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HomeMy WebLinkAbout2021-130 PO 20220156- Payne,Gregg Purchase Order Fiscal Year 2022 Page: 1 of: 1 B Tp RECORDER RDc €Ts �P�C .7. City of Ashland E I ATTN:Accounts Payable L 20 E. Main Purchase 20220156 Ashland, OR 97520 Order# T Phone: 541/552-2010 O Email: payable@ashland.or.us - ✓ H C/O Fire and Rescue Department E PAYNE, GREGG I 455 Siskiyou Blvd N 7491 HIGHWAY 238 p Ashland, OR 97520 D JACKSONVILLE, OR 97530 Phone: 541/482-2770 O T Fax: 541/488-5318 R i dorR ambQF— issio� L9 be.�ER qu ®g.1.1= o_s:_7-$ = Chris Chambers /ed–WI ate_Regmr• g.znsigi= =f RID.e'E;. - — ® a MD- ef:.10a - -- 09/30/2021 6031 City Accounts Payable SOFEE Design Work 1 SOFEE FireWorks curriculum template, logo redesign and nature 1.0 $2,960.00 $2,960.00 journal design work per attached proposal dated 09/08/2021 Services Agreement(Less than $25,000) Completion date: March 31, 2022 Project Account:. E-G00017-999 *************** GL SUMMARY*************** 072900-606100 $2,960.00 B ? I Date: -- <Y;c4a1,..a.,(A.4e(64,----)ev-7- AL FORIVI #3 CITY OF`� y � �� ASHLAND AX75 A�t;��liP'�i�,�h Te g' F�{ VI 0. �r �,':'�', 5�4�',t! D [�./ 4 C 1 lF r,�.. � S i' �tT 4.lEy REQUiSITION / Date of request: 09122/2021 Required date for delivery: 09/27/2021 Vendor Name Gregg Payne Art&Design Address,City,State,Zip 7491 Highway 238,Jacksonville OR 97530 Contact Name&Telephone Number Gregg Payne,(530)228-3399 Email address greggpayne©mac.com SOURCING METHOD ❑ Exempt from Competitive Bidding ❑ invitation to Bid 0 Emergency ❑ Reason for exemption: Date approved by Council: ❑ Form#13,Written findings and Authorization O AMC 2.50 , (Attach copy of council communication) 0 Written quote or proposal attached O Written quote or proposal attached (If council approval required,attach copy of CC) ❑ Small Procurement ❑ Request for Proposal Cooperative Procurement Not exceeding$5,000 Date approved by Council: ❑ State of Oregon ' ❑ Direct Award _(Attach copy of council communication) Contract# © Verbal/Written bid(s)or proposal(s) ❑ Request for Qualifications(Public Works) ❑ State of Washington , Date approved by Council: Contract# - . (Attach copy of council communication) 0 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 bids&solicitation attached 0 Form#4,Personal Services$5K to$75K Agency PERSONAL SERVICES Date approved by Council: ❑ Annual cost to City does"not exceed$25,000. Greater than$5,000 and less than$75,000 Valid until: m_...,..__Date Agreement approved by Legal and approved/signed by ❑ Less than$35,000,by direct appointment ❑ Special Procurement City Administrator.AMC 2.50.070(4) ❑ (3)Written proposals&solicitation attached 0 Form#9,Request for Approval ❑ Annual cost to City exceeds$25,000,Council ❑ Form#4,Personal Services$5K to$75K ❑ Written quote or proposal attached approval required.(Attach copy of council communication) Date approved by Council: Valid until: .,. (Date) Description of SERVICES Total Cost Developa logo, curriculum template andnature journal per grantfundingprovided vided from the Bureau of Land Management. Item # Quantity Unit Description of MATERIALS Unit Price Total Cost 1 Logo Design p 960.00 1 Template 400.00 1 Nature Journal 1600.00 © Per attached quote/proposal ::TOTAL.'`COST.`:' Project Number 9 0 0 0 1 7. 4 0 0 Account Number 0 7 2 9 0 0.6 0 6 1 0 0 ,.'L;960 ,.. Account Number__ _ - Account Account Number - `Expenditure must be charged fo the appropriate account numbers for the financials to accurately reflect 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 Clty's public contracting requirements have been satisfied. i` . _ Employee: (-----_,----'1. �=0�^ Department Head: • \t . C1 (Equal to or greater than$5,000) Department Manager/Supervisor: City Manager: (Equal to or greater than$25,000) Funds appropriated for current fiscal year: YES / NO - Finance Director-(Equal to or greater than$5,000) Date Comments: Formt3-Requisition • SERVICES AGREEMENT(LESS THAN$25,000) PROVIDER: Gregg Payne Art,&Design CITY O F PROVIDER'S CONTACT: ASHLAND 1 • 20 East Main Street EMAIL:greggpayne®mac,coi1 . Ashland,Oregon 97520 Telephone: 541/488-5587 ADDRESS: 7491 Highway 238,Jacksonville,OR 97530 Pax: 541/488-6006 PRONE: (530)228-3399 • This Services Agreement (hereinafter "Agreement") is entered into by and between the.City of Ashland, an Oregon municipal corporation(hereinafter"City")and Gregg Payne Art&Design,a domestic sole proprietorship ("hereinafter"Provider"),for graphic design and branding,identity work. 1. PROVIDER'S OBLIGATIONS • 1.1 Provide logo identity design development for Southern Oregon Fire Ecology Education, development of a template page for curriculum, and a guided nature journal to include cover page,back page and 10 designed pages as set forth in the "SUPPORTING DOCUMENTS" attached hereto and, by this reference, incorporated herein, Provider expressly acknowledges that time is of the essence of any completion date set forth in the SUPPORTING DOCUMENTS,and that no waiver or extension of such deadline may be authorized except in the same manner as herein provided for authority to exceed the. maximum compensation. The services defined and described in the "SUPPORTING DOCUMENTS" shall hereinafter be collectively referred to as"Work," 1,2 Provider shall obtain and maintain during the term of this Agreement and until City's final acceptance of all Work received hereunder, a policy or l olicies of liability insurance including commercial genera liability insurance with a combined single limit, or the equivalent, of not less than•$27900 988- ?