HomeMy WebLinkAbout2011-188 Contract - Lile International Contract for GOODS AND SERVICES
CITY OF CONTRACTOR: Lile International Companies
-1S H LAND CONTACT: Michael Spencer
20 East Main Street
Ashland, Oregon 97520 ADDRESS: 1957 Claxter Road NE, Salem, OR 97303
Telephone: 541/488-6002 (Corporate: 8060 SW Pfaffle St, Ste 200, Tigard, OR 97223)
Fax: 541/488-5311
TELEPHONE: 503-393-0110
DATE AGREEMENT PREPARED: 06/10/2011 FAX: 503-393-3561
BEGINNING DATE: August 24, 2011 COMPLETION DATE: September 5, 2011
COMPENSATION: "Guaranteed Not to Exceed $10,697.59" per Binding Estimate attached as Exhibit C.
GOODS AND SERVICES TO BE PROVIDED: Lile/North American Van Lines to provide moving services for
Bruce and Joanne Dickens from Park City, Utah to Ashland, Oregon. Binding estimate includes packing labor
and materials, full coverage valuation with a $0.00 deductible, loading, transportation and unloading, shipment
of vehicle (Kia Sole 2010), third party services(connect/re-connect washer and dryer, install front load washer
kit for LG model) and guaranteed pickup for August 25 2011. Binding Estimate is attached as Exhibit C.
ADDITIONAL TERMS:
NOW THEREFORE, pursuant to AMC 2.50.090 and after consideration of the mutual covenants contained herein the
CITY AND CONTRACTOR AGREE as follows:
1. All Costs by Contractor: Contractor shall, provide all goods as specified above and shall at its own risk and
expense, perform any work described above and, unless otherwise specified, furnish all labor,equipment and
materials required for the proper performance of such work.
2. Qualified Work: Contractor has represented, and by entering into this contract now represents,that any personnel
assigned to the work required under this contract are fully qualified to perform the work to which they will be assigned
in a skilled and worker-like manner and, if required to be registered, licensed or bonded by the State of Oregon, are
so registered, licensed and bonded. Contractor must also maintain a current City business license.
3. Completion Date: Contractor shall provide all goods in accordance with the standards and specifications, no later
than the date indicated above and start performing the work under this contract by the beginning date indicated
above and complete the work by the completion date indicated above.
4. Compensation: City shall pay Contractor for the specified goods and for any work performed, including costs and
expenses, the sum specified above. Payments shall be made within 30 days of the date of the invoice. Should the
contract be prematurely terminated, payments will be made for work completed and accepted to date of termination.
Compensation under this contract, including all costs and expenses of Contractor, is limited to$25,000.00, unless a
separate written contract is entered into by the City.
5. Ownership of Documents:All documents prepared by Contractor pursuant to this contract shall be the property of
City.
6. Statutory Requirements: ORS 2798.220, 2798.225, 2798.230, 2798.235, ORS Chapter 244 and ORS 670.600 are
made part of this contract.
7. Living Wage Requirements: If contractor is providing services under this contract and the amount of this contract
is$18,890 or more, Contractor is required to comply with chapter 3.12 of the Ashland Municipal Code by paying a
living wage,as defined in this chapter, to all employees performing work under this contract and to any subcontractor
who performs 50%or more of the work under this contract.Contractor is also required to post the notice attached
hereto as Exhibit B predominantly in areas where it will be seen by all employees.
8. Indemnification: Contractor agrees to defend, indemnify and save City, Its officers,employees and agents harmless
from any and all losses, claims, actions, costs,expenses,judgments,subrogations, or other damages resulting from
injury to any person(including injury resulting in death),or damage(including loss or destruction)to property, of
whatsoever nature arising out of or Incident to the performance of this contract by Contractor(including but not limited
to,Contractor's employees, agents,and others designated by Contractor to perform work or services attendant to this
contract). Contractor shall not be held responsible for any losses, expenses,claims, subrogations,actions, costs,
judgments, or other damages, directly, solely,and proximately caused by the negligence of City.
9. Termination:
a. Mutual Consent. This contract may be terminated at any time by mutual consent of both parties.
b. City's Convenience. This contract may be terminated at any time by City upon 30 days'notice in writing
and delivered by certified mail or in person.
C. For Cause. City may terminate or modify this contract in whole or in part, effective upon delivery of
Contract for Goods and Services, Revised 06/30/2011,Page 1 of 5
written notice to Contractor,or at such later date as may be established by City under any of the following
conditions:
i. If City funding from federal, state, county or other sources is not obtained and continued at levels
sufficient to allow for the purchase of the indicated quantity of services;
ii. If federal or state regulations or guidelines are modified, changed,or interpreted in such a way
that the services are no longer allowable or appropriate for purchase under this contract or are
no longer eligible for the funding proposed for payments authorized by this contract; or
iii. If any license or certificate required by law or regulation to be held by Contractor to provide the
services required by this contract is for any reason denied, revoked, suspended, or not renewed.
d. For Default or Breach.
I. Either City or Contractor may terminate this contract in the event of a breach of the contract by
the other. Prior to such termination the party seeking termination shall give to the other party
written notice of the breach and intent to terminate. If the party committing the breach has not
entirely cured the breach within 15 days of the date of the notice, or within such other period as
the party giving the notice may authorize or require, then the contract may be terminated at any
time thereafter by a written notice of termination by the party giving notice.
it. Time is of the essence for Contractor's performance of each and every obligation and duty under
this contract. City by written notice to Contractor of default or breach, may at any time terminate
the whole or any part of this contract if Contractor fails to provide services called for by this
contract within the time specified herein or in any extension thereof.
iii. The rights and remedies of City provided in this subsection(d)are not exclusive and are in
addition to any other rights and remedies provided by law or under this contract.
e. Obligation/Liability of Parties. Termination or modification of this contract pursuant to subsections a, b, or
c above shall be without prejudice to any obligations or liabilities of either party already accrued prior to such
termination or modification. However, upon receiving a notice of termination(regardless whether such notice is
given pursuant to subsections a, b, c or d of this section, Contractor shall immediately cease all activities under
this contract, unless expressly directed otherwise by City in the notice of termination. Further, upon termination,
Contractor shall deliver to City all contract documents, information,works-in-progress and other property that are
or would be deliverables had the contract been completed. City shall pay Contractor for work performed prior to
the termination date if such work was performed in accordance with the Contract.
10. Independent Contractor Status: Contractor is an independent Contractor and not an employee of the City.
Contractor shall have the complete responsibility for the performance of this contract.
11. Non-discrimination Certification:The undersigned certifies that the undersigned Contractor has not discriminated
against minority,women or emerging small businesses enterprises in obtaining any required subcontracts.
Contractor further certifies that it shall not discriminate in the award of such subcontracts, if any. The Contractor
understands and acknowledges that it may be disqualified from bidding on this contract, including but not limited to
City discovery of a misrepresentation or sham regarding a subcontract or that the Bidder has violated any
requirement of ORS 279A.110 or the administrative rules implementing the Statute.
12. Asbestos Abatement License: If required under ORS 468A.710,Contractor or Subcontractor shall possess an
asbestos abatement license.
13. Assignment and Subcontracts: Contractor shall not assign this contract or subcontract any portion of the work
without the written consent of City. Any attempted assignment or subcontract without written consent of City shall be
void. Contractor shall be fully responsible for the acts or omissions of any assigns or subcontractors and of all
persons employed by them, and the approval by City of any assignment or subcontract shall not create any
contractual relation between the assignee or subcontractor and City.
14. Use of Recyclable Products: Contractor shall use recyclable products to the maximum extent economically feasible
in the performance of the contract work set forth in this document.
15. Default. The Contractor shall be in default of this agreement if Contractor. commits any material breach or default of
any covenant,warranty, certification,or obligation it owes under the Contract; if it loses its QRF status pursuant to
the QRF Rules or loses any license, certificate or certification that is required to perform the work or to quality as a
QRF if Contractor has qualified as a QRF for this agreement; Institutes an action for relief in bankruptcy or has
instituted against it an action for insolvency; makes a general assignment for the benefit of creditors;or ceases doing
business on a regular basis of the type identified in its obligations under the Contract; or attempts to assign rights in,
or delegate duties under, the Contract.
16. Insurance. Contractor shall at its own expense provide the following insurance:
a. Worker's Compensation insurance in compliance with ORS 656.017, which requires subject employers to
provide Oregon workers'compensation coverage for all their subject workers
b. General Liability insurance with a combined single limit, or the equivalent, of not less than Enter one:
$200,000, $500,000, $1,000,000, $2,000,000 or Not Applicable for each occurrence for Bodily Injury and Property
Damage. It shall include contractual liability coverage for the indemnity provided under this contract.
C. Automobile Liability insurance with a combined single limit,or the equivalent,of not less than Enter one:
$200 000 $500,000, 1 000 000 or Not Applicable for each accident for Bodily In'ury and Property Damage,
Contract for Goods and Services,Revised 06/30/2011,Page 2 of 5
including coverage for owned, hired or non-owned vehicles, as applicable.
d. Notice of cancellation or chance. There shall be no cancellation, material change, reduction of limits or
intent not to renew the insurance coverage(s)without 30 days'written notice from the Contractor or its insurer(s)to
the City.
e. Additional Insured/Certificates of Insurance. Contractor shall name The City of Ashland, Oregon,and its
elected officials,officers and employees as Additional Insureds on any insurance policies required herein but only
with respect to Contractor's services to be provided under this Contract.As evidence of the insurance coverages
required by this Contract, the Contractor shall furnish acceptable insurance certificates prior to commencing work
under this contract. The contractor's insurance is primary and non-contributory. The certificate will specify all of the
parties who are Additional Insureds. Insuring companies or entities are subject to the City's acceptance. If
requested, complete copies of insurance policies,trust agreements, etc. shall be provided to the City. The
Contractor shall be financially responsible for all pertinent deductibles,self-insured retentions and/or self-
Insurance.
17. Governing Law;Jurisdiction;Venue: This contract shall be governed and construed in accordance with the laws
of the State of Oregon without resort to any jurisdiction's conflict of laws, rules or doctrines. Any claim,action, suit or
proceeding (collectively, "the claim")between the City(and/or any other or department of the State of Oregon)and
the Contractor that arises from or relates to this contract shall be brought and conducted solely and exclusively within
the Circuit Court of Jackson County for the State of Oregon. If, however,the claim must be brought in a federal
forum,then it shall be brought and conducted solely and exclusively within the United States District Court for the
District of Oregon filed in Jackson County, Oregon. Contractor, by the signature herein of its authorized
representative, hereby consents to the in personam jurisdiction of said courts. In no event shall this section be
construed as a waiver by City of any form of defense or immunity, based on the Eleventh Amendment to the United
States Constitution,or otherwise,from any claim or from the jurisdiction.
