Resolution No. 8185!F
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RESOLUTION NO. 8185
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
VERNON APPROVING AND AUTHORIZING THE EXECUTION OF
ENCROACHMENT LICENSE AGREEMENT NO. 399 BY AND
BETWEEN THE CITY OF VERNON AND DDI PROPERTIES, INC.
WHEREAS, DDI Properties, Inc. ("DDI") has filed an
application for an encroachment license agreement pursuant to Vernon
City Code Section 22.66 to install, use and maintain a monitoring well
located in 52nd Street approximately 1165 feet east of the centerline of
Alameda Street and approximately 43 feet south of the centerline of 52na
Street in the City of Vernon ("the Encroachment"); and
WHEREAS, the City Council is authorized to issue an
encroachment license pursuant to Chapter 22, Article VI, Encroachments,
of the Code of the City of Vernon which license shall be valid for a
period of twenty-five (25) years unless otherwise stated; and
WHEREAS, the City Council adopted Resolution No. 5088 on
February 21, 1984, authorizing fees for encroachment licenses; and
WHEREAS, DDI has provided proof of the required insurance, and
has paid the issuance fee of $2,500.00 and the first annual renewal fee
of $397.50; and
WHEREAS, by letter dated April 9, 2003, Bruce V. Malkenhorst,
City Administrator/City Clerk, has recommended the approval of
Encroachment License Agreement No. 399 to allow DDI to install, use and
maintain the Encroachment for a period of twenty-five (25) years,
subject to the terms and conditions of the aforesaid Article VI of
Chapter 22 of the Code of the City of Vernon; and
WHEREAS, the City Council believes it is in the best interest
of the City of Vernon to enter into Encroachment License Agreement No.
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399.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF VERNON AS FOLLOWS:
SECTION 1: The City Council of the City of Vernon hereby
finds and determines that the recitals contained hereinabove are true
and correct.
SECTION 2: The City Council of the City of Vernon hereby
approves the Encroachment License Agreement No. 399, a copy of which is
attached hereto as Exhibit "A" and made a part hereof.
SECTION 3: The City Council of the City of Vernon hereby
authorizes the Mayor and the City Clerk to execute said Agreement for,
and on behalf of, the City of Vernon.
SECTION 4: The City Council of the City of Vernon hereby
directs the City Clerk, or his designee, to send one fully executed
Agreement to:
DDI Properties, Inc.
Attn: Bill Caton
2607 N. Grandview Blvd.
Waukesha, Wisconsin 53188
SECTION 5: The City Clerk of the City of Vernon shall certify
to the passage of this resolution, and thereupon and thereafter the
same shall be in full force and effect. .
APPROVED AND ADOPTED this 16th day of April, 2003.
LEONIS C. MA BURG, Mayor
ATTEST:
BRUCE V. MALKENHORST, City Clerk
- 2 -
1 STATE OF CALIFORNIA )
2 ) ss
COUNTY OF LOS ANGELES )
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4 I, BRUCE V. MALKENHORST, City Clerk of the City of Vernon, do
5 hereby certify that the foregoing Resolution, being Resolution No.
6 8185, was duly adopted by the City Council of the City of Vernon at a
7 regular meeting of the City Council duly held on Wednesday, April 16,
8 2003, and thereafter was duly signed by the Mayor of the City of
9 Vernon.
10 X,
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BRUCE V. MALKENHORST, City Clerk
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EXHIBIT
AV
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KIM
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ENCROACHMENT LICENSE AGREEMENT NO. 399
The City of Vernon, a municipal corporation of the
State of California, as Licensor (hereinafter referred to as
"City" or "Licensor") and DDI Properties, Inc. (hereinafter
preferred to as "Licensee") do hereby agree as follows:
1. Licensee is the former owner of the real property
located at 2501 and 2533 E. 56th Street in the City of Huntington
Park, County of Los Angeles, State of California. Initial
environmental assessment and investigation by the California
Department of Toxic Substances Control (DTSC) has indicated that
former activities at this site have resulted in high levels of
soil and groundwater contamination from a range of chemicals.