� inillio dellat's)•per occurrence for Bodily Injury and Property Damage. 04 vati 0001Cneyrs;//•tii-i• 1.2.1 The insurance required in this Article shall include the following coverages: '°t(os) • Comprehensive General or Commercial General Liability, including personal h ' contractual liability,and products/completed operations coverage; and • . utemebile-Liability: ivy d i y in J rev)n0 � (Km.)V e- oM4.0 f nSw M1 i 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 fi:om the first dollar of liability; • Provider shall immediately notify the•City of any change in.insurance coverage- . • Page 1 of 6: Agreement between the Cit of Ashland and Gregg Payne Art&Design + Provider shall supply an endorsement naming the City,its officers,employees and agents as additional insureds by the Effective Date of this Agreement; and • Be evidenced by a certificate or certificates of such insurance approved by the City. . 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 employees. 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 Requirement: If the amount ofthis Agreement is$21,507.75 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. 2. CITY'S OBLIGATIONS • 2.1 City shall pay Provider the sum.of$2960,00 as provided herein as full compensation for the Work as - specified in the SUPPORTING DOCUMENTS. • 2.2 In.no event shall Provider's total of all compensation and reimbursement under this Agreement exceed the sum of two-thousand nine-hundred and sixty dollars without express,written approval from the City official whose signature appears below, or such official's successor in office. Provider expressly acknowledges that no other person has authority to order or authorize additional Work which would cause this maximum sum to be exceeded and that any authorization from the responsible official must be in writing. Provider further acknowledges that any Work delivered or expenses incurred without authorization as provided herein is done at Provider's own risk and as a volunteer without expectation of compensation or reimbursement, 3. GENERAL PROVISIONS 3.1 This is a non-exclusive Agreement. City is not obligated to procure any specific amount of Work from Provider and is free to procure similar types of goods and services from other providers in its sole discretion, i , 3.2 Provider is an independent contractor and not an employee or agent of the City for any purpose. Page 2 of 6: Agreement between the City of Ashland and Gregg Payne Art&Design 3,3 Provider is not entitled to,and expressly waives all claims to City benefits such as health and disability insurance,paid leave, and retirement, • 3,4 All Work product or 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 vestin and is hereby assigned to the City, 3.5 This Agreement embodies the full and complete understanding of the parties respecting the subject matter hereof. It supersedes all prior agreements,negotiations,and representations between the parties, whether written or oral, 3.6 This Agreement may be amended only by written instrument executed with the same formalities as this Agreement. - • 3.7 The following laws of the State of Oregon are hereby incorporated by reference into this Agreement: ORS 279B.220,279B.230 and 270;235. 3.7 This Agreement shall be governed by the laws of the State of Oregon without regard to conflict of laws principles. Exclusive venue for litigation of any action arising under this Agreement shall be in the Circuit Court of the State of Oregon for Jackson County unless exclusive jurisdiction is in federal court, • in which case exclusive venue shall be in the federal district court for the district of Oregon. Each party expressly waives any and all rights to maintain an action under this Agreement in any other venue, and expressly consents that, upon motion of the other party, any case may be dismissed or its venue transferred,as appropriate,so as to effectuate this choice of venue, 3.8 Provider shall defend,save,hold harmless and indemnify the City and its officers,employees and agents from and against any and all claims, suits, actions, losses, damages, liabilities, costs, and expenses of any nature resulting from, arising out of, or relating to the activities of Provider or its officers, employees,contractors,or agents under this Agreement. 3.9 Neither party to this Agreement shall hold the other responsible for damages or delay in performance caused by acts of God,strikes,lockouts,accidents,or other events beyond the control of the other or the other's officers,employees or agents. 