Resolution No. 2014-034AMENDMENT SIGNATURE ROUTING FORM
CONTRACTOR:
CONTRACT PURPOSE: Agreement accepting the assignment to Prepare the Hazardous Materials Emergency Plan
for the City of Vernon.
CONTRACT IS: ❑ FEDERAL ❑ PREVAILING WAGE ❑ COMPETITIVE SELECTION & NOTICED RFP
❑ COMPETITIVE BID & NOTICED INVITATION TO BID
®EXEMPT FROM COMPETITIVE PROCESS (APPROVAL ATTACHED)
❑SERVICES o MATERIALS o BUDGETED o NOT BUDGETED
TOTAL CONTRACT VALUE: $10,000 Charge Acct. No(s) 011-1061-595200
Amendment Value $ ❑ Contract is an Amendment to Contract No. (if applicable)
RESPONSIBLE DEPARTMENT PERSON: Leonard Grossberg_ PHONE: ext. 231
AUTHORIZATION: E Approved by Council on 06/17/2014
(Check One) Resolution No. 2014-34_ (if applicable)
❑ Approved by City Administrator on
Note: Attach supporting documentation
❑Amendment Approved by (if applicable)
ROUTING SEQUENCE: (Please Follow In Order — Do not use N/A) Initials Date
(1) Responsible Department Person
Checks substance of contract and assembles two (2) copies of 3 IZ /�
contract, insurance & bond documents, certifies compliance
with Competitive Bidding and Purchasing Ordinance r /
(2) Liability and Claims
Approves insurance and sureties, if bonds required
(3) Finance (Purchasing) r[
Checks compliance with Competitive Bidding & Living Wage Ordinances
and reflected in current budget
(4) City Attorney
Approves contract as to form, verifies bonds and insurance included
(5) City Signatory 16
Signs all copies on behalf of City /V7—,S
(6) City Clerk
Attests signatures, numbers, files contract, insurance and bonds, and IC.J
transmits duplicate original to contractor, notifies IT to remove related RFP/bid
notice, notifies any "consultant' of duties to file Form 700, if applicable
Rev. 1/27/14
TRANSMITTAL COMMUNICATION
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OFFICE OF THE CITY CLERK
4305 Santa Fe Avenue, Vernon, California 90058
Telephone (323) 583-8811
March 17, 2015
Brett Koontz
2575 E. Chevy Chase Drive
Glendale, CA 91206
Re: Services Agreement for Preparation of the Hazardous Materials Emergency Plan
Dear Mr. Koontz:
The insurance requirements have been met. Please find enclosed one fully executed copy of the
above -referenced agreement, approved by City Council on June 17, 2014, through Resolution
No. 2014-34.
If you have any questions regarding this matter, please call Leonard Grossberg at (323) 583-8811
ext. 231.
Very truly yours,
Deborah R. Juarez
Records Management Assistant
Enclosure
c: Leonard Grossberg
Purchasing Department
Agreement File No. 14-117
E,iccinsivefy Industrial
FULLY EXECUTED AGREEMENT
SERVICES AGREEMENT BETWEEN THE CITY OF VERNON AND BRETT KOONTZ
TO PREPARE THE HAZARDOUS MATERIALS EMERGENCY PLAN FOR THE CITY
OF VERNON
Contractor:
Notice Information - Contractor:
Notice Information - City:
Commencement Date:
Termination Date:
Consideration:
COVER PAGE
Brett Koontz
Brett Koontz
2575 E. Chevy Chase Drive
Glendale, CA 91206
Attention: Brett Koontz
Phone: (818) 636-4447
Email: brett.koontz@csun.edu
City of Vernon
4305 Santa Fe Avenue
Vernon, CA 90058
Attention: Leonard Grossberg, Director of
Health & Environmental Control
Telephone: (323) 583-8811 ext. 231
Facsimile: (323) 588-4320
March 17. 2015
September 15, 2015
Total not to exceed $10,000.00 (includes all
applicable sales tax); and more particularly
described in Exhibit C
Records Retention Period Three (3) years, pursuant to Section 9.19
SERVICES AGREEMENT BETWEEN THE CITY OF VERNON AND BRETT KOONTZ
TO PREPARE THE HAZARDOUS MATERIALS EMERGENCY PLAN FOR THE CITY
OFVERNON
This Contract is made between the City of Vernon ("City"), a California charter City and
California municipal corporation ("City'), and Brett Koontz ("Contractor").
