HomeMy WebLinkAbout2025-107 AGRMT Kleinberg Tech A � T V OFPersonal Services Agreement
SHLAND
City Information Consultant Information
City of Ashland Firm Name: Kleinberg Tech
Attn: Steven Matiaco Contact: Greg Kleinberg
Building Official Address: 4667 Torrey Pines Drive
Ashland, Oregon 97520 Medford, OR 97504
Phone: (541) 552-2077 Phone: 541-779-5491
Email: steven.matiaco@ashlandoregon.gov Email: admin@kleinbergtech.com
Contract Summary
Procurement Method: Direct Award
Completion Date: 06/30/2027
Contract Amount: Not to exceed $5,000
Description of Services: Inspection, plan review, and consultation services for building department projects.
Supporting Documents: Scope of Work/Fee Schedule Dated: 5/12/25
Professional Liability Insurance Dated: 11/3/24
Certificate of Insurance Dated: 10/17/24
Truck Insurance Dated: 2/1/25
This Personal Services Agreement (hereinafter "Agreement") is entered into by and between the
City of Ashland, an Oregon municipal corporation (hereinafter "City") and the Consultant listed
under Consultant Information above, ("hereinafter "Consultant"), for the services listed under
Description of Services and Supporting Documents as noted in the Contract Summary above. In
the event of conflict between provisions of the Supporting Documents, the Supporting Documents
shall be given precedence in the order listed above.
This Agreement, the Exhibits and the Supporting Documents shall be construed to be mutually
complementary and supplementary wherever possible. In the event of a conflict which cannot be
so resolved, the provisions of this Agreement itself shall control over any conflicting provisions in
any of the exhibits or supporting documents. The Consultant's initials rKC-K 1 herein signify
acknowledgment and agreement to this provision, if applicable, or if not sign "N/A".
Consultant's services are collectively referred to in this Agreement as the "Work."
Page 1 of 8 Personal Services Agreement Between the City of Ashland and Kleinberg Tech
NOW THEREFORE, in consideration of the mutual covenants contained herein, the City and
Consultant hereby agree as follows:
1. Effective Date and Duration: This Agreement shall become effective on the date of
execution on behalf of the City, as set forth below (the "Effective Date"), and unless sooner
terminated as specifically provided herein, shall terminate upon the City's affirmative
acceptance of Consultant's Work as complete and Consultant's acceptance of the City's final
payment therefore, but not later than the Completion Date listed under the Contract
Summary in the table one page one of this agreement.
1.1. Time is of the essence. Time is of the essence for Consultant's performance of each
and every obligation and duty under this Agreement. City, by written notice to Consultant
of default or breach, may at any time terminate the whole or any part of this Agreement if
Consultant fails to provide the Work called for by this Agreement within the time specified
herein or within any extension thereof.
2. Compensation: City shall pay Consultant the sum listed as the"Contract Amount" under the
Contract Summary on page one of this document as full compensation for Consultant's
performance of all Work under this Agreement. In no event shall Consultant's total of all
compensation and reimbursement under this Agreement exceed the Contract Amount without
the express, written approval from the appropriate Department Head or City Manager.
Payments shall be made within thirty(30)days of the date of receipt by the City of Consultant's
invoice. Should this Agreement be terminated prior to completion of all Work, payments will
be made for any phase of the Work completed and accepted as of the date of termination.
3. Consultant Obligations:
3.1. Independent Contractor Status. Consultant is an independent contractor and not an
employee of the City for any purpose. Consultant shall have the complete responsibility
for the performance of this Agreement. Consultant shall provide workers' compensation
coverage as required in ORS Chapter 656 for all persons employed to perform Work
pursuant to this Agreement. Consultant is a subject employer that will comply with ORS
656.017.
3.2. Qualified Work. Consultant has represented, and by entering into this Agreement now
represents,that all personnel assigned to the Work to be performed under this Agreement
are fully qualified to perform the services to which they will be assigned in a skilled manner
and, if required to be registered, licensed, or bonded by the State of Oregon, are so
registered, licensed, or bonded.
3.3. Assignment. Consultant shall not assign this Agreement 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 of the Work shall not
create any contractual relation between the assignee or subcontractor and City.
