HomeMy WebLinkAboutCounty of San Bernardino-2011-18 •
GiC '201 t—I
FOR COUNTY USE ONLY
WIT X New Vendor Code SC Dept. Contract Number
_ Change
Cancel
County Department Dept. Orgn. Contractors License No.
Board of Supervisors BDF BDC
County Department Contract Representative Telephone Total Contract Amount
County of San Bernardino Matthew Erickson 387-3937 $1,000.00
F A S Contract Type
E Revenue ❑ Encumbered Unencumbered ❑ Other.
STANDARD CONTRACT If not encumbered or revenue contract type,provide reason:
Commodity Code Contract Start Date Contract End Date Original Amount Amendment Amount
Fund Dept. Organization Appr. Obj/Rev Source GRC/PROJ/JOB No. Amount
MA CNA CNA 300 3305 $1.000.00
Fund Dept. Organization Appr. Obj/Rev Source GRC/PROJ/JOB No. Amount
Fund Dept. Organization Appr. ObjlRev Source GRC/PROJ/JOB No. Amount
Project Name Estimated Payment Total by Fiscal Year
City of Grand Terrace FY Amount I/D FY Amount lID
2010-11 $1,000.00
THIS CONTRACT is entered into in the State of California by and between the County of San Bernardino, hereinafter called
the COUNTY, and
Name
City of Grand Terrace hereinafter called "CONTRACTOR"
Address
22795 Barton Road
Grand Terrace, Ca 92313
Telephone Federal ID No.or Social Security No.
909-430-2229 95-3316135
IT IS HEREBY AGREED AS FOLLOWS:
This Contract is made and entered into by and between the COUNTY and CONTRACTOR.
WITNESSETH
WHEREAS, COUNTY recognizes the benefit in assisting with community events that promote health, safety, well-
being, and quality of life for residents of Grand Terrace, and surrounding communities within the COUNTY's Third District;
and,
WHEREAS, as part of the 2010-11 budget process, the Board of Supervisors set aside allocations for each
supervisorial district to finance unbudgeted priority needs throughout the fiscal year; and,
WHEREAS, CONTRACTOR holds public events in an effort to bring the community together and promote health,
safety, well-being, and quality of life to its residents; and,
WHEREAS, CONTRACTOR is hosting the "Grand Terrace Community Day" event which will include a Kid Zone,
featuring face painting, interactive activities, and games for children of all ages, dance performances, a car show, a tug-of-war
Auditor/Controller-Recorder Use Only Page 1 of 8
0 Contract Database D FM
Input Date Keyed By
contest, food vendors, a pancake breakfast, Friends of the Library book sale, Chamber of Commerce business and resource
fair, and a health and safety fair; and,
WHEREAS, the COUNTY residents of San Bernardino and the surrounding communities within the Third District will
be served by CONTRACTOR'S event.
NOW, THEREFORE, in consideration of the mutual covenants herein set forth and the mutual benefits to be derived
therefrom, the parties agree as follows:
1. PURPOSE OF CONTRACT
This Contract is made for the purpose of providing funding to support CONTRACTOR with public events in an effort to
bring the community together and promote health, safety,well-being, and quality of life to its residents.
2. SCOPE OF SERVICES
Funding arising out of this Contract will be used to assist CONTRACTOR with the Kid Zone activities that will be a
major part of the "Grand Terrace Community Day." The event will include the Kid Zone, featuring face painting,
interactive activities, and games for children of all ages, dance performances, a car show, a tug-of-war contest, food
vendors, a pancake breakfast, Friends of the Library book sale, Chamber of Commerce business and resource fair,
and a health and safety fair.
3. TIME OF PERFORMANCE
The services to be provided by CONTRACTOR shall commence upon approval of this contract and shall be
completed by June 30, 2011.
4. COMPENSATION AND METHOD OF PAYMENT
For performance of such services, COUNTY shall provide funding in an amount not to exceed one thousand dollars
($1,000.00). This payment shall constitute full and complete compensation to CONTRACTOR under this Contract.
Any costs in excess of the amount available in this section shall be the sole responsibility of CONTRACTOR. This
condition however, does not preclude COUNTY from providing additional funding at its sole discretion. For the
purpose of this Contract, COUNTY shall disburse compensation and monitor the CONTRACTOR's performance in
satisfying the scope of work obligations under the terms of this Contract.
