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HomeMy WebLinkAbout2021-083 PO 20220063- Design Source CITY RECORDER Purchase Order • Fiscal:Year 2022 Page: 1 of: 1 izT-371.1xafo_j_:TV -- EI B City of Ashland a"- lYY�, ATTN:Accounts Payable Purchase L Ashland, OR 97520 Order# 20220063 T Phone: 541/552-2010 0 Email: payable@ashland.or.us V H C/O Facilities Maintenance Div E DESIGN SOURCE I 90 North Mountain Ave N 1319 HARRISBURG DR p Ashland, OR 97520 O MEDFORD, OR 97501 Phone: 541/488-5358 R O Fax: 541/552-2304 illWrjiMWRIMEIM_I=1 = VZ If.. ---- (541) 821-6823 David Arnold EF_I--YL= 'I=1�h= :I-= [_I° — 07/27/2021 1886 FOB ASHLAND OR/NET30 Cit Accounts Pa able :r- •=-:z --= f=il i =`=f`==a H= DT== Office Furniture Sales 1 Interior design and office furniture sales and installation 1.0 $4,995.00 $4,995.00 Goods and Services Agreement(Less than $25,000) Completion date: 06/30/2022 Project Account: ***************GL SUMMARY*************** 088400-602400 $4,995.00 • BDate: =- y 07/29/2021 Authorized Signature y_,,�:,_� $4,995.00 • l FORM #3 CITY OF 1 A Nip loot i't))' .1 pLIi'c;i) 1t1.: `'y , /f�i/ /i .(12---e (';EGUIS04H®N / Date of request: 4/30/2021 1 Required date for delivery: Vendor Name Design Source Address,City,State,Zip 1319 Harrisburg Drive.Medford,OR 97501 — Contact Name&Telephone Number Molly Williams 541-821-8823 Email address . SOURCING METHOD ❑ Exempt from Competitive Bidding ❑ Emergency ❑ Reason for exemption: 0 Invitation to Bid ❑ Form 1113,Written findings and Authorization ❑ AMC 2,50 Dale approved by Council: ❑ Written quote or proposal attached ❑ Written quote or proposal attached (Attach copy of council communication) . (If council approval required,attach copy of CC) ® Small Procurement ❑•Request for Proposal Cooperative Procurement Not exceeding$5,000 Dale approved by Council: ❑ Slate of Oregon ❑ Direct Award _(Attach copy of council communication) Contract!! ❑ Verbal/Written quote(s)or proposal(s) ❑ Request for Qualifications(Public Works) ❑ State of Washington Dale approved by Council: Contract!! (Attach copy of council communication) ❑ Other government agency contract Intermediate Procurement ❑ Sole Source Agency GOODS&SERVICES ❑ Applicable Form(#5,6,7 or 8) Contract!! Greater than$5,000 and less than$100,000 ❑ Written quote or proposal attached Intergovernmental Agreement ❑ (3)Written quotes and solicitation aliached 0 Form 114,Personal Services>$5l(&<$75K Agency PERSONAL SERVICES' 0 Special Procurement ❑ Annual cost to City does not exceed$25,000, Greater than$5,000 and less than$75.000 0 Form#9,Request for Approval Agreement approved by Legal and approvedlsigned by ❑ Direct appointment not to exceed$35,000quoteproposal City Administrator.AMC 2.50.070 4 pp 0Wrillen or ro osal attached ❑ t) ❑ (3)Written proposalslwritten sollcliatlon Date approved by Council: Annual cost to City exceeds$25,000,Council ❑ Farm 1f4,Personal Services>$5K&<$75C Valid until: (Date) approval required.(Attach copy of council communication) j Description of SERVICES Total Cost Interior design and office furniture sales and Installation for FY22 • $4,995.00 Item# Quantity Unit Description of MATERIALS Unit Price Total Cost f i 1 i ❑ Per attached quotelproposal TOTAL COST Project Number - Account Number'j 0-602400 'Expenditure must be charged to the appropriate account numbers for the financials to accurately relied the actual expenditures. IT Director in collaboration with department to approve all hardware and software purchases: IT Director Date Support-Yes/No By signing this requisition form,i certify that the Cily's p 9116 contracting requirements have been satisfied. Employee: .`- Department Head: '-'9t4l ( al to , urea or liiian$5,000) , Department Manager/Supervisor: City Administrator: • (Equal to orgre e�ilt a7$/ J9/2O2 1 Funds appropriated for current fiscal year: YES/NO l.J`I 'L Deputy Finance Director-(Equaito or greater than$5,000) Date Comments: . I Form 113-Requisition GOODS AND SERVICES AGENT(LESS THAN$25,000) i PROVIDER: Design Source CITY OF PROVIDER'S -ASHLAND CONTACT: Molly Williams 20 East Main Street97520 Ashland,Oregon 975ADDRESS: 1319 Harrisburg Drive d Telephone: 541/488-5587 Medford,OR 97501 Fax 541/488-6006 PHONE: 541-821-6823 This Goods and Services Agreement(hereinafter"Agreement')is entered into by and between the City of - Ashland,an Oregon municipal corporation(hereinafter"City")and Design Source("hereinafter`Provider"),for interior design services. 1. PROVIDER'S OBLIGATIONS 1.1 Provide interior design services for FY22 as set forth in the"SUPPORTING DOCUMENTS"attached • hereto and,by this referent,incorporated herein. Provider expressly acknowledges that time is of the • essence of any completion date set forth in the SUPPORTING DOCUMENTS,and that no waiver or extension of such deadline may be authorized except in the same manner as herein provided for authority to exceed the maximum compensation. The services defined and described in the "SUPPORTING DOCUMENTS"shall hereinafter be collectively referred to as"Work" 1.2 Provider shall obtain and maintain during the term of Ibis Agreement and until City's final acceptance of all Work received hereunder,a policy or policies of liability insurance including commercial general liability insurance with a combined single limit,or the equivalent of not less than$2,000,000,;(twe— million dollars)per occurrence for Bodily Injury and Property Damage. (( LQ �j,,��` 1.2.1 The insurance required in this Article shall include the following coverages: • Comprehensive General or Commercial General Liability, including personal injury, contractual liability,and products/completed operations coverage; and • Automobile Liability. • Workers'Compensation 1.2.2 Each policy of such insurance shall be on an"occurrence"and not a"claims made"form,and shall: • Name as additional insured "the City of Ashland, Oregon, its officers, agents and employees" with respect to claims arising out of the provision of Work under