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HomeMy WebLinkAboutTufts Polygraph and Investigation 2008-01-31AGREEMENT FOR PROFESSIONAL CONSULTING SERVICES This Agreement, made and entered into this .81 day of N--_ 2008 ("Effective Date"), by and between CITY OF UKIAH, CALIFORNIA, hereinafter referred to as "City" and Tufts Polygraph and Investigation, a sole proprietorship [sole proprietorship, corporation, partnership, limited partnership, limited liability company, etc.] organized and in good standing under the laws of the state of California, hereinafter referred to as "Consultant". RECITALS This Agreement is predicated on the following facts: a. City requires consulting services related to Fire Captain Terry Israel and her alleged involvement in the events investigated by the Mendocino County Major Crimes Task Force leading to her arrest on January 18, 2008. b. Consultant represents that it has the qualifications, skills, experience and is properly licensed to provide these services, and is willing to provide them according to the terms of this Agreement. C. City and Consultant agree upon the Scope -of -Work and Work Schedule attached hereto as Attachment "A", describing contract provisions for the project and setting forth the completion dates for the various services to be provided pursuant to this Agreement. TERMS OF AGREEMENT 1.0 DESCRIPTION OF PROJECT 1.1 The Project is described in detail in the attached Scope -of -Work (Attachment ,A!,). 2.0 SCOPE OF SERVICES 2.1 As set forth in Attachment "A". 2.2. Additional Services. Additional services, if any, shall only proceed upon written agreement between City and Consultant. The written Agreement shall be in the form of an Amendment to this Agreement. 3.0 CONDUCT OF WORK 3.1 Time of Completion. Consultant shall commence performance of services as required by the Scope -of -Work upon receipt of a Notice to Proceed from City and shall complete such services within CIO bfk-i5 from receipt of the Notice to Proceed. Consultant shall complete the work to the City's reasonable satisfaction, even if contract disputes arise or Consultant contends it is entitled to further compensation. Tufts Polygraph & Investigation PAGE I OF 9 4.0 COMPENSATION FOR SERVICES 4.1 Basis for Compensation. For the performance of the professional services of this Agreement, Consultant shall be compensated on a time and expense basis not to exceed a guaranteed maximum dollar amount of twenty-six hundred dollars ($2,600). Labor charges shall be based upon hourly billing rates for the various classifications of personnel employed by Consultant to perform the Scope of Work as set forth in the attached Attachment "B", which shall include all indirect costs and expenses of every kind or nature, except direct expenses. The direct expenses and the fees to be charged for same shall be as set forth in Attachment "B". Consultant shall complete the Scope of Work for the not -to -exceed guaranteed maximum, even if actual time and expenses exceed that amount. 4.2 Changes. Should changes in compensation be required because of changes to the Scope -of -Work of this Agreement, the parties shall agree in writing to any changes in compensation. "Changes to the Scope -of -Work" means different activities than those described in Attachment "A" and not additional time to complete those activities than the parties anticipated on the date they entered this Agreement. 4.3 Sub -contractor Payment. The use of sub -consultants or other services to perform a portion of the work of this Agreement shall be approved by City prior to commencement of work. The cost of sub -consultants shall be included within guaranteed not -to -exceed amount set forth in Section 4.1. 