HomeMy WebLinkAbout5799GOODS AND SERVICES AGREEMENT
THIS AGREEMENT, is entered into between the City of Bremerton, a Washington Municipal Corporation ("City"), and
Sprague Mechanical LLC ("Vendor"), whose mailing address is: 6481 NE Bear Creek Dewatto Rd, Belfair WA 98528.
The parties agree as follows:
1. VENDOR SERVICES. The Vendor shall provide the following goods and materials and/or perform the following services
for the City: Test, and repair if necessary, back,(low assemblies within the City water system, as assigned by the Utilities
Compliance Specialist, within 10 days of being notified All repair work must be pre -approved by the Utilities Compliance
Specialist.
2. TERM OF CONTRACT. This agreement shall be in effect for a period of 1095 days from the date of signing. At the
discretion of the City, this agreement may be extended an additional 730 days.
3. COMPENSATION. The City shall pay the Vendor the total amount of $30.00 per backflow test, including applicable
Washington State Sales Tax, for the goods and services contemplated in this Agreement. The City shall pay the Vendor $50.00 per
hour plus materials and required tax for the necessary repairs to assemblies that do not pass the initial test. Minor repairs to the
assemblies that do not require replacement parts are included in the normal testing fee.
A. Defective or Unauthorized Work. The City reserves its right to withhold payment from Vendor for any defective or
unauthorized goods, materials or services.
4. INDEPENDENT CONTRACTOR. Contractor is and shall be at all times acting as an independent contractor and not as an
employee of the City. The Contractor shall secure at its expense, and shall be responsible for all payments of income tax, social
security, state disability insurance compensation, unemployment compensation, and all other payroll deductions for the Contractor,
officer, agents, employees and sub -contractors. The Contractor shall also secure all applicable business licenses, if required, in
connection with the contract services, including all required licenses for Contractor's officers, agents, employees and sub -contractors.
5. TERMINATION. The City may terminate this Agreement for good cause. "Good cause" shall include, without limitation,
any one or more of the following events:
A. The Vendor's refusal or failure to perform the assigned backflow tests.
B. The Vendor's failure to complete this Agreement within the time specified in this Agreement.
C. The Vendor's failure to comply with federal, state or local laws, rules or regulations.
D. The Vendor's filing for bankruptcy or becoming adjudged bankrupt.
If the City terminates this Agreement for good cause, the Vendor shall not receive any further monies under this Agreement
beyond the backflow tests that had previously been completed by the Vendor.
Rev. 7/14
6. CHANGES. The City may issue a written change order for any change in the goods, materials or services to be provided
during the performance of this Agreement. If the Vendor determines, for any reason, that a change order is necessary, Vendor must
submit a written change order request to an authorized agent of the City within fourteen (14) calendar days of the date Vendor knew or
should have known of the facts and events giving rise to the requested change. If the City determines that the change increases or
decreases the Vendor's costs or time for performance, the City will make an equitable adjustment. The City will attempt, in good
faith, to reach agreement with the Vendor on all equitable adjustments. However, if the parties are unable to agree, the City will
determine the equitable adjustment as it deems appropriate. The Vendor shall proceed with the change order work upon receiving
either a written change order from the City or an oral order from the City before actually receiving the written change order. If the
Vendor fails to require a change order within the time allowed, the Vendor waives its right to make any claim or submit subsequent
change order requests for that portion of the contract work. If the Vendor disagrees with the equitable adjustment the Vendor must
complete the change order work; however, the Vendor may elect to protest the adjustment as provided below:
A. Procedure and Protest by the Vendor. If the Vendor disagrees with anything required by a change order, another
written order, or an oral order from the City, including any direction, instruction, interpretation, or determination by
the City, the Vendor shall:
1. Immediately give a signed written notice of protest to the City;
2. Supplement the written protest within fourteen (14) calendar days with a written statement that provides the
following information:
a. The date of the Vendor's protest.
b. The nature and circumstances that caused the protest.
C. The provisions in this Agreement that support the protest.
d. The estimated dollar cost, if any, of the protested work and how that estimate was determined.
e. An analysis of the progress schedule showing the schedule change or disruption if the Vendor is
asserting a schedule change or disruption.
3. The Vendor shall keep complete records of extra costs and time incurred as a result of the protested work.
The City shall have access to any of the Vendor's records needed for evaluating the protest.
The City will evaluate all protests, provided the procedures in this section are followed. If the City determines that a
protest is valid, the City will adjust payment for work or time by an equitable adjustment. No adjustment will be
made for an invalid protest.
B. Vendor's Duty to Complete Protested Work. In spite of any protest, the Vendor shall proceed promptly to provide
the goods, materials and services required by the City under this Agreement.