Page 2 of 8 Personal Services Agreement Between the City of Ashland and Kleinberg Tech
3.4. Work Performance Obligation. Consultant shall, at its own risk, perform the Work
described in the Description of Services and in the Supporting Documents and, unless
otherwise specified in this Agreement, furnish all labor, equipment, and materials required
for the proper performance of such Work.
3.5. Certification. Consultant agrees to and shall sign the certification attached hereto as
"Exhibit C" and incorporated herein by this reference.
4. Insurance: Consultant shall, at its own expense, maintain the following insurance:
4.1. Worker's Compensation. 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.
4.2. Workers' Compensation Exemption. If applicable, Consultant affirms and certifies that
it is exempt from providing Workers' Compensation per ORS 656.027.
Exemption criteria: Enter criteria here or delete if not applicable
Consultant initials if exempt: Date:
4.3. Professional Liability insurance with a combined single limit, or the equivalent, of not
less than $1,000,000 (one million dollars) per occurrence. This is to cover any
damage caused by error, omission or negligent acts related to the Work to be provided
under this Agreement.
4.4. General Liability insurance with a combined single limit, or the equivalent, of not less
than$1,000,000(one million dollars)per occurrence for Bodily Injury, Death, and
Property Damage.
4.5. Automobile Liability insurance with a combined single limit, or the equivalent, of not
less than $500,000 (five hundred thousand dollars)for each accident for Bodily Injury
and Property Damage, including coverage for owned, hired or non-owned vehicles, as
applicable.
4.6. 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 thirty(30)days'
prior written notice from the Consultant or its insurer(s) to the City.
4.7. 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
Agreement. The consultant's insurance is primary and non-contributory. As evidence of
the insurance coverages required by this Agreement, the Consultant shall furnish
acceptable insurance certificates prior to commencing the Work under this Agreement.
The certificate will specify all of the parties who are Additional Insureds. Insuring
Page 3 of 8 Personal Services Agreement Between the City of Ashland and Kleinberg Tech
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.
5. Termination:
5.1. Mutual Consent. This Agreement may be terminated at any time by the mutual consent
of both parties.
5.2. City's Convenience. This Agreement may be terminated by City at any time upon not
less than thirty (30) days' prior written notice delivered by certified mail or in person.
5.3. For Cause. City may terminate or modify this Agreement, 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:
• 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; or
• 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 Agreement or are no longer eligible for the funding
proposed for payments authorized by this Agreement; or
• If any license or certificate required by law or regulation to be held by Consultant
to provide the services required by this Agreement is for any reason denied,
revoked, suspended, or not renewed.
5.4. For Default or Breach. Either City or Consultant may terminate this Agreement in the
event of a breach of the Agreement by the other. Prior to such termination the party
seeking termination shall give to the other party written notice of the breach and its intent
to terminate. If the party committing the breach has not entirely cured the breach within
fifteen (15) days of the date of the notice, or within such other period as the party giving
the notice may authorize in writing, then the Agreement may be terminated at any time
thereafter by a written notice of termination by the party giving notice.
5.4.1. 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 under the 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 Agreement; or attempts to assign rights in, or
delegate duties under, this Agreement.
Page 4 of 8 Personal Services Agreement Between the City of Ashland and Kleinberg Tech
5.5. Obligation/Liability of Parties. Termination or modification of this Agreement pursuant
to subsections 5.1, 5.2, or 5.3 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 of whether such notice
is given pursuant to subsection 5.1, 5.2, 5.3, or 5.4 of this section, Consultant
shall immediately cease all activities under this Agreement, unless expressly
directed otherwise by City in the notice of termination. Further, upon termination,
Consultant shall deliver to City all documents, information, works-in-progress and other
property that are or would be deliverables had the Agreement been completed. City
shall pay Consultant for Work performed prior to the termination date if such
Work was performed in accordance with this Agreement.
5.6. The rights and remedies of City provided in this subsection are not exclusive and are in
addition to any other rights and remedies provided by law or under this Agreement.
