSION/STTLMNT/HALF H 67017 AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 011 224,800 31.095 INCL 6,990 INCL D,MPGROUND-NFP 10332 GROSS SALES ROD/COMP OP SUBJ TO EN AGO LIMIT Philadelphia Indemnity Insurance Company C S F G C S F G C ➢u F G C S F G C ➢u F G C S F G S COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK2603726-015 Agent # 118028 Classifications Code No. Premium Basis Rates Prem./ Prod./ O s. Comp. O s. Advance Premiums Prem./ Prod./ O s. Comp. O s. R PREM NO. 011 3ELTER/MISSION/STTLMNT/HALF H 67017 174,240 105.746 INCL 18,425 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 012 3ELTER/MISSION/STTLMNT/HALF H 67017 2,040 105.746 INCL 216 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 012 P,REHOUSE-PRIVATE-NFP 68707 1,000 38.303 INCL 38 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 013 HELTER/MISSION/STTLMNT/HALF H 67017 1,594 105.746 INCL 169 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 013 P,REHOUSE-PRIVATE-NFP 68707 1,000 38.303 INCL 38 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 014 5,333 105.746 INCL 564 INCL HELTER/MISSION/STTLMNT/HALF H 67017 AREA ROD/COMP OP SUBJ TO EN AGO LIMIT BALANCE TO MEET PROD/COMP 83 :JBLINE MINIMUM 44444 Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK2603726-015 Agent # 118028 Classifications Code No. Premium Basis Rates Prem./ Prod./ O s. Comp. O s. Advance Premiums Prem./ Prod./ O s. Comp. O s. R DDL INS PRIMARY & NON-CONTRIBUTORY INS INCL R IABILITY DELUXE 44444 3,560 POLICY CHANGE DOCUMENT POLICY NO.: PHPK2603726-015 Philadelphia Indemnity Insurance Companyl 118028 Redwoods Leavitt Insurance Agency NAMED INSURED Rogue Retreat MAILING ADDRESS 711 E Main St Ste 25 Medford, OR 97504-7139 POLICY PERIOD: FROM 09/15/2024 TO 09/15/2025 at 12:01 A.M. Standard Time at your mailing address shown above. CHANGE EFFECTIVE 01/01/2025 CHANGE # 2 QDUI RHWM" 2 DESCRIPTION In consideration of the premium reflected, the policy is amended as indicated below: Adding Location Added: Loc #14 Bldg #1 2200 Ashland Street, Ashland, OR 97520 Per attached schedule Path ID 18170264 Total Annual Additional/Return Premium $ COUNTERSIGNED (Date) 01 /24/2025 Issue Date Total Prorate 746.00 Additional/Return Premium $ 525.00 ADDITIONAL ADDITIONAL BY (Authorized Representative) Insurance Policy Page 1 of 1 PI-LOC-SCH (08/20) Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2603726-015 Prems. Bldg. 0001 0001 529 N Riverside Ave Medford, OR 97501-4604 0001 0002 525, 529 N Riverside Ave Medford, OR 97501-4604 0002 0001 405, 415 S Grape/131-135 W 11th Medford, OR 97501-4639 0003 0001 1116 N Riverside Ave Medford, OR 97501-4617 0004 0001 726 W 4th St Medford, OR 97501-2654 0005 0001 821 N Columbus Ave Medford, OR 97501-1766 0005 0002 821 N Columbus Ave Medford, OR 97501-1766 0005 0003 821 N Columbus Ave Medford, OR 97501-1766 0005 0004 821 N Columbus Ave Medford, OR 97501-1766 0005 0005 821 N Columbus Ave Medford, OR 97501-1766 0005 0006 821 N Columbus Ave Medford, OR 97501-1766 0005 0007 821 N Columbus Ave Medford, OR 97501-1766 0005 0008 821 N Columbus Ave Medford, OR 97501-1766 0005 0009 821 N Columbus Ave Medford, OR 97501-1766 0005 0010 821 N Columbus Ave Medford, OR 97501-1766 0005 0011 821 N Columbus Ave Medford, OR 97501-1766 PI-LOC-SCH (08/20) Page 1 of 4 PI-LOC-SCH (08/20) Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2603726-015 Prems. Bldg. 0006 0001 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0002 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0003 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0004 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0005 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0006 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0007 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0008 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0009 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0010 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0011 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0012 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0013 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0014 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0015 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0016 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 PI-LOC-SCH (08/20) Page 2 of 4 PI-LOC-SCH (08/20) Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2603726-015 Prems. Bldg. 0006 0017 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0018 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0019 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0020 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0021 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0022 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0023 