18. THIS CONTRACT AND ATTACHED EXHIBITS CONSTITUTE THE ENTIRE AGREEMENT BETWEEN THE
PARTIES. NO WAIVER, CONSENT, MODIFICATION OR CHANGE OF TERMS OF THIS CONTRACT SHALL
BIND EITHER PARTY UNLESS IN WRITING AND SIGNED BY BOTH PARTIES. SUCH WAIVER,CONSENT,
MODIFICATION OR CHANGE, IF MADE, SHALL BE EFFECTIVE ONLY IN THE SPECIFIC INSTANCE AND FOR
THE SPECIFIC PURPOSE GIVEN. THERE ARE NO UNDERSTANDINGS,AGREEMENTS, OR
REPRESENTATIONS, ORAL OR WRITTEN, NOT SPECIFIED HEREIN REGARDING THIS CONTRACT.
CONTRACTOR, BY SIGNATURE OF ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES THAT
HE/SHE HAS READ THIS CONTRACT, UNDERSTANDS IT,AND AGREES TO BE BOUND BY ITS TERMS AND
CONDITIONS.
19. Nonapproprlations Clause. Funds Available and Authorized: City has sufficient funds currently available and
authorized for expenditure to finance the costs of this contract within the City's fiscal year budget. Contractor
understands and agrees that City's payment of amounts under this contract attributable to work performed after the
last day of the current fiscal year is contingent on City appropriations, or other expenditure authority sufficient to allow
City in the exercise of its reasonable administrative discretion, to continue to make payments under this contract. In
the event City has insufficient appropriations, limitations or other expenditure authority.City may terminate this
contract without penalty or liability to City, effective upon the delivery of written notice to Contractor,with no further
liability to Contractor.
20, Prior Approval Required Provision.Approval by the City of Ashland Council or the Public Contracting Officer is
required before any work may begin under this contract.
21. Certification. Contractor shall sign the certification attached hereto as Exhibit A and herein incorporated by
reference.
Byt/-- or. By of As hl
�`' Signature Deli;artment Head
Print Name Print Name
�� y�1�.l 1%'9 1 d✓ gl11
Title Date
W-9 One copy of a W-9 is to be submitted with
the signed contract. Purchase Order No.
Contract for Goods and Services, Revised 06/302011,Page 3 of 5
EXHIBIT A
CERTIFICATIONS/REPRESENTATIONS: Contractor, under penalty of perjury, certifies that(a) the
number shown on the attached W-9 form is its correct taxpayer ID (or is waiting for the number to be
issued to it and (b) Contractor is not subject to backup withholding because (i) it is exempt from
backup withholding or(ii) it has not been notified by the Internal Revenue Service (IRS) that it is
subject to backup withholding as a result of a failure to report all interest or dividends, or(iii) the IRS
has notified it that it is no longer subject to backup withholding. Contractor further represents and
warrants to City that (a) it has the power and authority to enter into and perform the work, (b) the
Contract, when executed and delivered, shall be a valid and binding obligation of Contractor
enforceable in accordance with its terms, (c)the work under the Contract shall be performed in
accordance with the highest professional standards, and (d) Contractor is qualified, professionally
competent and duly licensed to perform the work. Contractor also certifies under penalty of perjury
that its business is not in violation of any Oregon tax laws, and it is a corporation authorized to act on
behalf of the entity designated above and authorized to do business in Oregon or is an independent
Contractor as defined in the contract documents, and has checked four or more of the following
criteria:
(1) 1 carry out the labor or services at a location separate from my residence or is in a
specific portion of my residence, set aside as the location of the business.
(2) Commercial advertising or business cards or a trade association membership are
purchased for the business.
(3) Telephone listing is used for the business separate from the personal residence listing.
(4) Labor or services are performed only pursuant to written contracts.
(5) Labor or services are performed for two or more different persons within a period of one
year.
(6) 1 assume financial responsibility for defective workmanship or for service not provided
as evidenced by the ownership of performance bonds, warranties, errors and omission
insurance or liability insurance relating to the labor or services to be provided.
Contractor (Date)
Contract for Goods and Services,Revised 06/30/2011,Page 4 of 5
Kan Olson
From: Pat Touzios [Pat.Touzios @SIRVA.com]
Sent: Thursday, August 11, 2011 11:10 AM
To: 'olsonk @ash land.or.us'
Cc: 'Christina Linn'
Subject: certificate of insurance 654317
Attachments: 36765_20110811140540.pdf
Attached is the certificate of Bruce and Joanne Dickens.
Thank you,
Pat Touzios
pat.touzios(@sirva.com
Senior Insurance Administrator
Van Line Insurance Compliance Department
630-570-3014 Phone
630-570-8990 Fax
CONFIDENTIALITY NOTICE: The information contained in this e-mail message, including any
attachments, is for the sole use of the intended recipient(s) and may be privileged and
confidential. Any unauthorized review, use, disclosure or distribution is prohibited. If you
are not the intended recipient, please notify the sender by reply e-mail and delete the
original message and all copies from your computer.
1
--'ON DATE NWA D1YYYY)
ACORO' CERTIFICATE OF LIABILITY INSURANCE 08111201
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ACORD25(201005) 019W2010ACORD00PP01100HA0 rights reserved.
TheACORD name and logo am regstened marks dfACORD
ACd a ADDMONAL REMARKS SCHEDULE
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AGENCY Am Rsk hsurace Senkm West,Inc. INAMEDINSURED
POLICY NUMBER MWZY 59094,MWTT 13060,WC,F2S1456582-011 North American Van Lines,Inc.
CARRIER NAIC CODE ffFEcnVE DATE 04101/2011
Old RWffw kmrarce Ca nparrry 24147
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ONAORINARKS _�i3[ =ft
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
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MVERAGE APPLIES CNLY WHLE UNDER TIE AUTHORITY OF NORTH AMERICAN VAN LINES,INC.THE CITY OF ASHLAND,
)REGOR AND ITS ELECTED OFFICIALS,OFFICERS,AND EMPLOYEES ARE ADDED AS AODITIONAL INSUREDS FOR GENERAL
kND AUTO UABUTY AS REQUIRED BY WRITTEN CONTRACT BUT UMITED TO TIE OPERATIONS OF TIE INSURED UNDER SAID
MNMCK SUBJECT TO TIE POLICY TERMS,CCNDITTONS AND ELUSIONS."'WORKERS OOMP.POLICY IS AN
kLL-SlA'TES POLICY"'
ACO RD101(200&01) 02008AOOFDCUWOPAMUM rights reserved
The ACORD rem and logo are reptered marks ofACOPD
Certificate does rut reed to be mrwm d next year.
Kars Olson
From: Kameko Reynolds [ktr @propelinsurance.com] on behalf of Certificates
[certificates @propelinsu ranee.com]
Sent: Thursday, August 11, 2011 2:47 PM
To: olsonk @ashland.or.us
Cc: Christina Linn; michael.spencer @ lile.net; bill.jackson @lile.net; janet.gonzales @lile.net
Subject: Certificate - Lile International Companies / City of Ashland
Attachments: KTR00_45924_53144.pdf
Attached please find a copy of the certificate of insurance you requested.
If you need further assistance or corrections contact us directly.
Thank you,
Certificate Processing Unit
Propel Insurance
Commercial Insurance
1201 Pacific Avenue, Suite 1000
Tacoma, WA 98402-4321
253.761.3230 Direct
wwm Zpeli nsu rance.com
Effective immediately, Propel Insurance will no longer issue certificates of insurance not handled in accordance
with statutory laws. We will only issue the most current edition of the ACORM certificates of insurance.
Please note, a certificate of insurance is simply a synopsis or summary of the designated insurance policy and
does not/ cannot modify or amend the referenced insurance policy or confer any right upon the certificate
holder. In addition, the certificate holder is owed no duty to be notified in the event the insurance policy is
cancelled. Please contact your state department of insurance for further explanation or inquiries.
mail.propelinsurance.com made the following annotations
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------------------------------------------------------'--------------
1
Client#: 124414 LILEINTE
A'CORM CERTIFICATE OF LIABILITY INSURANCE DATO/YYYY)
an 1/20 vzo11
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 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 NAME, Jenny Healy
Propel Insurance PHONE 800 499-0933 866.577.1326
Seattle Commercial Insurance R:iih@propelinsurance.com Etl: ac,Na:
925 4th Ave,Suite 3200 ADDRESS: jlh @propelinsurance.com
Seattle,WA 98104 CUSTOMER ID#:
INSURER(S)AFFORDING COVERAGE NNC#
INSURED INSURER A:American Automobile Insurance C 21849
806 International Companies INSURER B:Vanliner Insurance Company
Tigard,OR R 9 972 23 Street,Suite 200 SAIF Corporation
INSURER C:
Tiga72
INSURER 0
• INSURER E
NSURER 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.
TYPE OF INSURANCE POLICY EFF POLICY EXP
POLICY NUMBER MMIDD MMIDD LIMIT
A GEIIERAL LIABILITY X X MZG80929459 3/31/2011 03/3112012 EACH OCCURRENCE $1000000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea oauoence 1 $1 000000
CLAIMS�MADE Fx1 OCCUR MED EXP(My..person) $20,000
X WA Stop Gap PERSONAL B ADV INJURY $1,000,000
GENERAL AGGREGATE E2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO E2,000,000
POLICY PRO, X LOC E JECT
B AITOMOBILELUIBILITY X TRV404370302 12/01/2010 1210112011 COMBINEDSINGLE LIMIT
(Ee ecddem) $1,000,000
X ANY AUTO Physical Damage: BODILY INJURY(Per Parson) $
ALL OWNED AUTOS Comp Ded-$1,000
SCHEDULEDAUTOS Coll Ded-$1,000 BODILY INJURY(Per axitlenp 8
PROPERTY DAMAGE $
HIRED AUTOS Hired Comp Ded- (Per accident)
NON-OWNEDAUTOS $100 $
Trlr Intrchng •$50,000 Limit $
B x UMBRELU LNB X OCCUR X UMV404370006 12/01L2010 12/0112011 EACH OCCURRENCE ES DDD DDD
EXCESS LIAB CLAIMS-MADE AGGREGATE E5 000 000
DEDUCTIBLE $
X RETENTION 10,000 $
C WORKERS COMPENSATION 745431 10/01/2010 1010112011 X WC STATU- OTH-
AND EMPLOYERS'LIABILITY
OFFICER/MEMBEREXCLUERrE ECUTIVEY[ WA E.L.EACH ACCIDENT $1,000,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
It yas,tlenAt*under
DESCRIPTION OF OPERATIONS balox E.L.DISEASE-POLICY LIMIT $1000000
A Motor Truck Cargo MZG80929459 3/31/2011 031311201 $1,000,000 per
$2,500 Ded/Oc, r Occurrence
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addltlonal RamaH Schedule,If mom epau is noulrW)
RE:All operations performed by the Named Insured. .
The City of Ashland,Oregon,and its elected officials,officers and employees are additional insureds per
the attached endorsement.