this Agreement; • Apply to each named and additional named insured as though a separate policy had been issued to each,provided that the policy limits shall not be increased thereby; • Apply as primary coverage for each additional named insured except to the extent that two or more such policies are intended to "layer" coverage and, taken together, they provide total coverage from the first dollar of liability; • Provider shall immediately notify the City of any change in insurance coverage • • Provider shall supply an endorsement naming the City,its officers,employees and agents as additional insureds by tine Effective Date of this Agreement; and Page 1 of(); Goode and Services Agreement between the City of Ashland end Design Sours • • Be evidenced by a certificate or certificates of such insurance approved by the City. 1.3 Provider shall, at its own expense, maintain Worker's Compensation insurance in compliance with ORS 656.017,which requires subject employers to provide workers'compensation coverage for all of its subject workers, 1.4 Provider agrees that no person shall,on the grounds of race,color,religion,creed,sex,marital status, familial status or domestic partnership, national origin, age, mental or physical disability, sexual orientation, gender identity or source of income, suffer discrimination in the performance of this Agreement when employed by Provider. Provider agrees to comply with all applicable requirements of federal and state civil rights and rehabilitation statutes,rules and regulations. Further,Provider agrees • not to discriminate against a disadvantaged business enterprise, minority-owned business, woman- owned business, a business that a service-disabled veteran owns or an emerging small business enterprise certified under ORS 200.055,in awarding subcontracts as required by ORS 279A.110. 1.5 In all solicitations either by competitive bidding or negotiation made by Provider for work to be performed under a subcontract, including procurements of materials or leases of equipment, each potential subcontractor or supplier shall be notified by the Providers of the Provider's obligations under this Agreement and Title VI of the Civil Rights Act of 1964 and other federal nondiscrimination laws. 1.6 Living Wage Requirements: If the amount of this Agreement is$22,002.43 or more,Provider 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. Provider is also required to post the notice attached hereto as"Exhibit A"predominantly in areas where it will be seen by all employees. 1.7 Assignment: Provider shall not assign this Agreement or subcontract any portion of the Work to be provided hereunder without the prior written consent of the City. Any attempted assignment or • subcontract without written consent of the City shall be void. Provider 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 the City of any assignment or subcontract shall not create any contractual relation between the assignee or subcontractor and the City. 2. CITY'S OBLIGATIONS una�aseefeEe, o 2.1 City shall pay Provider the sum�uldbe-hourly ratep� revide mta-es-fall�eempa ti the.x as specified in the SUPPORTING Ijs�� • DOCUMENTS. 2.2 In no event shall Provider's total of all compensation and reimbursement under this Agreement exceed the sum of$5,000.00,five thousand dollars without express,written approval from the City official whose signature appears below,or such offioial's successor in office. Provider expressly acknowledges that no other person has authority to order or authorize additional Work which would cause this maximum sum to be exceeded and that any authorization from the responsible official must be in writing. Provider further acknowledges that any Work delivered or expenses incurred without • authorization as provided herein is done at Provider's own risk and as a volunteer without expectation of compensation or reimbursement. Page 2 of 6: Goods and Services Agreement between the City of Ashland and Design Source 3. GENERAL PROVISIONS • fcure any specific amount of Work from '- 3.1 This is a non-exclusive Agreement. City is not obligated to pro Provider and is free to procure similar types of goods and services from other providers in its sole discretion. I 32 Provider is an independent contractor and not an employee or agent of the City for any purpose. - 3.3 Provider is not entitled to,and expressly waives all claims to City benefits such as health and disability 1 insurance,paid leave,and retirement. of the parties respecting the subject ' 3.4 This Agreement embodies the full and complete understanding between the parties, 1 matter hereo£It supersedes all prior agreements,negotiations,and representations whether written or oral. 3.5 This Agreement may be amended only by writteninstrument executed with the same formalities as this Agreement. 3.6 The following laws of the State of Oregon are hereby incorporated by reference into this Agreement ORS 279B.220,279B.230 and 279B,235. shall be governed by the laws of the State of Oregon withoutregardto conflict of laws 3.7 Thn Agreement action arising under this Agreement shall be in the P principles. Exclusive venue for litigation of any Circuit Court oldie 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. Bach party expressly waives any and all rights to maintain an action underr thisAe may ent indiany s d other oitsvenue, e,vand nd expressly consents that, upon motion of the other party, any transferred,as appropriate,so as to effectuate this choice of venue. I 3.8 Provider shall defend, save,hold harmless and indemnify the City and its officers, employees and I suits, actions,losses, damages, liabilities, costs, and 1 agents Ecom and against any and all claims, I • expenses of any nature resulting from, arising iunder this of, or relating to the activities of Provider or its ' officers,employees,contractors,or ager 3.9 Neither party to this Agreement shall hold the other responsible for damages or delay in performance caused by acts of God,strikes,lockouts,accidents,or other events beyond the control of the other or the other's officers,employees or agents. 