C. Vendor's Acceptance of Changes. The Vendor accepts all requirements of a change order by: (1) endorsing it, (2)
writing a separate acceptance, or (3) not protesting in the way this section provides. A change order that is accepted
by Vendor as provided in this section shall constitute full payment and final settlement of all claims for contract time
and for direct, indirect and consequential costs, including costs of delays related to any work, either covered or
affected by the change.
D. Failure to Protest Constitutes Waiver. By not protesting as this section provides, the Vendor also waives any
additional entitlement and accepts from the City any written or oral order (including directions, instructions,
interpretations, and determination).
2
Rev. 7/14
E. Failure to Follow Procedures Constitutes Waiver. By failing to follow the procedures of this section, the Vendor
completely waives any claims for protested work and accepts from the City any written or oral order (including
directions, instructions, interpretations, and determination).
7. CLAIMS. The Vendor shall give written notice to the City of all claims other than change orders within fourteen (14)
calendar days of the occurrence of the events giving rise to the claims. Any claim for damages, additional payment for any reason, or
extension of time, whether under this Agreement or otherwise, shall be conclusively deemed to have been waived by the Vendor
unless a timely written claim is made in strict accordance with the applicable provisions of this Agreement; or, if (and only if) no such
provision is applicable, unless that claim is set forth in detail in writing and received by the City within seven (7) calendar days from
the date Vendor knew, or should have known, of the facts giving rise to the claim. At a minimum, a Vendor's written claim must
include the information set forth regarding protests in Section 6(A)(2)(a)-(e).
FAILURE TO PROVIDE A COMPLETE, WRITTEN NOTIFICATION OF CLAIM WITHIN THE TIME ALLOWED
SHALL BE AN ABSOLUTE WAIVER OF ANY CLAIMS ARISING IN ANY WAY FROM THE FACTS OR EVENTS
SURROUNDING THAT CLAIM OR CAUSED BY THAT DELAY.
Vendor must, in any event, file any claim or bring any suit arising from or connected with this Agreement within 120
calendar days from the date the contract work is complete.
8. WARRANTY. The Vendor shall correct all defects in workmanship and materials within 30 days from the date of the City's
acceptance of the satisfactory test report. When defects are corrected, the warranty for that portion of the work shall extend for 30
days from the date such correction is completed and accepted by the City. The Vendor shall correct any defects within seven (10)
calendar days of its receipt of notice from the City of the defect.
9. INDEMNIFICATION. Vendor shall defend, indemnify and hold the City, its officers, officials, employees, agents and
volunteers harmless from any and all claims, injuries, damages, losses or suits, including all legal costs and attorney fees, arising out
of or in connection with the performance of this Agreement. Vendor's obligation to indemnify shall not extend to that portion of
damages caused by the City's sole negligence.
The City's inspection or acceptance of any of Vendor's work when completed shall not be grounds to avoid any of these
covenants of indemnification.
Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115, then, in the event of
liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent
negligence of the Vendor and the City, its officers, officials, employees, agents and volunteers, the Vendor's liability hereunder shall
be only to the extent of the Vendor's negligence.
IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THIS INDEMNIFICATION
CONSTITUTES THE VENDOR'S WAIVER OF IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY
FOR THE PURPOSES OF THIS INDEMNIFICATION. THE PARTIES ACKNOWLEDGE THAT THEY HAVE MUTUALLY
NEGOTIATED THIS WAIVER.
The provisions of this section shall survive the expiration or termination of this Agreement.
3
Rev. 7/14
10. INSURANCE. The Vendor shall procure and maintain for the duration of this Agreement, insurance against claims for
injuries to persons or damage to property that may arise from or in connection with the performance of the Contract work by the
Vendor, its agents, representatives, employees or subcontractors.
Before beginning work on the project described in this Agreement, the Vendor shall provide a Certificate of Insurance
evidencing:
1. Automobile Liability insurance with limits no less than $500,000.00 combined single limit per accident for bodily
injury and property damage; and
2. Commercial General Liability insurance written on an occurrence basis with limits no less than $1,000,000
combined single limit per occurrence and $2,000,000 aggregate for personal injury, bodily injury and property
damage. Coverage shall include but not be limited to: blanket contractual; products/completed operations/broad
form property damage; and employer's liability.
Any payment of deductible or self insured retention shall be the sole responsibility of the Vendor.
All required policies shall be provided on an "occurrence" basis except professional liability insurance (if required), which
shall be provided on a "claims -made" basis.
The City shall be named as an additional insured on the Commercial General Liability insurance policy, as respects work
performed by or on behalf of the Vendor and a copy of the endorsement naming the City as additional insured shall be
attached to the Certificate of Insurance. The City reserves the right to receive a certified copy of all the required insurance
policies.
The Vendor's Commercial General Liability insurance shall contain a clause stating that coverage shall apply separately to
each insured against whom claim is made or suit is brought, except with respects to the limits of the insurer's liability.