CERTIFICATE HOLDER CANCELLATION
City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Attn:Karl Olson THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Purchasing Representative
90 N Mountain Avenue AUTHORIZED REPRESENTATIVE
Ashland,OR 97520
01988.2009 ACORD CORPORATION.All rights reserved.
ACORD 25(2009109) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S7229661M634883 KTR00
Why We Are Using the Latest ACORD 25 Certificate of Insurance
In September 2009, ACORD revised the ACORD 25 Certificate of Insurance form. One of the major
changes was the removal of the cancellation notice provision. For the following reasons, we are
unable to issue an older edition of this form, modify the current form, or complete a proprietary form
you provide
• Notice of cancellation is a policy right, not an unregulated service. No insurer shown on this
certificate is able to provide the cancellation notice you desire by endorsement. For example, the
insured can cancel immediately, so it would be impossible for the insurer to give you the notice you
request. State law also grants the insurer the right to cancel for reasons such as nonpayment with
less notice than you require.
• For the reason just cited, if our agency was to issue a certificate that provides the cancellation
notice you request, we would do so with the full knowledge that it would be impossible to actually
give that amount of notice under certain circumstances. As such, the certificate could be alleged to
constitute a misrepresentation or fraud which could subject our agency and staff to serious civil
and criminal:penalties.
• If a certificate purports to provide a policy right different from that provided by the policy itself, then
the certificate effectively purports to be a policy form. Policy forms must be filed and approved by
our state department of insurance. Use of nonfiled policy forms is illegal and could result in legal
sanctions distinct from the assertion that the certificate is fraudulent.
• Under the ACORD Corporation's licensing agreement, the prior editions of superseded forms can
be used for one year from the time the new forms are introduced. Beginning in September 2010,
this is another reason we cannot use an older edition of the ACORD 25. Doing so would violate
ACORD's licensing agreement and, as a copyrighted document,federal copyright law.
• Likewise, we are unable to modify the new certificate to add a notice of cancellation. ACORD forms
are designed to be completed, not altered. ACORD's Forms Instruction Guide says that a
certificate should not be used "To waive rights...To quote wording from a contract—To quote any
wording which amends a policy unless the policy itself has been amended." In addition, our
insurance company contracts only allow us to issue unaltered ACORD forms.
• We are often asked to issue proprietary certificates provided by the certificate requestor. Again, our
insurance company contracts only allow us to issue unaltered ACORD forms. Many proprietary
certificates include broad, vague or ambiguous language that may or may not be incompliance with
state laws, regulations, and insurance department directives. Therefore, we cannot issue any
proprietary certificates.
We appreciate your understanding of the legal restrictions on our ability to fully comply with your
request
Lile International Companies
MZG80929459
MultiCoverf, - CG 71 58 12 07
Policy Amendment(s) Commercial General Liability Coverage Fonn
Your Commercial General Liability Coverage Fonn is (3) Coverage B does not apply to per-
revised as follows: sonal and advertising injury arising
out of an offense committed before
1. Broadened Named Insured you acquired or formed the organ-
ization.
A. SECTION 11 - WHO IS AN INSURED,
item 3., is deleted and replaced by the follow- B. SECTION II - WINO IS AN INSURED, the
ing: last paragraph, is deleted and replaced by the
following:
3. Any organization that you own at the
inception of this policy, or newly acquire No person or organization is an insured with
or form during the policy period, and respect to the conduct of any current or past
over which you maintain during the pol- partnership, joint venture, or limited liability
icy period majority ownership or major- company that is not shown as a Named In-
ity interest, will qunlify as a Named sured in the Declarations. However, this does
Insured if: not apply to a limited liability company that
meets all of the conditions in Section II -
a. There is no other similar insurance Who Is An Insured, item 3., above.
available to that organization; and
2. Additional Insured
b. The first Named Insured shown in SECTION II - WHO IS AN INSURED, sub-
the Declarations has the responsi- section 2.e., is added as follows:
bility of placing insurance for that
organization; and C. Any person or organization is included as an
additional insured, but only to the extent such
c. That organization is incorporated or person or organization is held liable for
organized under the laws of the bodilyinjury,property damage or personaland
United Stales of America. advertising injury caused by your acts or
omissions. With respect to the insurance af-
However. forded to such insured, all of the following
(1) Coverage under this provision 3 is additional provisions apply:
afforded only until the next occur- (1) You and such person or organization
. ring annual anniversary of the be- have agreed in a written insured contract
ginning of the policy period shown that such person or organization be
in the Declarations, or the end of the added as an additional insured under this
policy period, whichever is earlier, policy;
and
(2) The bodily injury, property damage or
(2) Coverage A does not apply to bodily personal and advertising injury for which
injury or property damage that oc- said person or organization is held liable
curred before you acquired or occurs subsequent to the execution of
formed the organization; and such insured contract;
This Fonn must be attached to Change Endorsement when issued after the policy is written.
One of the Fireman's Fund Insurance Companees®as named in die policy
;��, (���
Secretary U President
CG715012-07S
Copyright 2007,Flraman a Fund Insurance Company,Novato, CA. All rights reserved.
Includes copyrighted material of Insurance ServlcesOgme, Inc, with Its permission. Page I of 7
• Life International Companies
MZG80929459 '
(3) The most we will pay is the lesser of behalf of the additional insured at
either the Limits of insurance shown in the site of the covered operations,
the Declarations or the limits of insur- has been completed;
once required by the insured contract;
(c) Which takes place after that portion
(4) Such person or organization is an insured - of your work out of which the injury
only with respect to: or damage arises has been put to its
intended me by any other person or
(a) Their ownership; maintenance, or organization other than another
use of that part of the premises, or contractor or subcontractor engaged
land, owned by, rented to, or leased in performing operations for a prin-
to you, except such person or or- cipal as part of the same project;
ganization is not an insured with re-
spect to structural alterations, new (d) Which takes place after the expim-
construction or demolition oper- lion of any equipment lease to
ations performed by or on behalf of which (4)(d) above applies;
such person or organization;
(6) With respect to architects, engineers or
(b) Your ongoing operations performed surveyors, coverage does not apply to
for that insured; bodily injury, property damage or per-
sonal and advertising injury arising out
(c) Their financial control of you, ex- of the rendering or failure to render any
cept such person or organization is professional services by or for you, in-
not an insured with respect to struc- cluding:
rural alterations, new construction
or demolition operations performed (a) The preparing, approving, or failing
by or on behalf of such person or to prepare or approve, maps, shop
organization; drawings, opinions, reports, surveys,
field orders, change orders, or draw-
(d) The maintenance, operation or use ings and specifications;
by you of equipment leased to you
(h) Supervisory, inspection, archilec-
by such person or organization; rural, or engineering services.
(e) Operations performed by you or on However, if an Additional Insured endorsement is
your behalf and for which a state or attached to this policy that specifically names a
political subdivision has issued a .person or organization as an insured, then this
permit, provided such operations are subsection 2.e. does not apply to such person or
not performed for such state or poi- organization.
itical subdivision, and are not in-
cluded within the products-completed 3. Additional Insured- Vendors
operations hazard;
Unless the products-completed operations hazard
(5) This insurance does not apply to bodily is excluded from this policy, SECTION I7 -WHO
injury, property damage, personal and IS AN INSURED, item 2.f. is added as follows:
advertising Injury, occurrence or offense:
f Any vendor of yours is included as an addi-
(a) Which takes place at a particular tional insured, but only with respect td bodily
premises after you cease to be a Injury or property damage caused by your
tenant of that premises; products which are distributed or sold in the
regular course of the vendor's business, sub-
(b) Which takes place after all work, in- ject to the following additional exclusions:
cluding materials, parts or equip-
ment furnished in connection with (1) The insurance afforded the vendor does
such work to be performed by or on not apply to:
CG7158 12-075
Copyright 2007,Fireman's Fund Insurance Company,Novato, Ck All rights reserved.
Includes copyrighted material or Insurance ServlcasCOke, Inc,with its permission. Page 2 of 7
Lila International Companies
MZG80929459
(a) Bodily injury or propertydamage for into, accompanying- or containing such
which the vendor is obligated to pay products.
damages by reason of the assump-
tion of liability in a contract or However, if an Additional Insured - Vendors
agreement This exclusion does not endorsement is attached to this policy that
apply to liability for damages that specifically names a person or organization as
the vendor would have in the ab- an insured, then this subsection 2.f. does not
sence of the contract or agreement; apply to that person or organization.
(b) Any express warranty unauthorized 4. Additional Insured - Limited Primary and Non-
by you; contributory Provision
(c) Any physical or chemical change in The following is added as a second paragraph to
the product made intentionally by Section IV Conditions, Condition 4. Other Insur-
the vendor, ance, following paragraph b.(2):
(d) Repackaging, unless unpacked solely However, if you have added any person, organiza-
for the purpose of inspection, dem- tion or vendor of yours as an additional insured to
onstmtion, testing, or the substi- this policy by way of this MultiCover fi endorse-
tution of parts under instructions ment and have agreed in a written insured contract
from the manufacturer, and then re- that this insurance is primary and non-contribu-
packaged in the original container, Tory with other insurance available to that addi-
tional insured, this insurance is primary and we
(e) Any failure to make such in- will not seek contribution from such additional
spections, adjustments, tests or set- insured's other insurance. This provision does not
vicing as the vendor has agreed to apply to other insurance to which such additional
make or normally undertakes to insured has been added as an additional insured.
make in the usual course of busi-
ness, in connection with the distrib- 5. Waiver of Subrogation
uton or sale of the products;
SECTION IV - COMMERCIAL GENERAL
(f) Demonstration, installation, servic- LIABILITY CONDITIONS, item 8, is deleted
ing or repair operations, except such and replaced by the following:
operations performed by the vendor
in fall compliance with the man- S. Transfer of Rights of Recovery Against Oth-
ufacturer's written instructions at the ers to Us and Blanket Waiver of Subrogation
vendor's premises in connection
with the sale of the product; a• If the insured has rights to recover all or
part of any payment we have made under
(g) Products which, after distribution this Coverage Part, those rights are
or sale by you, have been labeled or transferred to us. The insured must do
relabeled or used as a container, part nothing after the loss to impair those
or ingredient of any other thing or rights. At our request, the insured will
substance by or for the vendor, or bring suit or transfer those rights to us
and help us enforce them.
(It) Bodily injury or property damage
arising out of the liability of the b. If required by a written insured contract
vendor for its own acts or omissions executed prior to the occurrence or of-
or those of its employees or anyone fense, we waive any right of recovery we
else acting on its behalf. may have against any person or organ-
ization named in such insured contract,
(2) This insurance does not apply to any in- because of payments we make for injury
sured person or organization from whom or damage arising out of your operations
you have acquired such products or any or your work for that person or organ-
ingredient, part or container, entering ization.
CG715812-075
Copyright 2007,Fireman's Fund Insurance Company,Novato, CA. All rights reserved.