3.10 if any provision of this Agreement is found by a court of competent jurisdiction to be unenforceable, such provision shall not affect the other provisions,but such unenforceable provision shall be deemed modified to the extent necessary to render it enforceable,preserving to the fullest extent permitted The intent of Provider and the City set forth in this Agreement. 3.11 Deliveries will be F.O.B destination.Provider shall pay all transportation and handling charges or the Goods.Provider is responsible and liable for loss or damage until final inspection and acceptance the Goods by the City. Provider remains liable for latent defects,fraud,and warranties. 3.12 The City may inspect and test the Goods.The City may reject non-conforming Goods and require Provider to correct them without charge or deliver them,at a reduced price,as negotiated.If Provider does not cure any defects within a reasonable time,the City may reject the Goods and cancel this Pogo 3 of 6; Goods and Services Agreement between the City of Ashland and Design Source Agreement in whole or in part.This paragraph does not affect or limit the City's rights,including its • rights under the Uniform Commercial Code,ORS Chapter 72(UCC). 3.13 Provider represents and warrants that the Goods are new, current, and fully warranted by the manufacturer:Delivered Goods will comply with SUPPORTING DOCUMENTS and be free from defects in labor,material and manufacture.Provider shall transfer all warranties to the City. 4. SUPPORTING DOCUMENTS . The following documents are, by this reference, expressly incorporated in this Agreement, and are collectively referred to in this Agreement as the"SUPPORTING DOCUMENTS:" • The Provider's hourly rate sheet. • The Provider's firm price bid(s)for each individual project. S. REMEDIES 5.1 In the event Provider is in default of this Agreement,City.may,at its option,pursue any or all of the remedies available to it under this Agreement and at law or in equity,including,but not limited to: • 5.1.1 Termination of this Agreement; 5.1.2 Withholding alimonies due for the Work that Provider has failed to deliver within any scheduled completion dates or any Work that have been delivered inadequately or defectively; 5.1.3 Initiation of.an action or proceeding for damages, specific perfomoance, or declaratory or injunativerelief 5.1.4 These remedies are cumulative to the extent the remedies are not inconsistent,and City may pursue any remedy or remedies singly,collectively,successively Orin any order whatsoever:` • 5.2 In no event shall City be liable to Provider for any expenses related.to termination of•this Agreement or for anticipated profits.If previous amounts paid to Provider exceed the amount due,Provider shall pay immediately any excess to City upon written demand provided.- 6. TERM AND TERMINATION ° 6.1 Term This Agreement shall be effective from the date of execution on behalf of the City as set forth below (the"Effeetive Dat• e")and shall continue in fall force and effect until June 30,2022,unless sooner terminated as provided in Subsection 6.2. 6.2 Termination 6.2.1 The City and Provider maytenninate this•Agreethent by mutuaal agreement at any time. 6.2.2 The City may,upon not less than thirty(30)days'prior written notice,terminate this Agreement • • - for any reason deemed appropriate in its sole discretion, 6.2.3 Either party may terminate this Agreement,with cause,by not less Oran fourteen(14)days'prior written notice if the cause is not cured within that'fourteen(14)day period after written notice. Such termination is in addition to and not hr lieu of any'Other remedy at law or equity. 7. NOTICE Whenever notice is required or permitted to be given under this Agreement,such notice shall be given in writing to the other party by personal delivery,by sending via a reputable commercial ov ' t courier,or by mailing using registered or certified United States mail,return receipt requested,postage prepaid,to the address set forth below: If to the City: Page 4 016: Goods and Services Agreement between the City of Ashland and Design Semen• City of Ashland Facilities Maintenance Department Attn: David Arnold 20 E.Main Street Ashland,Oregon 97520 Phone:(541)552-2292 With a copy to: City of Ashland—Legal Department 20 E.Main Street Ashland,OR 97520 Phone:(541)488-5350 If to Provider: Design Source Attn:Molly Williams 541-821-6823 8. WAIVER OF BREACH One or more waivers or failures to object by either party to the other's breach of any provision, term, condition, or covenant contained in this Agreement shall not be construed as a waiver of any subsequent breach,whether or not of the same nature. 9. PRO'VIDER'S COMPLIANCE WITH TAX LAWS 9.1 Provider represents and warrants to the City that: 9.1.1 Provider shall,throughout the term of this Agreement,including any extensions hereof,comply with: (i) All tax laws of the State of Oregon,including but not limited to ORS 305.620 and ORS chapters 316,317,and 318; (ii) Any tax provisions imposed by a political subdivision of the State of Oregon applicable to Provider;and (iii) Any rules,regulations,charter provisions,or ordinances that implement or enforce any of the foregoing tax laws or provisions. 9.1.2 Provider,for a period of no fewer than six(6)calendar years preceding the Effective Date of this Agreement; has faithfully complied with: (i) All tax laws of the State of Oregon,including but not limited to ORS 305.620 and ORS chapters 316,317,and 318; (ii) Any tax provisions imposed by a political subdivision of the State of Oregon applicable to Provider;and (iii) Any rules,regulations,charter provisions,or ordinances that implement or enforce any of the foregoing tax laws or provisions. 