The Vendor's insurance shall be primary insurance as respects the City and and it shall be an affirmative obligation upon
Vendor to advise the City's Risk Manager by fax at (360)1144[73-5161, or by certified mail, return receipt requested to City of
Bremerton, atm: Risk Management, 345 61 Street, Suite W,—Bremerton, WA 98337 within two days of the cancellation,
suspension or substantive change of any insurance policy set out herein, and failure to do so shall be construed to be a breach
of this Agreement.
The City also reserves its unqualified right to require at any time and for any reason, proof of coverage in the form of a
duplicate of the insurance policy with all endorsements as evidence of coverage.
11. MISCELLANEOUS.
A. Licenses and Taxes. Vendor shall possess a current Bremerton Business License and any regulatory license required
to fulfill Vendor's obligations under this contract. B&O taxes shall be paid when due, and Vendor, by this
agreement, assigns any payments due under this contract to the City Clerk for payment of such taxes which have
been declared delinquent.
B. Conflict and Precedence. In the event of a conflict between the contract documents, the document which rates
4
Rev. 7/14
higher on the following list shall take precedence:
1. Addenda, if any,
2. Contract,
3. Specifications,
4. Terms and Conditions,
5. Contractor's proposal.
C. Documents Incorporated by Reference. The following documents are incorporated by reference, to include, but not
be limited to:
1. Terms and Conditions,
2. Specifications,
3. Proposal, and
4. Non -Collusion Affidavit.
D. Use of Photographs and Images. Vendor shall not use or distribute photographs or images depicting City officials,
personnel, property, or equipment whether prepared by Vendor or provided by City without prior written consent of
the City. The City will not unreasonably withhold its consent.
E. Nondiscrimination. In the hiring of employees for the performance of work under this Agreement the Vendor, its
subcontractors, or any person acting on behalf of Vendor shall not, by reason of race, religion, color, sex, sexual
orientation, national origin, or the presence of any sensory, mental, or physical disability, discriminate against any
person who is qualified and available to perform the work to which the employment relates.
F. Compliance with Laws. Vendor shall comply with all federal, state and local laws, rules and regulations throughout
every aspect in the performance of this Agreement.
G. Work Performed at Vendor's Risk. Vendor shall take all precautions necessary and shall be responsible for the
safety of its employees, agents, and subcontractors in the performance of this Agreement. All work shall be done at
Vendor's own risk, and Vendor shall be responsible for any loss of or damage to materials, tools, or other articles
used or held for use in connection with the work.
H. Governing Law. This Agreement shall be governed and construed in accordance with the laws of the State of
Washington. If any dispute arises between the City and Vendor under any of the provisions of this Agreement,
resolution of that dispute shall be available exclusively under the jurisdiction, venue and rules of the Kitsap County
Superior Court, Kitsap County, Washington.
I. Attorney's Fees. In any claim or lawsuit for damages arising from the parties' performance of this Agreement, each
party shall be responsible for payment of its own legal costs and attorney's fees incurred in defending or bringing
such claim or lawsuit; however, nothing in this subsection shall limit the City's right to indemnification under
Section 9 of this Agreement.
J. Written Notice. All communications regarding this Agreement shall be sent to the parties at the addresses listed
below, unless otherwise notified. Any written notice shall become effective upon delivery, but in any event three (3)
calendar days after the date of mailing by registered or certified mail, and shall be deemed sufficiently given if sent
to the addressee at the address stated in this Agreement.
Notices to be sent to:
Notices to be sent to:
5
Rev. 7/14
VENDOR: CITY:
Attn: _ Gordon Sprague Attn: Dave Carter
Sprague Mechanical LLC Utilities Division
6481 Bear Creek Dewatto Rd 100 Oyster Bay Ave N
Belfair, WA. 98528 Bremerton, WA. 98312
K. Assignment. Any assignment of this Agreement by the Vendor without the written consent of the City shall be void.
L. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement shall be binding
unless in writing and signed by a duly authorized representative of the City and Vendor.
M. Severability. If any one or more sections, sub -sections, or sentences of this Agreement are held to be
unconstitutional or invalid, that decision shall not affect the validity of the remaining portion of this Agreement and
the remainder shall remain in full force and effect.
N. Entire Agreement. The written provisions and terms of this Agreement, together with any attached Exhibits,
supersede all prior verbal statements by any representative of the City, and those statements shall not be construed as
forming a part of or altering in any manner this Agreement. This Agreement and any attached Exhibits contain the
entire Agreement between the parties. Should any language in any Exhibit to this Agreement conflict with any
language contained in this Agreement, the terms of this Agreement shall prevail.
IN WITNESS WHEREOF, the parties below have executed this Agreement.