Includes copyrighted material of Insurance ServlcesOfllce, Inc.,vrith Its pennisslon. Page 3 of 7
' Lile International Companies
MZG80929459
6. Cancellation - 120 Days in the Declarations, for property damage
to any one premises while rented to you,
Common Policy Conditions endorsement IL0017, or in the case of damage by fire, explo-
A. Cancellation, item 2.b. is deleted and replaced sion, sprinkler leakage, or lightning while
by the following: rented to you, temporarily occupied by
b. 120 days before the effective date of cancella- you with the permission of the owner,
tion if we cancel for any other reason. or managed by you under a written
agreement with the owner, is the greater
7. Liberalization of
SECTION 1V - COMMERCIAL GENERAL a. $1,000,000 Any One Premises; or
LIABILITY CONDITIONS , the following is ad-
ded as an additional Condition: b. The Damage To Premises Rented
To You Limit shown in the Decla-
Liberalization rations.
If we adopt a change in our forms or rules which C. SECTION IV - COMMERCIAL GEN-
would broaden the coverage provided by any form ERAL LIABILITY CONDITIONS, 4.
that is a part of this policy without an extra Other Insurance, b. Excess Insurance, (1)(a),
premium charge, the broader coverage will apply items (i) and (iii), are deleted and replaced by
to this policy. This extension is effective upon the the following:
approval of such broader coverage in your state.
8. Fire, Explosion, Sprinkler Leakage, or Lightning
(i) That is Fire, Explosion, Sprinkler Leak-
Legal Liability Coverage age, or Lightning insurance for premises
while rented to you, temporarily occu-
A. SECTION I - COVERAGES, COVERAGE pied by you with permission of the
A BODILY INJURY AND PROPERTY owner, or managed by you under a writ-
DAMAGE LIABILITY, 2. Exclusions, the ten agreement with the owner;
last paragraph, is deleted and replaced by the
following: (iii) That is insurance purchased by you to
cover your liability as a tenant for
Exclusions c. through n. do not apply to property damage to premises rented to
damage by fire, explosion, sprinkler leakage, you, temporarily occupied by you with
or lightning to premises while: the permission of the owner, or managed
1. Rented to you; by you under a written agreement with
the owner; or
2. Temporarily occupied by you with the
permission of Ore owner; or D. SECTION V - DEFINITIONS, 9. Insured
Contract, item a., is deleted and replaced by
3. Managed by you under a written agree- the following:
ment with the owner.
(a) A contract for a lease of premises.
A separate limit of insurance applies to this However, that portion of the contract for
coverage as described in Section III - LIMITS a lease of premises that indemnifies any
OF INSURANCE. person or organization for damage by
B. SECTION III - LIMITS OF INSURANCE, fire, explosion, sprinkler leakage, or
item 6., is deleted and replaced by die follow- lightning to premises while rented to you,
ing: temporarily occupied by you with per-
mission of the owner, or managed by you
6. Subject to 5. above, the Damage to under a written agreement with the
Premises Rented To You Limit shown owner, is not an insured contract;
CG715812-07S
Copyright 2007,Rreman's Find Insurance Company,Novato, C0. PJI rights reserved.
Includes copyrighted material of Insurance ServlcesGRce, Inn,vdth Its permisslon. Page 4 of 7
Lite International Companies
MZG80929459
9. Damage to Invitees' Automobiles from Falling 11. Chartered Aircraft
Trees or Tree Limbs- Limited Coverage
SECTION I - COVERAGES, COVERAGE A
This coverage applies to direct physical damage to BODILY INJURY AND PROPERTY DAM-
automobiles owned by invitees subject to all of the AGE LIABILITY, 2. Exclusions, S. Aircraft,
following: Auto Or Watercraft, item (6), is added as follows:
L Provided such damage originates from trees (6) An aircraft in which you have no ownership
on premises owned, managed, leased or rented interest and that you have chartered with
by an insured; crew.
2. Coverage applies only to invitees of an in-
12. Coverage Territory- Broadened
sured or an insured's tenant; SECTION V - DEFINITIONS, item 4.a., is de-
3. Such damage is directly caused by wind-dri-
leted and replaced by the following:
ven falling trees or tree limbs; a. The United States of America (including its
territories and possessions), Puerto Rico,
4. The most we will pay for any one loss is the Canada, Bermuda, the Bahamas, The Cayman
lowest of: Islands, and the British Virgin Islands;
a. the actual cash value of die damaged au- 13. Personal and Advertising Injury- Contractual
tomobile as of the time of the loss; or
Unless personal and advertising injury is excluded
b. the cost of repairing the damaged auto- from this policy the following applies:
mobile; or
SECTION I - COVERAGES, COVERAGE B,
c. the cost of replacing the damaged auto- 2. Exclusions, item e., is deleted.
mobile with another automobile of like 14 Fellow Employee Coverage
kind and quality. ,
SECTION II - WI-10 IS AN INSURED, 2.a.,
Regardless of the number of occurrences, item (1) is deleted and replaced by the following:
losses or claims, Otis coverage is subject to a
limit of$25,000 in any one policy period; (1) Personal and advertising injury:
5. This coverage is not subject to the General However, subsections (a), (b), (c) and (d) of item
Liability General Aggregate Limit; and (1) remain unchanged.
6. We will make payments under this coverage 15. Bodily Injury Definition - Broadened
without regard to fault. SECTION V - DEFINITIONS, 3. Bodily Injury
10. Non-Owned or Chartered Watercraft is deleted and replaced by the following:
SECTION I - COVERAGES, COVERAGE A Bodily injury means bodily injury, sickness or dis-
ease sustained by a person including death or
mental anguish resulting from any of these at any
AGE LIABILITY, 2. Exclusions, item g.Aircraft, time. Mental anguish means any type of mental
Auto, or Watercraft, item (2), is deleted and re- or emotional illness or disease.
placed by the following:
16. Expected or Intended Injury- Amendment to Ex-
(2) A watercraft you do not own that is: elusion
(a) Less than 51 feet long; and SECTION I. Coverage A Bodily Injury and Pro-
perty Damage Liability, 2. EXCLUSIONS, a. Ex-
(b) Not being used for public transportation petted or Intended Injury, is deleted and replaced
or as a common carrier, by the following:
CG715812-07S
Copyright 2007,FIrsman's Fund Insurance Company,Novato, CA. All rights reserved
Includes copyrighted material of Insurance SeMcesOake, Inc.,with Its permisslen. Page 5 of 7
• Lile International Companies
MZG80929459
a. Expected or Intended Injury (a) You, if you are an individual;
Bodily injury or property damage expected or (b) Your partner or member, if you are a
intended from the standpoint of die insured. partnership or joint venture;
This exclusion does not apply to bodilyinjury (c) Your member, ifyou are a limited liabil-
or property damage resulting from the use of ity company;
reasonable force to protect persons or prop-
er. (d) Your executive officer if you are an or-
ganization other than a partnership, joint
17. Unintentional Failure to Disclose Hazards venture or limited liability company; or
SECTION IV - COMMERCIAL GENERAL (e) Your authorized representative or insur-
LIABILITY CONDITIONS, item 6. Representa- ance manager.
tions, the following is added: Knowledge of an occurrence or offense by
d. If you unintentionally fail to disclose any ha- persons other than those listed above does not
zards existing at the inception date of this imply that those listed above also have such
policy, we will not deny coverage under this knowledge.
Coverage Form because of such failure.
However, this provision does not affect our (2) To the extent possible, notice should include:
right to collect additional premium or exercise
l (°) How, when and where the occurrence or
our right of cancellation or non-renewa
offense took place;
18. Supplementary Payments - Increased Limits
(b) The names and addresses of any injured
SECTION 1 - COVERAGES, SUPPLEMEN-
persons and witnesses; and
TARY PAYMENTS - COVERAGES A AND (c) The nature and location of any injury or
B, items I.b. and I.d., are deleted and replaced by damage arising out of the occurrence or
the following: offense.
b. The cost of bail bonds required because of 20. Non Employment Discrimination Liability
accidents or traffic law violations arising out
of die use of any vehicle to which the Bodily Unless personal and advertising injury is excluded
Injury Liability Coverage applies. We do not from this policy the following applies:
have to furnish these bonds. A. SECTION V - DEFINITIONS, 14. Personal
d. All reasonable expenses incurred by the in- and advertising injury, item h. is added as fol-
sured at our request to assist us in the inves- lows:
tigation or defense of the claim or suit, - h. Discrimination.
including substantiated loss of earnings up to
$500 a day because of time off from work. B. SECTION V - DEFINITIONS, item 23. is
added as follows:
19. Duties in the Event of an Occurrence, Offense,
Claim or Suit -Amended 23. Discrimination means the unlawful treat-
ment of a person or class of persons be-
SECTION IV - COMMERCIAL GENERAL cause of their specific race, color, religion,
LIABILITY CONDITIONS, item 2.a. is deleted gender, age, or national origin in com-
and replaced by the following: parison to one or more persons who are
(1) You must see to it that we Or any licensed not members of the specified class.
agent of ours are notified of a General C. SECTION I - COVERAGES, COVERAGE
Liability occurrence or offense which may re- B PERSONAL AND ADVERTISING
sult in a claim as soon as practicable after it INJURY LIABILITY, 2. Exclusions, the
becomes known to: following are added:
CG715812-075
Copyright 2007,Rreman's Fund Insurance Company,Novato,CA. All rights reserved.
Includes copyrighted material of Insurance ServlcesOfllce, Inc.,with Its permission. Page 6 Of 7
Life International Companies
MZG80929459
q. Discrimination directly or indirectly re- A. SECTION I - COVERAGES, COVERAGE
lated to the past employment, employ- C MEDICAL PAYMENTS, 2. Exclusions,
ment or prospective employment of any item f is deleted and replaced by the follow-
person or class of persons by any insured; ing:
r. Discrimination directly or indirectly re- f. Products-Completed Operations Hazard
lated to the sale, rental, lease or sublease
or prospective sale, rental, lease or sub- Included within the products-completed
lease of any dwelling or permanent lodg- operations hazard However, this exclu-
ing by or at the direction of any insured; sion does not apply to expenses for den-
tal services.
S. Discrimination, if insurance thereof is
prohibited by law; or B. Section I - COVERAGES, COVERAGE C
MEDICAL PAYMENTS, is amended to in-
t. Fines, penalties, specific performance, or elude item 3. as follows:
injunctions levied or imposed by a gov-
ernmental entity, governmental code, 3. Limit of Insurance
law, or statute because of discrimination
The Medical Expense Limit of Insurance
21. Medical Payments shall be the greater of:
Unless COVERAGE C MEDICAL PAY- a. $20,000 Any One Person; or
MENTS, or the products-completed operations
hazard has been excluded from this policy the fol- b. The amount shown in the Declara-
lowing applies: tions.
CG715812-07S
Copyright 2007,Fireman's Fund Insurance Company,Novato, CA. All rights reserved.