4.4 Terms of Payment. Payment to Consultant for services rendered in accordance with this contract shall be based upon submission of monthly invoices for the work satisfactorily performed prior to the date of the invoice less any amount already paid to Consultant, which amounts shall be due and payable thirty (30) days after receipt by City. The invoices shall provide a description of each item of work performed, the time expended to perform each task, the fees charged for that task, and the direct expenses incurred and billed for. Invoices shall be accompanied by documentation sufficient to enable City to determine progress made and to support the expenses claimed. 5.0 ASSURANCES OF CONSULTANT 5.1 Independent Contractor. Consultant is an independent contractor and is solely responsible for its acts or omissions. Consultant (including its agents, servants, and employees) is not the City's agent, employee, or representative for any purpose. It is the express intention of the parties hereto that Consultant is an independent contractor and not an employee, joint venturer, or partner of City for any purpose whatsoever. City shall have no right to, and shall not control the manner or prescribe the method of accomplishing those services contracted to and performed by Consultant under this Agreement, and the general public and all governmental agencies regulating such activity shall be so informed. Those provisions of this Agreement that reserve ultimate authority in City have been inserted solely to achieve compliance with federal and state laws, rules, regulations, and interpretations thereof. No such provisions and no other provisions of this Agreement Tufts Polygraph & Investigation PAGE 2 OF 9 shall be interpreted or construed as creating or establishing the relationship of employer and employee between Consultant and City. Consultant shall pay all estimated and actual federal and state income and self- employment taxes that are due the state and federal government and shall furnish and pay worker's compensation insurance, unemployment insurance and any other benefits required by law for himself and his employees, if any. Consultant agrees to indemnify and hold City and its officers, agents and employees harmless from and against any claims or demands by federal, state or local government agencies for any such taxes or benefits due but not paid, by Consultant, including the legal costs associated with defending against any audit, claim, demand or law suit. Consultant warrants and represents that it is a properly licensed professional or professional organization with a substantial investment in its business and that it maintains its own offices and staff which it will use in performing under this Agreement. 5.2 Conflict of Interest. Consultant understands that its professional responsibility is solely to City. Consultant has no interest and will not acquire any direct or indirect interest that would conflict with its performance of the Agreement. Consultant shall not in the performance of this Agreement employ a person having such an interest. If the City Manager determines that the Consultant has a disclosure obligation under the City's local conflict of interest code, the Consultant shall file the required disclosure form with the City Clerk within 10 days of being notified of the City Manager's determination. 6.0 INDEMNIFICATION 6.1 Insurance Liability. Without limiting Consultant's obligations arising under Paragraph 6.2 Consultant shall not begin work under this Agreement until it procures and maintains for the duration of this Agreement insurance against claims for injuries to persons or damages to property, which may arise from or in connection with its performance under this Agreement. A. Minimum Scope of Insurance Coverage shall be at least as broad as: 1. Insurance Services Office ("ISO) Commercial General Liability Coverage Form No. CG 00 01 11 85. 2. ISO Form No. CA 0001 (Ed. 1/87) covering Automobile Liability, Code 1 "any auto" or Code 8, 9 if no owned autos and endorsement CA 0025. 3. Worker's Compensation Insurance as required by the Labor Code of the State of California and Employers Liability Insurance. 