9.2 Provider's failure to comply with the tax laws of the State of Oregon and all applicable tax laws of any political subdivision of the State of Oregon shall constitute a material breach of this Agreement. Further,any violation of Provider's warranty,as set forth in this Article 9,shall constitute a material breach of this Agreement. Any material breach of this Agreement shall entitle the City to terminate this Agreement and to seek damages and any other relief available under this Agreement,at law,or in equity. • Pogo 5 of 6: Goods end Services Agreement between the(tty of Ashland and Design Boone IN wan.SS " :i a' ° I F the parties have caused this Agreement to be signed in their respective names by their duly authorized representatives as of the dates set forth below. CITY OF ASHLAND:43 Design-Source(PROVIDER): • BY: By: .2 o ui.11 __ Signature .s ilnatare /4c16- Molly 1/41 10111 a rus Printed Name Printed Name Aamel•r Ocom eJ Title Title 74r/R1 'V Az8/2oa1 ( Date Date (a is to be submitted with this signed Agreement) 7 a Purchase Order No. 3 • • • • , Page 6 or6: Goods and Services Agreement between the City of Ashland and Design Source DESIGN SOURCE 6114 1319 Harrisburg Dr.Medford,OR 97501 Phone:541-821-6823 Mollyatdesignsource@hotmail.com April,26 2021 To:City of Ashland To whom it concerns, Regarding the City of Ashland's Service Agreement General Liability Insurance requirement,I would like to request an exception. As the owner of Design Source,my company currently carries$1,000,000 per occurrence and $2,000,000 for general aggregate and products worth of Liability Insurance while providing the assembly of office furnishings. During the process of performing these services,incidents are extremely rare and personal injury or property damage Is almost unheard of. Please contact me if you have any questions or would like more information as you consider my request, Thank you, Molly Williams,owner Design Source DESIGN SOURCE } 1319 Harrisburg Dr.Medford,OR 97501 Phone:541-821-6823 Mollyatdesignsource©hotmail.com Rate Schedule July 1, 2021 June 30, 2022 Service labor for assembly of furniture items new or existing $50 per hour per person Non-BOLI assignments �� ® DATE(MMlDD/YYYY) �°►`�D VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE 05/27/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. This form Is used to report coverages provided to a single specific vehicle or equipment.Do not use this form to report liability coverage provided to multiple vehicles under a single policy.Use ACORD 25 for that purpose. , PRODUCER NAMEACT Russell P Brown SfateFarm Russell P Brown Ins Agcy Inc see,,No,Ext1: 541-776-8466 FAX Net: 541-776-8473 2581 W Maln Si AE-MAIL russell@russellbrown.blz 00, • paOOUCER Medford,Or 97501 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIL# INSURED INSURERA: State Farm Mutual Automobile Insurance Company 25178 Williams,Molly INSURER B: PI 1319 Harrisburg Drive INSURER C: K2 Medford,Or 97501 INSURER D: K2 INSURER E: DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR MAKE(MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER 2012 Ford . Escape Utility 1FMCUOE72CKC19053 DESCRIPTION VEHICLE/EQUIPMENT VALUE SERIAL NUMBER $ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICY(IES)OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S)INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICY(IES)DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICY(1ES). INSR Annt POLICY EFFECTNE POLICY EXPIRATION LIMITS LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YYYY) DATE(MMJDD/YYYY) X I VEHICLE LIABILITY COMBINED SINGLE LIMIT $ BODILY INJURY(Per person) $ 100000 A X 155 6519-C22-37F 03/22/2021 03/22/2022 BODILY INJURY(Per accident) $ 300000 PROPERTY DAMAGE $ 100000 GENERAL LIABILITY EACH OCCURENCE 8 OCCURRENCE GENERAL AGGREGATE $ — CLAIMS MADE $ INSR Loss POLICY EFFECTIVE POLICY EXPIRATION LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YYYY) DATE(MMIDDIYYYY) LIMITS!DEDUCTIBLE VEH COLLISION LOSS ❑ACV 0 AGREED AMT $ LIMIT ❑ 0 STATED ANT $ DED VEH COMP I I VEH OTC 0 ACV ❑AGREED MIT $ LIMIT ❑ 0 STATED AMT $ DED EQUIPMENT 0 ACV 0 AGREED AMT : LIMIT BASIC BROAD ❑RC 0 STATED AMT $ DED SPECIAL ❑ REMARKS(INCLUDING SPECIAL CONDITIONSI OTHER COVERAGES)(Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) ADDITIONAL INTEREST CANCELLATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED The additional Interest described below hes been added to the pollcy(lee)listed herein by policy number(s). BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE 1I A rayuect has bean submitted to add the additional Interest described below to the policy(les) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. listed herein by pollcv numberle). VEHICLE/EQUIPMENT INTEREST: I LEASED FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST — NAME AND ADDRESS OF ADDITIONAL INTEREST X ADDITIONAL INSURED LOSS PAYEE — Certificate Holder: LENDER'S LOSS PAYEE City of Ashland LOAN!LEASE NUMBER 20 E Maln St / '� Ashland,OR 97520 AUTH I£iYED 're NE I =2U1 A 0 COR�O I Irl served. ACORD 23(2016/03) The ACORD name and logo are registered marks of ACORD 1004381 142 7.3 01-20-2010 AC R® CERTIFICATE OF-LIABILITY INSURANCE DATEIMMfODIYYYY) 14..,........--" 041z71zOz1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE-DOES NOTAFFIRMA11VELY 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 I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.. IMPORTANT. If the oertlfloete holder Is an ADDITIONAL INSURED{the pailoy(les)must have ADDITIONAL.INSURED proVisions or be.endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the.polioy,certain policies may require an endorsement. A statement on this oert(floate does not confer rights to the certifloate holder In lieu of suoh endorsement(s). i PRODUCER CONTACT Tanis Herber .NAME: Ashland Insurance IncPHONE (541)057.0678 I A1C,No): ( 541 857-9883 •me No.Eat1: ) _ 801 O'Hare Parkway,Ste 101 no aEss: tharber®ashiandinsurance.com I i ! INSURER(S)AFFORDING COVERAGE NAIL N, i Medford OR 97504 INSURER A: Ohio Security Insurance Co. 24082 INSURED INSURERS: Design Source INSURER C: 1319 Harrisburg Dr INSURERD: i INSURER E: MedfoMOR 97501 INSURER F COVERAGES .