Includes copyrighted matelot of Insurance SerAc"Office. Inc., with Its permission. Page 7 of 7
Client#: 124414 LILEINTE
A'CORD,a CERTIFICATE OF LIABILITY INSURANCE DATE(MM0 YYYI
8111/2011
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 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 NAME, Jenny Healy
Propel Insurance
aC,Na: 866.577.1326
Seattle Commercial Insurance 499-0933 aS# h 80@0 propelinsurance.com
925 4th Ave,Suite 3200
Seattle,WA 98104 CUSTOMER to#:
INSURER(S)AFFORDING COVERAGE NAIOp
INSURED Lile International Companies INSURERA:American Automobile Insurance C 21849
8060 SW Pfaffle Street,Suite 200 INSURER a:Vanliner Insurance Company
Tigard,OR 97223 INSURER C:SAIF Corporation
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POLICY NUMBER MMIIDD�E/YYYY (MMIODIYYYY) LIMITS dWL LUL
A GENERAL LIABILITY X X MZG80929459 3131/2011 03/3112012 EACH OCCURRENCE $111-0-0 DION-0
X COMMERCIAL GENERAL LIABILITY PREMISES Ea ocourrenca $1,000,000
CLAIMS-MADE rX OCCUR MED EXP(My one person) $20000
X WA Stop Gap PERSONAL S ADV INJURY $1,000,000
GENERALAGGREGATE $2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000
POLICY PRO- X LOC E
JPCT B AUTOMOSILEUABIUTY X TRV404370302 12/01/2010 12/01/2011 COMBINED SINGLE LIMIT
(Ee eccidsm) $1,000,000_
X ANY AUTO Physical Damage: BODILY INJURY(Per person) $
ALL OWNED AUTOS Comp Ded-$1,000 BODILY INJURY(Per anulort) $
SCHEDULED AUTOS Coll Ded-$1,000 PROPERTY DAMAGE
HIRED AUTOS Hired Comp Ded- (Per accldenl) $
NON-OWNEDAUTOS $100 $
1
Trlr Intrchng '$50,000 Limit $
B X UMBRELLALIAia X OCCUR X UMV404370006 1210112010 12/01/2011 EACH OCCURRENCE $5000000
EXCESS LIAB CLAIMS-MADE AGGREGATE s5-100010-00
DEDUCTIBLE $
X RETENTION S 10,000 1 $
C WORKERS COMPENSATION 745431 10/01/2010 1-010112011 X WCSTATU- OTH-
AND EMPLOYERS'Lu SILITY YIN ITS ER
ANY
OFFICEOPRIETOEREXCLUDED ECUTIVW N/A E.L.EACH ACCIDENT $1,000,000
(Mandatory In NH) E.L.DISEASE-EAEMPLOYEE 11,000,000
/(yea,describe under
DESCRIPTION OF OPERATIONS belox E.L.DISEASE-POLICY LIMIT $1,000,000
A Motor Truck Cargo MZG80929459 3/31/2011 031311201 $1,000,000 per
$2,500 Ded/Occ. Occurrence
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ANach ACORD 101,Additional Remarks Schedule,If more space Is rapulred)
RE:All operations performed by the Named Insured.
The City of Ashland,Oregon,and its elected officials,officers and employees are additional insureds per
the attached endorsement.
CERTIFICATE HOLDER CANCELLATION
City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Attn: Karl Olson ACCORDANCE WITH THE POLICY PROVISIONS.
Purchasing Representative
90 N Mountain Avenue AUTHORIZED REPRESENTATIVE
Ashland,OR 97520
01988.2009 ACORD CORPORATION.All rights reserved.
ACORD 25(2009109) 1 Of 1 The ACORD name and logo are registered marks of ACORD
#S722966/M634883 KTR00
1 \
Why We Are Using the Latest ACORD 25 Certificate of Insurance
In September 2009, ACORD revised the ACORD 25 Certificate of Insurance form. One of the major
changes was the removal of the cancellation notice provision. For the following reasons, we are
unable to issue an older edition of this form, modify the current form, or complete a proprietary form
you provide
• Notice of cancellation is a policy right, not an unregulated service. No insurer shown on this
certificate is able to provide the cancellation notice you desire by endorsement. For example, the
insured can cancel immediately, so it would be impossible for the insurer to give you the notice you
request. State law also grants the insurer the right to cancel for reasons such as nonpayment with
less notice than you require.
• For the reason just cited, if our agency was to issue a certificate that provides the cancellation
notice you request, we would do so with the full knowledge that it would be impossible to actually
give that amount of notice under certain circumstances. As such, the certificate could be alleged to
constitute a misrepresentation or fraud which could subject our agency and staff to serious civil
and criminal,penalties.
• If a certificate purports to provide a policy right different from that provided by the policy itself, then
the certificate effectively purports to be a policy form. Policy forms must be filed and approved by
our state department of insurance. Use of nonfiled policy forms is illegal and could result in legal
sanctions distinct from the assertion that the certificate is fraudulent.
• Under the ACORD Corporation's licensing agreement, the prior editions of superseded forms can
be used for one year from the time the new forms are introduced. Beginning in September 2010,
this is another reason we cannot use an older edition of the ACORD 25. Doing so would violate
ACORD's licensing agreement and, as a copyrighted document,federal copyright law.
• Likewise, we are unable to modify the new certificate to add a notice of cancellation. ACORD forms
are designed to be completed, not altered..ACORD's Forms Instruction Guide says that a
certificate should not be used "To waive rights...To quote wording from a contract...To quote any
wording which amends a policy unless the policy itself has been amended." In addition, our
insurance company contracts only allow us to issue unaltered ACORD forms.
• We are often asked to issue proprietary certificates provided by the certificate requestor. Again, our
insurance company contracts only allow us to issue unaltered ACORD forms. Many proprietary
certificates include broad, vague or ambiguous language that may or may not be incompliance with
state laws, regulations, and insurance department directives. Therefore, we cannot issue any
proprietary certificates.
We appreciate your understanding of the legal restrictions on our ability to fully comply with your
request
Lime International Companies
MZG80929459
MultiCoverf - CG 71 58 12 07
Policy Amendment(s) Commercial General Liability Coverage Form
Your Commercial General Liability Coverage Form is (3) Coverage B does not apply to per-
revised as follows: sonal and advertising injury arising
out of an offense committed before
1. Broadened Named Insured you acquired or formed the organ-
A. SECTION 11 - WHO IS AN INSURED, ization.
item 3., is deleted and replaced by the follow- B. SECTION 11 - WINO IS AN INSURED, the
ing: last paragraph, is deleted and replaced by the
following:
3. Any organization that you awn at the
inception of this policy, or newly acquire No person or organization is an insured with
or form during the policy period, and respect to the conduct of any current or post
over which you maintain during the pol- partnership, joint venture, or limited liability
icy period majority ownership or major- company that is not shown as a Named In-
ity interest, will qualify as a Named sured in time Declarations. However, this does
Insured if: not apply to a limited liability company that
meets all of the conditions in Section II -
a. There is no other similar insurance Who Is An Insured, item 3., above.
available to that organization; and
2. Additional Insured
b. The first Named Insured shown in SECTION If - WHO IS AN INSURED, sub-
the Declarations has the responsi- section 2.e., is added as follows:
bility of placing insurance for that
organization; and C. Any person or organization is included as an
additional insured, but only to the extent such
c. That organization is incorporated or person or organization is held liable for
organized under the laws of the bodilyinjury property damage orpersonaland
United States of America. advertising injury caused by your acts or
omissions. With respect to the insurance af-
1-lowever. . forded to such insured, all of the following
(1) Coverage under this provision 3 is additional provisions apply:
afforded only until the next occur- (I) You and such person or organization
ring annual anniversary of the be- have agreed in a written insured contract
ginning of the policy period shown that such person or organization be
in the Declarations, or the end of the added as an additional insured under this
policy period, whichever is earlier, policy;
and
(2) The bodily injury, property damage or
(2) Coverage A does not apply to bodily personal and advertising Injury for which
Injury or property damage that oc- said person or organization is held liable
curd before you acquired or occurs subsequent to the execution of
formed the organization; and such insured contract;
This Form must be attached to Change Endorsement when issued alter the policy is written.
one of the Fireman's Fund Insurance Componles®as named in the policy
1 r,{1 lIG�c 2R ,�OCCO
Secretary U President '
CG715812-07S
Copyright 2007,Fireman's Fund Insurance Company,Novato, CA. All rights reserved.
Includes copyrighted material or Insurance ServlcasOfres, Inc., with Its pennksion. Page I of 7
Lile International Companies `
MZG80929459
(3) The most we will pay is the lesser of behalf of the additional insured at
either the Limits of Insurance shown in the site of the covered operations,
the Declarations or the limits of insur- has been completed;
ance required by the insured contract;
(c) Which takes place after that portion
(4) Such person or organization is an insured of your workout of which the injury
only with respect to: or damage arises has been put to its
intended use by any other person or
(a) Their ownership, maintenance, or organization other than another
use of that part of die premises, or contractor or subcontractor engaged
land, awned by, rented to, or leased in performing operations for a prin-
to you, except such person or or- cipal as part of the same project;
ganization is not an insured with re-
spect to structural alterations, new (d) Which takes place after the expire-
construction or demolition oper- tion of any equipment lease to
ations performed by or on behalf of which (4)(d) above applies;
such person or organization;
(6) With respect to architects, engineers or
(b) Your ongoing operations performed surveyors, coverage does not apply to
for that insured; bodily injury, property damage or per-
sonal and advertising injury arising out
(c) Their financial control of you, ex- of the rendering or failure to render any
cept such person or organization is professional services by or for you, in-
not an insured with respect to struc- cluding:
coral alterations, new construction
or demolition operations performed (a) The preparing, approving, or failing
by or on behalf of such person or to prepare or approve, maps, shop
organization; drawings, opinions, reports, surveys,
field orders, change orders, or draw-
(d) The maintenance, operation or use ings and specifications;
by you of equipment leased to you
by such person or organization; (b) Supervisory, inspection, architec-
tonal, or engineering services.
(e) Operations performed by you or on However, if an Additional Insured endorsement is
your behalf and for which a state or attached to this policy that specifically names a
political subdivision has issued a person or organization as an insured, then this
permit, provided such operations are subsection 2.e. does not apply to such person or
not performed for such state or pol- organization.
itical subdivision, and are not in- '
eluded within the products-completed 3. Additional Insured- Vendors
operations hazard;
Unless the products-completed operations hazard
(5) This insurance does not apply to bodily is excluded from this policy, SECTION H -WFIO
injury, property damage, personal and IS AN INSURED, item 21. is added as follows:
advertising injury, occurrence or offense:
f. Any vendor of yours is included as an addi-
(a) Which takes place at a particular tional insured, but only with respect to bodily
premises after you cease to be a •injury or property damage caused by your
tenant of that premises; products which are distributed or sold in the
regular course of the vendor's business, sub-
(b) Which tapes place after all work, in- ject to the following additional exclusions:
cluding materials, parts or equip-
ment furnished in connection with (1) The insurance afforded the vendor does
such work to be performed by or on not apply to:
CGI150 12.075
Copyright 2007,Fireman's Fund Insurance Company,Novato, CA. All rights reserved.