4. Errors and Omissions liability insurance appropriate to the consultant's profession. Architects' and engineers' coverage is to be endorsed to include contractual liability. Tufts Polygraph & Investigation PAGE 3 OF 9 L3 C. ri' Minimum Limits of Insurance Consultant shall maintain limits no less than: General Liabilitv: $1,000,000 combined single limit per occurrence for bodily injury, personal injury and property damage. If Commercial General Liability Insurance or other form with a general aggregate limit is used, the general aggregate limit shall apply separately to the work performed under this Agreement, or the aggregate limit shall be twice the prescribed per occurrence limit. 2. Automobile Liabilitv: $1,000,000 combined single limit per accident for bodily injury and property damage. 3. Worker's Compensation and Employers Liability: Worker's compensation limits as required by the Labor Code of the State of California and Employers Liability limits of $1,000,000 per accident. 4. Errors and Omissions Liabilitv: $1,000,000 per occurrence. Deductibles and Self -Insured Retentions Any deductibles or self-insured retentions must be declared to and approved by the City. At the option of the City, either the insurer shall reduce or eliminate such deductibles or self-insured retentions with respect to the City, its officers, officials, employees and volunteers; or the Consultant shall procure a bond guaranteeing payment of losses and related investigations, claim administration and defense expenses. Other Insurance Provisions The policies are to contain, or be endorsed to contain, the following provisions: 1. Tufts Polygraph & Investigation PAGE 4 OF 9 General Liability and Automobile Liability Coverages a. The City, it officers, officials, employees and volunteers are to be covered as additional insureds as respects; liability arising out of activities performed by or on behalf of the Consultant, products and completed operations of the Consultant, premises owned, occupied or used by the Consultant, or automobiles owned, hired or borrowed by the Consultant.. The coverage shall contain no special limitations on the scope -of -protection afforded to the City, its officers, officials, employees or volunteers. b. The Consultant's insurance coverage shall be primary insurance as respects to the City, its officers, officials, employees and volunteers. Any insurance or self-insurance maintained by the City, its officers, officials, employees or volunteers shall be in excess of the Consultant's insurance and shall not contribute with it. C. Any failure to comply with reporting provisions of the policies shall not affect coverage provided to the City, its officers, officials, employees or volunteers. d. The Consultant's insurance shall apply separately to each insured against whom claim is made or suit is brought, except with respect to the limits of the insurer's liability. 2. Worker's Compensation and Employers Liability Coverage The insurer shall agree to waive all rights of subrogation against the City, its officers, officials, employees and volunteers for losses arising from Consultant's performance of the work, pursuant to this Agreement. 3. Professional Liability Coverage If written on a claims -made basis, the retroactivity date shall be the eff ctive date of this Agreement. The policy period shall extend from +t �Z "� to 61 L z_., 8.. 4. All Coverages Each insurance policy required by this clause shall be endorsed to state that coverage shall not be suspended, voided, canceled by either party, reduced in coverage or in limits except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. E. Acceptability of Insurers Insurance is to be placed with admitted California insurers with an A.M. Best's rating of no less than A- for financial strength, AA for long-term credit rating and AMB -1 for short-term credit rating. F. Verification of Coverage Consultant shall furnish the City with Certificates of Insurance and with original Endorsements effecting coverage required by this Agreement. The Certificates and Endorsements for each insurance policy are to be signed by a person authorized by that insurer to bind coverage on its behalf. The Certificates and