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HomeMy WebLinkAbout1996-072 License - Ambulance Operators CITY Of ASHLAND APPLICATION FOR AMBULANCE OPERATOR LICENSE AMC Ch. 6.40 Applicant's Name~: ASHLAND FIRE & RESCUE Trade Name, if any: Address: 455 SlSKIYOU BLVD. ASHLAND, OREGON 97520 Telephone number: (541) 482-2770 Ambulance descriptions: 1. 1992 FORD LIFELINE Manufacturer LIFELINE 2. 1992 WHEELED COACH 3. 1985 BRAUN WHEELED COACH BRAUN Addresses and descriptions of the premises at and from to maintain and operate such ambulances: 1. 455 SlSKIYOU BLVD., ASHLAND, OR 97520 2. 1860 HIGHWAY 66, ASHLAND, OR 97520 VIN # License # 1FDKE3 0M7PH A05945 Exempt 1FDJS3 4M4NH A34394 Exempt 1 FDJE3 0L8FHA 49888 Exempt which it is proposed [] Attach information showing that every proposed driver, attendant, and driver- attendant is qualified as required in Ashland Municipal Code Chapter 6.40 and as required by the laws of the state of Oregon. [] Enclose with the application, the initial license fee of $300 plus $100 per ambulance. [] Enclose a performance bond in the amount of $500,000. ~ If corporation also give date and place of incorporation, address of its principal place of business and the names of its principal officers, together with their respective residence addresses; or if a partnership, association or unincorporated company, the names of the partners, or of the persons comprising such association or company, and the business and residence address of each partner or person. Attach additional pages as necessary. PAGE 1-APPLICATION (p:fire\ambulan.app) [] Enclose an insurance policy meeting the requirements of AMC §6.40.110.7. Attach additional pages as necessary. Explain any box not checked. Submit your application and required enclosures to Barbara Christensen, City Recorder, City Hall, 20 East Main Street, Ashland, Oregon 97520. I certify that each ambulance listed above is adequate and safe for the purposes for which it is to be used and that it is equipped as required by Ashland Municipal Code Chapter 6.40 and the laws of the state of Oregon. Print name: Keith E. Woodley Title: Fire Chief PAGE 2-APPLICATION (p:fire\ambulan.app) Last Name Anders Burns Burns Case Caswell Cockell II Curtis Eaton Formolo Freiheit Frentress Hahstein Hollingsworth Jones Paul Robbins Robinson Rosenlund Sallee Saurman Stoy White First Name Walt Kelly Martin Greg Timothy Robert Danny Wesley Curt Matthew Kenny David Scott Gregory Don Robb William Derek Dana Daniel John Danial LIST ASHLAND FIRE DEPARTMENT OF CURRENT PERSONNEL AS OF 12/31/95 Date of Birth 10/30/56 11/25/69 04/28/45 06/15/58 05/03/43 12/25/61 08/25/36 08/26/40 09/20/61 03/16/68 02/21/73 09/23/60 10/23/61 12/06/50 04/18/45 11/06/42 03/27/43 01/16/59 06/29/65 ,09/02/49 08/18/65 10/26/44 Driver License # 1955034 5207865 1033841 3254941 2056576 6109120 2042833 1533069 3738940 4927105 4805199 2524064 2830146 1423603 3873194 663615 839679 5541498 3654752 2518612 4856227 3697732 Employment Status Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Full Time Position EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT EMT Cert Level B P B P B P B B P P P P P B B B B P P B P B City, Services Salem, OR 97301 (503) 585-1121 CERTIFICATE OF COVERAGE Covered Entity: City of Ashland Agent: Direct This is to certify that coverage is provided to the designated entity as noted below. 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 terms, exclusions and conditions of such coverage are not amended by this certificate. TYPE OF COVERAGE X~ Comprehensive Liability (Including Owned and Non-owned Auto) X~Auto Physical Damage (If Specified Vehicles Only, See Notes Below) Deductible: Collision $ 500 O0 Comprehensive $ 5,000 X~ Property (Replacement Cost Unless Specified Otherwise) Deductible: Property $ 10.000 Inland Marine $ 10,000 [] Workers' Compensation [] Employer's Liability Certificate Holder Effective Expiration Date Date 07/01/95 06/30/96 07/01/95 06/30/96 Limit of Liability Single Limit ACV 07/01/95 06/30/96 $ Per Filed Values Statutory $2,000,000 Should any of the above described coverage be canceled before the expiration date thereof, City/County Insurance Services will endeavor to provide 30 days ~'fitten notice Io the certificate holder named herein, but failure to provide such notice shall impose no obligation or liability of any kind upon CIS. ils agents. or representatives. Signa re~~sue Date SUBJECT: NOTE: The following vehicles are covered for Auto Physical Damage:_ PRODUCER Security Insurance Medford 1175 East Main Street "4ford OR 97504 ~n N. King 503 -772 -1111 ZNSURED CERTIFICATE OF INSURANCE CSR FBDA",MM O y, ASHLA11 12/21/95 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE COMPANY A COMPANY COMPAI~' C Safety National Casualty Co. City of Ashland Ashland City Hall COMPANY Ashland OR 97530 D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSUF-~NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREM_qNT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO ~.VHICH 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 POLI~£S. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. COI ~'PE OF INSURANCE POUCY NUMBER IPOUCY EFFECTivE POUCYEXPIRATIONI LTR DATE {MM/DDfY¥! DATE (MM;DD/YY} *See I G EN EP~.L L!;- ~ILIT¥ ----] COMMERCIAL GENERAL LIABIL/TY t ] CLAIMS MADE ~-] OCCUR ! OWNER'S & CONTRACTOR'S PROT J _AU.TOMOBILE LIA~ILFTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED ALFTOS GARAGE LIABILITY I ANY ALFT0 EXCESS UABILITY IUMBRELLA FORM OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOPJ ~ INCL PARTNERSEXECUTIVE OTHER A Excess Workers SP 3715 OR 07/01/95 07/01/96 LIMITS GENERAL AGGREGATE PRODUCTS - COMP/OP AGO PERSONAL & ADV INJURY EACH OCCURRENCE FIRE DAMAGE (Any one fire] MED EXP IAny one person) COMBINED SINGLELIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE AUTO ONLY - EA ACCIDENT OTHER THAN AUTO ONLY: EACH ACCIDENT AGGREGATE EACH OCCURRENCE AGGREGATE j STATUTORY LIMITS EACH ACCIDENT DISEASE * POLICY LIMIT DISEASE - EACH EMPLOYEE Below D~CRI~IONOFOPERATIONS&OCATIONSNEHIC~S~P~ITEMS Excess Workers Compensation Self-Insured Retention: $300,000 Employees Classified Code 7539 $250,000 All O~her Classifications Limit of Indemnity - Statutory Maximu~ Limit Employers Liability - $1,000,000 CERTIFICATEHOLDER CANCELLATION ' ACORD 25-S (3/93) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXP,RATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL XX~ DAYS WRC~I'EN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Bert FAJLURE TO MA SfL---~NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIN~N THE COM/)ANY. IT($ AGENTS.OR R~I~f~ENT~TIjVES. AUTHOR E R ESE AT, // ©'~ORPORATION CERTIFICATE OF MEMBERSHIP No. 95LASH CITY/COUNTY INSURANCE SERVICES TRUST LIABILITY RISK SHARING POOL This certifies that Ashland is a Member of the City/County Insurance Services Trust for liability coverage during the period set forth below. Period: July 1, 1995 to June 30, 1996 Limit of Liability: $1,000,000 In accordance with and subject to the Trust Agreement, Bylaws and Rules of the Trust. and in consideration of the contribution for which this coverage agreement is written, except where specifically provided otherwise within this agreement, the Trust will pay on behalf of the Member all sums which the Member shall be legally obligated to pay as damages because of: Coverage A: Coverage B: Coverage C: Coverage D: Coverage E: Liability arising under Oregon Revised Statutes 30.260 to 30.300 and caused by an occurrence; Liability arising under 42 U.S. Code, § 1983, 42 U.S. Code § 2000e et seq. (Title VII of the Civil Rights Act of 1964), 29 U.S. Code § 621 et seq. (Age Discrimination Employment Act of 1967); The Americans With Disabilities Act; The Civil Rights Act of 1991; 42 U.S. Code § 1981; or any law amendatory thereof, provided such liability is caused by an occurrence; Bodily Injury, Personal Injury and Property Damage for which the Member is legally liable under the laws of any jurisdiction other than the State of Oregon to which this coverage agreement applies caused by an occurrence; Uninsured Motorists Coverage as defined by ORS 742.504, pursuant to ORS 278.215. The Limits of Liability of such coverage shall be those set forth as minimums under ORS 806.070 ($10,000 property damage/S25,000 per person bodily injury or death/S50,000 aguegate bodily injury or death). The property damage coverage under Coverage D is subject to the conditions and limitation of ORS 742.510; Liability of others assumed by the Named Member under contract, except as hereinafter limited in the definition of the term "Member." In accordance with and subject to the Trust Agreement, Bylaws and Rules of the Trust, and in consideration of the contribution for which this coverage agreement is written, and independent of Coverages A - E above, the Trust will pay: Coverage F: Legal expenses reasonably incurred by a public official of the Named Member arising out of defense of a complaint alleging violation of ORS 244.040 or 244.120-.135, subject to the terms and conditions set forth on page 7 below. l of 7 7/01/95 No. SP -3137-OR SPECIFIC EXCESS WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE AGREEMENT SAFETY NATIONAL CASUALTY CORPORATION ST. LOUIS, MISSOURI (Hereinafter called ~he CORPORATION), In consideration of the payment of premium and subject to all the terms of this Agreement, hereby agrees with the EMPLOYER named in the Declarations (hereinafter called the EMPLOYER), as follows: A. Coverage of Agreement - This Agreement applies only to koss sustained by the EMPLOYER because of liability imposed upon the EMPLOYER (2) by the Workers' Compensation or Employers' Liability Laws of: (1) the State(s) designated in the Declarations, or (2) other State(s), provided that the "Loss" shall not be greater than it would have been had liability been imposed by the State(s) specified in the Declarations, on account of bodily injury by accident