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0024 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0006 0025 728, 734 & 742 W McAndrews Rd Medford, OR 97501-2371 0007 0001 711 E Main St, Ste 20,22,23,24,25,28 Medford, OR 97504-7139 0008 0001 35 N Orange St Medford, OR 97501-2637 0009 0001 722 N Riverside Ave Medford, OR 97501-4609 0010 0001 685-691 Market St Medford, OR 97504-6125 0011 0001 848 W McAndrews Rd Medford, OR 97501-2360 0011 0002 848 W McAndrews Rd Medford, OR 97501-2360 0011 0003 848 W McAndrews Rd Medford, OR 97501-2360 PI-LOC-SCH (08/20) Page 3 of 4 PI-LOC-SCH (08/20) Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2603726-015 Prems. Bldg. 0011 0004 848 W McAndrews Rd Medford, OR 97501-2360 0011 0005 848 W McAndrews Rd Medford, OR 97501-2360 0011 0006 848 W McAndrews Rd Medford, OR 97501-2360 0012 0001 1130 N Riverside Ave (Welcome Center) Medford, OR 97501-4617 0012 0002 1130 N Riverside Ave Maintenance Building Medford, OR 97501-4617 0013 0001 2555 Brookside Dr Medford, OR 97504-5162 0014 0001 2200 Ashland St Ashland, OR 97520-1406 PI-LOC-SCH (08/20) Page 4 of 4 Philadelphia Indemnity Insurance Company C S F G C S F G F G C S F G C S C S F G C S F G COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK2603726-015 Agent # 118028 Classifications Code No. Premium Basis Rates Prem./ Prod./ O s. Comp. O s. Advance Premiums Prem./ Prod./ O s. Comp. O s. R PREM NO. 001 3ELTER/MISSION/STTLMNT/HALF H 67017 14,680 105.746 INCL 1,552 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 001 HELTER/MISSION/STTLMNT/HALF H 67017 750 105.746 INCL 79 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 001 DNSULTANT-NOC 41677 20,000 0.892 INCL 18 INCL PAYROLL ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 002 HELTER/MISSION/STTLMNT/HALF H 67017 3,612 105.746 INCL 382 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 003 ECONDHAND/SALVAGE DEAL/DISTR 16881 156,500 5.307 1.359 831 213 GROSS SALES R PREM NO. 004 1,930 105.746 INCL 204 INCL HELTER/MISSION/STTLMNT/HALF H 67017 AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 005 1,100 105.746 INCL 116 INCL HELTER/MISSION/STTLMNT/HALF H 67017 AREA ROD/COMP OP SUBJ TO EN AGO LIMIT Philadelphia Indemnity Insurance Company C S F G C E F G C L F G C S F G C S F G C S F G E F G COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK2603726-015 Agent # 118028 Classifications Code No. Premium Basis Rates Prem./ Prod./ O s. Comp. O s. Advance Premiums Prem./ Prod./ O s. Comp. O s. R PREM NO. 006 3ELTER/MISSION/STTLMNT/HALF H 67017 1,900 105.746 INCL 201 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 007 LDG/PREMS-OFFICE-NOC-NFP 61227 7,424 144.380 INCL 1,072 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 007 D,NDSCAPE GARDENING 97047 120,710 9.636 INCL 1,163 INCL PAYROLL ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 008 3ELTER/MISSION/STTLMNT/HALF H 67017 2,264 105.746 INCL 239 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 009 3ELTER/MISSION/STTLMNT/HALF H 67017 18,500 105.746 INCL 1,956 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 010 12,765 105.746 INCL 1,350 INCL 3ELTER/MISSION/STTLMNT/HALF H 67017 AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 011 224,800 31.095 INCL 6,990 INCL D,MPGROUND-NFP 10332 GROSS SALES ROD/COMP OP SUBJ TO EN AGO LIMIT Philadelphia Indemnity Insurance Company C S F G C S F G C ➢u F G C S F G C ➢u F G C S F G S COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK2603726-015 Agent # 118028 Classifications Code No. Premium Basis Rates Prem./ Prod./ O s. Comp. O s. Advance Premiums Prem./ Prod./ O s. Comp. O s. R PREM NO. 011 3ELTER/MISSION/STTLMNT/HALF H 67017 174,240 105.746 INCL 18,425 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 012 3ELTER/MISSION/STTLMNT/HALF H 67017 2,040 105.746 INCL 216 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 012 P,REHOUSE-PRIVATE-NFP 68707 1,000 38.303 INCL 38 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 013 HELTER/MISSION/STTLMNT/HALF H 67017 1,594 105.746 INCL 169 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 013 P,REHOUSE-PRIVATE-NFP 68707 1,000 38.303 INCL 38 INCL AREA ROD/COMP OP SUBJ TO EN AGO LIMIT R PREM NO. 014 5,333 105.746 INCL 564 INCL HELTER/MISSION/STTLMNT/HALF H 67017 AREA ROD/COMP OP SUBJ TO EN AGO LIMIT BALANCE TO MEET PROD/COMP 83 :JBLINE MINIMUM 44444 Philadelphia Indemnity Insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK2603726-015 Agent # 118028 Classifications Code No. Premium Basis Rates Prem./ Prod./ O s. Comp. O s. Advance Premiums Prem./ Prod./ O s. Comp. O s. R DDL INS PRIMARY & NON-CONTRIBUTORY INS INCL R IABILITY DELUXE 44444 3,560 Forrn Request for Taxpayer give form to the (Pev. March 2024) Identification NumbeM and Certificationrequester. fro not Department of the Treasury Send to the IRS. ln, e:,nttal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information. Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below. _ ____.----------- 1 Name of entity/individual . An entry is required. (for a sole proprietor of disrrett,ardetd entity, enter the ownr r s nariie on line 1, and enrw the busme ss/disregarded entity's name, on line 2.) o ue Retreat 2 Business name/disregarded entity name, of different from above. r'a ar rears cs. 0 at; C CL 0 Z 2 a.. to a, +a> tip 3a C:heck'Hie appropriate box for federal tax classification of the entity/individual whose name; is entered on line '1. check 4 Exemptions (codes apply only to only one of'i1he'folowing seven boxeascertain ar,tifies, not lndividuals; see instructions or) page 3): } IndvidUal/scree paroprietot C, corporation S corporation � � Partnership rust/estate LLC. Enter the tax classification ('C - C corporation, S - S corporation, P = partnership) Exempt payee cone (lf any) Note': Check the "LL.C" box above and, in the east __.....__, ry pence, enter trac <xpaprerrai tln'Cea code; (Cie is or �) far the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity .should instead. check "le appropriate Exemption from Foreign Account Tax box for the tax classification of its owner. Compliance Act (FAT -CA) reporting Other (see instructions) nonprofit corporations code (if any) 3b If on line 3a you checked "Partnership" or "Trust/estate," or checked LLC and entered F at its tax cla sd'rrationy�___._ and you are providing this form to a partnership, trust or estate in which you have, an ownerships inie,*.iesi check (Applies to accounts maintained this box if oaa have any foreign partners, owners, or beneficiaries Se;c histrw,,t'ions outsrce� the United Mates.) Y y % pe' { r.l 5 Address (number, street, and apt. or suite no.). Sec; instructions. f11 Main at #2 ____._._._...,_..........._.._..__._ _ ____.__.._.._____.__ 5 tarty, stale, sicced ZIP code Requester's naone, and address (optional) MU dford, OR 97504 7 LiSt account riuniber(s) here; (optional) Taxpayer Identification Number (TIN) Yappropriate___.__..__.___........_..._......_.!_.._.._.y.__._.._......._.._..__..____.__...._..... ocra9securityrauanber. _....._... Eater your TIN in the box. The TIN provided iciest match the n�arr'roa* ive n on lure, 1 tc avosd �� J ......_.. _ ackup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, :gee the instructions for Part I, later. For other entitles, it is your employer identification number (FIN). If you do not have a number, see How to get a - T'IN, later. or, ['niployer identification nurnber Note: If the account is in more than one narne, see the instructions for line 1. See, also What Name and Number To Give the Nequester for guidelines on whose number to enter. 1 J T31 -- 1--' 6 T 9 9 �9 Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a nurnber to be issued to me); and 2. 1 am riot subject to backup withholding because (a) 1 am exempt from backup withholding, or (b) I have not: beers notified by the Internal Revenue Service (IRS) that I alit subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this farm (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross Out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, ite*rn 2 does not apply. For rnortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and, generally, payments other than interest and dividendd,you are not required to sign the certification, but you must provide Your correct TIN. See the instructions for Part 11, later. Sign Signature of Here U,S. person Section references are to the Internal Revenue Code unless otherwise noted. Facture developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FornnW9. Line 3a has been modified to clarify how a disregarded entity c:;oriipleteus Date New line 3b has been added to this form. A flow --through entity is required to complete ih'is line to indicate that it has direct or indirect foreign partners, owners, orbeneficiaries when it provides the Form W-9 to another flow through entity in which it has an ownership interest. This change is intended to provide a flow -through entity with information regarding the status of its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnershira In; tr't.iotion;-;'lcr;Tchedu@en K ,) and K-3 (Frain 1nft51. this line. An LLC that is a disregarded entity should check the Purpose of Farm appropriate box for the tax classification of its owner. Otherwise, it should check the "LLC" box and enter its appropriate tax classification. An individual or entity (Form W-9 requester) who is required to file an information return with the IRS is giving you this form because they Cat. No. 1023'1X Form W-9 (Rev, 3-2024)