Endorsements are to be on forms provided or approved by the City. Where by statute, the City's Workers' Compensation - related forms cannot be used, equivalent forms approved by the Insurance Commissioner are to be substituted. All Certificates and Endorsements are to be received and approved by the City before Consultant begins the work of this Agreement. The City reserves the right to require complete, certified copies of all required insurance policies, at any time. If Consultant fails to provide the coverages required herein, the City shall have the right, but not the obligation, to purchase any or all of them. In that Tufts Polygraph & Investigation PAGE 5 OF 9 event, the cost of insurance becomes part of the compensation due the contractor after notice to Consultant that City has paid the premium. G. Subcontractors If Consultant uses subcontractors or sub -consultants, it shall cover them under its policies or require them to separately comply with the insurance requirements set forth in this Paragraph 6.1. 6.2 Indemnification. Notwithstanding the foregoing insurance requirements, and in addition thereto, Consultant agrees to indemnify the City for any claim, cost or liability that arises out of, or pertains to, or relates to the performance of services under this contract by Consultant, but this indemnity does not apply to liability for damages for death or bodily injury to persons, injury to property, or other loss, arising from the sole negligence, willful misconduct or defects in design by the City, or arising from the active negligence of the City. "Indemnify;" as used herein includes the expenses of defending against a claim and the payment of any settlement or judgment arising out of the claim. Defense costs include all costs associated with defending the claim, including, but not limited to, the fees of attorneys, investigators, consultants, experts and expert witnesses, and litigation expenses. References in this paragraph to City or Consultant include their officers, employees, agents, and subcontractors. 7.0 CONTRACT PROVISIONS 7.1 Ownership of Work. All documents furnished to Consultant by City and all documents or reports and supportive data prepared by Consultant under this Agreement are owned and become the property of the City upon their creation and shall be given to City immediately upon demand and at the completion of Consultant's services at no additional cost to City. Deliverables are identified in the Scope -of -Work, Attachment "A". All documents produced by Consultant shall be furnished to City in digital format and hardcopy. Consultant shall produce the digital format, using software and media approved by City. 7.2 Governing Law. Consultant shall comply with the laws and regulations of the United States, the State of California, and all local governments having jurisdiction over this Agreement. The interpretation and enforcement of this Agreement shall be governed by California law and any action arising under or in connection with this Agreement must be filed in a Court of competent jurisdiction in Mendocino County. 7.3 Entire Agreement. This Agreement plus its Attachment(s) and executed Amendments set forth the entire understanding between the parties. 7.4 Severability. If any term of this Agreement is held invalid by a court of competent jurisdiction, the remainder of this Agreement shall remain in effect. 7.5 Modification. No modification of this Agreement is valid unless made with the agreement of both parties in writing. Tufts Polygraph & Investigation. PAGE 6 OF 9 7.6 Assignment. Consultant's services are considered unique and personal. Consultant shall not assign, transfer, or sub -contract its interest or obligation under all or any portion of this Agreement without City's prior written consent. 7.7 Waiver. No waiver of a breach of any covenant, term, or condition of this Agreement shall be a waiver of any other or subsequent breach of the same or any other covenant, term or condition or a waiver of the covenant, term or condition itself. 