The City and Contractor agree as follows:
1.0 EMPLOYMENT OF CONTRACTOR. City agrees to engage Contractor to
perform the services as hereinafter set forth.
2.0 SCOPE OF SERVICES. On June 17, 2014, the City Council approved
Resolution No. 2014-34 approving and ratifying the execution of an application to the California
Office of Emergency Services for the 2014/2015 Hazardous Materials Emergency
Preparedness Planning Grant (the "Grant"). Pursuant to the Grant the City has received
approximately $10,000.00 in grant funds to hire Contractor to work on updating the City's
existing hazardous materials emergency plan.
2.1 Contractor shall perform all work necessary to complete the existing
hazardous materials emergency plan.
2.2 All services shall be performed to the satisfaction of City.
2.3 All services shall be performed according to the standards then prevailing
in the hazardous materials profession.
3.0 PERSONNEL.
3.1 Contractor represents that it employs, or will employ, at its own
expense, all personnel required to perform the services under this Contract.
3.2 Contractor shall not subcontract any services to be performed by it
under this Contract without prior written approval of City.
3.3 All of the services required hereunder will be performed by Contractor or
by City approved subcontractors. Contractor, and all personnel engaged in the work, shall be
fully qualified and authorized or permitted under State and local law to perform such services
and shall be subject to approval by the City.
4.0 TERM. The term of this Contract shall commence on March 17, 2015, and it
shall continue until September 15, 2015, unless terminated at an earlier date pursuant to the
provisions thereof.
5.0 COMPENSATION AND FEES.
5.1 Contractor has established rates for the City of Vernon which are
comparable to and do not exceed the best rates offered to other governmental entities in and
around Los Angeles County for the same services.
5.2 Contractor's grand total compensation for the entire term of this Contract
shall not exceed $10,000.00.
5.3 Contractor shall, at its sole cost and expense, furnish all necessary and
incidental labor, material, supplies, facilities, equipment and transportation which may be
required for furnishing services pursuant to this Contract. Materials shall be of the highest
quality. The above Contract fee shall include all staff time and all clerical, administrative,
overhead, insurance, reproduction, telephone, air travel, auto rental, subsistence, and all related
costs and expenses.
6.0 PAYMENT.
6.1 As scheduled services are completed, Contractor shall submit to the
City an invoice for the services completed, authorized expenses, and authorized extra work
actually performed or incurred according to said schedule.
6.2 Each such invoice shall state the basis for the amount invoiced, including
a detailed description of the services completed, the number of hours spent, reimbursable
expenses incurred and any extra work performed.
6.3 Contractor shall also submit a progress report with each invoice that
describes in reasonable detail the services and the extra work, if any, performed in the
immediately preceding calendar month.
6.4 Contractor understands and agrees that invoices which lack sufficient
detail to measure performance will be returned and not processed for payment.
6.5 City will pay Contractor the amount invoiced within thirty (30) days after
the City approves the invoice.
6.6 Payment of such invoices shall be payment in full for all services,
authorized costs and authorized extra work covered by that invoice.
7.0 CHANGE ORDERS. There is no change order authority provided in this
Contract.
8.0 CITY'S RESPONSIBILITY. City shall cooperate with Contractor as may be
reasonably necessary for Contractor to perform its services; and will give any required decisions
as promptly as practicable so as to avoid unreasonable delay in the progress of Contractor's
services.