Disbursement of funds to CONTRACTOR shall be made in one lump sum. Payment may be provided in advance,
upon execution of this Contract. CONTRACTOR shall submit a final expenditure report documented with "audit
ready"supportive evidence of each expenditure and proof of payment until all funds have been justified.
5. COMPLIANCE WITH LAWS
CONTRACTOR hereby agrees that it will comply with all applicable federal, state and local laws. CONTRACTOR
agrees that acceptance of funds pursuant to this Contract may require the payment of prevailing wages for
construction projects if such funds are used in connection with construction projects. CONTRACTOR agrees that it
will determine whether the payment of prevailing wages is required and will require the payment of prevailing wages
in any contract if necessary. CONTRACTOR, pursuant to Paragraph 19, Indemnification, agrees to indemnify, defend
and hold harmless COUNTY in the event any claims, actions, losses, damages and/or liability arises out of the failure
to pay prevailing wages in the event such wages are applicable.
6. PREVAILING WAGES
By its execution of this Agreement, CONTRACTOR certifies that it is aware of the requirements of California Labor
Code Sections 1720 et seq. and 1770 et seq. As well as California Code of Regulations, Title 8, Section 16000 et
seq. ("Prevailing Wage Laws"), which require the payment of prevailing wage rates and the performance of other
requirements on certain "public works" and "maintenance" projects. If the Services are being performed as part of an
Auditor/Controller-Recorder Use Only Page 2 of 8
0 Contract Database l7 FAS
Input Date Keyed By
applicable "public works" or "maintenance" project, as defined by the Prevailing Wage Laws, and if the total
compensation is $1,000 or more, CONTRACTOR agrees to fully comply with such Prevailing Wage Laws.
CONTRACTOR shall make copies of the prevailing rates of per diem wages for each craft, classification or type of
worker needed to execute the Services available to interested parties upon request, and shall post copies at the
CONTRACTOR'S principal place of business and at the project site. CONTRACTOR shall defend, indemnify and
hold the COUNTY, its elected officials, officers, employees and agents free and harmless from any claims, liabilities,
costs, penalties or interest arising out of any failure or alleged failure to comply with Prevailing Wage Laws.
7. ON-SITE INSPECTION
COUNTY, its officers, agent and employees, will have the privilege and right to on-site inspection of the
CONTRACTOR'S facility for the duration of this Contract. CONTRACTOR will ensure that its employees or agents
furnish any information, that in the judgment of COUNTY, may be relevant to a question of compliance with
contractual conditions, or the effectiveness, legality, and achievements of the program.
8. ACCOUNTING AND RECORDS
CONTRACTOR must establish and maintain on a current basis an adequate accounting system in accordance with
Generally Accepted Accounting Principles. CONTRACTOR agrees to maintain all records relating to this Contract for
a period of three years after the termination or expiration of this Contract. County or any appointee thereof shall have
absolute right to review and audit all records, books, papers, documents, corporate minutes, and other pertinent items
as requested.
9. VIOLATION OF CONTRACT
In the event that CONTRACTOR violates any of the terms and conditions of this Contract, COUNTY shall give written
notice of violation and demand for correction. If, within thirty (30) days from receipt of written notice, CONTRACTOR
has not corrected the violation or shown acceptable cause, COUNTY has the right to terminate this Contract. County
will provide a written Notice of Termination. It is agreed that in the event of a termination due to a violation of this
Contract by CONTRACTOR, it shall pay to COUNTY within ten (10) days of receipt of a Notice of Termination, any
and all unexpended funds. Said sum is agreed to represent a reasonable endeavor by both parties hereto, to be a
fair compensation for the foreseeable losses that might result from such a breach or default. If CONTRACTOR
violates any terms and conditions regarding the proper expenditure of funds, CONTRACTOR will be required to
reimburse COUNTY for any improper expenditures.
10. ASSIGNMENT
This Contract is not assignable by CONTRACTOR, without the express written consent of COUNTY. Any attempt by
CONTRACTOR to assign any performance of the terms of this Contract shall be null and void and shall constitute a
material breach of this Contract.