7.8 Termination. This Agreement may only be terminated by either party: 1) for breach of the Agreement; 2) because funds are no longer available to pay Consultant for services provided under this Agreement; or 3) City has abandoned and does not wish to complete the project for which Consultant was retained. A party shall notify the other party of any alleged breach of the Agreement and of the action required to cure the breach. If the non -breaching fails to cure the breach within the time specified in the notice, the contract shall be terminated as of that time. If terminated for lack of funds or abandonment of the project, the contract shall terminate on the date notice of termination is given to Consultant. City shall pay the Consultant only for services performed and expenses incurred as of the effective termination date. In such event, as a condition to payment, Consultant shall provide to City all finished or unfinished documents, data, studies, surveys, drawings, maps, models, photographs and reports prepared by the Consultant under this Agreement. Consultant shall be entitled to receive just and equitable compensation for any work satisfactorily completed hereunder, subject to off -set for any direct or consequential damages City may incur as a result of Consultant's breach of contract. 7.9 Duplicate Originals. This Agreement may be executed in duplicate originals, each bearing the original signature of the parties. When so signed, each such document shall be admissible in administrative or judicial proceedings as proof of the terms of the Agreement between the parties. 8.0 NOTICES Any notice given under this Agreement shall be in writing and deemed given when personally delivered or deposited in the mail (certified or registered) addressed to the parties as follows: CITY OF UKIAH FIRE DEPARTMENT 300 SEMINARY AVENUE UKIAH, CALIFORNIA 95482-5400 Tufts Polygraph & Investigation PAGE 7 OF 9 MIKE TUFTS/OWNER TUFTS POLYGRAPH & INVESTIGATION P.O. BOX 1880 MIDDLETOWN, CA 95461 ATTACHMENT "A' SCOPE OF WORK In consideration of the agreements made in this Agreement for Professional Consulting Services, Tufts Polygraph and Investigation and its employees will conduct investigative activities consisting of an internal affairs investigation, necessary interviews, required research, meetings, conferences, and completed written report. This investigation is for the purposes of determining any administrative malfeasance, violation of federal/state/county/city laws, violation of Ukiah Fire Department Policy and Procedure and/or violations of the City of Ukiah Employees' Manual or Rules and Regulations by the employee referred to in Recitals (a) of this Agreement. WORK SCHEDULE Investigation activities will begin on or about January 30, 2008, and continue until the investigation is considered concluded by City or when the maximum amount of $2,600 total time and costs to Tufts Polygraph and Investigation has been reached. ATTACHMENT "B" COMPENSATION The City authorizes Tufts Polygraph and Investigation to bill a maximum of twenty-six hundred dollars $2,600) to be billed as follows: Billable time at the rate of sixty-five dollars ($65.00) per hour; 2. Mileage at the rate of $.55/mile; and 3. Actual necessary costs and expenses. 4. The City agrees that if additional investigation and/or court appearances are required in the future Tufts Polygraph and Investigation will be compensated an additional amount at the rate of sixty-five dollars ($65.00) per hour, mileage at the rate of $.55/mile and necessary costs and expenses. Should this situation arise, the additional services and compensation will be outlined in an Amendment to this Agreement. Tufts Polygraph & Investigation PAGE 9 OF 9 9.0 SIGNATURES IN WITNESS WHEREOF, the parties have executed this Agreement the Effective Date: CONSULTANT BY - PRINT NAME: 33 -1X (ms a&�<' IRS IDN Number CITY OF UKIAH BY: C D� CITY MANAGE _ ATTE rown CITY CLERK Tufts Polygraph & Investigation PAGE 8 OF 9 �3�� � Date Date Date A- G -URD. CERTIFICATE OF LIABILITY