9.0 GENERAL TERMS AND CONDITIONS.
9.1 INDEPENDENT CONTRACTOR.
9.1.1 It is understood that in the performance of the services herein
provided for, Contractor shall be, and is, an independent contractor, and is not an agent or
employee of City and shall furnish such services in its own manner and method except as
required by this Contract. Further, Contractor has and shall retain the right to exercise full
control over the employment, direction, compensation and discharge of all persons employed by
Contractor in the performance of the services hereunder. Contractor shall be solely responsible
for, and shall indemnify, defend and save City harmless from all matters relating to the payment
of its employees, including compliance with social security, withholding and all other wages,
salaries, benefits, taxes, exactions, and regulations of any nature whatsoever.
9.1.2 Contractor acknowledges that Contractor and any subcontractors,
agents or employees employed by Contractor shall not, under any circumstances, be
considered employees of the City, and that they shall not be entitled to any of the benefits or
rights afforded employees of City, including, but not limited to, sick leave, vacation leave,
holiday pay, Public Employees Retirement System benefits, or health, life, dental, long-term
disability or workers' compensation insurance benefits.
9.2 CONTRACTOR NOT AGENT. Except as the City may authorize
in writing, Contractor and its subcontractors shall have no authority, express or implied, to act
on behalf of or bind the City in any capacity whatsoever as agents or otherwise.
9.3 OWNERSHIP OF WORK. All reports, drawings, plans, specifications,
computer tapes, floppy disks and printouts, studies, memoranda, computation sheets and other
documents prepared by Contractor in furtherance of the work shall be the sole property of City
and shall be delivered to City whenever requested. Contractor shall keep such documents and
materials on file and available for audit by the City for at least three (3) years after completion or
earlier termination of this Contract. Contractor may make duplicate copies of such materials
and documents for its own files or for such other purposes as may be authorized in writing by
the City.
9.4 CORRECTION OF WORK. Contractor shall promptly correct any
defective, inaccurate or incomplete tasks, deliverables, goods, services and other work, without
additional cost to the City. The performance or acceptance of services furnished by Contractor
shall not relieve the Contractor from the obligation to correct subsequently discovered defects,
inaccuracy or incompleteness.
9.5 WAIVER. The City's waiver of any term, condition, breach or default of
this Contract shall not be considered to be a waiver of any other term, condition, default or
breach, nor of a subsequent breach of the one waived.
9.6 SUCCESSORS. This Contract shall inure to the benefit of, and shall be
binding upon, the parties hereto and their respective heirs, successors and/or assigns.
9.7 NO ASSIGNMENT. Contractor shall not assign or transfer this Contract
or any rights hereunder without the prior written consent of the City and approval by the City
Attorney, which may be withheld in the City's sole discretion. Any unauthorized assignment or
transfer shall be null and void and shall constitute a material breach by the Contractor of its
obligations under this Contract. No assignment shall release the original parties or otherwise
constitute a novation.
9.8 COMPLIANCE WITH LAWS. Contractor shall comply with all Federal,
State, County and City laws, ordinances, rules and regulations, which are, as amended from
time to time, incorporated herein and applicable to the performance hereof, including but without
limitation, the Vernon Living Wage Ordinance. Violation of any law material to performance of
this Contract shall entitle the City to terminate the Contract and otherwise pursue its remedies.
9.9 ATTORNEY'S FEES. If any action at law or in equity is brought to
enforce or interpret the terms of this Contract, the prevailing party shall be entitled to reasonable
attorney's fees, costs and necessary disbursements in addition to any other relief to which such
party may be entitled.
9.10 INTERPRETATION.
9.10.1 Applicable Law. This Contract, and the rights and duties of
the parties hereunder (both procedural and substantive), shall be governed by and construed
according to the laws of the State of California.
9.10.2 Entire Agreement. This Contract, including any exhibits
attached hereto, constitutes the entire agreement and understanding between the parties
regarding its subject matter and supersedes all prior or contemporaneous negotiations,
representations, understandings, correspondence, documentation and agreements (written or
oral).