11. TERMINATION AND TERMINATION COSTS
This Contract may be terminated in whole or in part at any time by either party upon giving (30) days notice in writing
to the other party. The Chief Executive Officer is hereby empowered to give said notice subject to ratification by the
COUNTY Board of Supervisors if required.
COUNTY may immediately terminate this Contract upon the termination, suspension, discontinuation or substantial
reduction in COUNTY funding for the Contract activity or if for any reason the timely completion of the services under
this Contract is rendered improbable, infeasible or impossible. If CONTRACTOR fails to comply with any material
term of this Contract, COUNTY may take one or more of the following actions: disallowing non-compliant costs,
wholly or partly suspending or terminating the award, withholding further awards, and other remedies that are legally
available.
12. REVERSION OF ASSETS
• Auditor/ControllerRecorder Use Only Page 3 of 8
O Contract Database 0 FAS
Input Date Keyed By
Upon Contract termination, CONTRACTOR shah transfer to COUNTY all COUNTY Funds on hand at the time of
expiration and any accounts receivable attributable to the use of COUNTY Funds.
13. TIME OF PERFORMANCE MODIFICATIONS
The Chief Executive Officer may grant time of performance modifications to this Contract when such modifications:
a. In aggregate do not exceed twelve(12)calendar months;
b. Are specifically requested by CONTRACTOR;
c. Will not change the project goals or scope of services;
d. Are in the best interests of COUNTY and CONTRACTOR in performing the scope of services under
this Contract; and
e. Do not alter the amount of compensation under this Contract.
14. INDEPENDENT CONTRACTOR
All parties hereto in the performance of this Contract will be acting in independent capacities and not as agents,
employees, partners, joint venturers, or associates of one another. The employees or agents of one party shall not
be deemed or construed to be the agents or employees of the other party for any purpose whatsoever.
15. DISCRIMINATION
No person shall, on the grounds of race, sex, creed, color, religion, or national origin, be excluded from participating
in, be refused the benefits of, or otherwise be subjected to discrimination in any activities, programs, or employment
supported by this Contract.
16. CONTRACT COMPLIANCE
CONTRACTOR shall comply with Executive Orders 11246, as amended by Executive Orders 11375, 11478, 12086,
and 12107, (Equal Employment Opportunity), Executive Orders 11625, 12138, 12432, 12250, and Executive Order
13279 (Equal Protection of the Laws for Faith-Based and Community Organizations), Title VII of the Civil Rights Act
of 1964, and the California Fair Housing and Employment Act, and other applicable federal, state and COUNTY laws,
regulations and policies relating to equal employment and contracting opportunities, including laws and regulations
hereafter enacted.
17. IMPROPER CONSIDERATION
CONTRACTOR shall not offer (either directly or through an intermediary) any improper consideration, such as, but
not limited to, cash, discounts, services or the provision of travel or entertainment, or any items of value to any officer,
employee or agent of COUNTY in an attempt to secure favorable treatment regarding this Contract or any contract
awarded by COUNTY. COUNTY, by notice, may immediately terminate this Contract or any COUNTY contract if it
determines that any improper consideration as described in the preceding sentence was offered to any officer,
employee or agent of COUNTY with respect to any proposal or award process involving this Contract or any other
COUNTY contract. This prohibition shall apply to any amendment, extension or evaluation process once this
Contract or any COUNTY contract has been awarded. Attorneys shall immediately report any attempt by any
COUNTY officer, employee or agent to solicit(either directly or through an intermediary) improper consideration from
CONTRACTOR. The report shall be made to the supervisor or manager charged with supervision of the employee or
to the County Administrative Office. In the event of a termination under this provision, COUNTY is entitled to pursue
any available legal remedies.
18. MISREPRESENTATION
If during the course of the administration of this Contract, COUNTY determines that CONTRACTOR has made a
material misstatement or misrepresentation or that materially inaccurate information has been provided to COUNTY,
Auditor/Controller-Recorder Use Only Page 4 of 8
0 Contract Database 0 FAS
Input Date Keyed By
this Contract may be immediately terminated. If this Contract is terminated according to this provision, COUNTY is
entitled to pursue any available legal remedies.