INSURANCE 12£x"" 20°o ' PRODUCER (925)673-2200 FAX: (925)673-2212 Insurance Management Corporation 6160 Center Street THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. License# 0054731 POLICY TEY EFFECTIVE! Clayton CA 94517 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:Arch Insurance Co Mike Tufts INSURER B: DBA: Tufts Polygraph and Investigation INSURER C: 21152 Calistoga Rd Ste 105 INSURER D: Middletown CA 95461 INSURER E: rrnteoer_cc 11/2/2007 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. REG kTE LIMITS S OWN MAY HAVE BEE 4 REDUCED By PAID CLAIMS, IN SR Abb'L EM TYPE OF INSURANCE POLICY NUMBER POLICY TEY EFFECTIVE! PDLAITCEY —WIMNA D TION.LM LIMITS GENERAL LIABILITY -EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑X OCCUR BIPXG0025700 11/2/2007 11/2/2008 - DAMAGEcORENTED $ 100,000 p MED EXp jAjTv one arson $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEWLAGGREGATE LIMIT APPLIES PER: X PRO L p p $ 1,000,000 PROPESSIOUAL LIAB 1,000,000 AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS SCHEDULEDAUTOS BODILY INJURY (Per Person) $ BODILY INJURY (Paz acddent) $ FIRED AUTOS NON -OWNED AUTOS PROPERTYDAMAGE $ (Paz accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHERTHAN ANYAUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY OCCURRENCE $ AGGREGATE $ OCCUR r-1 CLAIMS MADE $ $ DEDUCTIBLE $ RETENn0N WORKERS COMPENSATION AND C STATU- OTH- S I EMPLOYERS' LIABILITY _ E.L. EACH ACCIDENT $ ANY PROPRIETOWPARTNERIEXECUTIVE OFFICEWMEMBER EXCLUDED? 1TYes. describe under E.L.DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ SPECIAL PROVISIONS be! OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Proof of Coverage 10 Day Notice of Cancellation for Non Payment of Premium. Proof of Insurance OCnRn 25120011081 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO 50 SHALL IMPOSE No OBLIGATION OR LIABILITY OF ANY KIND UPON THE AUTHORIZM REPRESENTATIVE Hary Hall/MARY��7�1C a dCnRD rnRPnRATInN 1988 INS025(oiotlpu Page 1 of 2 Tuft's Polygraph and Investigation Commercial General Liability Policy Arch Insurance Terms . Insurer: Coverage: Arch Insurance Company (AM Best Rated A,. XV - Admitted) General Liability Professional Liability LIABILITY COVERAGE SECTION Coverage Each Occurrence General Aggregate Products/Completed Operations Aggregate Limit Personal & Advertising Injury Limit Damage to Premises Rented to You Medical Expenses Policy Rate Limit $1,000,000 $1,000,000 $1,000,000 $1,000,000 $ 100,000 $ 5,000 $7.50 per $1,000 of annual Investigator/Consultant Receipts (subject to minimum premium of $1,500) Exposure $200,000 Annual Receipts (maximum receipts to stay at minimum premium) I®IMC INSURANCE SERVICES S331AH39 3ONyunSN1 �HII1 o;e `Aj!anaes s;uana lWaods `joijed `aatn,ies p renB Bugpue;s `NioM p ienBApoq `uo oa;o id and;naaxe) suW;eaado peen f) A;!.noes Aue aoi oBeaanoo ap!nord;ou saop Aoaijod :31ON solsegsy • AIlillgel-1 peak 4941 • (96aego a aol algenouaa�l) aulueo (96aego a aol epenouaab) Wiely uollnllod • saoiloead palelal:l Iu9wAoldw3 :SNoisn, ox3 afiaego leugil!ppe ou papnloul e5ea9noo wsiaoaaal Ajy!ge!7 aonbi7 IsgH Appge -I le,6a-I a# j Ajnfu/ ,6uisipanp y 96ewed A:pedaad WJOJ peoa8 Auedwoo u;lnn ailj uo aleolllpao aad se ao Ioeiluoo uallpnn Aq paalnbai jI papnloui Alleoilewolne — paansul leuol;lppV ;uello;o „9ou96il69u alos,, Ideoxe — lenloeiluoo laNuel8 • alebei66e/9ouenn000 000`Oq$ jo Buell-qns ol;oefgns — sAa>l Iso -i paansul osle seeAoldw3 — seeAoldw3 lenloeiluoo 6uipnloul ole `AoeAlad Io uolsenui `aapuels `Isaaae asiej — Ainful leuosaad 96eaanoo ,,wJO gad of aanlle3„ — suoissiwo V saoaa3 -s;lnesse Ieluapiooe se Mann se leuollualul ao; 96eJ9noO - Aaa;;eq V Ilnessy S440114111H GljeJGAO3 penuijuo3 sw ie L aaueansul g3jV 3110d ;i/ige�p jeaaueq leiwoulwoo uo!;eA/;sanuI pue cideJBA10d S JJnl California Casualty AUTO & HOME INSURANCE Coverage provided by: CALIFORNIA CASUALTY INDEMNITY EXCHANGE Named Insured(s): Refer to page 1 Policy Period: 01/01/08 to 01/01/09 Policy Number: 102 2101764 Amendment Effective: 01/31/08 