VENDOR:
Sprague Mechanical LLC_
By:
Print Name: Gordan Sprague
Its:
Date: 3
CITY:
Dave Carter
By: `� Com_
Print Name: Dave Carter
Its:
Date:
APPROVED AS TO FORM:
By: 0� I
Bremerto ity Attorney
ATTE "
By:
City Clerk
6
Rev. 7/14
Phone: (360)473-5290
ACOR 1 0
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
03/15/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME: Becky Bayness
Rubens Insurance
PAH/CN o Ext: (360)692-2172 ac No: (360)516-6429
ADDRESS: Becky@Rubenslns.com
10042 Silverdale Way NW
INSURER(S) AFFORDING COVERAGE NAIC#
Silverdale, WA 98383
INSURER A: Security National Insurance Company
j 03/09/2019
INSURED
INSURER B
INSURER C:
Sprague Mechanical, LLC
INSURER D:
6481 NE Bear Creek Dewatto Rd
INSURER E:
Belfair, WA 98528
INSURER F;
COVERAGES CERTIFICATE NUMBER: 00000000-68526 REVISION NUMBER: 2
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
IVSD
WVD
POLICY NUMBERLICY
MMIDD/YYYY
EXP
MIC M/DD/YYYY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
Y
NA122272800
03/09/2018
j 03/09/2019
EACH OCCURRENCE$ 1 OOO O
CLAIMS -MADE Q0tUR
DAMAGE TO RENTED
PREMISES Ea occurrence $ 100,066
MED EXP (Any one person) $ 5 000
PERSONAL &ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 2 000 0.,
X POLICY D PRO-
JECT1-1 LOC
PRODUCTS - COMP/OP AGG _$_ _ 2 OOO O
$
OTHER:
AUTOMOBILE
LIABILITY
CEa OMBINED SINGLE LIMIT $
accident
BODILY INJURY (Per person) $
ANYAUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident) $
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE $
Peraccident
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
DED I I RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
PER OTH-
STATUTE ER
E.L. EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
❑
N / A
E.L. DISEASE- EA EMPLOYE $
(Mandatory in NH)
If yes, describe under
_
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Certificate holder is additional insured with respects the named insured's operations, subject to policy conditions,
exclusions, and endorsements.
V
CERTIFICATE HOLDER CANCELLATION
I @ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Printed by BLB on March 15, 2018 at 08:06AM
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Bremerton
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
345 6th Street, Suite 100
Bremerton, WA 98337
I I
AUTHORIZED REPRESENTATIVE
I lw*� BLB
I @ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Printed by BLB on March 15, 2018 at 08:06AM
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
BLANKET ADDITIONAL INSUREDS -
OWNERS, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Policy Number: NA122272800
Endorsement Effective: 3/9/2018 12:01 a.m.
Named Insured
Gordon Sprague, DBA: Sprague Mechanical, LLC
Countersigned y:
/ n
SCHEDULE
Name of Person or Organization:
Any person or organization that the named insured is obligated by virtue of a written contract or
agreement to provide insurance such as is afforded by this policy.
Location:
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
A. Section II —Who Is An Insured is amended to include as an insured the person or organization
shown in the Schedule, but only to the extent that the person or organization shown in the
Schedule is held liable for your acts or omissions arising out of your ongoing operations
performed for that insured.
B. With respect to the insurance afforded to these additional insureds, the following exclusion is
added:
2. Exclusions
This insurance does not apply to "bodily injury" or "property damage" occurring after:
(1) All work, including materials, parts or equipment furnished in connection with such
work, on the project (other than service, maintenance or repairs) to be performed by
or on behalf of the additional insured(s) at the site of the covered operations has been
completed; or
(2) That portion of "your work" out of which the injury or damage arises has been put to
its intended use by any person or organization other than another contractor or
subcontractor engaged in performing operations for a principal as a part of the same
project.
C. The words "you" and "your' refer to the Named Insured shown in the Declarations.
D. "Your work" means work or operations performed by you or on your behalf; and materials, parts
or equipment furnished in connection with such work or operations.
Primary Wording
If required by written contract or agreement: Such insurance as is afforded by this policy shall be
primary insurance, and any insurance or self-insurance maintained by the above additional
insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute
to it.
Waiver of Subrogation
If required by written contract or agreement: We waive any right of recovery we may have against
an entity that is an additional insured per the terms of this endorsement because of payments we
make for injury or damage arising out of "your work" done under a contract with that person or
organization.
49-0108 07 11 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1
Used with permission
POLICY NUMBER:
BUSINESS AUTO DECLARATIONS
ITEM ONE
PRODUCER:
NAMED INSURED: _-
MAILING ADDRESS: _- - -
'OMMERCIAL AUTO
POLICY PERIOD: From - _ _ - tc yi- _ - at '2 01 A.M. Stanc rd Time at your
�T mai,ing address sh wn above
PREVIOUS POLICY NUMBER:
I
FORM OF BUSINESS:
CORPORATION LIMITED LIABILITY COMPANY j INDI DUAL
PARTNERSHIP OTHER
IN RETURN FOR THE PAYMENT OF THE PREMIUM.. AND SUBJECT TO ALL THE TERMS4 F THIS POLICY.