19. INDEMNIFICATION
CONTRACTOR agrees to indemnify, defend (with counsel reasonably approved by COUNTY) and hold harmless
COUNTY and its authorized officers, employees, agents and volunteers from any and all claims, actions, losses,
damages, and/or liability arising out of this Contract from any cause whatsoever, including the acts, errors or
omissions of any person and for any costs or expenses incurred by COUNTY on account of any claim except where
such indemnification is prohibited by law. This indemnification provision shall apply regardless of the existence or
degree of fault indemnitees. CONTRACTOR'S indemnification obligation applies to COUNTY's "active" as well as
"passive" negligence but does not apply to COUNTY's"sole negligence" or"willful misconduct" within the meaning of
Civil Code Section 2782.
20. INSURANCE REQUIREMENTS
CONTRACTOR agrees to provide insurance set forth in accordance with the requirements herein. If CONTRACTOR
uses existing coverage to comply with these requirements and that coverage does not meet the specified
requirements, CONTRACTOR agrees to amend, supplement, or endorse the existing coverage to do so. The type(s)
of insurance required is determined by the scope of the contract services.
Without in any way affecting the indemnity herein provided and in addition thereto, CONTRACTOR shall self-insure to
the levels identified herein or shall secure and maintain throughout the Contract the following types of insurance with
limits as shown:
Workers' Compensation/Employer's Liability - A program of Workers' Compensation insurance or a state-
approved Self-Insurance Program in an amount and form to meet all applicable requirements of the Labor
Code of the State of California, including Employers' Liability with $250,000 limits, covering all persons
including volunteers providing services on behalf of CONTRACTOR and all risks to such persons under this
Contract.
If CONTRACTOR has no employees, it may certify or warrant to COUNTY that it does not currently have any
employees or individuals who are defined as "employees" under the Labor Code and the requirement for
Workers' Compensation coverage will be waived by the COUNTY's Risk Manager.
With respect to contractors that are non-profit corporations organized under California or Federal law,
volunteers for such entities are required to be covered by Workers' Compensation insurance. If the
COUNTY's Risk Manager determines that there is no reasonably priced coverage for volunteers, evidence of
participation in a volunteer insurance program may be substituted.
Commercial/General Liability Insurance —CONTRACTOR shall carry General Liability Insurance covering all
operations performed by or on behalf of CONTRACTOR providing coverage for both bodily injury and
property damage with a combined single limit of not less than one million dollars ($1,000,000), per
occurrence. The policy coverage shall include:
a) Premises operations and mobile equipment
b) Products and completed operations
c) Broad form property damage(including completed operations)
d) Explosion, collapse and underground hazards
e) Personal injury
f) Contractual liability
g) $2,000,000 general aggregate limit
Automobile Liability Insurance-Primary insurance coverage shall be written on ISO Business Auto coverage
form for all owned, hired, and non-owned automobiles or symbol 1 (any auto). The policy shall have a
combined single limit of not less than one million dollars ($1,000,000)for bodily injury and property damage,
per occurrence.
Page 5 of 8
Auditor/Controller-Recorder Use Only
❑Contract Database D FPS
Input Date I Keyed By
If CNTCTOR is transorting
or more
p
in performnce of
services,
ne
s
the automobile liability policy shallll have a combined singleal mat of two million dollars ($2 000,000)ifor bodily
injury and property damage per occurrence.
If CONTRACTOR owns no autos, a non-owned auto endorsement to the General Liability policy described
above is acceptable.
Umbrella Liability Insurance-An umbrella (over primary)or excess policy may be used to comply with limits
or other primary coverage requirements. When used, the umbrella policy shall apply to bodily injury/property
damage, personal injury/advertising injury and shall include a "dropdown" provision providing primary
coverage for any liability not covered by the primary policy. The coverage shall also apply to automobile
liability.
Additional Insured - All policies, except for the Workers' Compensation, Errors and Omissions and
Professional Liability policies shall contain endorsements naming COUNTY and its officers, employees,
agents and volunteers as additional insureds with respect to liabilities arising out of the performance of
services hereunder. The additional insured endorsements shall not limit the scope of coverage for COUNTY
to vicarious liability
shall
additional
ided by the
uch
insured coverage shall be at least as broad as full
Additional Insured (Formv policy.B)endorsementformSISO,
CG 2010.11 85.