9.10.3 Written Amendment. This Contract may only be changed
by written amendment signed by Contractor and the City Administrator or other authorized
representative of the City, subject to any requisite authorization by the City Council. Any oral
representations or modifications concerning this Contract shall be of no force or effect.
9.10.4 Severability. If any provision in this Contract is held by any
court of competent jurisdiction to be invalid, illegal, void, or unenforceable, such portion shall be
deemed severed from this Contract, and the remaining provisions shall nevertheless
continue in full force and effect as fully as though such invalid, illegal, or unenforceable portion
had never been part of this Contract.
9.10.5 Order of Precedence. In case of conflict between the
terms of this Contract and the terms contained in any document attached as an Exhibit or
otherwise incorporated by reference, the terms of this Contract shall strictly prevail. The terms
of the City's Request for Proposals shall control over the Contractor's Proposal.
9.10.6 Choice of Forum. The parties hereby agree that this
Contract is to be enforced in accordance with the laws of the State of California, is entered into
and/or is to be performed in the City of Vernon and that all claims or controversies arising out of
or related to performance under this Contract shall be submitted to and resolved in a forum
within the County of Los Angeles at a place to be determined by the rules of the forum.
9.10.7 Duplicate Oriainals. There shall be two (2) fully signed
copies of this Contract, each of which shall be deemed an original.
9.11 TIME OF ESSENCE. Time is strictly of the essence of this -contract and
each and every covenant, term and provision hereof.
9.12 AUTHORITY OF CONTRACTOR. The Contractor hereby represents
and warrants to the City that the Contractor has the right, power, legal capacity and authority to
enter into and perform its obligations under this Contract, and its execution of this Contract has
been duly authorized.
9.13 ARBITRATION OF DISPUTES. Any dispute arising out of or relating to
the negotiation, construction, performance, non-performance,
breach or any other aspect of this Contract, shall be settled by binding arbitration in accordance
with the Commercial Rules of the American Arbitration Association at Los Angeles, California
and judgment upon the award rendered by the Arbitrators may be entered in any court having
jurisdiction thereof. The City does not waive its right to object to the timeliness or sufficiency of
any claim file or required to be filed against the City and reserves the right to conduct full
discovery.
9.14 INDEMNITY.
9.14.1 Contractor agrees to indemnify, hold harmless, release
and defend (even if the allegations are false, fraudulent or
groundless), to the maximum extent permitted by law, and
covenants not to sue, the City, its Council and each
member thereof, and its officers, employees, commission
members and representatives, from any and all liability,
loss, suits, claims, damages, costs, judgments and
expenses (including attorneys fees and costs of litigation)
which in whole or in part result from, or arise out of, or are
claimed to result from or to arise out of, any performance
under this Agreement, or any acts, errors or omissions
(including, without limitation, professional negligence) of
Contractor, its employers, representatives, subcontractors,
or agents in connection with the performance of this
Agreement.
9.14.2 This Agreement to indemnify includes, but is not limited to,
personal injury (including death at any time) and property
or other damage (including, but without limitation, contract
or tort or patent, copyright, trade secret or trademark
infringement) sustained by any person or persons
(including, but not limited to, companies, or corporations,
Contractor and its employees or agents, and members of
the general public).
9.15 INSURANCE.
9.15.1 Contractor shall, at its own expense, procure and maintain
policies of insurance of the types and in the amounts set
forth below, for the duration of the Agreement, including
any extensions thereto.
9.15.2 Automobile Liability with minimum limits of at least
$100,000/300,000/500,000 if written on a personal
automobile liability form, for using a personal vehicle; or an
amount of $500,000 including owned, hired, and non -
owned liability coverage if written on a Commercial
automobile liability form.
9.15.3 Contractor shall comply with the applicable sections of the
California Labor Code concerning workers' compensation
for injuries on the job. Compliance is accomplished in one
of the following manners:
9.15.4 Provide copy of permissive self-insurance certificate
approved by the State of California; OR
9.15.5 Secure and maintain in force a policy of workers'
compensation insurance with statutory limits and
Employer's Liability Insurance with a minimal limit of
$1,000,006 per accident. The policy shall be endorsed to
waive all rights of subrogation against City, its Council,
commissioners, officers, employees, and volunteers for
losses arising from performance of this Agreement; OR
9.15.6 Provide an insurance exemption form certifying that no
employees subject to workers' compensation law will be
used in performance of this Agreement.