Includes copyrighted material of Insurance ServlcesGfte, Inc.,with Its permission. Page 2 of 7
Life International Companies
MZG80929459
(a) Bodily injury or property damage for into, accompanying or containing such
which the vendor is obligated to pay products.
damages by reason of the assump-
tion of liability in a contact or However, if an Additional Insured - Vendors
agreement. This exclusion does not endorsement is attached to this policy that
apply to liability for damages that specifically nnmes a person or organization as
the vendor would have in the ab- an insured, then this subsection 21. does not
sence of the contract or agreement; apply to that person or organization.
(b) Any express warranty unauthorized 4. Additional Insured - Limited Primary and Non-
by you; contributory Provision
(c) Any physical or chemical change in The following is added as a second paragraph to
the product made- intentionally by Section IV Conditions, Condition 4. Other Insur-
the vendor, ance, following paragraph b.(2):
(d) Repackaging, unless unpacked solely However, ifyou have added any person, organiza-
for the purpose of inspection, dem- tion or vendor of yours as an additional insured to
onstration, testing, or the substi- this policy by way of this MultiCover ti endorse-
tution of parts under instructions ment and have agreed in a written insuredcontract
from the manufacturer, and then re- that this insurance is primary and non-contribu-
packaged in the original container; tory with other insurance available to that addi-
tional insured, this insurance is primary and we
(e) Any failure to make such in- will not seek contribution from such additional
spections, adjustments, tests or ser- insured's other insurance. This provision does not
vicing as the vendor has agreed to apply to other insurance to which such additional
make or normally undertakes to insured has been added as an additional insured.
make in the usual course of busi-
ness, in connection with the distrib- 5. Waiver of Subrogation
ution or sale of the products;
SECTION IV - COMMERCIAL GENERAL
(I) Demonstration, installation, servic- LIABILITY CONDITIONS, item S, is deleted
ing or repair operations, except such and replaced by the following:
operations performed by the vendor
in full compliance with the man- S. Transfer of Rights of Recovery Against Oth-
ufacturer's written instructions at the ers to Us and Blanket Waiver of Subrogation
vendor's premises in connection
with the sale of the product; a• If the insured has rights to recover all or
part of any payment we have made under
(g) Products which, after distribution this Coverage Part, those rights are
or sale by you, have been labeled or transferred to us. The insured must do
relabeled or used as a container, part nothing after the loss to impair those
or ingredient of any other thing or rights. At our request, the insured will
substance by or for the vendor, or bring suit or transfer those rights to us
and help us enforce them.
(h) Bodily injury or property damage
arising out of the liability of the b. If required by a written insured contract
vendor for its own acts or omissions executed prior to the occurrence or of-
or those of its employees or anyone fense, we waive any right of recovery we
else acting on its behalf. may have against any person or organ-
ization named in such insured contract,
(2) This insurance does not apply to any in- because of payments we make for injury
sured person or organization from whom or damage arising out of your operations
you have acquired such products or any or your worlt for tint person or organ-
ingredient, part or container, entering ization.
CG715812-07S
Copyrighl 2007,Fireman's Fund Insurance Company,Novato, CA. All rights reserved.
Includes copyrighted material of Insurance SandcesORco, Ino„with Its permission. Page 3 of 7
Lile Intemational Companies
MZG80929459
6. Cancellation - 120 Days in the Declarations, for property damage
to any one premises while rented to you,
Common Policy Conditions endorsement IL0017, or in the case of damage by fire, explo-
A. Cancellation, item 2.b. is deleted and replaced sion, sprinkler leakage, or lightning while
by the following: rented to you, temporarily occupied by
b. 120 days before the effective date of cancella- you with the permission of the owner,
tion if we cancel for any other reason. or managed by you under a written
agreement with the owner, is the greater
7. Liberalization oF.
SECTION IV - COMMERCIAL GENERAL a. $1,000,000 Any One Premises; or
LIABILITY CONDITIONS , the fallowing is ad-
ded as an additional Condition: b. The Damage To Premises Rented
To You Limit shown in the Decla-
Liberalization rations.
If we adopt a change in our forms or roles which C. SECTION IV - COMMERCIAL GEN-
would broaden the coverage provided by any form ERAL LIABILITY CONDITIONS, 4.
that is a part of this policy without an extra Other Insurance, b. Excess Insurance, (1)(a),
premium charge, the broader coverage will apply items (i) and (iii), are deleted and replaced by
to this policy. This extension is effective upon the the following:
approval of such broader coverage in your state.
8. Fire, Explosion, Sprinkler Leakage, or Lightning (i) That is Fire, Explosion, Sprinkler Leak-
Legal Liability Coverage age, or Lightning insurance for premises
while rented to you, temporarily occu-
A. SECTION I - COVERAGES, COVERAGE pied by you with permission of the
A BODILY INJURY AND PROPERTY owner, or managed by you under a writ-
DAMAGE LIABILITY, 2. Exclusions, the ten agreement with the owner;
last paragraph, is deleted and replaced by the
following: (iii) That is insurance purchased by you to
cover your liability as a tenant for
Exclusions c. through n. do not apply to property damage to premises rented to
damage by fire, explosion, sprinkler leakage, you, temporarily occupied by you with
or lightning to premises while: the permission of the owner, or managed
1. Rented to you; by you under a written agreement with
the owner; or
2. Temporarily occupied by you with the
permission of die owner; or D. SECTION V - DEFINITIONS, 9. Insured
Contract, item a., is deleted and replaced by
3. Managed by you under a written agree- the following:
ment with the owner.
(a) A contract for a lease of premises.
A separate limit of insurance applies to this However, that portion of the contract for
coverage as described in Section III - LIMITS a lease of premises that indemnifies any
OF INSURANCE. person or organization for damage by
B. SECTION III - LIMITS OF INSURANCE, fire, explosion, sprinkler leakage, or
item 6, is deleted and replaced by the follow- lightning to premises while rented to you,
ing: temporarily occupied by you with per-
mission of the owner, or managed by you '
6. Subject to 5. above, the Damage to under a written agreement with the
Premises Rented To You Limit shown owner, is not an insured contract;
C0715812-078
Copydghl 2007,Fireman's Fund Insumnce Company,Novato, CA. All rlghts reserved.
Includes copyrighted material of Insumnoe ServlcesOtfce, Inc.,with Ile pem isslon. Page 4 of 7
Life International Companies
MZG80929459
9, Damage to Invitees' Automobiles from Failing 11. Chartered Aircraft
Trees or Tree Limbs- Limited Coverage
SECTION I - COVERAGES, COVERAGE A
This coverage applies to direct physical damage to BODILY INJURY AND PROPERTY DAM-
automobiles owned by invitees subject to all of the AGE LIABILITY, 2. Exclusions, g. Aircraft,
following: Auto Or Watercraft, item (6), is added as follows:
1. Provided such damage originates from trees (6) An aircraft in which you have no ownership
on premises owned, managed, leased or rented interest and that you have chartered with
by an insured; crew.
Coverage applies only to invitees of an in-
12. Coverage Territory- Broadened
sured or an insured's tenant; SECTION V - DEFINITIONS, item 4.a., is de-
3. Such damage is directly caused by wind-dri-
leted and replaced by the following:
ven falling trees or tree limbs; a. The United States of America (including its
territories and possessions), Puerto Rico,
4. The most we will pay for any one loss is the Canada, Bermuda, the Bahamas, The Cayman
lowest of: Islands, and the British Virgin Islands;
a. the actual cash value of the damaged au- 13. Personal and Advertising Injury- Contractual
tomobile as of the time of the loss; or
Unless personal and advertising injury is excluded
b. the cost of repairing the damaged auto- from this policy the following applies:
mobile; or
SECTION I - COVERAGES, COVERAGE B,
C. the cost of replacing the damaged auto- 2• Exclusions, item e., is deleted.
mobile with another automobile of like 14 Fellow Employee Coverage
kind and quality.
SECTION li - WHO IS AN INSURED, 2.a.,
Regardless of the number of occurrences, item (I) is deleted and replaced by the following:
losses or claims, this coverage is subject to a
limit of$25,000 in any one policy period; (1) Personal and advertising injury;
5. This coverage is not subject to the General However, subsections (a), (b), (c) and (d) of item
Liability General Aggregate Limit; and (1) remain unchanged.
6. We will make payments under this coverage 15. Bodily Injury Definition - Broadened
without regard to fault. SECTION V - DEFINITIONS, 3. Bodily Injury
10. Non-Owned or Chartered Watercraft is deleted and replaced by the following:
SECTION I - COVERAGES, COVERAGE A Bodily injury means bodily injury, sickness or dis-
BODILY INJURY AND PROPERTY DAM- ease sustained by a person including death or
mental anguish resulting from any of these at any
t type AGE LIABILITY, 2. Exclusions, item g. Aircraft, time. Mental anguish means any type of mental
Auto, or Watercraft, item (2), is deleted and re- or emotional illness or disease.
placed by the following:
16. Expected or Intended Injury- Amendment to Ex-
(2) A watercraft you do not own that is: elusion
(a) Less than 51 feet long; and SECTION I. Coverage A Bodily Injury and Pro-
perty Damage Liability, 2. EXCLUSIONS, a. Ex-
(b) Not being used for public transportation pected or Intended Injury, is deleted and replaced
or as a common carrier, by the following:
CG715612-075
Copyright 2007,Fireman's Fund Insurance Company,Novato,CA. All rights reserved.
Includes copyrighted material of Insurance SeMcesGake, Inc,Wan Its permission. Page 5 of 7
Lile International Companies
MZG80929459
a. Expected or Intended Injury (a) You, if you are an individual;
Bodily injury or property damage expected or (b) Your partner or member, if you are a
intended from the standpoint of die insured. partnership or joint venture;
This exclusion does not apply to bodilyinjury (c) Your member, ifyou are a limited liabil-
or property damage resulting from the use of ity company;
reasonable force to protect persons or prop-
em,, (d) Your executive officer if you are an or-
ganization other than a partnership, joint
17. Unintentional Failure to Disclose Hazards venture or limited liability company; or
SECTION IV - COMMERCIAL GENERAL (e) Your authorized representative or insur-
LIABILITY CONDITIONS, item 6. Representa- ance manager.
tions, the following is added: Knowledge of an occurrence or offense by
d. If you unintentionally fail to disclose any ha- persons other than those listed above does not
zards existing at the inception date of this imply that those listed above also have such
policy, we will not deny coverage under this knowledge.
Coverage Farm because of such failure.