2. Licensor has all requisite power of authority to
enter into this Encroachment License Agreement No. 399
(hereinafter referred to as "License"). Subject to the right of
the City of Vernon to terminate this License for reasonable
cause, as defined below, the City hereby grants to Licensee a
license to install, use and maintain a monitoring well, located
at 52nd Street approximately one thousand one hundred sixty five
feet (11651) east of the centerline of Alameda Street and
approximately forty three feet (431) south of the centerline of
52nd Street, City of Vernon, as shown in more detail on
engineer's drawings marked Exhibit "A" attached and made a part
hereof as though fully set forth herein.
3. This License is granted subject to the terms
and conditions set forth in the Code of the City of Vernon,
Chapter 22 Article VI, and the acceptance hereof shall evidence
the Licensee's agreement to all terms of said article and the
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if said present Index had not been discontinued or revised
5. Licensee shall secure and keep in full force and
effect at all times during the term of this License, general
liability insurance in the amounts determined by the City of
Vernon on an annual basis and shall file proof thereof with the
City Clerk, which proof shall include the following:
(1) A standard certificate of insurance.
(2) An endorsement naming the City of Vernon,
its officers, and employees as insured under this policy.
(3) An endorsement providing the City of Vernon
thirty (30) days notice of cancellation or material reduction of
coverage.
(4) A notarized letter from the underwriter or
carrier certifying that the coverage and statements in the
standard certificate of insurance (attached thereto) are true
and correct and that the signator is an officer authorized to so
certify.
6. Licensee shall obtain a Vernon Health Department
Well Permit prior to the construction and /or destruction of
these monitoring wells in accordance with the City of Vernon,
Chapter 25, Article II. Licensee shall maintain constructed
wells so as to prevent the intrusion of rainwater or other
material from entering the wells.
7. Licensee shall maintain the City property in first
class condition to the satisfaction of the City of Vernon, and
Licensee shall not construct any structure without having
received a permit therefore from the City of Vernon. Upon
completion of the activities to be performed under the
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CITY: CITY OF VERNON
ATTN: CITY ADMINISTRATOR
4305 SANTA FE AVENUE
VERNON, CA. 90058-0805
FAX: (323) 826-1438
LICENSEE: DDI Properties, Inc.
ATTN: BILL CATON
2607 N. GRANDVIEW BLVD.
WAUKESHA, WISCONSIN 53188
FAX: (262) 548-6069
Ll
SUPPORTING
DOCUMENTS
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ENCROACHMENT LICENSE AGREEMENT NO. 399
The City of Vernon, a municipal corporation of the
State of California, as Licensor (hereinafter referred to as
"City" or "Licensor") and DDI Properties, Inc. (hereinafter
referred to as "Licensee") do hereby agree as follows:
1. Licensee is the former owner of the real property
located at 2501 and 2533 E. 56th Street in the City of Huntington
Park, County of Los Angeles, State of California. Initial
environmental assessment and investigation by the California
Department of Toxic Substances Control (DISC) has indicated that
former activities at this site have resulted in high levels of
soil and groundwater contamination from a range of chemicals.
2. Licensor has all requisite power of authority to
enter into this Encroachment License Agreement No. 399
(nereinatter referred to as "License"). Subject to the right of
the City of Vernon to terminate this License for reasonable
cause, as defined below, the City hereby grants to Licensee a
license to install, use and maintain a monitoring well, located
at 52nd Street approximately one thousand one hundred sixty five
feet (11651) east of the centerline of Alameda Street and
approximately forty three feet (431) south of the centerline of
52nd Street, City of Vernon, as shown in more detail on
engineer's drawings marked Exhibit "A" attached and made a part
hereof as though fully set forth herein.
3. This License is granted subject to the terms
and conditions set forth in the Code of the City of Vernon,
Chapter 22 Article VI, and the acceptance hereof shall evidence
the Licensee's agreement to all terms of said article and the
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411
ladditional conditions hereinafter contained.
3. Licensee shall during the life of this License,
pay to the City of Vernon the issuance fee of Two Thousand Five
Hundred Dollars ($2,500.00), prior to the issuance of the
License. Licensee shall also pay to the City the annual
Renewal fee of Three Hundred Ninety Seven Dollars and Fifty
Cents ($397.50) payable each year during the term of the License
on or before the anniversary of the date of this License.