or bodily injury by occupational disease due to Occurrences raking place within the Liability Period to Employees of the EMPLOYER engaged in the business operations specified in the Declarations and all other operations necessary, incidental, or appurtenant thereto. Bodily injury includes resulting death. The inclusion of more than one EMPLOYER in Ihe Declara- tions shall not increase the EMPkOYER's Self-Insured Retention nor the CORPORATION's Maximum Limit of Indemnity. The insurance afforded by this Agreement applies Io operations in the State(s) specified in the Declarations, including, however, incidental operations conducted by Employees who are regularly (3) engaged in operations in the specified State(s), but who may be temporarily outside the specified State(s). In no event shall the CORPORATION be liable for any Loss voluntarily assumed by the EMPLOYER under any contract or agreement, expressed or implied. In no event shall this Agreement apply to Loss for which the EMPLOYER carries a full coverage \Vorkers' Compensation and Employers' Liability policy, nor shall this Agreement apply to provisions of any law that provides non-occupational disability benefits. B. Specific Excess Insurance With respect to each Occurrence taking place within a Liability Period, the EMPLOYER shall retain as its own Loss, as defined below, the amount specified in hem 7 of the Declarations, and the CORPORATION agrees to reimburse the EMPLOYER only for such Loss in excess of such Self-Insured Retention, subject to the Maximum Limit of Indemnity Per Occurrence, or the Employers' Liability Maximum Limit of Indemnity Per Occurrence, which- ever is applicable, as specified in Item 8 of the Declarations. The separate Employers' Liability Maximum Limit of Indemnity Per Occurrence shall not operate, in any case, to increase the total amount the CORPORATION agrees to reimburse the EMPLOYER for Loss per any one Occurrence as per Item 8 (a) of the Declarations. For Agreements having multi-year Liability Periods, the Self-Insured Retention established for the EMPLOYER is subject to annual review and possible revision. Co (1) Definitions "Loss" - shall mean actual payments legally made by the EMPLOYER to Employees and their dependents in satisfac- tion of: (a) statutory benefits, (b) settlements of suits and claims, (c) awards and judgments, and (d) Claim Expenses. The term "Loss" shall not include the items specifically excluded by Paragraph 3 of this Section. "Claim Expenses" - shall mean interest upon awards and judgments and the reasonable costs of investigation, adjust- ment, defense. and appeal (provided that the prosecution of such appeal is approved by CORPORATION} of claims, suits or other proceedings brought against the EMPLOYER under the Workers' Compensation or Employers' Liability Laws of the State(s) designated in the Declarations, or other State(s), as provided in Section A, for bodily injury or occupational disease sustained during the respective Liabil- ity Period by the Employees engaged in the business opera- tions to which this Agreement applies, even though such claims, suits, proceedings or demands are wholly ground- less, false, or fraudulent, provided the CORPORATION is promptly notified of every claim, suit, or proceeding and is given the opportunity to participate in the defense. Claim Expenses shall not include fees to the EMPLOYER's Ser- vice Company. "Exclusions from Loss" - shall refer to the following amounts paid by the EMPI:OYER, and specifically excluded from the term "Loss": (a) Salaries, wages, and remuneration provided to Em- ployees; (b) Fees to the EMPLOYER's Service Company and/or costs of self-administration of claims; (c) Punitive or exemplary damages; (d) Fines or penalties assessed against the EMPLOYER for any violation by the EMPLOYER, or its representa- tive(s), of any statute or regulation, or as a result of any proceedings brought by or against an)' Employee of the EMPLOYER; (e) Assessments and taxes made upon the EMPLOYER as self-insurer whether imposed by statute, regulation, or otherwise; (f) Any amounts required to be paid by the EMPLOYER because of: 1) Serious and willful misconduct of the EMPLOYER, including intentional acts or omis- sions resulting in injury, 2) Coercion, criticism, demotion, evaluation, re- assignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any Employee and/or related personnel prac- tices, policies, acts, or omissions by the EMPLOYER, 3) Knowingly employing an Employee in violation of law, 4) Rejection by the EMPLOYER of any Workers' Compensation law, 5) Failure to comply with any health, safety, or noti- fication law or regulation, and (g) Injury sustained by any Employee in, upon, cnlering, or aligning from any EMPLOYER owned, leased, or City of Ashland Ambulance Operator's License License issued to: City of Ashland Fire and Rescue Department Licensee has met all requirements of AMC Ch. License expires December 31, 1996. 6.40. Date Signed