9.15.7 Each insurance policy included in this clause shall be
endorsed to state that coverage shall not be canceled
except after thirty (30) days' prior written notice to City.
9.15.8 Insurance shall be placed with insurers with a Bests rating
of no less than B:VIII.
9.15.9 Prior to commencement of performance, Contractor shall
furnish City with a certificate of insurance for each policy.
Each certificate is to be signed by a person authorized by
that insurer to bind coverage on its behalf. The
certificate(s) must be in a form approved by City. City may
require complete, certified copies of any or all policies at
any time.
9.15.10 Failure to maintain required insurance at all times shall
constitute a default and material breach. In such event,
Contractor shall immediately notify City and cease all
performance under this Agreement until further directed by
the City. In the absence of satisfactory insurance
coverage, City may, at its option: (a) procure insurance
with collection rights for premiums, attorneys fees and
costs against Contractor by way of set-off or recoupment
from sums due Contractor, at City's option; (b) immediately
terminate this Agreement; or (c) self -insure the risk, with all
damages and costs incurred, by judgment, settlement or
otherwise, including attorneys fees and costs, being
collectible from the Contractor, by way of set-off or
recoupment from any sums due to the Contractor.
9.16 NOTICES. Any notice or demand to be given by one party to the other
be given in writing and by personal delivery or prepaid first-class, registered or certified mail,
addressed as follows. Notice simply to the City of Vernon or any other City department is not
adequate notice.
If to the City:
City of Vernon
Attention: Leonard Grossberg, Director of Health and Environmental Control
4305 Santa Fe Avenue
Vernon, CA 90058
If to the Contractor:
Brett Koontz
2575 E. Chevy Chase Drive
Glendale, CA 91206
Any such notice shall be deemed to have been given upon delivery, if personally
delivered, or, if mailed, upon receipt or upon expiration of three (3) business days from the date
of posting, whichever is earlier. Either party may change the address at which it desires to
receive notice upon giving written notice of such request to the other party.
9.17 TERMINATION FOR CONVENIENCE (Without Cause). City may
terminate this Contract in whole or in part at any time, for any cause or without cause, upon
fifteen (15) calendar days' written notice to Contractor. If the Contract is thus terminated by City
for reasons other than Contractor's failure to perform its obligations, City shall pay Contractor a
prorated amount based on the services satisfactorily completed and accepted prior to the
effective date of termination. Such payment shall be Contractor's exclusive remedy for
termination without cause.
9.18 DEFAULT. In the event either party materially defaults in its obligations
hereunder, the other party may declare a default and terminate this Contract by written notice to
the defaulting party. The notice shall specify the basis for the default. The Contract shall
terminate unless such default is cured before the effective date of termination stated in such
notice, which date shall be no sooner than ten (10) days after the date of the notice.
Termination for cause shall relieve the terminating party of further liability or
responsibility under this Contract, including the payment of money, except for payment for
services satisfactorily and timely performed prior to the service of the notice of termination, and
except for reimbursement of (1) any payments made by the City for service not subsequently
performed in a timely and satisfactory manner, and (2) costs incurred by the City in obtaining
substitute performance.
9.19 MAINTENANCE AND INSPECTION OF RECORDS.
The City, or its authorized auditors or representatives, shall have access
to and the right to audit and reproduce any of the Contractor's records to the extent the City
deems necessary to insure it is receiving all money to which it is entitled under the Contract
and/or is paying only the amounts to which Contractor is properly entitled under the Contract or
for other purposes relating to the Contract.
The Contractor shall maintain and preserve all such records for a period
of at least 3 years after termination of the Contract.