6. Indemnification: Consultant hereby agrees to defend, indemnify, save, and hold City, its
officers, employees, and agents harmless from any and all losses, claims, actions, costs,
expenses, judgments, 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 Agreement by Consultant
(including but not limited to, Consultant's employees, agents, and others designated by
Consultant to perform Work or services attendant to this Agreement). However, Consultant
shall not be held responsible for any losses, expenses, claims, costs, judgments, or other
damages, caused solely by the gross negligence of City.
7. Consultant's Compliance with Tax Laws: Consultant represents and warrants to the City
that: Consultant shall comply with all Oregon tax laws, including but not limited to ORS
305.620, ORS 305.380(4), and ORS Chapters 316, 317, 318, in addition to any rules,
regulations, charter provisions, or ordinances that implement or enforce any of the foregoing
tax laws or provisions and any tax provisions imposed by a political subdivisions of the State
of Oregon.
8. Living Wage Requirements: If the amount of this Agreement is $26,429.65 or more,
Consultant is required to comply with Chapter 3.12 of the Ashland Municipal Code by paying a
living wage, as defined in that chapter, to all employees performing Work under this
Agreement and to any Subcontractor who performs 50% or more of the Work under this
Agreement. 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. 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, by mailing using registered or certified United States
mail, return receipt requested, postage prepaid, or by electronically confirmed at the
addresses set forth on page one of this agreement with a copy to:
Page 5 of Personal Services Agreement Between the City of Ashland and Kleinberg Tech
City of Ashland — Legal Department
20 E. Main Street
Ashland, Oregon 97520
Phone: (541) 488-5350
10. General Provisions:
10.1. Ownership of Work/Documents: All Work, work product, or other documents
produced in furtherance of this Agreement belong to the City, and any copyright, patent,
trademark proprietary or any other protected intellectual property right shall vest in and is
hereby assigned to the City.
10.2. Non-appropriations Clause - Funds Available and Authorized: City has
sufficient funds currently available and authorized for expenditure to finance the costs of
this Agreement within the City's fiscal year budget. Consultant understands and agrees
that City's payment of amounts under this Agreement 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 Agreement. In the
event City has insufficient appropriations, limitations or other expenditure authority, City
may terminate this Agreement without penalty or liability to City, effective upon the
delivery of written notice to Consultant, with no further liability to Consultant.
10.3. Statutory Requirements: The following laws of the State of Oregon are hereby
incorporated by reference into this Agreement: ORS 27913.220, 27913.230 and
27913.235.
10.4. Nondiscrimination: Consultant 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 any Work under this
Agreement when employed by Consultant. Consultant agrees to comply with all
applicable requirements of federal and state civil rights and rehabilitation statutes, rules
and regulations. Further, Consultant 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.
10.5. Governing Law: 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
Page 6 of Personal Services Agreement Between the City of Ashland and Kleinberg Tech
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.
11. Merger: This agreement and the attached exhibits constitute the entire understanding and
agreement between the parties. No waiver, consent, modification or change of terms of this
agreement 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 agreement. Consultant, by signature of its
authorized representative, hereby acknowledges that he/she has read this agreement,
understands it, and agrees to be bound by its terms and conditions.
Page 7 of 8 Personal Services Agreement Between the City of Ashland and Kleinberg Tech
WITNESS WHEREOF, the parties have executed this Agreement in their respective names by
their duly authorized representatives as of the dates indicated below. This Agreement may be
executed in two counterparts, each of which shall be deemed an original, with equal force and
effect as if executed in a single document.
City of Ashland: Kleinberg Tech (Consultant)
By: CC,
Signature
Kelly C. Kleinberg
Date
Printed Name
Owner
Title
Purchase Order No.
08/18/2025
Date
(W-9 is to be submitted with this signed Agreement)
APPROVED AS TO FORM:
N/A
City Attorney
Date
Page 8 of 8 Personal Services Agreement Between the City of Ashland and Kleinberg Tech
CITY OF OREGON
City of Ashland
LIVING
WAGE
per hour, effective June 30, 2024.