` •.. : •CERTIFiCATENUMBER: 2021 GL ... 4IEVISIONNUMBER: THIS IS TO CERTIFYTHATTHE POLICIES OFINSURANCE LISTED BELOW HAVE BEEN 1SSUEOTO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY'REQUIREMENT,TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCEAFFOROED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTOALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN.MAY HAVE BEEN REDUCED BY PAID CLAIMS. L NR TYPE OF INSURANCE AODLEUBR - -" _..... -POLICY EFF POLICY EXP ., INSD WVD POLICY NUMBER (MMIDDIYYYY) (LAnmo1YYYv) UMITE COIMIERCIAL:GENERAL WI&,LITY 1,000,000 X EACH OCCURRENCE • S -CLAIMS-MADE OCCUR PREM SE (S EaomREcimence) S D 1.000;000 © 15;000 — on)MEDEXP(Anycne! SS A Y Y BLS58165091 07/24/2020 07/24/2021 PERSONAL SADVINJURY $ 1.000,000 GENT.AGGREGATE LIMiTAPPUESPER: GENERAL AGGREGATE ' $ 2000,000 X POLICY n rja • LOC PRODUCTS-COMP/OP AGO, $ 2000,000 OTHER: S AUTOMOBILE UASIUTY • MBBoIINEDISINGLE LIMIT S ANYAUTO BODILY INJURY(Perpencogl .5 • I ; —OWNED ':SCHEDULED BOOILYINJURY(Per,eocrdenl) ,4 AUTOS ONLY _AUTOS . _ HIRED NONOWNED. PROPERTY DAMAGE• -• -3 AUTOS ONLY AUTOS ONLY (Pereaddenl) - • 3 . UMBRELLA UM OCCUR' EACH OCCURRENCE :S — EXCESSLLAB ICLAIMS-MADE AGGREGATE S -. .. BED I I RETENTION S '..S ` • . ' WORKERS COMPENSATION..° .; PER STH• .:::::.., ': ..: . AND EMPIOYERS'UAUIUTY Y/ti. STATUTE ER .,• • ... ANY PROPRIErOR,PAFRTNERIEXECUrIVE 1 1„H!A E.L.EACHACCIDEiT ' S OFFICER/MEMBER EXCLUDED'? E.L.DISEASE-EA EMPLOYEE S If yas,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY UMIT '4 • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Addltlonal Remarks Schedule,may be attached If more space Is required) Certflcato holder Is included as Additional Insured for General Liability coverages with written contract.This form Issubject to policy terms,conditions and exclusions. l i I I CERTIFICATE HOLDER CANCELLATION • I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City Of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. .• 20 East Main Street • I AUTHORIZED REPRESENTATIVE f. �j� ' • Ashland OR 97520 /�;"�`^'� i ©1888.2016 ACORD CORPORATION.All rights reserved, I ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD I AC R CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDITYYY) 04/27/2021 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(les)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 Tants Herber NAME: Ashland Insurance Inc PHONE (541)857-0879 FAX (541)857-9883 (NC.No.Ext): (AiC,No): 801 O'Hare Parkway,Ste 101 E-MAIL tharber@ashlandlnsurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL I! Medford OR 97604 INSURERA: Ohio Security Insurance Co. 24082 INSURED INSURER B: Design Source INSURER C: 1319 Harrisburg Dr INSURER D: INSURER E Medford OR 97501 INSURER F: COVERAGES CERTIFICATE NUMBER: 20 21 GL 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 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. IL7R TYPE OF INSURANCE ADMSUHH POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 CLAIMS-MADE OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) $ 15,000 A Y Y BLS58165091 07/24/2020 07/24/2021 PERSONAL&ADV INJURY _ $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY 1-1 PRO- ri 2,000,000 )ECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea acddent) ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) S UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER 0TH- AND EMPLOYERS'LIABILITYPROPRIETOR/PARTNER/EXECUTIVESTATUTE ER S ANY PROPRIETOR/PARTNER/EXECUTIVE ri EL.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certficate holder is Included as Additional Insured for General Liability coverages with written contract.This form is subject to policy terms,conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. 20 East Main Street AUTHORIZED REPRESENTATIVE Ashland OR 97520 eaotioa. A +--- I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • COMMERCIAL GENERAL LIABILITY CG 88 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY EXTENSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART INDEX SUBJECT PAGE NON=OWNED AIRCRAFT 2 NON-OWNED WATERCRAFT 2 PROPERTY DAMAGE LIABILITY-ELEVATORS 2 . a EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) 2 MEDICAL PAYMENTS EXTENSION 3 EXTENSION OF SUPPLEMENTARY PAYMENTS -COVERAGES A AND B 3 ADDITIONAL INSUREDS -BY CONTRACT, AGREEMENT OR PERMIT 3 PRIMARY AND NON-CONTRIBUTORY- ADDITIONAL INSURED EXTENSION 5 ADDITIONAL INSUREDS -EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" 6 WHO IS AN INSURED -INCIDENTAL MEDICAL ERRORS/MALPRACTICE AND WHO IS AN INSURED -FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES 6 NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES 7 FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES 7 KNOWLEDGE OF OCCURRENCE,OFFENSE,CLAIM OR SUIT 7 LIBERALIZATION CLAUSE 7 BODILY INJURY REDEFINED 7 EXTENDED PROPERTY DAMAGE 8 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - 8 WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU i ! I � I ' © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 1 of 8 With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. A. NON-OWNED AIRCRAFT Under Paragraph 2. Exclusions of Section I - Coverage A - Bodily Injury And Property Damage Liability, exclusion g.Aircraft, Auto Or Watercraft does not apply to an aircraft provided: 1. It is not owned by any insured; 2. It is hired, chartered or loaned with a trained paid crew; 3. The pilot in command holds a currently effective certificate, issued by the duly constituted authority of the United States of America or Canada, designating her or him a commercial or airline pilot; and 4. It is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the insured other valid and collectible insurance, whether primary, excess (other than insurance written to apply specifically in excess of this policy), contingent or on any other basis, that would also apply to the loss covered under this provision. B. NON-OWNED WATERCRAFT Under Paragraph 2.Exclusions of Section I-Coverage A-Bodily Injury And Property Damage Liability, Subparagraph (2) of exclusion g.Aircraft, Auto Or Watercraft is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) Less than 52 feet long; and (b) Not being used to carry persons or property for a charge. C. PROPERTY DAMAGE LIABILITY-ELEVATORS 1. Under Paragraph 2. Exclusions of Section I -Coverage A -Bodily Injury And Property Damage Liabil- ity, Subparagraphs (3), (4) and (6) of exclusion j. Damage To Property do not apply if such "property damage" results from the use of elevators. For the purpose of this provision, elevators do not include vehicle lifts. Vehicle lifts are lifts or hoists used in automobile service or repair operations. 