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HomeMy WebLinkAbout2020-029 PO 20200338- JD Dietrich Purchase Order spril CITY RECORDER ,a Fiscal Year 2020 Page: 1 of: 1 l 3i1a W j ruj 1 1t'ig maq4g =3 71/ LG B City of Ashland ATTN: Accounts Payable20 E. Main Purchase L. Ashland, OR 97520 Order# 20200338 T Phone: 541/552-2010 O Email: payable@ashland.or.us • V H C%O Fire and Rescue Department E JD DIETRICH I 455 Siskiyou Blvd 2874 N ROSEDALE AVE p Ashland, OR 97520 . O BOISE, ID 83704 Phone: 541/482-2770 R T Fax: 541/488-5318 E sr a i 7-t ' is a ' o fl E 13i � �,. —r_s i el-r- l 1 �.t_Isl 1, _ P'T -2 — David Shepherd. y6FT:A a , _. _- 02/18/2020 5221 Ti ! Ci Accounts Payable Install Stryker Loading System 1 Installation of Stryker cot loading systems 1 $3,300.0000 $3,300.00 (3) Each-$1,100 per ambulance , Goods &Services Agreement(Less than $25,000) Completion date: 03/27/2020 . Project Account: E-000751-999 ***************GL SUMMARY*************** 071200-.703000 $3,300.00 I I. L • I _ By: ril&SDate: ?i • i 1 20I/°' Authorized Signatures . . _,_ _ $3 300.00 �j /it, j Y FORM #3 vi)4Aia,e a ✓d `I T O F A f�� � ± erytei,,,,, ( v1/41)1ASH LAN D REQUISITION 0 / Date of request: .., -/17// i7 - Required date for delivery: 03 i J'9--/°f • Vendor Name JD Dietrich 4fr Address,City,State,Zip 2874 N Rosedale Ave, Boise ID, 83704 y,/ 0-4- , Contact Name&Telephone Number jddietrich795@Gmail.Com /� 1/`l T " (7,0 Email address , A ' o !!, / (I? SOURCING METHOD ❑ Exempt from Competitive Bidding ❑ Emergency ❑ Reason for exemption: ❑ Invitation to Bid - ❑ Form#13,Written findings and Authorization ❑ AMC 2.50 Date approved by Council: . 0 Written quote or proposal attached, ID 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 Date approved by Council: 0 State of Oregon ❑ Direct Award (Attach copy of council communication)- ! Contract# ❑ Verbal/Written bid(s)or proposal(s) ❑ Request for Qualifications(Public Works) 0 State of Washington Date approved by Council: Contract# _(Attach copy of council communication) ❑ Other government agency contract Intermediate Procurement 0 Sole Source 1 Agency GOODS&SERVICES ❑■ Applicable Form(#5,6,7 or 8) Contract#-- Greater than$5,000 and less than$100,000 0 Written quote or proposal attached Intergovernmental Agreement ❑ (3)Written bids&,solicitation attached ❑ Form#4,Personal Services$5K to$75K Agency PERSONAL SERVICES ❑ Special Procurement ❑i 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 approved/signed by ❑ Less than$35,000,by direct appointment -❑ Written quote or proposal attached City Administrator.AMC 2.50.070(4) ❑ (3)Written proposals&solicitation attached Date approved by Council: 0 Annual cost to City exceeds$25,000,Council ❑ Form#4,Personal Services$5K to$75K Valid until: — (Date) approval required.(Attach copy of council communication) Description of SERVICES Total Cost Installation of abulance gurney power load systems. `'r�, ✓ e6 1F L�0-414 � 9�i¢�+.g�0 202oo2�j6 '3�30Qr.•..._._ : ..,._ Item # Quan qty Unit Description of MATERIALS Unit Price Total Cost - ❑ Per attached quote/proposal '¢¢TOTAL`COST' / Project Number 000751 999_ Account Number - Account Number 071200 - 703000 Account Number *Expenditure must be charged to 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 City's public contracting requirements have been satisfied. Employee: ��' e O(� Department Head: �'{' /�, o or greater than$5,000) Department Manager/Superv,----. City Administrator: Otc (Equal t. .r greater than$25,000) Funds appropriated for current fiscal year:. YES /'NO - 1 Deputy Finance Director-(Equal to or greaterthan,$5,000) Date Comments: - Form#3-Requisition • GOODS AND SERVICES AGREEMENT (LESS THAN$25,000) PROVIDER: JD Dietrich CITY O.F PROVIDER'S CONTACT: JD Dietrich ASHLAN D 20 East Main Street ADDRESS: 2874 N Rosedale Ave, Boise ID 83704 Ashland, Oregon 97520 Telephone: 541/488-5587 PHONE: 208-901-2860 Fax: 541/488-6006 EMAIL;jddietrch795@gmail.com This Services Agreement (hereinafter "Agreement") is entered into by and between the City of Ashland, an Oregon municipal corporation(hereinafter "City")and JD Dietrich; ("hereinafter"Provider"), for installation of Stryker floor plates and load systems in three(3) ambulances. 1. PROVIDER'S OBLIGATIONS 1.1 Install Stryker floor plates and load systems in three (3) ambulances 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 policies of liability insurance including commercial general liability insurance with a combined single limit, or the equivalent, of not less th o million dollars)per occurrence for Bodily Injury and Property Damage. / 1 MO teas 1.2.1 The insurance required in this Article shall include the following coverages: %3 , 't • Comprehensive General or Commercial General Liability, including personal injury, contractual liability, and products/completed operations coverage;and • Automobile Liability. 