��. The Living Wage is adjusted annually every
June 30 by the Consumer Price Index.
portion of the business of of health care, retirement,
their employer, if the 401 K, and IRS eligible
employer has ten or more cafeteria plans (including
employees, and has received childcare) benefits to the
➢ For all hours worked under a financial assistance for the employee's amount of wages.
service contract between their project or business from the
employer and the City of City of Ashland over ➢ Note: For temporary and
Ashland if the contract $26,429.65; part-time employees, the
exceeds$26,429.65 or more. Living Wage does not apply
➢ If their employer is the City of to the first 1040 hours worked
➢ For all hours worked in a Ashland, including the Parks in any calendar year. For
month, if the employee and Recreation Department. more details, please see
o Ashland Municipal Code
spends 50/o or more of the ➢employee's time in that month In calculating the living wage, Section 3.12.020.
working on a project or employers may add the value
For additional information:
Call the Ashland City Manager's office at 541-488-6002 or write to the City Manager,
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 in areas where it can be seen by all employees.
A IT OF
Exhibit C
Certifications/Representations: Consultant, by and through its authorized
representative, 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) Consultant 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. Consultant further represents and warrants to City that: (a)
it has the power and authority to enter into this Agreement and perform the Work, (b) the
Agreement, when executed and delivered, shall be a valid and binding obligation of Consultant
enforceable in accordance with its terms, (c) the work under the Agreement shall be performed in
accordance with the highest professional standards, and (d) Consultant is qualified, professionally
competent, and duly licensed (if applicable) to perform the Work. Consultant also certifies under
penalty of perjury that its business is not in violation of any Oregon tax laws, it is an independent
contractor as defined in the Agreement, it is authorized to do business in the State of Oregon,
and Consultant has checked four or more of the following criteria that apply to its business.
X (1) Consultant carries out the work or services at a location separate from a private
residence or is in a specific portion of a private residence, set aside as the location of
the business.
X (2) Commercial advertising or business cards or a trade association membership are
purchased for the business.
X (3) Telephone listing is used for the business separate from the personal residence
listing.
X (4) Labor or services are performed only pursuant to written contracts.
X (5) Labor or services are performed for two or more different persons within a period
of one year.
X (6) Consultant assumes financial responsibility for defective workmanship or for
service not provided as evidenced by the ownership of performance bonds,
warranties, errors and omission (professional liability) insurance or liability insurance
relating to the Work or services to be provided.
Cons ant's signature
08/18/2025
Date
Page 1 of 1: Exhibit C
DATE(MM/DD/YYYY)
ACCORD® CERTIFICATE OF LIABILITY INSURANCE
10/17/2024
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
NAME:
HISCOXInc. PHONE $$$ 202-3007 FAX
5 Concourse Parkway -MA Lo Ext: ( ) vc No
Suite 2150 ADDRESS: contact@hiscox.com
Atlanta GA, 30328 INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: Hiscox Insurance Company Inc 10200
INSURED
INSURER B
Kleinberg Tech Development&Technical Solutions,LLC INSURERC:
4667 Torrey Pines Dr.
Medford, OR 97504 INSURER D
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUBR POLICPOLICY NUMBER MM/DDY EFF MM/POLICY EXP DLIMITS
LTR
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE DAMAGE TO RETED
� OCCUR PREMISES(Ea occurrrence) $ 1������
MED EXP(Any one person) $ 5,000
A Y P102.683.257.2 12/01/2024 12/01/2025 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000
PRO-
X POLICY ECT LOC PRODUCTS-COMP/OP AGG $ S/T Gen.Agg.
OTHER: $
AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS APer accident
UMBRELLALIAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? ❑ N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE f
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
AM HISCOX INSURANCE COMPANY INC. (A Stock Company)
H I SCOX PROm
30 North LaSalle Street,Suite 1760, Chicago, IL 60602
(646)452-2353
Insurance for Professionals
DECLARATIONS
NOTICE: YOUR POLICY CONTAINS CLAIMS-MADE LIABILITY COVERAGE. CLAIMS-MADE COVERAGE APPLIES ONLY TO
CLAIMS THAT ARE FIRST MADE DURING THE POLICY PERIOD OR DISCOVERY PERIOD, IF PURCHASED, AND REPORTED
IN ACCORDANCE WITH THE TERMS OF THE POLICY.
THE LIMIT OF LIABILITY AVAILABLE TO PAY DAMAGES WILL BE REDUCED AND MAY BE EXHAUSTED BY CLAIMS
EXPENSES. FURTHERMORE, CLAIMS EXPENSES WILL BE APPLIED AGAINST THE RETENTION.