2. The following is added to Section IV - Commercial General Liability Conditions, Condition 4. Other • Insurance, Paragraph b. Excess Insurance: The insurance afforded by this provision of this endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) If Damage To Premises Rented To You is not otherwise excluded from this Coverage Part: 1. Under Paragraph 2. Exclusions of Section I-Coverage A-Bodily Injury and Property Damage Liability: a. The fourth from the last paragraph of exclusion j. Damage To Property is replaced by the follow- ing: Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" (other than damage by fire, lightning, explosion, smoke, or leakage from an automatic fire protection system) to: (i) Premises rented to you for a period of 7 or fewer consecutive days; or (ii) Contents that you rent or lease as part of a premises rental or lease agreement for a period of more than 7 days. Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" to contents of premises rented to you for a period of 7 or fewer consecutive days. A separate limit of insurance applies to this coverage as described in Section III - Limits of Insurance. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 2 of 8 b. The last paragraph of subsection 2. Exclusions is replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section III -Limits Of Insurance. 2. Paragraph 6. under Section III -Limits Of Insurance is replaced by the following: 6. Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of"property damage" to: a. Any one premise: (1) While rented to you; or (2) While rented to you or temporarily •occupied by you with permission of the owner for damage by fire, lightning, explosion, smoke or leakage froth automatic protection sys- tems; or b. Contents that you rent or lease as part of a premises rental or lease agreement. 3. As regards coverage provided by this provision D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) -Paragraph 9.a. of Definitions is replaced with the following: 9.a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with the permission of the owner,, or for damage to contents of such premises that are included in your premises rental or lease agreement, is not an"insured contract". E. MEDICAL PAYMENTS EXTENSION If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided by this policy are amended as follows: Under Paragraph 1. Insuring Agreement of Section I-Coverage C-Medical Payments, Subparagraph (b) of Paragraph a. is replaced by the following: (b) The expenses are incurred and reperted within three years of the date of the accident; and F. EXTENSION OF SUPPLEMENTARY PAYMENTS -COVERAGES A AND B 1. Under Supplementary Payments -Coverages A and B,Paragraph 1.b. is replaced by the following: b. Up to $3,000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. !+ 2. Paragraph 1.d. is replaced by the following: d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work. G. ADDITIONAL INSUREDS -BY CONTRACT, AGREEMENT OR PERMIT 1. Paragraph 2. under Section II -Who Is An Insured is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written •: agreement or permit. Such person or organization is an additional insured but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused in whole or in part by: a. Your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your on going operations for the additional insured that are the subject of the written contract or written agreement provided that the "bodily injury" or "property damage" occurs, or the "per- sonal and advertising injury" is committed, subsequent to the signing of such written contract or written agreement; or © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 3 of 8 b. Premises or facilities rented by you or used by you; or c. The maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or d. Operations performed by you or on your behalf for which the state or political subdivision has issued a permit subject to the following additional provisions: (1) This insurance does not apply to "bodily injury", "property damage", or "personal and ad- vertising injury" arising out of the operations performed for the state or political subdivision; (2) This insurance does not apply to "bodily injury" or "property damage" included within the "completed operations hazard". (3) Insurance applies to premises you own, rent, or control but only with respect to the following hazards: (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 expo- • sures; or (b) The construction, erection, or removal of elevators; or (c) The ownership, maintenance, or use of any elevators covered by this insurance. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to Paragraph 1.a. above, a person's or organization's status as an additional insured under this endorsement ends when: (1) 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 (2) 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. With respect to Paragraph 1.b. above, a person's or organization's status as an additional insured under this endorsement ends when their written contract or written agreement with you for such premises or facilities ends. .73 With respects to Paragraph 1.c. above, this insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or"property damage". We have no duty to defend an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured as required in Paragraph b. of Condition 2. Duties In the Event Of Occurrence, Offense, Claim Or Suit under Section IV - Commercial General Liability Condi- tions. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 4 of 8 2. With respect to the insurance provided by this endorsement, the following are added to Paragraph 2. Exclusions under Section I-Coverage A-Bodily Injury And Property Damage Liability: This insurance does not apply to: a. "Bodily injury" or"property damage" arising from the sole negligence of the additional insured. b. "Bodily injury" or "property damage" that occurs prior to you commencing operations at the location where such "bodily injury" or"property damage" occurs. c. "Bodily injury", "property damage". or"personal and advertising injury" arising. out of the render- ing of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving,' or falling to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occur- rence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising. injury", involved the rendering of, or the failure to render, any professional architectural, engineering or surveying services. d. "Bodily injury" or"property damage" occurring after: (1) 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 (2) 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. e. Any person or organization specifically designated as an additional insured for ongoing operations by a separate ADDITIONAL INSURED -OWNERS, 'LESSEES'OR CONTRACTORS endorsement is- sued by us and made a part of this policy. 3. With respect to the insurance afforded: to these additional insureds, the following is added to Section III -Limits Of Insurance: If coverage provided tothe additional insured is required. bya contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits, of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declaratio ns. H. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. Condition 4. Other Insurance of SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS is amend- ed as follows: a. The following is added to Paragraph a. Primary Insurance: If an additional insured's policy has an Other Insurance provision making its policy excess, and you have agreed in a written contract or written agreement to provide the additional insured coverage on a primary and noncontributory basis, this policy shall be primary and we will not seek contribution from the additional insured's policy for damages we cover. _ I � © 2013 Liberty Mutual insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with Its permission. Page 5 of 8 b. The following is added to Paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreement, or permit issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the addi- tional insured is designated as a Named Insured. Regardless of the written agreement between you and an additional insured, this insurance Is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional insured has been added as an additional insured on other policies. I. ADDITIONAL INSUREDS -EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. 1. The following is added to Condition 2. Duties In The Event Of Occurrence, Offense, Claim or Suit: An additional insured under this endorsement will as soon as practicable: a. Give written notice of an "occurrence" or an offense that may result in a claim or"suit" under this insurance to us; b. Tender the defense and indemnity of any claim or "suit" to all insurers whom also have insurance available to the additional insured; and c. Agree to make available any other insurance which the additional insured has for a loss we cover under this Coverage Part. d. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a"suit" by the additional insured. 2. The limits of insurance applicable to the additional insured are those specified in a written contract or written agreement or the limits of insurance as stated in the Declarations of this policy and defined in Section III - Limits of Insurance of this policy, whichever are less. These limits are inclusive of and not in addition to the limits of insurance available under this policy. J. WHO IS AN INSURED -INCIDENTAL MEDICAL ERRORS 1 MALPRACTICE WHO IS AN INSURED -FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES Paragraph 2.a.(1) of Section II-Who Is An Insured is replaced with the following: (1) "Bodily injury" or"personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), to a co-"employee" while in the course of his or her employ- ment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; • (b) To the spouse, child, parent, brother or sister of that co-"employee" or "volunteer worker" as a consequence of Paragraph (1) (a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1) (a) or(b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. However, if you are not in the business of providing professional health care services or providing profes- sional health care personnel to others, or if coverage for providing professional health care ser- vices is not otherwise excluded by separate endorsement, this provision (Paragraph (d)) does not apply. Paragraphs (a) and (b) above do not apply to "bodily injury" or"personal and advertising injury" caused by an "employee" who is acting in a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, includes the direct supervision of other "employ- ees" of yours. However, none of these "employees" are insureds for "bodily injury" or "personal and © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 6 of 8 advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to cause "bodily .injury' or "personal and advertising injury", or caused in whole or in part by their intoxica- tion by liquor or controlled substances. The coverage provided by provision J. is excess over any other valid and collectable insurance available to your "employee". K. NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES Paragraph 3. of Section II-Who Is An Insured is replaced by the following: 3. Any organization you newly acquire or form and over which you maintain ownership or majority interest, will qualify as a Named Insured if there is no Other'similar Insurance available to that organization. However: a. Coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply,..to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. d. Records and descriptions ofoperations must:be maintained by the first Named Insured. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations or qualifies as an insured under this provision. L. FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES Under Section IV -Commercial General Liability Conditions, the following is added to Condition 6. Repre- sentations: Your failure to disclose all hazards or prior "occurrences" existing as of the inception date of the policy shall not prejudice the coverage afforded by this policy provided such failure to disclose all hazards or prior "occurrences" is not intentional. M. KNOWLEDGE OF OCCURRENCE, OFFENSE,CLAIM OR SUIT Under Section IV -Commercial General Liability Conditions, the following is added to Condition 2. Duties In The Event of Occurrence, Offense, Claim Or Suit: Knowledge of an "occurrence", offense, claim or "suit" by an agent, servant or "employee" of any insured shall not in itself constitute knowledge of the insured unless an insured listed under Paragraph 1. of Section II -Who Is An Insured or a person who has been designated by them to receive reports of "occurrences", offenses, claims or "suits" shall have received such notice from the agent, servant or "employee". N. LIBERALIZATION CLAUSE If we revise this Commercial General Liability Extension Endorsement to provide more coverage without additional premium charge, your policy will automatically provide the coverage as of the day the revision is effective in your state. O. BODILY INJURY REDEFINED Under Section V-Definitions, Definition 3. is replaced by the following: 3. "Bodily Injury" means physical injury, sickness or disease sustained by a person. This includes mental anguish, mental injury, shock, fright or death that results from such physical injury, sick- ness or disease. @ 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 7 of 8 P. EXTENDED PROPERTY DAMAGE Exclusion a. of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the following: a. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. Q. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU • Under Section IV - Commercial General Liability Conditions, the following is added to Condition 8. Trans- fer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against a person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard" provided: 1. You and that person or organization have agreed in writing in a contract or agreement that you waive such rights against that person or organization; and a ' 2. The injury or damage occurs subsequent to the execution of the written contract or written agree- ment. "N N ® 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 8 of 8 CERTIFICATION OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE REQUIREMENTS Contractor is exempt from the requirement to obtain workers compensation insurance under ORS Chapter 656 for the following reason. Contractor is to initial the appropriate box as follows: „,(,(,t Ji SOLE PROPRIETOR (Initials) n Contractor is a sole proprietor,and • Contractor has no employees,and • Contractor will not hire employees or subcontractors to perform this contract, CORPORATION-FOR PROFIT (Initials) • Contractor's business is incorporated;and • Albemployees of the corporation are officers and directors and have a substantial ownership interest*in the corporation,and • All work will be performed by the officers and directors;Contractor will not hire other employees or subcontractors to perform this contract. CORPORATION-NONPROFIT (Initials) • Contractor's business is incorporated as a nonprofit corporation,and • Contractor has no employees;all work is performed by volunteers,and. • Contractor will not hire employees orsubcontractors.to perform this contract. PARTNERSHIP (Initials) • Contractor is a partnership,and • Contractor has no'employees,and • All work will be performed by the partners;Contractor will not hire employees or'subcontractors to perform this- contract,and • Contractor is not engaged in work performed in direct connection with the construction,alteration,repair, improvement,moving or demolition of an improvement to real property or appurtenances thereto.** LIMITED LIABILITY COMPANY (Initials) • Contractor is a'limited liability con ipa iy,and • Contractor has no employees,and • All work will be performed by the members;Contractor will not hire employees or subcontractors to perform this contract,and • If Contractor has more than one member,;Contractor is not engaged in work performed in direct connection with the construction,alteration,repair,improvement,moving or demolition of an improvement to real property or appurtenances thereto.** 1 •//S¢/202./ (Sia ; f e of Authorized Signer) (Date) Ow vi-e-1/ (Signer'sTitle *NOTE: Under 0AR436-50-050 a shareholder has a"substantial ownership”interest if the shareholder owns 10%of the corporation,or if less than 10%is owned,the shareholder has ownership that is at least equal to or greater than the average percentage of ownership of all shareholders. **NOTE: Under certain circumstances partnerships and limited liability companies can claim an exemption even when performing • construction work. The requirements for this exemption are.complicated. Consult with City Attorney's Office before an exemption request is accepted from a contractor who will perform construction work. • i •