`AE AGREE WITH YOU TO PROMDE THE INSURANCE AS STATED IN THIS POLICY.
Premum snown s pavable at inception
AUDIT PERIOD (IF APPLICABLE ANNUALLY SEMI- QUARTERLY I MONTHLY
ALLY
ANNU
ENDORSEMENTS ATTACHED TO THIS POLICY:
IL 0017—Common Policy Ccndit�ons (IL 0146 ir Wasn�ngtor
IL 00 21 —Broad Form Nuc ear Exclusior not Apol e it New YorK) (IL 0198 in Wasn;ng�)r.i
SEE SCHEDULE OF FORMS AND ENDORSEMENTS
COUNTERSIGNED
BY
I, Date; (Authorized
DA CW 01 1013 Allstate Irsurance Company j Wage 1
ITEM TWO
Schedule Of Coverages And Covered Autos
11,s DG;'( -y InuvLea only uru'se coverayes Wren a : Idrye is if, J�e premium column
erow. tacn oT :rese
coverages A' apply oily to those "autos" shown as covered "autos" 'Autos" are shown as
overed 'butos" for a
particular coverage by the entry of one or more of the symbols from the Covered Autos s
on of the Business
Auto Coverage Form next to the name of the coverage.
COVERED
COVERAGES
AUTOS LIMIT
PREMIUM
COVERED AU -CS L:ABI_'TY
i
PERSCNAL INJURY
SEPARATELY TED IN EACH P P ENDCRSE",EENT
PRCT_CT ON or Ati ;,`a'en-,
,'IN„S I
DEDJC73_D.
ADDED PERSONAL INJURY
SEPARATELY STATED IN EACH ADDED P.IP
l
PROTECTION oregoiv&en�
ENDORSEMENT.
Added No-fault Ccverace
SEPARATELY STATED IN THE PROPERTY
PROPER-" PROTECTION
PROTECTION !N5 F2ANCE ENDORSEMENT
I INSURANCE ,M,cr gan or y,
M NLS DEDUCTIBLE FOR EACH ACCIDE
A;!TO % EDICAL PAYMENTS
EACH INSURED
MEDICAL EXPENSE AND
SEPARATELY STATED IN THE MEDICAL
INCC%1E _::SS BENEFTS
EXPENSE AND INCO.":'E LOSS BENE;'
i
v ry,r a or!y
ENDORSE%1ENT.
JNINS-R:D'.1CTORISTS
— --
JNDER;%SCRED
I
f 10-CR'STS
, w`!len f vi rC dyer I"
i
I
U-nsured Mc,onsts Coverage;
ACTUAL CASH VALUE OR COST OF REPAIR
I
j
�PHYS CAL DA"."AGE
I. NH CHEVER IS LESS %1IN JS
-
CO: FRE"ENS `1E
DED 'BLE FOREACH CC`.`ERED Ali-C,BuT,NO
; I
CO',.'ERAGE
DED C -ISLE APP_,ES TC LOSS CAUSED BY FIRE OR
'�1�-1TN,NG
See ATE%! FOJR For Hina or Borrowed Autos
f
ACTUAL CASH `JAL'JE OR COST OF REPAIR,
YSICAL DAt.1AGE
ECIFIED
ESPJSES
ff"ciCrEVER?S LESS MINUS
OF _OSS
DEDUCTIBLE FOR EACH CCVERED A; 'C FOR LOSS
CERAGE
CAUSED BY %1iSCH!EF OR VANDALIS%I
See !TEP,1 FOUR rcr H.red Or Borm:,,ec Autos
ACTUAL CASH 1/A' _iE OR COST OF REPAIR
PHYS.CAL DAFaAGE
'AHC :EVER 6 LESS ^,11NUS
CO' S C C0VERfiGE
DEDUCT13 E FOR EACH COVERED AUTO
I�
See TE'".1 FOUR For Hired Or Borro:ved Antos
{ PHYS'CAL DAP.1AGE FOR EACH DISA3LEME:N T j
1 -Ci", " NG AND LABOR OF A PR'VATE PASSENGER AU -0
TAX/ SURCHARGE/ FE
PREMIUM FOR ENDORSEMEN
'ESTIMATED TOTAL PREMIU
-This oci .cy may be sub;ect tic `nal audit.
DA CW 01 10 13 Al state lnsurarce Company '; I Page 2
ITEM THREE
SCHEDULE OF COVERED AUTOS YOU OWN
j DESCRIPTION
Year, Model, Trade Name. Body Type
Covered Serial Number (S) Vehicle Identification
Auto No. Number (VIN)
f
TERRITORY
Town & State Where The I
Covered Auto Will Be
Principally Garaged
Original Cost New
i
1
'
I
i
i
�
I
j
Covered
Auto No.