PLEASE READ YOUR POLICY CAREFULLY AND CONSULT YOUR INSURANCE ADVISOR ABOUT ANY QUESTIONS YOU
MIGHT HAVE.
Broker No.: US 0002312 Indemnity Excess&Surplus Agency Inc.
Policy No.: MPL4644014.24 1915 NE Stucki Ave Ste 450
Renewal of: MPL4644014.23 Hillsboro, OR 97006
1. Named Insured: Kleinberg Tech Development&Technical Solutions LLC
Address: 4667 Torrey Pines Dr
Medford, OR 97504-9295
2. Policy Period: Inception Date: 11/03/2024 Expiration Date: 11/03/2025
Inception date shown shall be at 12:01 A.M. (Standard Time)to Expiration date shown above at
12:01 A.M. (Standard Time)at the address of the Named Insured.
3. General terms and PLP P0001 CW(07-19)
conditions wording: The General terms and conditions apply to this policy in conjunction with the specific wording
detailed in each section below.
4. Endorsements: E6020.4-War, Civil War, Cyberwarfare, and NCBR Exclusion Endorsement, E6017.3-Nuclear
Incident Exclusion Clause-Liability-Direct(Broad) Endorsement, E9035.3-Oregon Amendatory
Endorsement, and E6366.2-Privacy, Biometrics, and Cyber Incidents Clarification Endorsement
(PL)
5. Optional Extension Extended Reporting Period of 12/24/36 months at 75/150/225 percent of the annual premium.
Period:
6. Notification of Hiscox Claims
claims to: 5 Concourse Parkway, Suite 2150
Atlanta GA, 30328
Fax: 678-731-9501
Email: HiscoxClaims aD..Hiscox.com
Additional Notification NONE
requirements:
PLP D0001 CW(04/14) Page 1 of 3
RAC"'C hLe': �C hLhR';;t
HISCOX INSURANCE COMPANY INC. (A Stock Company)
AM 30 North LaSalle Street,Suite 1760, Chicago, IL 60602
(646)452-2353
H I SCOX PROm
Premium: $1890.00
Broker Fee: $175.00
Total: $2065.00
Insurance for Professionals
DECLARATIONS
7. Policy Premium: $ 1,890 Premium Allocated to TRIA: $0 State Surcharge: N/A
Miscellaneous Professional Liability Claims-made and Reported Coverage Part: PLPMPL P0001 CW
(06-14)
Covered Professional Services: Building Code Compliance Consulting services, for others for a fee
Professional Liability(PL): $ 1,000,000 Each Claim/$ 1,000,000 Aggregate
Defense of Licensing Proceedings: $25,000 Aggregate (Separate Limit)
Subpoena Assistance: $ 10,000 Aggregate (Separate Limit)
Retroactive Date: 11/03/2020
Retention: $7,500
PL Premium: $ 1,890
Endorsements: E6115.2-Financial Services Exclusions Endorsement
IN WITNESS WHEREOF,the Insurer indicated above has caused this Policy to be signed by its President and Secretary, but this
Policy shall not be effective unless also signed by the Insurer's duly authorized representative.
PLP D0001 CW(04/14) Page 2 of 3
RAC"'C hLe': �C hLhR';;t
HISCOX INSURANCE COMPANY INC. (A Stock Company)
Am 30 North LaSalle Street,Suite 1760, Chicago, IL 60602
TM (646)452-2353
H ISCOX
Insurance for Professionals
DECLARATIONS
0
President
�µ
Secretary
�6
Authorized Representative
Kevin Kerridge
October 7, 2024
Hiscox Inc.
PLP D0001 CW(04/14) Page 3 of 3
RAC"'C hLe': �C hLhR';;t
State Farm Mutual Automobile Insurance Company
PO Box 2358
Bloomington IL 61702-2358 A. State Farm
AT2 A-2310 A
KLEINBERG, JOHN & KELLY C p p p�pl p
4667 TORREY PINES DR AU'roIII°' III° II II ��
MEDFORD OR 97504-9295
PREMIUM PAID: $297.64
DO NOT IPAY.