This annual renewal fee shall be revised in accordance
with the changes in the Consumers Price Index published by the
United States Department of Labor, Bureau of Labor Statistics
for Urban Earners and Clerical Workers -Annual Average - Los
Angeles - Anaheim -Riverside area, California - all items. In
the event said Index as the anniversary date is higher than said
Index for the issuance date, the renewal fee shall be increased
effective the anniversary date by multiplying said renewal fee
by a fraction, the numerator of which is the Index for the
current anniversary date and denominator of which is the Index
existing on the issuance date. There shall be no reduction in
fees by operation of this provision. If, in the future, said
Index shall be changed so that the base year differs from that
used as of the date of commencement of the term hereof, it shall
be converted in accordance with the conversion factor published
by the United States Department of Labor, Bureau of Labor
Statistics. In the event said Index is discontinued•or revised
during the term of this License, such other governmental Index
or computation with which it is replaced, shall be used in order
to obtain substantially the same result that would be obtained
�A
1 if said present Index had not been discontinued or revised
2 S. Licensee shall secure and keep in full force and
3 effect at all times during the term of this License, general
4 liability insurance in the amounts determined by the City of
5 Vernon on an annual basis and shall file proof thereof with the
6 City Clerk,.which proof shall include the following:
7 (1) A standard certificate of insurance.
8 (2) An endorsement naming the City of Vernon,
9 its officers, and employees as insured under this policy.
10 (3) An endorsement providing the City of Vernon
11 thirty (30) days notice of cancellation or material reduction of
12 coverage.
13 (4) A notarized letter from the underwriter�or
14 carrier certifying that the coverage and statements in the
15 standard certificate of insurance (attached thereto) are true
16 and correct and that the signator is an officer authorized to so
17 certify.
18 6. Licensee shall obtain a Vernon Health Department
19 Well Permit prior to the construction and /or destruction of
20 these monitoring wells in accordance with the City of Vernon,
21 Chapter 25, Article II. Licensee shall maintain constructed
22 wells so as to prevent the intrusion of rainwater or other
23 material from entering the wells.
24 7. Licensee shall maintain the City property in first
25 class condition to the satisfaction of the City of Vernon, and
26 Licensee shall not construct any structure without having
27 received a permit therefore from the City of Vernon. Upon
28 completion of the activities to be performed under the
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License, Licensee shall return the City property to the
condition it was in at the time of execution of this license.
8. In the event that Licensee shall fail to
utilize the City's property covered by this License for a
consecutive period of six (6) months during any period of time
after it has been placed in operation, the City Council of the
City of Vernon shall have the right, at its sole discretion, to
declare this License terminated.
9. Licensee shall not sell, transfer, assign or
lease this License, or any part hereof any of the rights or
privileges granted hereby. Licensee may not assign its duties
hereunder, and may not assign its rights hereunder to a public
futility.
10. In the event Licensee fails to keep,
fulfill or perform any of the terms or conditions of this
License and fails to remedy such default within thirty (30) days
after written notice from the City, the City may declare this
License terminated. Upon such a declaration of termination and
failure to remedy such default this License shall be cancelled
and all of the rights and privileges of Licensee under this
License shall be surrendered. The City may thereafter exclude
Licensee from further use of the street under this License.
11. Licensee shall promptly repair at its own cost
and expense, to the reasonable satisfaction of the City of
Vernon, any damage caused to any street, alley or other public
property in the City of Vernon by reason of any breaks, or
failure of the facilities installed, constructed, maintained, or
operated under this License and if Licensee fails to comply with
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any instructions of the City relative thereto within ten (10)
days after the service of written notice upon Licensee requiring
compliance therewith, then the City may immediately do whatever
work is necessary to carry out said instructions at the
reasonable cost and expense of said Licensee, which costs by the
acceptance of this License, said Licensee agrees to pay upon
demand.
12. In the event of the termination of this
License, Licensee shall at its own cost and expense, remove the
encroachment facilities as the City in its reasonable discretion
may decide. This provision may be suspended by the City of
Vernon at its sole discretion during such period as Licensee may
be negotiating with the City of Vernon for renewal of this
License. If Licensee is directed to remove the encroachment
facilities and fails to do so, City shall have the right to
remove them at Licensee's sole expense.