CLASSIFICATION
Size
Business Use GVW
GCW Or
Radius s=service Vehicle Seat-
Of r= retail ing
Operation c=commercial Capacity
Age
Group
Secondary
Rating Classification
Cod
1
EXCEPT For Towing.
All Physical Damage
Loss Is Payable To
You And The Loss
Payee Named Below
According To Their
Interests In The Auto
At The Time Of The
Loss: I
I
i
i
I
I
�
I
COVERAGES - PREMIUMS. LIMITS AND DEDUCTIBLES '
(Absence of a deductible or limit entry in any column below means that the limit orded
in the corresponding ITEM TWO column applies instead.
ictible entry
COVERED AUTOS
LIABILITY
PERSONAL INJURY
PROTECTION
ADDED P.I.P.
PROPERTY
PROTECTION
(Michigan Only)
' Covered
Auto No.
Limit
Premium
Limit Stated !
In Each P.LP. I
Endt. Minus
Deductible
Shown Below i Premium
Premium For
Limit Stated In
Each Added
P.I.P. Endt.
Lim
I
End
De
Sho
tated
.P.I.
Minus
Alible
Below
Premium
i
i
I
I
I
�
i
i
I
I
Total
Premium
j
DA CW 01 10 13 Allstate 1^surance Compary Page 3
ITEM THREE
SCHEDULE OF COVERED AUTOS YOU OWN (Continued)
DA CW 01 10 13 4state Insurance Company Page 4
COVERAGES - PREMIUMS. LIMITS AND DEDUCTIBLES
(Absence of a deductible or limit entry in any column below means that the limit or den
uctible entry
'
in the corresponding ITEM TWO column applies instead.
AUTO MEDICAL
PAYMENTS
MEDICAL EXPENSE AND
INCOME LOSS BENEFITS
(Virginia Only)
UNINSURED MOTORISTS
UNDERINSURED
MOTORISTS
Limit Stated
In The Medical
Expense and
Income Loss
Benefits
Covered
Limit
Endorsement
i
Auto No.
Each Insured
Premium
For Each Person
Premium
Limit
Pre um
Premium
I
Total
Premium
r.
COVERAGES - PREMIUMS. LIMITS AND DEDUCTIBLES j
(Absence of a deductible or limit entry in any column below means that the limit or dedctible entry
in the corresponding ITEM TWO column applies instead.)
SPECIFIED CAUSES
COMPREHENSIVE
OF LOSS
COLLISION
1 OWING & LABOR
I
Limit
Limit
Limit
Stated In
Stated In
Stated In
I
ITEM TWO
ITEM TWO
ITEM TWO
I
Minus
Minus
Minus
Deductible
Deductible
Deductible
Covered
Shown
Shown
Shown
Li Per
Auto No.
Below
Premium
Below
Premium
Below
Premium
Disa ment
I Premium
I
I
I
I
�
�
�
t
"
Tota I
k
d' -
Premium
DA CW 01 10 13 4state Insurance Company Page 4
ITEM FOUR
SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS
UUVCRCU NU I VO LIM04LI I i V V VCfV1VG - VVJI V1 rmc r Ullnj vaaw wnu•vo vv.
Motor Carrier Operations (Other Than Mobile Or Farm Equipment)
COVERED AUTOS ESTIMATED ANNUAL
LIABILITY COVERAGE STATE COST OF HIRE FOR EACH STATE PREMIUM
a^e,ar; �nverac,e
1
�xt�ss C.veraye
-
�
4
TOTAL HIRED AUTO PREMIUM
For "autos" used in your motor carrier operations cost of hire means_
1. The tota dollar amourt of costs you ncurred for the hire of automob ies 1 rin ; udes ''railers" an�
semtrailers� and f not included therein.
2. The total remunerations c` all operators and drivers helpers. of hired auto mob ,les whether h4
with a driver by
lessor or an "employee" of the'essee. or any cther third pary. arc
���
other costs (e.. reow maintenar.�ce. fuel- eto.i directly associa
ont cf any L
3. Thetota' debar amu
with operatirg
the ,vred automob!'.es wrether such costs are absorbed by the "insured". paid to the lessor or
ner, or paid to
atrers.
COVERED AUTOS LIABILITY COVERAGE — Cost Of Hire Rating Stasis for Autos NOT U
In Your
Motor Carrier Operations ( Other Than Mobile Or Farm Equipment)
COVERED AUTOS
ESTIMATED ANNUAL
l LIABILITY COVERAGE
STATE
COST OF HIRE FOR EACH STATE
IREMIUM
�rimar; Coverage
-xoess Coverage
i
F
_
Tr)TAI HIRFn A11T0 PRFMIIIM
- -
For "auos"NOT used _n your motor earner cperatons cast of 7 r moans the total amount you it-, r for the hire of
"a:,tcs" you don't ewn :,not including "autos" you bo-o�., or rent from your partners cr "employees r their fami'_y
r,embersi. Ccs' of h_re does rot ncude charges for services per`crrred by motor carriers of prop ft
y or passergers.