However, this provision does not affect our (2) To the extent possible, notice should include:
right to collect additional premium or exercise (a) How, when and where the occurrenceor
our right of cancellation or non-renewal offense took place;
18. Supplementary Payments - Increased Limits
(b) The names and addresses of any injured
SECTION 1 - COVERAGES, SUPPLEMEN- persons and witnesses; and
TARY PAYMENTS - COVERAGES A AND (c) The nature and location of art injury or
B, items Lb. and l,d., are deleted and replaced b y J ry
P Y damage .arising out of the occurrence or
the following: offense,
b. The cost of bail bonds required because of 20. Non Employment Discrimination Liability
accidents or traffic law violations arising out
of the use of any vehicle to which the Bodily Unless personal and advertising injury is excluded
Injury Liability Coverage applies. We do not from this policy die following applies:
have to furnish these bonds. A. SECTION V - DEFINITIONS, 14. Personal
d. All reasonable expenses incurred by the in- and advertising injury, item h, is added as fol-
sured at our request to assist us in the inves- lows:
tigation or defense of the claim or suit, h. Discrimination.
including substantiated loss of earnings up to
$500 a day because of time off from work. B. , SECTION V - DEFINITIONS, item 23. is
added as follows:
19. Duties in the Event of an Occurrence, Offense,
Claim or Suit -Amended 23. Discrimination means the unlawful treat-
ment of a person or class of persons be-
SECTION IV - COMMERCIAL GENERAL cause of their specific race, color, religion,
LIABILITY CONDITIONS, item 2.a. is deleted gender, age, or national origin in com-
and replaced by the following: parison to one or more persons who are
(1) You must see to it that we or any licensed not members of the specified class.
agent of ours are notified of a General C. SECTION 1 - COVERAGES, COVERAGE
Liability occurrence or offense which may re- B PERSONAL AND ADVERTISING
sult in a claim as soon as practicable after it INJURY LIABILITY, 2. Exclusions, the
becomes known to: following are added:
CG715012-075
Copydght 2007,Fireman's Fund Insurance Company,Novato, CA. All rights reserved.
Includes copyrighled material of Insumnca 5ervicesOfGce, Inc, wllh Its permission. Page 6 of 7
ry .
Lile International Companies
MZG80929459
q. Discrimination directly or indirectly re- A. SECTION I - COVERAGES, COVERAGE
lated to the past employment, employ- C MEDICAL PAYMENTS, 2. Exclusions,
ment or prospective employment of any item f., is deleted and replaced by the follow-
person or class of persons by any insured; ing:
r. Discrimination directly or indirectly re- f. Products-Completed Operations Hazard
lated to the sale, rental, lease or sublease
or prospective sale, rental, lease or sub- Included within the products-completed
lease of any dwelling or permanent lodg- operations hazard However, this exclu-
ing by or at the direction of any insured; sion does not apply to expenses for den-
tal services.
s. Discrimination, if insurance thereof is
prohibited by law; or B. Section I - COVERAGES, COVERAGE C
MEDICAL PAYMENTS, is amended to in-
t. Fines, penalties, specific performance, or elude item 3. as follows:
injunctions levied or imposed by a gov-
emmental entity, governmental code, 3. Limit of Insurance
law, or statute because of discrimination
The Medical Expense Limit of Insurance
21. Medical Payments shall be the greater of
Unless COVERAGE C MEDICAL PAY- a. 520,000 Any One Person; or
MENTS, or the products-completed operations
hazard has been excluded from this policy the fol- b. The amount shown in the Declara-
lowing applies: tions.
C0715812-075
Copyright 2007,Fireman's Fund Insurance Company,Novalo,CA. All rights reserved.
Includes copyrighled material or Insurance ServicesoPoce, Inc., with Its permission. Page 7 of 7
t
-_ Binding Estimate REFERENCE#
northAmerican®
nonkftencan. PO Box 988
MOVING SERVICES
Fort Wayne,IN 46801-0988
DOT 070851 (260)429-2511 (806)348-2111 August 5,2011
Customs An.nCv
Bruce And Joanne Dickens H:(435) 649-7119 Redman Van&Sig Co D481000
1218 Pine Brush Dr. O: 2571 W.2590 S. (801) 972-4420
Park City,UT 84098 C:(435) 640-0152 Salt Lake City,Utah 84119
Wasatch Co.
E-mail:
Destination Address Salesperson
Bruce And Joanne Dickens H: Lennon Natter (801) 972-4420 x326
460 Park Side St O: Sales Consultant lennon @redmanvan.com
Ashland,OR 97520 Jackson Co.
Signature:
Tariff: PLCK H Tariff Date: August 5,2011 HHG Will: 15,694
Requested August 24,2011 Requested August 25,2011 Requested Augusl27,2011 Miles Cube Item Count
Pack: —TO— Load: —To— Delivery: —TO— 743 I 2,241 394
August 24,2011 August 25,2011 September 1,2011
Type of Payment: ❑Prepaid ❑COD nvoice Method of Payment: ❑Cashier's Check [—]Cash ❑Credit Card
CUSTOMER ACKNOWLEDGES LIABILITY FOR PAYMENT OF THE FOLLOWING SERVICES LISTED BELOW AND ON THE ATTACHED PAGES,I HEREBY ALSO ACKNOWLEDGE THAT
I HAVE RECEIVED THE'READY TO MOVE}'BROCHURE AND THE HOAR RIGHTS AND RESPONSIBILITIES WHEN YOU MOVE'BOOKLET,WHICH ALSO CONTAINS A DESCRIPTION
OF NORTHAMERICAWS COMPLAINT AND INQUIRY HANDLING PROCEDURE AND ITS ARBITRATION PROGRAM, x
Customer Sig,Mtum
Transportation Services: Quantity Net
Transportation(Household Weight) 15,894 If
Load Charge Sch 2(M-F 8-5) 15,694 If 627.76
Unload Charge Sch 3(M-F 8-5) 15,694# 698.39
Linehaul Transportation 15,694# 4,811.17
Maximum Value Protection $100,000 799.00
MVP Deductible$0
Subtotal Transportation Services: $6,936.32
Other Services: Quantity Net
Fuel Surcharge 0.0025 15,694 If 291.52
Insurance Surcharge $4,546.16 181.85
Park City,UT,84098
Packing Materials-see packing detail 124 803.00
Packing Labor-see packing detail(M-F 8-5) 124 642'25
Day Certain Pickup 1 500.00
Ship KID Sole 2010 door to door service 1 811.00
Washer/dryer disconnect,install LG kit 1 211.65
Flat screen N box 42" 1 150.00
Ashland,OR,97620
Connect washer and dryer,remove LG kit 1 170'00
Subtotal Other Services: - $3,761.27
Guaranteed Not To Exceed $10,697.59
Version 9.0.2
IIII II 11111111 II Pagel
ECS
Customer Aq enc
Bruce And Joanne Dickens H:(435) 649-7119 Redman Van&Big Co 0481000
1218 Pine Brush Dr. O: 2571 W.2590 S. (801) 972-4420
Park City,UT 64098 C:(435) 640-0152 Salt Lake City,Utah 84119
Wasatch Co.
E-mall:
Destination Address Selesoerson
Bruce And Joanne Dickens H: Lennon Natter (801) 972-4420 x326
460 Park Side St O: Sales Consultant lennon @redmanvan.com
Ashland,OR 97520 Jackson Co.
Signature:
Tariff. PLCK H Tariff Date: August 5,2011 HHG Wgt: 15,694
Requested August 24,2011 Requested August 25,2011 Requested August 27,2011 Miles I Cube I Item Count
Pack: —TO— Load: —TO— Delivery: —TO—
August 24,2011 August 25,2011 September 1,2017 743 2,241 394
This Guaranteed-Not-To-Exceed Price is not a contract,but a binding and guaranteed not to exceed price quote only for those
articles,quantities,and services listed on the accompanying Estimate Inventory Summary and this Binding Estimate. Additional
articles,quantifies,and/or services requested or required to service this shipment,it any,will be added to the price shown above.
Payment for any additional articles,quantities,and/or services is due upon delivery. Some examples of additional articles,quantities,
and/or services are:articles not listed on the Estimate Inventory Summary or listed as"Not Shipped",packing materials and labor for
items identified as being packed by the customer,Origin shuttles,appliance servicing and additional days in storage.
C.O.D.shipments must be paid in cash or certified check. Payment may also be charged to a Credit Card provided a written credit
application and approval are obtained prior to the day of loading. If the charges for the shipment are to be paid by the employer,you
will be responsible for any and all charges your employer is unwilling or unable to pay.
Along with this estimate you should receive the"READY TO MOVE?"brochure and the booklet"YOUR RIGHTS AND
RESPONSIBILITIES WHEN YOU MOVE".If you have not received these documents,request them from the Carriers agent
identified above.It is important you read and understand all printed materials provided by the Cartier.
GUARANTEED RATE REDUCTION(GRR): If actual weight is less than the estimated weight of 15,694 pounds,the GRR
Guaranteed price will be reduced by$17.10/cwt for the weight difference between the actual and estimated weight. Actual
Packing charges to be based on guaranteed container and packing rates subject to a maximum packing charge of $1,445.25.
Version 9.0.2
I)I I II I I II Page 2 cuaomOr lniuels
ECS
Customer Agency
Bruce And Joanne Dickens H:(435) 649-7119 Redman Van 6 Sig Cc 0481000
1218 Pine Brush Dr. O: 2571 W.259D S. (801) 972-4420
Park City,UT 84098 C:(435) 640-0152 Salt Lake City,Utah 84119
Wasatch Co.
E-mail:
Destination Address Salesperson
Bruce And Joanne Dickens H: Lennon Natter (801) 972-4420 x 326
460 Park Side St O: Sales Consultant lnnon @mdmanvan.com
Ashland,OR 97520 Jackson Co.
signature:
Tariff•. PLCK H Tariff Date: August 5,2011 HHG Win: 15,694
Requested August 24,2011 Requested August 25,2011 Requested August 27,2011 Miles Cube Item Count
Pack: —Ta— Load: —TO— Delivery: —To— 743 2,241 394
August 24,2011 August 25,2011 September 1,2011
Detail Of Cartons,Packing and Unpacking
(Included in price quote)
Park City,UT(Wasatch) Material Sen. Packing Sch.1
Gtv. Net Gtv. Net
Dishpack/Drum 8 96.00 8 100.00
Carton<3 d 32 88.00 - 32 104.00
3 d Carton 50 225.00 50 230.00
4.5 d Carton 7 38.50 7 42.00
6 d Carton 2 12.00 2 13.50
Wardrobe Carton 11 132.00 11 35.75
Double Mattress 1 14.50 1
King/Queen Mattress 4 80.00 4
Corrugated Container 9 117.00 9 117.00
Net Subtotal: 124 $803.00 124 $642.25
Subtotal-Cartons and Packing Services Only: $1,445.26
Subtotal-Unpacking Services: $0.00
Total Cartons,Packing and Unpacking Services: $1,446.26
(Included In price quote)
Version 9.0.2
III I I I II IIII I III Page 3 customer Initials
ECS
Customer Agency
Bruce And Joanne Dickens H: (435) 649-7119 Redman Van&Sig Co 0481000
1218 Pine Brush Dr. O: 2571 W.2590 S. (801) 972-4420
Park City,UT 84098 c:(435) 640-0152 Salt Lake City,Utah 84119
Wasatch Co.