13. Licensee shall preserve and save harmless the
City and each officer and employee thereof from any liability or
responsibility for any accident, loss or damage to persons or
property happening or occurring as a proximate result of the
encroachment or the construction thereof.
14. Any notice, communication, request,
instruction or other document required or permitted hereunder
shall be in writing and deemed given when hand -delivered or sent
by confirmed facsimile or U.S. Mail service, to the following:
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CITY: CITY OF VERNON
ATTN: CITY ADMINISTRATOR
4305 SANTA FE AVENUE
VERNON, CA. 90058-0805
FAX: (323) 826-1438
LICENSEE: DDI Properties, Inc.
ATTN: BILL CATON
2607 N. GRANDVIEW BLVD.
WAUKESHA, WISCONSIN 53188
FAX: (262) 548-6069
6
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EXECUTED IN DUPLICATE this day of 2002.
ATTEST:
BRUCE V. MALKENHORST, City Clerk
APPROVED•FORM:
• �•�r • OLIVO, A: -
CITY OF VERNON
�_LEONISC .��ML�G,�Maor
DDI PROPERTIES, INC.
By: 0J 4
Si nature
Cqi 6,J
Print Name
Title
By:
Signature
Print Name
Title
State of Wisconsin
Cou t
y of Waukesha
AIAL tappeared before me as
of DDI Properties, Inc. on day o
NOTE: Please type amen below signatures.
Signatures sh 1 be notarize
I .
ary(PXblic
My Commission .Expires
7
Certificate of Insurance
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER THIS CERTIFICATE IS NOT AN
INSURANCE POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW.
This is to Certify that
D�OVER CORP/
I DOVER DIVERSIFIED, INC. LibertX
P.O. BOX 1027 Name and MUt11dITM
WAUKESHA, N 53187-1027 '— address of
Insured.
Is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the listed licy(ies) is subject to all their terms, exclusions
and conditions and is not altered by any requirement, tens or condition of any contract or other document with respect to which this certificate may be issued.
EXP. DATE
* ❑ CONTINUOUS
TYPE OF POLICY
❑ EXTENDED
POLICY NUMBER
LIMIT OF LIABILITY
POLICY TERM
WORKERS
COVERAGE AFFORDED UNDER WC
EMPLOYERS LIABILITY
COMPENSATION
LAW OF THE FOLLOWING STATES:
Bodily Injury By Accident
JAN 1, 2004
WC2-629-004112-163
IDAHO, MONTANA,
Each
OREGON, WISCONSIN
$1,000,000 Accident
WA1-62D-004112-973
Bodily Injury By Disease
ALL OTHER STATES EXCEPT
$1 000 000 Policy
MONOPOLISTIC STATES
Limit
Bodily Injury By Disease
$1,000,000 Each
GENERAL LIABILITY
RG1-621-004855-033
General Aggregate - Other than Products/Completed Operations
COVERAGE IS INCLUDED FOR
$15,000,000
❑ CLAIMS MADE
JAN 1, 2004
EXPLOSION, COLLAPSE AND
UNDERGROUND PROPERTY
Products/Completed rations
P gg egate
Aggregate
PERSONAL INJURY
AD BROAD
ANAD FORM PROPERTY
$15,000,000
DATE
LrAGEPCONTRACTRUAL
BodilyInjuryand Property YDama a Liability
COBILYRODUCTS/
MP OPERATIONS,
INDEPENDENT
Per
$5,000,000 Occurrence
CONTRACTORS/
CONTRACTORS PROTECTIVE,
ADDITIONAL
Per Person/
® OCCURRENCE
INSURED -VENDORS
Organization
Other
Other
AUTOMOBILE LIABILITY
Each Accident - Single
$3,000,000
®
JAN 1, 2004
AS1-621-004275-093
Limit
B.I. and P.D. Combined
OWNED
(All States)
Each Person
Each Accident or Occurrence
19 NON -OWNED
®
AS1-621-004112-983
Each Accident or Occurrence
HIRED
(Ohio)
OTHER
ADDITIONAL COMMENTS
ADDITIONAL INSURED: THE CITY OF VERNON, ITS OFFICERS, AND EMPLOYEES
I
•--••r•••••••,• •+••••• •� ....... — — ac;:::, yuu will ua 1 mimu it coverage is Ierminatea or reGUCeG More Me certificate expiration ciate.