Your premium is billed through the State Farm Payment Plan
State Farm Payment Plan Number: 1170330915
Your State Farm Agent
SHANE CUNNINGHAM INS AGCY INC
Policy Number: 172 7423-B01-37C Office: 541-772-3040
Policy Period: February 1, 2025 to August 1, 2025 Address: 820 S RIVERSIDE AVE
Vehicle: MEDFORD, OR 97501-7840
1999 FORD F350 SD If}ou have anew ordifferent car,have added any ddver,�orhavemoved,
Principal Driver: #ease contact your agent.
JOHN KLEINBERG Thank you for choosing State Farm.
Based on your driving record, you have our Accident-Free information from your check to make an electronic fund
Discount for preferred customers. transfer,funds may be withdrawn from your account as soon
When you provide a check as payment, you authorize us as the same day we receive your payment, and you will not
either to use information from your check to make a receive your check back from your financial institution.
one-time electronic fund transfer from your account or to
process the payment as a check transaction. When we use
Policy Number:172 7423-B01-37C Page number 1 of 5
Prepared December 10,2024
1004583 143562 202 01-15-2018
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Review your policy information carefully. If anything is incorrect,or if there are any changes to your vehicle information, please
let us know right away.
Vehicle Identification
Vehicle Description Number(VIN) Who principally drives this vehicle? How is this vehicle normally used?
1999 FORD F350 SD 1 FTSW31 F7XEC64812 JOHN KLEINBERG,a married male,who To Work,School or Pleasure.
will be age 61 as of February 01,2025.
Other Household Vehicle(s)
Your premium may be influenced by other State Farm
policies that currently insure the following vehicle(s)
in your household:
2008 TOYOTA HIGHLANDER
The premium for this renewal was determined using an Premium Adjustment
annual mileage this vehicle is expected to be driven that Each year,we review our medical payments and personal
was developed from information we obtained or was injury protection coverages claim experience to determine
provided by you. The national average is more than 12,000 the vehicle safety discount that is applied to each make and
miles driven annually according to the U.S. Department of model. In addition,we review the comprehensive, collision,
Transportation. Please contact us if you expect your annual bodily injury and property damage claim experience
mileage to change over the next year. annually to determine which makes and models have
earned decreases or increases from State Farm's standard
rates. If any changes result from our reviews, adjustments
are reflected in the rates shown on this renewal notice.
I II II II",;°III 1I1Wl"ORNIATQN
Assigned Driver(s)
The following driver(s)are assigned to the vehicle(s)on this policy.
Age as of Marital
Name February 1,2025 Gender Status
JOHN KLEINBERG 61 Male Married
Other Household Driver(s)
In addition to the Principal Driver(s)and Assigned
Driver(s),your premium may be influenced by the
drivers shown below and other individuals permitted to
drive your vehicle. This list does not extend or expand
coverage beyond that contained in this automobile
policy. The drivers listed below are the drivers reported
to us that most frequently drive other vehicles in your
household.
KELLY C KLEINBERG
Policy Number:172 7423-B01-37C Page number 2 of 5
Prepared December 10,2024
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Principal Driver&Assigned Drivers premium may be influenced by the information shown for
For each automobile, the Principal Driver is the individual these drivers.
who most frequently drives it.
Each driver is designated as an Assigned Driver on the
household automobile that they most frequently drive.Your
f, II',;1II A �1'-.,;1' AND t,,,II IM IITS See your policy for an explanation of these coverages.
A Liability
Bodily Injury 250,000/500,000
Property Damage 100,000 $94.80
P2 Personal Injury Protection
Includes Medical 25,000
Income Loss 3000/mo/yr $26.73
D 100 Deductible Comprehensive $52.31
G 250 Deductible Collision $81.48
H Emergency Road Service $6.43
R1 Car Rental&Travel Expense
$50 Per Day,$1,500 Max $8.61
U1 Uninsured Motor Vehicle
Bodily Injury 25,000/50,000
Property Damage 20,000 $27.28
'fatal Premium 297.64
If any coverage you carry is changed to give broader you the broader protection without issuing a new policy,
protection with no additional premium charge,we will give starting on the date we adopt the broader protection.
1Y1SCOtJNTS These adjustments have already been applied to your premium.