DA CW 01 10 13 Allstate Insurance Compary I Page 5
ITEM FOUR
SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS (Cont'd)
Physical Damage Coverages- Cost Of Hire Rating Basis For All Autos
I (Other Than Mobile or Farm Equipment)
ESTIMATED
ANNUAL
COST OF HIRE
FOR EACH STATE!
(Excluding Autos i
Hired With
COVERAGE
STATE
LIMIT OF INSURANCE
A Driver) PREMIUM
ACTUAL CASH VALUE OR COST OF REPAIR
COMPREHENSIVE
�ti,H.IC;-EVER;SLESS ''INCS
DEDUCTIBLE FOR EACH CO'.'EREC A�70 BUT
NO DEDUCTIBLE APPLES -0 LOSS CACSED BY
FIRE OR LIGHTNING.
i
ACTUAL CASH VALDE OR COST OF REPAIR.
i
SPECIFIED
'iVH CHEVER iS LESS %1IN'CS
CAUSES OF LOSS
DED jC7BLE FOR EACH COVEREC AU -C FOR
LOSS CAUSED BY %I1ISCHIEF CRVANDALISN!
COLLISION
ACTUA; ,--ASH VAL E OR COST OF REPAIR.
'A`- 1CHEVER ,S LESS %�INOS
CED. C-'B_E -OR EACh1 CCVEREC Al7C
TOTAL HIRED AUTO PRE MIU
For Physical Damage Coverages. cost of h re means the total amount you incur for the hire of "aut " you don't owr
(not mctuding 'autos" you barrow or ren; from your par?ners or "employees" or their famJ'y membe )Cost of hire does
not include charges for any "auto" that is leased. Fired. rented or borrowed with a driver
DA CW 01 10 13 Al state Insurarce Company 11 Page 6
ITEM FOUR
C!`LICM ! C A1C U10Cr% !1O 0l100A%AICN f r%XJCE2cn A"r^ rn%/COAnc A\111 r2MCRIII 11AC
V VIIL✓VLL VI 1111\1V VI\ VVIV\V •ALV VV�LI\L✓ I"�V 1 V VV�LIVIVL N\✓ � 1V.1�11 VIN 1V VIIL V�
Cost Of Hire Rating Basis For Mobile Or Farm Equipment — Other Than Physical Darnago
overages
ESTIMATED ANNUAL
pR,
COST OF HIRE FOR EACH STATE
IUM
COVERAGE STATE
Mobile Farm Mobile
Farm
Equipment Equipment Equipment
Equipment
Covered Autos L ability -
Pr rnar, Ccv erage
Covered Autos L:abili,y - j
Excess Coverage
f
PersoraInjury Protection
—
i
Medica. Expense Benefits
j
i ;Vrginia Only)
Ircor-e Loss Berefr.s
Vrginia Only
Au'c Medical Payments
I
TOTAL HIRED AUTO PREMIUM
Cost of hire means ,he total amount you rncur for the lyre of "autos" you dont own ;not #njl
ding "autos" you
bor�o,l. or rent from your par.ners cr "employees" or ;heir `amity members Cost of hire does not
chide charges for
sery ces performed by motor carriers of property or passengers
DA CW 01 10 13 A is,ate insurance Company i ( Page
ITEM FOUR
SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS (Cont'd)
Cost Of Hire Rating Basis For Mobile or Farm Equipment - Physical Damage Coverag�
TOTAL HIRED AUTO PREMIUM i
For P ysca. Damage Coverages. cost o' hire means the total amcunt yo., ircur for the hire of 'I tos" you don t own �
no-, ircludirg "autos" ycu bo-rov. or reit from. your partners or "employees" or their `amity memb� Cost of hire does
rot nc'ude charges `or any autc that 's'.easec hired. rented or bo rowec with a over
DA CW 01 10 13 Allstate Insurance Company ; I Page 8
ESTIMATED ANNUAL
COST OF HIRE
FOR EACH STATE
I
(Excluding Autos Hired
j
With A Driver)
PREMIUM
Mobile I
Farm
Mo
Ant
Farm
COVERAGE
STATE
LIMIT OF INSURANCE
Equipment
Equipment
Equi
Equipment
ACTUAL CASH VALUE OR
COST 0;: REPA'R.
Vti'HICHE`JER :S LESS
V1NUS
[ EDUC-IBLE =OR EAC -1
'
J COMPREHENSIVE
COVERED AUTO. BUT NO
I i
DEDUCTIBLE A:)c)'JFS TC,,
_OSS CAUSE- BY' -IRE
OR LIGHTNING.