3.10 If any provision of this Agreement is found by a court of competent jurisdiction to be unenforceable, such provision shall not affect the other provisions, but such unenforceable provision shall be deemed modified to the extent necessary to render it enforceable, preserving to the fullest extent permitted the intent of Provider and the City set forth roilis Agreement, 4. SUPPORTING DOCUMENTS 4.1 The following documents are, by this reference, expressly incorporated in. this Agreement, and are collectively referred to in.this Agreement as the"SUPPORTING DOCUMENTS:" • The Provider's complete written Proposal dated 09/0812021. 4.2 This Agreement and the SUPPORTING DOCUMENTS shall be construed to be mutually complimentary 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 hi any of the SUPPORTING DOCUMENTS. In. the event of conflict between provisions of two of the Page 3 of 6: Agreement between the City of Ashland and Gregg Payne Art&Design • SUPPORTING DOCUMENTS,the several supporting documents shall be given precedence in the order - listed iii Subsection 4.1, 5. REMEDIES 5.1 In the event Provider is in.default of this Agreement, City may, at its option,pursue any or all of the remedies available to it under this Agreement and at law or in equity,including,but not limited to: 5,1,1 Termination of this Agreement; _ 5.1.2 Withholding all monies due for the Work that Provider has failed to deliver within any scheduled completion dates or any Work that have been delivered inadequately or defectively; 5,13 Initiation of an action or proceeding for damages, specific performance, or declaratory or injunctive relief, 5,1.4 These remedies are cumulative to the extentthe remedies are not inconsistent,and City may pursue any remedy or remedies singly, collectively,successively or in.any order whatsoever, 5,2 In no event shall City be liable to Provider for any expenses related to termination of this Agreement or for anticipated profits.If previous amounts paid to Provider exceed the amount due,Provider shall pay immediately any excess to City upon written demand provided. 6. TERM AND TERMINATION 6,1 Term This Agreement shall be effective from the date of execution on behalf of the City as set forth below (the "Effective Date") and shall continue in full force and effect until March 31, 2022,unless sooner terminated as provided in Subsection 6.2. 6.2 Termination 6.2,1 The City and Provider may terminate this Agreement by mutual agreement at any time. 6,22 The City may,upon not less than thirty(30)days'prior written notice,terminate this Agreement for any reason deemed appropriate in its sole discretion, 6.2.3 Either party may terminate this Agreement, with cause,by not less than.fourteen(14) days' prior written notice if the cause is not cured within that fourteen(14) day period after written notice, Such teruinination is in addition to and not in lieu of any other remedy at law or equity. 7. NOTICE Whenever notice is required or permitted to be given under this Agreement, such notice shall be given in writing to the other party by personal delivery,by sending via a reputable commercial overnight courier, or by mailing using registered or certified United States mail, return receipt requested,postage prepaid,to the address set forth below: If to.'the City: City of Ashland—Ashland Fire&Rescue Attn: Sara Sones 455 Siskiyou Blvd S • Ashland, Oregon 97520 • Phone: (541)552-2218 With a copy to: • City of Ashland--Legal Department 20 E.Main Street Ashland, OR 97520 Page 4 of 6: Agreement between the City of Ashland and Gregg Payne Art&Design • Phone: (541)4885350 • • If to Provider: Attn: Gregg Payne Gregg Payne Art&Design 7491 Highway 238 Jacksonville,OR 97530 Email: greggpayne@mac.com Phone: (530)228-3399 8. WAIVER OF BREACH One or more waivers or failures to object by either party to the other's breach of any provision,term,condition, or covenant contained in this Agreement shall not be construed as a Waiver of any subsequent breach,whether or not of the same nature. 9. PROVIDER'S COMPLIANCE WITH TAX LAWS 9.1 Provider represents and warrants to the City that: 9.1.1 Provider shall, throughout the term of this Agreement, including any extensions hereof, comply with: (i) All tax laws of the State of Oregon, including but not limited to ORS 305.620 and ORS chapters 316,317,and 318; (ii) Any tax provisions imposed by a political subdivision of the State of Oregon applicable to Provider;and (iii) Any rules,regulations, charter provisions,or ordinances that implement or enforce any of the foregoing tax laws or provisions, ' 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) AU 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, 92 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. • Page 5 of 6: Agreement between the City or Ashland and Gregg Payne Art&Design • IN WITNESS WHEREOF the parties have caused this Agreement to be signed in their respective names by their duly authorized representatives as of the dates set forth below. CITY OF ASHLAND: Gregg Payne Art&Design(PROVIDER): By: . y�B : Signature Signature Ralph Sartain Gregg