Waiver of Subrogation Rights - CONTRACTOR shall require the carriers of required coverages to waive all
rights of subrogation against COUNTY, its officers, employees, agents, volunteers, contractors and
subcontractors. All general or auto liability insurance coverage provided shall not prohibit CONTRACTOR
and its employees or agents from waiving the right of subrogation prior to a loss or claim. CONTRACTOR
hereby waives all rights of subrogation against COUNTY.
Policies Primary and Non-Contributory - All policies required herein are to be primary and noncontributory
with any insurance or self-insurance programs carried or administered by COUNTY.
Severability of Interests - CONTRACTOR agrees to ensure that coverage provided to meet these
requirements is applicable separately to each insured and there will be no cross liability exclusions that
preclude coverage for suits between CONTRACTOR and COUNTY or between COUNTY and any other
insured or additional insured under the policy.
Acceptability of Insurance Carrier - Unless otherwise approved by Risk Management, insurance shall be
written by insurers authorized to do business in the State of California and with a minimum "Best" Insurance
Guide rating of"A-VII".
Deductibles and Self-Insured Retention - Any and all deductibles or self-insured retentions in excess of
$10,000 shall be declared to and approved by Risk Management.
Failure to Procure Coverage-In the event that any policy of insurance required under this contract does not
comply with the requirements, is not procured, or is canceled and not replaced, COUNTY has the right but not
the obligation or duty to cancel the contract or obtain insurance if it deems necessary and any premiums paid
by COUNTY will be promptly reimbursed by CONTRACTOR or COUNTY payments to CONTRACTOR will be
reduced to pay for COUNTY purchased insurance.
21. PROOF OF COVERAGE
CONTRACTOR shall furnish certificates of insurance to the COUNTY evidencing the insurance coverage, including
endorsements, as required, prior to the commencement of performance of services hereunder, which certificates shall
provide that such insurance shall not be terminated or expire without thirty (30) days written notice to COUNTY, and
CONTRACTOR shall maintain such insurance from the time it commences performance of services hereunder until
the completion of such services. Within fifteen (15) days of the commencement of this Contract, CONTRACTOR
Page 6 of 8
Auditor/controller Recorder Use Only
0 contract Database 0 FAS
Input Date I Keyed By
shall furnish a copy of the Declaration page for all applicable policies and will provide complete certified copies of the
policies and endorsements immediately upon request.
22. INSURANCE REVIEW
Insurance requirements are subject to periodic review by COUNTY. The COUNTY's Risk Manager, or designee, is
authorized, but not required, to reduce, waive, or suspend any insurance requirements whenever Risk Management
determines that any of the required insurance is not available, is unreasonably priced, or is not needed to protect the
interests of COUNTY. In addition, if Risk Management determines that heretofore unreasonably priced or unavailable
types of insurance coverage or coverage limits become reasonably priced or available, the Risk Manager, or
designee, is authorized, but not required, to change the above insurance requirements, to require additional types of
insurance against COUNTY, higher coverag
any otherit mtm re reasonably related that
d to the COUNTY's riskreasonable in light of past claims
Any change requiring additional types of insurance coverage or higher coverage limits must be made by amendment
to this contract. CONTRACTOR agrees to execute any such amendment within thirty(30)days of receipt.
Any failure,
indemnification alleged, on
s will the part of CUNTY to monitor or enforce not be deemed as a waiver of any rights on part compliance
any of the insurance and
or of COUNTY.
23. ELECTRONIC FUNDS
CONTRACTOR shall accept all payments from COUNTY via electronic funds transfer (EFT) directly deposited into
the CONTRACTORS designated checking or other bank account. CONTRACTOR shall promptly comply with
directions and accurately complete forms provided by COUNTY required to process EFT payments.
24. LEGAL FEES
CONTRACTOR understands and agrees that any and all legal fees or costs associated with lawsuits concerning this
Contract against the COUNTY shall be the CONTRACTOR'S sole expense and shall not be charged as a cost under
this Contract. In the event of any Contract dispute hereunder, each party to this Contract shall bear its own attorney's
fees and costs regardless of who prevails in the outcome of the dispute.
25. AMENDMENTS:VARIATIONS
This writing, with attachments, embodies the whole of the Contract of the parties hereto. There are no oral
ageementsor
berval d unlesnmade in the form of a written lamendment todtlhisn provided, adtion Contract tformally approved andion of the terms of s Contract shall
tained here . Except as executed
parties.