ACTUAL CASH v.'ALUE OR
COST OF REPAIR
!
A"HICHEVER IS LESS
SPECIFIED
I
i
CAUSES OF LOSS
DEDUC&.E=UREACH
CO'iERED ALTO FCR
_OSS CAUSED BY Vis -
CH EF OR':'ANDALISI-'-
ACTUAL CASH VAL-E OR
COST C= REPAIR.
—H CHE`JER',S LESS
COLLISION
=;
I `.'INUS CE
DUC7'.BLE POR EACH
CC`JERED AUTO?
TOTAL HIRED AUTO PREMIUM i
For P ysca. Damage Coverages. cost o' hire means the total amcunt yo., ircur for the hire of 'I tos" you don t own �
no-, ircludirg "autos" ycu bo-rov. or reit from. your partners or "employees" or their `amity memb� Cost of hire does
rot nc'ude charges `or any autc that 's'.easec hired. rented or bo rowec with a over
DA CW 01 10 13 Allstate Insurance Company ; I Page 8
ITEM FOUR
i
I
i
SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS (Cont'd)'
Rental Period Rating Basis For Mobile Or Farm Equipment i
ESTIMATED
NUMBER OF DAYS
PREMIUM
EQUIPMENT WILL
BE RENTED
TOWN AND STATE
WHERE THE JOB SITE
Mobile
Farm
Mo
Farm
COVERAGE
IS LOCATED
Equipment
Equipment
Equi
ent
Equipment
,ve—c Ai tcs L -,in;
Prima^, Coverage
j
Co'reree otos L'.abilAy -
�-xress Cc,,eraee
j Perso^ai 'r ury
I
Protec:i�-
i %!e- ca Ex;;aa se
9enef�a 'Vrginia Onl;
�
I-co^-e L uss Senef is
A_tz- Vec cal Pavme^ts
i—
TOTAL HIRED AUTO PREMIUMS
ITEM FIVE
't
SCHEDULE FOR NON-OWNERSHIP COVERED AUTOS LIABILITY
NAMED INSURED'S
BUSINESS
RATING BASIS NUMBER
REMIUM
T-i,4 Garace Serr,.ce Oo-
Nur�berOF -r;, ovees
t10?he
0—er T-ar
Nu,-lber Of Pa^.rcr�
,. S JF'r'.�,^,f AGC: ,.. ,...r
i
A;;ive and Inactive I
.
e Jed ., 2r ;.,,te r.5
%l,r ber i)f En'plo`ee._ ;M1.;_.se
Princ�pai Duty'nvolves
e Operatic, Of A.:*- s
Nur-ber Of Parrers
i
So is AGerc e5
NU"'-be..`^�f Er-,ae5
I
j
Peg iarly ase A,,�tcs
To Trarspor Clents
Nur-re, 0' Parners
I
iA�!ive and Trac. ve,
TOTAL NON-OWNERSHIP COVERED AUTOS LIABILITY PREMIUM
�{
DA CW 01 10 13 Allstate Insurance Corrpany I Page 9
I
�i
ITEM SIX
SCHEDULE FOR GROSS RECEIPTS OR MILEAGE BASIS
i
Type Of Risk ; Check one): �' Public Autos Leasing Or Rental Concern
Rating Basis (Check ore): Gross Receipts (Per $100) 1 Mileage (Per Mile)
Estimated Yearly (Check One). Gross Receipts (Per $100) Mileage
Premums
Covered Autos Liabilityl
Personal Injury Protection
Added Personal Injury Protection
Property Protection Insurance (Michigan Only)
Auto Medical Payments
Medical Expense And Income Loss Benefits (Virginia Only)
Comprehensive
Specified Causes Of Loss
Collision
Towing And Labor
I
4Vnen used as a oremium basis.
i
FOR PUBLIC AUTOS
Gross receipts means the total amount earrec by the named insured for transporting jl
assengers, mail an:
merchandise
Gross receipts Coes not include.
1. Amourts pais to air sea c, arc carriers operating under their owr perrnits-
2. Advertising reverie.
3. Taxes collected as a separate item and paid cirectly to the government.
i
4. C O.D collections for cost of mail cr merchandise nc:ud ng collection fees
Mileage means the total live and read mileage of all reven=ue producing "autos" during the policy
enod-
FOR RENTAL OR LEASING CONCERNS
Gross receipts mears the total amount earred by the ramed insures for the 'easing ori
renting of "autos" t(
others w,tnout crvers.
Mileage means the total live and dead mileage of all "altos" yo,: leased or rented to otners witho1],
t
i
i
drivers
I
i
DA CW 01 10 13 A !state Insu,arce Ccmpany
Page 10