SPECIAL NOTICE-OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN
APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILT`OF INSURANCE FRAUD.
IMPORTANT NOTCE TO FLORDA POLICYHOLDERS AND CERTFICATE HOLDERS IN THE EVENT YOU HAVE ANY QUESTIONS OR NEED INFORMATION
LBOUT THIS OWER RIGHT HANDCATE FOR CORNER OFF THE CERTIFICATE. ATE. TPLEASE HE AAPPPRO)PRIATE LOCAL SALES OFFR LOCAL SALES ICE MAILING ADDRESS SS MAVkLSO E AND BE OBTAINED BY CALLING THIS NE NUMBER APPEARS N THE Liberty Mutual Group
46UMBBBE bF CANCELLATION: NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.) BEFORF THE STATED EXPIRATION DATE THE COMPANY WILL
VOT CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL AT LEAST 30 DAYS
I CITY OF VERNON 202 I
A-2
IRTIFICAM Eileen Kiniery
AUTHORIZED REPRESENTATIVE
New York Office (212) 391-7500 3/28/2003
OFFICE PHONE NUMBER DATE ISSUED
his certificate is executed by LIBERTY MUTUAL GROUP as respects such insurance as is afforded by Those Comvanies BS 7721, R2
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY NUMBER. RG1-621-004855-033
DOVER CORPORATION/DOVER DIVERSIFIED
ADDITIONAL INSURED - OWNERS, LESSEES
OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization
CITY OF VERNON
As required by written contract
(If no entry appears above, information required to complete this endorsement will be shown in
the Declarations as applicable to this endorsement.) I
Who Is An Insured (Section II) is amended to include as an insured the person or organization
shown in the Schedule, but only with respect to liability arising out of your ongoing operations
performed for that insured
CG 2010 30 97 Copyright, Insurance Services Office, Inc.1996
POLICY CERTIFICATION FORM
RE: NAMEDINSURED
POLICY NUMBER:
EFFECTIVE DATES:
DOVER CORPORATION
WC2-621-004112-163
01/01/2003 TO 01/01/2004
XQI certify this is to be a true copy of the original policy issued.
❑ I certify this is to be a true copy of the original Declarations page issued.
I certify this is to be a true copy of the original Uninsured/Underinsured
Motor Acception/Rejection and/or the Personal Injury Acception/Rejection form(s).
This policy was retrieved from Liberty Mutual's files and is Liberty Mutual's best
current evidence of the policy. Liberty Mutual, however, reserves the right to
supplement or amend this policy should further or different terms, conditions,
endorsements, or exclusions become known. Liberty Mutual does not acknowledge
that this is a certified copy of the policy, or that it is the exact copy of the policy that
was delivered to the Insured.
LIBERTY MUTUAL RESERVES THE RIGHT TO FURTHER AMEND OR SUPPLEMENT THIS POLIC)
SHOULD ANY ADDITIONAL TERMS, CONDITIONS OR EXCLUSIONS COME TO OUR ATTENTION.
a,d .. /- - 4 -r
Colleen Lahey, Production Manager
Commercial Markets Support Operations
Lewiston, Maine
Date: 03/28/03
Xa�
POLICY CERTIFICATION FORM
RE: NAMED INSURED: DOVER CORPORATION
POLICY NUMBER: WA1-62D-004112-973
EFFECTIVE DATES: 01/01/2003 TO 01/01/2004
X�I certify this is to be a true copy of the original policy issued.
F-1I certify this is to be a true copy of the original Declarations page issued.
❑1 certify this is to be a true copy of the original Uninsured/Underinsured
Motor Acception/Rejection and/or the Personal Injury Acception/Rejection form(s).
QThis policy was retrieved from Liberty Mutual's files and is Liberty Mutual's best
current evidence of the policy. Liberty Mutual, however, reserves the right to
supplement or amend this policy should further or different terms, conditions,
endorsements, or exclusions become known. Liberty Mutual does not acknowledge
that this is a certified copy of the policy, or that it is the exact copy of the policy that
was delivered to the Insured.