26. INVALID CONDITIONS
If any one or more of the terms, provisions, sections, promises, covenants or conditions of this Contract shall to any
extent be judged invalid, unenforceable, void or voidable for any reason whatsoever, by a court of competent
jurish and all of
he
rovisions, sections,
mises,
s
nd
ions
Contiracts shall not be affected thereby,remaining
thereby, and shall Abe valid and enforceable ttoothe fullest extenttperrmitted by law.
of the
law.
27. BINDING INTEREST
This Contract shall be binding on the parties, successors in interest, heirs and assigns.
28. NOTICES
All notices shall be served in writing. The notices shall be sent to the following addresses:
Page 7 of 8
Auditor/Controller-Recorder Use Only
❑Contract Database 0 FAS
Input Date I Keyed By
County of San Bernardino City of Grand Terrace
385 North Arrowhead Ave. 22795 Barton Road
San Bernardino, CA 92415 Grand Terrace, Ca 92313
Attn: Matthew Erickson Attn: Betsy Adams, City Manager
29. COUNTERPART EXECUTION
This Contract may be executed in counterparts. When executed, each unterpart shall be
irrespective of date of execution. Said counterparts shall together constitute one and the same Contract.deemed an original
IN WITNESS WHEREOF, the parties have caused this Contract to be executed as of the day and year written below.
COUNTY OF SAN BERNARDINO CONTRACTOR \)_n
► By i 1:4r-57 ,
Purchasing Agent (Aut 'zed signature-
sign
in
blue ink)
Name Name � -- i
(Print or type name) (Print or e name of person signing Contract)
Title G
Date: / (Print or Type)
Date: 4 - 2—//
APPROVED AS TO LEGAL FORM
JEAN-RENE BASLE
County Counsel
By:
MICHELLE D. BLAKEMORE
Chief Assistant County Counsel
Date:
Auditor/Controller-Recorder Use Only Page 8 of 8
0 contract Database 0 FAS
Input Date I Keyed By
EVANSTON INSURANCE COMPANY
CERTIFICATE NO.: -
CERTIFICATE OF INSURANCE
SPECIAL EVENT LIABILITY PROGRAM
PRODUCER PUBLIC ENTITY(ADDITIONAL INSURED)
Alliant Insurance Services,Inc.in conjunction with
Apex Insurance Services
P.O. Box 6450
Newport Beach,CA 92658
License No:OC 36861
NAMED INSURED(EVENT HOLDER): EVENT INFORMATION:
City of Grand Terrace TYPE: Grand Terrace Days 2011
22795 Barton Road DATE(S): June 25.2011
Grand Terrace,CA 92313 LOCATION: Rollins Park
*Liquor Liability Yes 0 No El
**Liquor Liability after 12 am ends before 2 am ❑
This is to certify that the insurance policy listed below has been issued to the above insured named(event holder)for the policy
period indicated. 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 policy listed and it does not
constitute a contract between the insurance carrier,authorized representative,producer and certificate holder. The insurance
described herein is subject to all the teens,exclusions and conditions of such policy(ies).
INSURANCE CARRIER: Evanston Insurance Company
MASTER POLICY NUMBER: I ISEP1000001
MASTER POLICY DATES: EFFECTIVE: JANUARY 1,2011 EXPIRATION:JANUARY 1,2012
COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE
General Aggregate Limit S 2,000,000
Products&Completed Operations 1,000,000
Personal&Advertising Injury 1,000,00D
Each Occurrence Limit 1,000,000
Fire Damage(Any One Fire) 50,000
Medical Payments(Any One Person) 5,000
Liquor Liability (If purchased) 1,000,000
The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event.
"Who is insured"is amended to include,as an insured,the person or organization shown in this schedule,but only with respect to liability arising out of the
ownership,maintenance or use of the premises used by the named insured(event holder). This insurance does not apply to: Any"occurrence"which takes place
after the event holder ceases to be a tenant in that premises.
OTHER ADDITIONAL INSUREDS
Colton Joint Unified School District
CANCELLATION: Should the above described policy be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy
provisions.
AUTHORIZED REPRESENTATIVE:
DATE ISSUED: 5/3/11