Payne _Printed Name ~Printed Name Fire Chief Owner Title Title 9/22/2021 Date Date Purchase Order No, (W-9 is to be submitted with this signed Agreement) • Page 6 of 6: Agreement between the City of Ashland and Gregg Payne Art&Design GREGG • PAYNE ART & DESIGN • 7491 Hwy 23.8 Jacksonville OR 97530 9/9/2021 • Proposal for SOFEE FireWorks Curriculum FireWorks logo redesign and adaptation to Southern Oregon Fire Ecology Education [SOFEE] identity and design elements for print and web use. [1 2 hrs] Curriclum Template - Design layout for replication. [5 hrs] .Nature Journal design work to include'cover page, back cover and 10 designed nature journal guidance pages based on the SOFEE Curriculum, inspired by the Redi-Jedi Journal. [20 hrs] Mock-ups and print ready art provided as jpeg's, pdf's and vector files in adobe illustrator. • 37 hrs @ 80. per hr. $2,960. • • • • • greggpaynet mac.com greggpayne.com 530 228-3399 • • • CERTIFICATION OF EXEMPTION FROM WORKERS' COMPENSATIoN INSURANCE REQUIRE ENTS • Contractor is exempt from the requlirement to obtain workers compensation insurance pursuant to ORS, Chapter 656 for the following reason. Contractor is to initial the appropriate box as follows: SOLE PROPRIETOR t 1nitinh • Contractor is a sole proprietor,and • Contractor has no employees,and • • Contractor will not him employees or subcontractors to perform this contract. • CORPORATION—FOR PROFIT (initials) • Contractor's business is incorporated;and • Ml employees of the corporation are officers and dile'tors and base a substantial ownership intere;sr& in the corporation,and • All Work will be performed by the officers and directors; Contractor will not hire other employees or seb,„eontractors to perform this contract. _ CORPORATION-NONPROFIT t3rtiti is) I. Contractor's bininess is incorporated as a nonprofit corporation,and • Contractor has no employees;all work is performed by voltuttcer,and • • Contra-dor will not hire employees or subcontractors to perform this contract. PARTNERSHIP onit:tls) • Contractor is r7 partnership,and • Contractor has no employees,and • • Ali work will be performed by the paIrnen;Contractor will.not hire employees or subcontractors to perform this contract,and • Contruolor is not engaged in work performed in direct connection with the construction,alteration,repair, improvement,moving Or demolition:of an improvement to real pmperty or appurtenances thereto.** LIMITED LIABILITY COMPANY (initials) • Contractor is a limited liability company,and • Contractor has no employees,and All work will be Bed 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, iirrtpt +wcntett,tttt%IHg yr destiolition ofarn improvement to mil propertyor appurtenances thereto.'' Ce=2— I (Sign, o' u rk'd Signer) (T. .Ip) T.) 7 V �`)a }11 � (-(:) .e _.. (Auth it+d Signer's Title) *NOTE: UnderOAR434r-3O-USO a shareholder has a'tsub-Aantial ownership"interest lithe shareholder ows 1(A'o 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 ail shareholders. UUridtr certain circucnstnnoes partnerships and limited liability companies can claim en exemption even when performing construction work. The requirements for.thisextrinption are complicated. Consult with City Attorney's Office before an exemption request is accepted firma u contractor who will perform.constraction work. ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) . 4.1.....------ ... 03/19/2021 THIS CERTIEICATEIS 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 pollcy(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). CONTACT Judi Johnson PRODUCER NAME: StateFarm Judi Johnson State Farm Insurance PHONE 541-899-1875 (AIC.No.Extl: (A/C,No): Street EMAIL ) judi.ohnson.cmId statefarm Com O645 N 5th 0ADDRESS: Jacksonville,OR 97530-9659 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: State Farm Fire and Casualty Company 25143 INSURED INSURER B Gregg Payne Art&Design INSURER C: 7491 Highway 238 INSURER D: Jacksonville,OR 97530-9139 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. BTR ADDLTYPE OF INSURANCE IVSD SUER POLICY NUMBER (MMIDD//YYY YY) (F MM/DD!!YYYY) LIMITS CY EXP LTR INSD WVD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE IX1 OCCUR PREMISES(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 97-CP-S421-2 04/03/2020 04/03/2022 PERSONAL&ADV INJURY $ 1,000,000 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PR - JECOT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY[ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT. $ ' (Ea accident) _ ANY AUTO BODILY INJURY(Per person) ' $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED . PROPERTY DAMAGE $ , AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ — EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N N l A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be 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 City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. 20 East Main Street AUTHORIZED REPRESENTATIVE Ashland,OR 97520 Judi Johnson by electronic signature I . ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016