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 the Effective Date of this Agreement; and • Be evidenced by a certificate or certificates of such insurance approved by the City. Page 1 of 5: Agreement between the City of Ashland and JD Dietrich 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 ofsupplier 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 $21,507.75 or more, Provider is 4 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 whelre it will be seen by all employees. 2. CITY'S OBLIGATIONS • 2.1 City shall pay Provider the sum of$3,300.00 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$3,300.00 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. 3.2 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 insurance,paid leave, and retirement. 3.4 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. 3.5 This Agreement may be amended only by written instrument executed with the same formalities as this Agreement. Page 2 of 5: Agreement between the City of Ashland and JD Dietrich 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. 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. I 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 for the Goods. Provider is responsible and liable for loss or damage until final inspection and acceptance of 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 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 arenew, current, and ;fully warranted by the l 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 complete written Estimate#1094 dated 12/02`/2019. , 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 dr 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; • Page 3 of 5: Agreement between the City of Ashland and JD Dietrich 5.1.3 Initiation of an action or proceeding for damages, specific performance, or declaratory or injunctive relief; 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 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 27, 2020, 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. 6.2.2 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 than 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 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: Ashland Fire &Rescue Attn: David Shepherd 455 Siskiyou Blvd. Ashland, Oregon 97520 Phone: (541) 488-2770 • With a copy to: City of Ashland Attn: Legal Department 20 E. Main Street Ashland, OR 97520 Phone: (541) 488-5350 If to Provider: S _ JD Dietrich 2874 N Rosedale Ave r Boise, ID 83704 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. � Page 4 of 5: Agreement between the City of Ashland and JD Dietrich , 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) 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,lordinances 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. K 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 AS AND: JD DIETRIC .. (P O IDER): By: G�% � By: Si:E.ture Signature 2u' l G J✓,L/I� Printed Name Printed ame F-3(7 teig Title Title ,V_/ 2002 0 P? Date Date Purchase Order No. 01—©AZ:9/9 J"Fe (W-9 is to b submitted with this signed agreement.) Page 5 of 5: Agreement between the City of Ashland and JD Dietrich • JD Dietrich 2874 N Rosedale Ave ! hMaste9 VISA DISCOVER Boise, ID 83704 jddietrich795@gmail.com Estimate ADDRESS ESTIMATE# 1094 Daivd Roselip DATE 12/02/2019 Ashland Fire & Rescue !EXPIRATION DATE 01/02/2019 Ashland, Oregon - I ACTIVITY' _ 3 ! I,QTY RATE AMOUNT 1 Install customer supplied Stryker floor plate and load system. 1 1,100.00 1,100.00 #1069 Install customer supplied Stryker Floorplate and load system. 1 1,100.00 1,100.00 #963 Install customer supplied Stryker Floorplate and load system 1 1,100.00 1,100.00 #845 • Customer will supply a vehicle bay for the installation. TOTAL $3,300.00 Thank you for your business. Price per unit is only valid if all 3 are installed on the same trip. Cancellation Policy-If the customer cancels within 48 hours' of the start time there will be penalty of 10%of the estimate or$250,whichever is more. . - I • II i f Invoice is Due Upon Receipt DATE(MM/DD/YYYY) AC 0 CERTIFICATE OF LIABILITY INSURANCE 1/27/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR!ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsem'ent(s). CONTACT PRODUCER Liberty Mutual Insurance NAME: PO Box 188065 PHONE FAX Fairfield, OH 45018 (A/C. ,Ext): 800-962-7132 (A/c,No): 800-845-3666 ADDRESS: BusinessService@LibertyMutuaLcom INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: 0i Security Insurance Company 24082 INSURED INSURER B: Gerald Dietrich INSURERC: DBA JD Dietrich 2874 N Rosedale Ave INSURERD: Boise ID 83704 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 53797352 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY W /YEFF POLICY EXP LIMITS LTR INS!) POLICY NUMBER (MM/DD/YYYY) (MM/DDYYY) A `/ COMMERCIALGENERALLIABILITY ✓ BKS60896501 1/27/2020 1/27/2021 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTE CLAIMS-MADE ✓ OCCUR ! PREMISES(Ea occurrence) $1,000,000 MED EXP(Any one person) X000 PERSONAL&ADV INJURY $1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE _ $2,000,000 PRo- ✓ POLICY JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 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 LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N I STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Ashland,its elected officials,officers and employees are Additional Insured if required by written contract or written agreement subject to General Liability Blanket Additional Insured Provision. This Policy is Primary and we will not ask for contribution of the Policy issued to the Additional Insured. CERTIFICATE HOLDER CANCELLATION Cityof Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 E Main St ACCORDANCE WITH THE POLICY PROVISIONS. Ashland OR 97520 • AUTHORIZED REPRESENTATIVE 9ulto Julie Thomas I©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 53797352 1 60896501 1 20-21 Master Certificate 1 Julie Thomas 1 1/27/2020 11:22:25 AM (PST) 1 Page 1 of 1 Important Information GEICO. Idaho Insurance ID Card geico.com 1-800-841-3000 • Here are your Policy Identification Cards. Two cards GEICO ADVANTAGE INSURANCE COMPANY have been provided for each vehicle insured. P.O. Box 509090 •San Diego, CA 921:50`9090 Please destroy your old cards when the new cards become effective. Policy Number Effective Date Expiration Date Due to space limitations on the ID card, only the 4353-20-91-92 01-24720 07-24-20 Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please Year Make Model; Vehicle ID No. log onto geico.corn or reference the Drivers section 2004 GMC YKN XL DNL t' 1 GKFK66U74J281784 of your Declarations Page,which is included with Insured: your insurance packet. �� Gerald Arthur Dietrich Jr 2874 N Rosedale Ave Please notify us promptly of any change in your Boise ID 83704-5873 address to be sure you receive all important policy documents. Prompt notification will enable us to service you better. s n Your policy is recorded under the name and policy number shown on the card. If you would like additional ID cards, you can go online to geico.com or call us at 1-800-841'-3000. GERALD ARTHUR DIETRICH JR 2874 N ROSEDALE AVE BOISE ID 83704-5873 GEICO. Idaho Insurance ID Card geico.com 11-800-841-3000 GEICO ADVANTAGE;INSURANCE COMPANY P.O. Box 509090• San Diego, CA 92150-9090 Policy Number Effective Date Expiration Date 4353-20-91-92 01-24-201+;? 07-24-20 Year Make Model: Vehicle ID No. 2004 , GMC YKN 1GKFK66U74J281784 Insured: Gerald Arthur Dietrich kJr 2874 N Rosedale Ave Boise ID 83704-5873 s'' �F What to do at the time of an accident. •.,Do not admit fault. • Do not reveal the limits of your liability coverage to anyone. • Exchange contact information; get year, make, model, plate number,insurance carrier and policy number of all involved.Also, identify witnesses and collect contact information. • ,Contact the police or 911 if applicable. • Contact GEICO by calling 1-800-841-3000 or visit geico.com to report the accident. U-4-ID(10-09) What to do at the time of an accident. • Do not admit fault. • Do not reveal the limits of your liability coverage to anyone. • Exchange contact information; get year, make, model, plate number,insurance carrier and policy number of all involved.Also, identify witnesses and collect contact information. • Contact the police or 911 if applicable. • Contact GEICO by calling 1-800-841-3000 or visit geico.com to report the accident. U-4-ID(10-09) . • CERTIFICATION OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE REQUIREMENTS ti Con ctor is exempt from the requirement to obtain workers compensation insurance pursuant to ORS • • s 'r 656 for the following reason. Contractor is to initial the appropriate box as follows: SOLE PROPRIETOR ( witials) • Contractor is a sole pfoprietor,and • Contractor has nolemployees,and • Contractor'will not hire employees or subcontractors to perform this contract. ' I CORPORATION—FOR PROFIT (Initials) • Contractor's'business is incorporated;and •- All employees 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 or subcontractors 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 performedin 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 company,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 a urtenances thereto.** (S a attire of Aut i orized Signer) (Date) (Aut onzed Signer's Title) - *NOTE: Under OAR436-50-050 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. ) �