The Contractor shall maintain all such records in the City of Vernon. If
not, the Contractor shall, upon request, promptly deliver the records to the City of Vernon or
reimburse the City for all reasonable and extra costs incurred in conducting the audit at a
location other than the City of Vernon, including, but not limited to, such additional (out of the
City) expenses for personnel, salaries, private auditors, travel, lodging, meals and overhead.
9.20 CONFLICT. Contractor hereby represents, warrants and certifies that no
member, officer or employee of the Contractor is a director, officer or employee of the City of
Vernon, or a member of any of its boards, commissions or committees, except to the extent
permitted by law.
9.21 ENFORCEMENT OF WAGE AND HOUR LAWS. Eight hours labor
constitutes a legal day's work. The Contractor, or subcontractor, if any, shall forfeit twenty-five
dollars ($25) for each worker employed in the execution of this Agreement by the respective
Contractor or subcontractor for each calendar day during which the worker is required or
permitted to work more than 8 hours in any one calendar day and 40 hours in any one calendar
week in violation of the provisions of Sections 1810 through 1815 of the California Labor Code
as a penalty paid to the City; provided, however, work performed by employees of contractors in
excess of 8 hours per day, and 40 hours during any one week, shall be permitted upon
compensation for all hours worked in excess of 8 hours per day at not less than 13/2 times the
basic rate of pay.
9.22 LIVING WAGES Contractor, and any Subcontractor(s), shall comply with
the City's Living Wage Ordinance. The current Living Wage Standards are set forth in Exhibit
"A". Upon the City's request, certified payroll records shall promptly be provided to the City.
9.23 EQUAL EMPLOYMENT OPPORTUNITY PRACTICES. Contractor
certifies and represents that, during the performance of this Contract, it and any other parties
with whom it may subcontract shall adhere to equal employment opportunity practices to assure
that applicants, employees and recipients of service are treated equally and are not
discriminated against because of their race, religion, color, national origin, ancestry, disability,
sex, age, medical condition, sexual orientation or marital status. Contractor further certifies that
it will not maintain any segregated facilities. Contractor further agrees to comply with The Equal
Employment Opportunity Practices provisions as set forth in Exhibit "B".
[Signatures Begin on Next Page].
IN WITNESS WHEREOF, the Parties have signed this Agreement as of the date stated
in the introductory clause.
City of Vernon, a California charter City
and California municipal corporation
By.
L on rd Grossberg, Director o
Health & Environmental Control
ATTEST:
Maria E. Iyala, City C16tk
Ma; ai0:1-DYM-11111ii1MiU"IF
F'"Hem a el, CitAttorney
Brett Koontz
By:
Name:
Title:
By:
Name:
Title:
EXHIBIT A
LIVING WAGE PROVISIONS
Minimum Living Wanes:
A requirement that Employers pay qualifying employees a wage of no less than $10.30 per hour
with health benefits, or $11.55 per hour without health benefits.
Paid and Unpaid Days Off:
Employers provide qualifying employees at least twelve compensated days off per year for sick
leave, vacation, or personal necessity, and an additional ten days a year of uncompensated
time for sick leave.
No Retaliation:
A prohibition on employer retaliation against employees complaining to the City with regard to
the employer's compliance with the living wage ordinance. Employees may bring an action in
Superior Court against an employer for back pay, treble damages for willful violations, and
attorney's fees, or to compel City officials to terminate the service contract of violating
employers.
EXHIBIT B
EQUAL EMPLOYMENT OPPORTUNITY
PRACTICES PROVISIONS
A. Contractor certifies and represents that, during the performance of this Agreement, the
contractor and each subcontractor shall adhere to equal opportunity employment practices
to assure that applicants and employees are treated equally and are not discriminated
against because of their race, religious creed, color, national origin, ancestry, handicap,
sex, or age. Contractor further certifies that it will not maintain any segregated facilities.
B. Contractor agrees that it shall, in all solicitations or advertisements for applicants for
employment placed by or on behalf of Contractor, state that it is an "Equal Opportunity
Employer' or that all qualified applicants will receive consideration for employment without
regard to their race, religious creed, color, national origin, ancestry, handicap, sex or age.