E-mail:
Destination Address Salesoenon
Bruce And Joanne Dickens H: Lennon Nader (801) 972-4420 x326
460 Park Side St O: Sales Consultant Lnnon@redmanvan.com
Ashland,OR 97520 Jackson Co.
Signature:
Tariff: PLCK H Tariff Date: August 5,2011 HHG Wgt: 15,694
Requested August 24,2011 Requested August 25,2011 Requested August 27,2011 Miles I Cuba I Item Count
Pack: --"To— Load: —To— Delivery: —To"—
August 24,2011 August 25,2011 September 7,2077 743 2,247 394
Additional Services`
"Customer has been advised that this total"Not to E m
xceed"estimate of charges include all known and/or requested sites and their applicable charges.
Should additional services be requested or required at Destination or on route,the estimated costs of these services are fisted below in the Additional
Services section.
uant Net
Load Charge Sch 2(OT) 15,694# 878.86
Unload Charge Sch 3(OT) 15,694# 977.75
Destination Self-Storage Sch 3(M-F 8-5) 15,694# 190.05
Destination Self-Storage Sch 3(OT) 15,694# 285.08
Extra Delivery Sch 3 1 53.35
Extra Pickup Sch 1 1 47,75
Extra Labor Charge Sch 3(M-F 8-5) 1.00 hr 23.60
(rate per worker per hour)
Extra Labor Charge Sch 3(07) 1.00 hr 33.04
Origin Shuttle Service Sch 1 (M-F 8-5)25 miles 15,694# 893.68
Origin Shudle Service Sch 1(OT)25 miles 15,694# 1,340.52
Quantity Net
MVP Deductible-$0 Deductible $100,000 799.00
MVP Deductible-$250 Deductible $100,000 606.00
MVP Deductible-$500 Deductible $100,000 508.00
Transportation(Auto 204-A Auto)
Linehaul Transportation(Auto 204-A) 743 mi 810.00
Depreciated Value Protection $50,000
DVP Deductible$0
Excess Coverage over$50000 N/A
Auto Extra Slop N/A
Oversize Vehicle-Class 1 743 mi 199.00
Oversize Vehicle-Class II 743 mi 299.00
Oversize Vehicle-Class III 743 mi 449.00
Oversize Vehicle-Class IV Consult Agent
Quantity Not
SIT(Household Weight)
Destination Storage First Day-15694 lbs i day 1,114.27
Additional Days-15694 Ibs 1 day 45.51
SIT Drayage Sch 3
Up to 30 miles 15,694# 2,742,51
31 to 60 miles 15,694# 4,367.48
61 to 90 miles 15,694# 4,663.21
Insurance Surcharge(SIT Drayage) $4,663.21 186.53
Version 9.0.2
IIIIIIIIIIIII II Page cuvomerinaiats
ECS
Customer Agency
Bruce And Joanne Dickens H: (435) 649-7119 Redman Van&Sig Co 0481000
1218 Pine Brush Dr. O: 2571 W.2590 S. (801) 972-4420
Park City,UT 84096 C: (435) 640-0152 Salt Lake City,Utah 84119
Wasatch Co.
E-mail:
Destination Address Salesperson
Bruce And Joanne Dickens H: Lennon Natter (801) 972-4420 x 326
460 Park Side St O: Sales Consultant lennon@redmanvan.com
Ashland,OR 97520 Jackson Co.
Slgnatum:
Tariff: PLCK H Tariff Date: August 5,2011 HHG 1 15,694
Requested August 24,2011 Requested August 25,2011 Requested August 27,2011 Mlles Cuba Item Count
Pack: -To- Load: -Tit- Delivery: -To- mil 2,241 394
August 24,2011 August 25,2011 September 1,2011
Additional Services*
'Customer bas been advised that this total"Not to Exceed"estimate of charges include all known and/or requested services and their applicable
charges. Should additional services be requested or required at Destination or an mute,the estimated costs ofthese services are listed below in the
Additional Services section.
Additional Hauler or Destination Agent Supplied Containers,Packing and Unpacking
Per Container Charges,Unpacking schedule 3
Regular Overtime
Carton Typ Material Packing Unpacking Material Packing Unpacking
Dishpack/Drum 16.85 21.30 7.75 23.59 29.82 10.85
Carton e 3 d 4.50 6.75 2.10 6.30 9.45 2.94
3 of Carton 7.15 11.75 4.30 10.01 16.45 6.02
4.5 of Carton 7.15 11.75 4.30 10.01 16.45 6.02
6 cf Carton 7.15 11.75 4.30 10.01 16.45 6.02
6.5 of Carton 7.15 11.75 4.30 10.01 16.45 6.02
Wardrobe Carton 15.05 7.50 2.10 21.07 10.50 2.94
Crib Mattress 11.40 15.96
Single Mattress 11.40 15.96
Double Mattress 11.40 15.96
King/Queen Mattress 20.95 29.33
Long Mattress 11.40 15.96
Mattress Cover 11.40 15.96
Corrugated Container 16.85 21.30 7.75 23.59 29.82 10.85
Crates per cubic If Charge 10.30 2.10 14.42 2.94
Crates Minimum Charge 41.20 8.40 57.68 11.76
Grandfather Clock 7.15 11.75 10.01 16.45
Gun Carton 7.15 11.75 10.01 16.45
Lamp Shade Cm 7.15 11.75 10.01 16.45
Pole Lamp Carton 7.15 11.75 10.01 16.45
Ski Carton 7.15 11.75 10.01 16.45
Next Day Minimum Unpacking Charge" 104.75 146.65
' cf=cubicfool
A minimum charge applies if unpacking is not performed at time of delivery.
Overtime Packing/Unpacking occurs any time except 8 A.M.through 5 P.M.Monday through Friday
and on a legal holiday.
Version 9.0.2
IIIIIII III III III Page - customer Initials
ECS
ASHLAND PARKS AND RECREATION COMMISSION
340 SO.PIONEER STREET ASHLAND,OREGON 97520
COMMISSIONERS: - ,�"F"'S Don Robertson
JoAnne Eggers _ Director
Rick Landt
TEL:(541)488-5340
Jim Lewis - r FAX:(541)488-5314
Rich Rosenthal
Stetani Seffinger
August 9,2011
Lile International Companies
Attn: Michael Spencer
1957 Claxter Road NE
Salem,OR 97303
Corporate Office:
8060 SW Pfattle Street, Suite 200
Tigard, OR 97223
Dear Michael:
Please accept this letter as written authorization to provide moving services for Bruce and Joanne
Dickens from Park City,Utah, to Ashland, Oregon.
Ashland Parks&Recreation will be paying for the moving services"Guaranteed Not to Exceed
$10,697.59"upon the receipt of an invoice.
Please reference PO#00053 on your invoice.
Michael, your assistance and attention to all the details has been greatly appreciated by all.
Thank y
Don Robertson,Director
Ashland Parks and Recreation
DR:ssd
Home of Famous Lithia Park
CITY RECORDER Page 1 / 1
Ashland Park Commission DATE- P NUMBER
20 E MAIN ST. 8/12/2011 00053
ASHLAND, OR 97520
(541)488-5300
VENDOR: 003804 SHIP TO:
LILE INTERNATIONAL COMPANIES
8060 SW PFAFFLE STREET#200
TIGARD, OR 97223
FOB Point: Req.No.:
Terms: net Dept.:
Req.Del.Date: Contact: Don Robertson
Special Inst: Confirming? Yes
,.'4uahtf `s; Unrt; ' ' ;Dekri 'tiorr . - Unit Price, ..!LxCPr:ce._.i ..
Moving Services 10,697.59
Bruce Dickens, Parks Superintendent
Park City, Utah to Ashland, Oregon
Guaranteed not to exceed $10,697.59
Per attached Binding Estimate dated
August 5, 2011
Contract for Goods and Services
Beginning date: 08/24/2011
Completion date: 09/05/2011
Insurance required/On file
SUBTOTAL 10 697.59
BILL TO: TAX 0.00
FREIGHT 0.00
TOTAL 10,697.59
Aciount�NuinSer ,,,. �:' ' P,iojectNumber'> Amount '• ".AccounbNumber PrgecY,Number `Amount,' -
E 211.12.02.06.604100 10 697.59
Authoriaid Signature VENDOR COPY
FORM #3 CITY OF
,, ASHLAND
A request for a Purchase Order
REQUISITION Date of request:
Required date for delivery:
Vendor Name i .4 _yrt�c.st-E
Address,City,State,Zip C!.ec Ors ee _ -Contact Name&Telephone Number L ����d, x -2
Fax Number
SOLICITATION PROCESS
❑ Exempt from Competitive Bidding ❑ Emeraencv
❑ Wdtten Findings(Form attached) ❑ Invitation to Bid (Copies on file) ❑ Wdtten findings attached
❑ Quote or Proposal attached Date approved by Council: ❑ Quote or Proposal attached
❑ Small Procurement Cooperative Procurement
Less than$5,000 ❑ Request for Proposal (Copies on file) ❑ State of Oregon
Note:Total contract amount,including any Date approved by Council: Contract#
amend e!"* ❑ State of Washington
Intermediate Procurement ❑ Sole Source Contract If
GOODS&SERVICES ❑ Written Findings(Form attached) ❑ Other government agency contract
5 00 100 000 ❑ Quote or Proposal attached Agency
(3)Wntlen quotes attache Contract#
-PERSONALSERVICES-�:� ❑ Special Procurement ❑ Intergovernmental Agreement
$5.000 to$75.000 ❑ Written Findings(Form attached) Agency
❑ Less than$35,000,by direct appointment ❑ Quote or Proposal attached Contract#
❑ 3 Written proposals attached Date approved by Council: Date approved by Council:
Description of SERVICES Total Cost
Item # Quantity Unit Description of MATERIALS Unit Price Total Cost
Q P p �J �� $SOTAL+COST "-
❑ Per attached uotel ro osal ����
Project Number---------- "AccountNumber.)JI-q 0 `/J
Account Number Account Number�q !91141
'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
By signing this requisition form,I certify that the information provided above satisfies the City's public contracting requireme s and the documentation can be
provided upon request.
Vz
Employee Signaturet- Department Head Signature:
Additional signatures(if applicable):
Funds appropriated for current fiscal year: iYE / NO
Finance Director Date
Comments:
G:FlnaneeTiowdureVAPTormslFoim#3-Requisidon.doc Updated on:81912011