COVERAGE FOR: 04 CHEVR TRAILBLAZER VEHICLE ID NUMBER: 1GNET16P646142497 GARAGED AT: 21055 LOCONOMI RD MIDDLETOWN CA 95461 LIENHOLDER: CAPITAL ONE AUTO FINANCE Class: 2PUMOO Symbol: 13 Limit: See your Policy Contract for coverage details. Coverage is provided where a premium is shown. See your Policy Contract for coverage details. PREMIUM COVERAGE LIMITS DEDUCTIBLE PREMIUM BODILY INJURY LIABILITY $500,000/$1,000,000 $259.00 PROPERTY DAMAGE LIABILITY EACH PERSON/EACH ACCIDENT $118.00 PROPERTY DAMAGE LIABILITY $300,000 $153.00 UNINSURED MOTORISTS -BODILY INJURY EACH ACCIDENT $16.00 UNINSURED MOTORISTS -BODILY INJURY $15,000/$30,000 $21.00 OTHER THAN COLLISION EACH PERSON/EACH ACCIDENT $103.00 OTHER THAN COLLISION ACTUAL CASH VALUE $500 $88.00 COLLISION SUBJECT TO DEDUCTIBLE $291.00 COLLISION ACTUAL CASH VALUE $500 $353.00 TRANSPORTATION EXPENSE SUBJECT TO DEDUCTIBLE INCLUDED TRANSPORTATION EXPENSE .APPLIES INCLUDED TOWING AND LABOR COSTS $20 PER DAY/$600 MAXIMUM $8.00 TOWING AND LABOR COSTS BROAD COVERAGE $12.00 APPLIES Total Premium: $ 886.00 Your premium for this vehicle reflects the following discounts: PLATINUM DISCOUNT MULTI -CAR DISCOUNT GOOD DRIVER DISCOUNT PERSISTENCY RATING APPLIES GROUP MEMBER DISCOUNT COVERAGE FOR: 07 CHEVR IMPALA LS VEHICLE ID NUMBER: 2G1WB55K279117163 LIENHOLDER: CITI FINANCIAL AUTO Class: 2PCFOO Symbol: 11 Limit: Coverage is Provided where a premium is shown. See your Policy Contract for coverage details. COVERAGE LIMITS DEDUCTIBLE PREMIUM BODILY INJURY LIABILITY $500,000/$1,000,000 $210.00 EACH PERSON/EACH ACCIDENT PROPERTY DAMAGE LIABILITY $300,000 $118.00 EACH ACCIDENT UNINSURED MOTORISTS -BODILY INJURY $15,00EACH 030,000 $16.00 ACCIDENT OTHER THAN COLLISION ACTUAL CASH VALUE $500 $103.00 SUBJECT TO DEDUCTIBLE COLLISION ACTUAL CASH VALUE $500 $291.00 SUBJECT TO DEDUCTIBLE TRANSPORTATION EXPENSE APPLIES INCLUDED $20 PER DAY/$600 MAXIMUM TOWING AND LABOR COSTS BROAD COVERAGE $8.00 APPLIES Total Premium: Your premium for this vehicle reflects the following discounts: PLATINUM DISCOUNT MULTI -CAR DISCOUNT GOOD DRIVER DISCOUNT PERSISTENCY RATING APPLIES $ 746.00 U P-1176 (08/99) INSURED COPY 01/31/08 Page: 2 Of 3 CITY OF UKIAH RISK MANAGEMENT 300 Seminary Avenue, Ukiah, CA 95482-5400 707.463-6287 FAX 707-463.6204 — Risk Management WORKERS' COMPENSATION DECLARATION I have and will maintain a certificate of consent to self -insure for workers' compensation as provided for by Section 3700 of the Labor Code, for the performance of the work for the City of Ukiah, its officers, officials employees and volunteers. I have and will maintain a certificate showing current workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for the City of Ukiah, its officers, officials, employees and volunteers. I certify that in the performance of the work for the City of Ukiah, its officers, officials, employees and volunteers, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions and provide the City of Ukiah with a Certificate of Insurance. In addition, if at any time during the performance of the work for the City, I hire an employee from a temporary agency, I will immediately notify and provide the City with a current workers' compensation certificate from said temporary agency. I plan to hire employees using a temporary agency. The name of the agency is I have attached a copy of the temporary agency's workers compensation certificate. If at any time during the performance of the work for the City, I decide to use some other temporary agency, I will immediately notify the City's Risk Management Division, and provide the corresponding workers compensation certificate. Signature i Print Name t a 1 ! xc,02� Date �e�-•poi' ! a � (s Ac'ot`aE2 (�-� :��..� i Job Estimated time -frame of job. 1 ; Sic Company Name Company Address CA WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. Mitt i SHERIFF'S DEPARTMENT PEACE OFFICER The pmm identified bmw to a SERGEANT 1,.RETTRED swom of w of the Lice County swffs S 6 ATURE� Dept. and b a pow Ow u deNned ' Sec. moil offt pendt code.