LIBERTY MUTUAL RESERVES THE RIGHT TO FURTHER AMEND OR SUPPLEMENT THIS POLIC)
SHOULD ANY ADDITIONAL TERMS, CONDITIONS OR EXCLUSIONS COME TO OUR ATTENTION.
Colleen Lahey, Production Manager
Commercial Markets Support Operations
Lewiston, Maine
Date: nAOMI
a
POLICY CERTIFICATION FORM
RE: NAMED INSURED: DOVER CORPORATION
POLICY NUMBER: RG1-621-004855-033
EFFECTIVE DATES: 01/01/2003 TO 01/01/2004
XQ I certify this is to be a true copy of the original policy issued.
I certify this is to be a true copy of the original Declarations page issued.
I certify this is to be a true copy of the original Uninsured/Underinsured
Motor Acception/Rejection and/or the Personal Injury Acception/Rejection form(s).
F—JThis policy was retrieved from Liberty Mutual's files and is Liberty Mutual's best
current evidence of the policy. Liberty Mutual, however, reserves the right to
supplement or amend this policy should further or different terms, conditions,
endorsements, or exclusions become known. Liberty Mutual does not acknowledge
that this is a certified copy of the policy, or that it is the exact copy of the policy that
was delivered to the Insured.
LIBERTY MUTUAL RESERVES THE RIGHT TO FURTHER AMEND OR SUPPLEMENT THIS POLICI
SHOULD ANY ADDITIONAL TERMS, CONDITIONS OR EXCLUSIONS COME TO OUR ATTENTION.
Colleen Lahey, Production Manager
Commercial Markets Support Operations
Lewiston, Maine
Date: 03/28/03
POLICY CERTIFICATION FORM
RE: NAMED INSURED: DOVER CORPORATION
POLICY NUMBER: AS1-621-004275-093
EFFECTIVE DATES: 01/01/2003 TO 01/01/2004
Xn I certify this is to be a true copy of the original policy issued.
QI certify this is to be a true copy of the original Declarations page issued.
F-1I certify this is to be a true copy of the original Uninsured/Underinsured
Motor Acception/Rejection and/or the Personal Injury Acception/Rejection form(s).
This policy was retrieved from Liberty Mutual's files and is Liberty Mutual's best
current evidence of the policy. Liberty Mutual, however, reserves the right to
supplement or amend this policy should further or different terms, conditions,
endorsements, or exclusions become known. Liberty Mutual does not acknowledge
that this is a certified copy of the policy, or that it is the exact copy of the policy that
was delivered to the Insured.
LIBERTY MUTUAL RESERVES THE RIGHT TO FURTHER AMEND OR SUPPLEMENT THIS POLICI
SHOULD ANY ADDITIONAL TERMS, CONDITIONS OR EXCLUSIONS COME TO OUR ATTENTION.
Colleen Lahey, Production Manager .
Commercial Markets Support Operations
Lewiston, Maine
Date: 03/28/03
3-0,03
QW
POLICY CERTIFICATION FORM
RE: NAMED INSURED: DOVER CORPORATION
POLICY NUMBER: AS1-621-004112-983
EFFECTIVE DATES: 01/01/2003 TO 01/01/2004
X�I certify this is to be a true copy of the original policy issued.
QI certify this is to be a true copy of the original Declarations page issued.
I certify this is to be a true copy of the original Uninsured/Underinsured
Motor Acception/Rejection and/or the Personal Injury Acception/Rejection form(s).
This policy was retrieved from Liberty Mutual's files and is Liberty Mutual's best
current evidence of the policy. Liberty Mutual, however, reserves the right to
supplement or amend this policy should further or different terms, conditions,
endorsements, or exclusions become known. Liberty Mutual does not acknowledge
that this is a certified copy of the policy, or that it is the exact copy of the policy that
was delivered to the Insured.
LIBERTY MUTUAL RESERVES THE RIGHT TO FURTHER AMEND OR SUPPLEMENT THIS POLICl
SHOULD ANY ADDITIONAL TERMS, CONDITIONS OR EXCLUSIONS COME TO OUR ATTENTION.
dqen� 1--toe
Colleen Lahey, Production Manager
Commercial Markets Support Operations
Lewiston, Maine
Date: 03/2R/03