Multiple Line ✓
Multicar ✓
Vehicle Safety ✓
Accident-Free ✓
Annual Mileage ✓
Total Mlscdunts $361.9
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AUTOMOBILE RATING PLAN -Applies to private you may qualify for our Accident-Free Discount. Once you
passenger cars only. qualify, this discount applies as long as there are no
Accident-Free Discount —Once your policy has been in chargeable accidents, and may even increase over time.
force for at least three years with no chargeable accidents,
(continued on next page)
Policy Number:172 7423-BOl-37C Page number 3 of 5
Prepared December 10,2024
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Good Driving Discount - Newer policyholders who do not and receive accident surcharges. But if the accident is the
yet qualify for our Accident-Free Discount (available after first to become chargeable in nine years and this policy has
three years with no chargeable accidents) may already be been in force for at least that long, the Accident-Free
receiving a Good Driving Discount. This discount continues Discount will continue and no surcharge will apply. The
to apply until your policy qualifies for the Accident-Free surcharge for each accident depends upon the number and
Discount as long as there are no chargeable accidents and timing of the accidents, and each accident surcharge will
no new drivers. If you add new drivers, they must also remain in effect up to three years.
qualify in order for your Good Driving Discount to continue. Surcharges will be removed if the company is given
Chargeable Accidents - For new business rating, an satisfactory evidence that the driver involved is no longer a
accident is chargeable if it results in $750 or more of member of the household or will not be driving the car in the
damage to any property. For renewal business, an accident future. If that driver is insured on another State Farm policy,
is chargeable as of the date State Farm pays at least$750 his or her driving record will be considered in the rating of
(for accidents occurring on or after April 1, 1999) under the other policy.
property damage liability and collision coverages for an These discounts and surcharges do not apply to all
at-fault accident. coverages. For complete details, see your State Farm agent.
Surcharges — If there are chargeable accidents, you may
lose your Good Driving Discount or Accident-Free Discount
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If any information on this renewal notice is incomplete or information regarding discounts or coverages, see your
inaccurate, or if you want to confirm the information we have State Farm agent or visit statefarm.com®.
in our records, please contact your agent. For additional
Nof6ice of Ihi uuraunce Ihifoirmaf6ion I1"racrf6ice
We may collect personal information from persons other than the individual or individuals applying for coverage. Such personal
information as well as other personal or privileged information subsequently collected may, in certain circumstances, be disclosed
to third parties without your authorization as permitted by law. If you would like additional information about the collection and
disclosure of personal information, please contact your State Farm agent.You may also act upon your right to see and correct any
personal information in your State Farm files by writing your State Farm agent to request this access.
Eir l�ottarnf Nof6ice IRea am°din Your IFlm° i uiu,Amr
State Farm works hard to offer you the best combination of price, service,and protection. The amount you pay for automobile
insurance is determined by many factors including:
• The coverage you have
• Where you live
• The kind of car you drive
• How the car is used
• Who drives the car
Any premium adjustment is reflected on this Auto Renewal. If you have any questions, please contact your agent.
Buyhng a new car? R irnem lber fay contact your age nd
When you buy an additional car or one that replaces a car already on your policy, you need to report the change to your agent
Promptly. Even though the dealership you purchased the car from may offer to notify your agent or insurance company, you, as
the named insured, are responsible for reporting all changes to your auto policy. By contacting your agent, you can help:
• avoid any complications or lack of coverage in the event of an accident or loss,
• avoid insurance verification problems with a lienholder, the police, or the department of motor vehicles, and
• ensure that you receive any new discounts you may be entitled to.
(continued on next page)
Policy Number:172 7423-B01-37C Page number 4 of 5
Prepared December 10,2024
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Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited
number of days after you take possession of the car. Please refer to your policy for the number of days that applies in your state.
If you have any questions about coverage for a newly acquired car, please contact your State Farm agent.
Disclaimer- This message is provided for informational purposes only and does not grant any insurance coverage. The terms and
conditions of coverage are set forth in your State Farm Car Policy booklet, the most recently issued Declarations Page, and any
applicable endorsements.
Policy Number:172 7423-B01-37C Page number 5 of 5
Prepared December 10,2024