C. Contractor agrees that it shall, if requested to do so by the City, certify that it has not, in the
performance of this Agreement, discriminated against applicants or employees because of
their membership in a protected class.
D. Contractor agrees to provide the City with access to, and, if requested to do so by City,
through its awarding authority, provide copies of all of its records pertaining or relating to its
employment practices, except to the extent such records or portions of such records are
confidential or privileged under state or federal law.
E. Nothing contained in this Agreement shall be construed in any manner as to require or
permit any act which is prohibited by law.
INSURANCE
DOCUMENTS
Insurance exemption form
I, Brett Koontz, certify that no employees subject to workers' compensation law will be used in
performance of the subject Agreement: Service agreement between the City of Vernon and Brett Koontz
to prepare the hazardous materials emergency plan for the City of Vernon (commencing March 17, 2015
and terminating on September 15, 2015).
0
Brett Koontz
March 12, 2015
ALLSTATE NORTHBROOK INDEMNITY COMPANY Calendar Date: 03/12/2015
Home Office
Northbrook, Illinois
Insured : BRETT KOONTZ
Address : 2575 E CHEVY CHASE DRIVE
City : GLENDALE
Home Phone No.: 818-246-1210
USAGE AND RATE CLASSIFICATION
1999
CAMRY
Class Code 1670001570
Est. Ann. Miles (000): 13000
Principal Use : Work/School
Miles to Work/School : 21
Uses Car Pool : N
CHANGE COVERAGE
1999
CAMRY
Bodily Injury : 100/300
Property Damage : 500
Policy Number: 914499187 10/07
St.: CA Zip Code: 91206
THIS REQUEST IS SUBJECT TO POLICY TERMS AND IS EFFECTIVE ONLY IF THE POLICY NOTED
ABOVE IS CURRENTLY IN FORCE
Br Flo Mar 015
Effective 11 : 40 A.M. 03/12/2015
Policyholder's Signature
STEVE TOVMASYAN 064789 UJT
Agent/Agency Name Agent # Location
AR1871
(323)776-3355(Phor.
Agent's Phone #
Page 1 of 1
+ 914499187ZZZZZZ064789AR1 87 1 CA1 +
Customer Name: BRETTKOONTZ
Trailing Documents/Forms for Customer
Legal Trailing Documents
Uninsured/Underinsured Motorist Form
Forms
Document Center Summary
Service Request
Life Teaser Quote
Premium Summary
Premiums displayed are Full -Tenn
Adjusted Vehicle Premium
Current Vehicle Premium
Adjusted Total Premium
Current Total Premium
Difference from Current Premium
Rates as of Date
Policy Number: 914499187
Document Center Summary
1999 TOYOTA
CAMRY
$707.05
$645.48
Form No.
AUR953 -1
Form No.
SARI 871
$707.05
$645.49
$61.57
10/O1/2014
#
CALIFORNIA
SELECTION OF COVERAGE LIMITS FOR UNINSURED MOTORISTS AND
UNDERINSURED MOTORISTS INSURANCE PROTECTION
OR
REJECTION OF UNINSURED MOTORISTS INSURANCE
REJECTION OF UNDERINSURED MOTORISTS INSURANCE
The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury
liability insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor
vehicle. These provisions also permit the insurer and the applicant to delete the coverage completely or to delete
the coverage when a motor vehicle is operated by a natural person or persons designated by name, or agree to
provide the coverage in an amount less than that required by subdivision (m) of Section 11580.2 of the
Insurance Code, but not less than the financial responsibility requirements.
Uninsured motorists coverage insures the insured, his or her heirs, or legal representatives for all sums within
the limits established by law, which the person or persons are legally entitled to recover as damages for bodily
injury, including any resulting sickness, disease, or death, to the insured from the owner or operator of an
uninsured motor vehicle not owned or operated by the insured or a resident of the same household. An
uninsured motor vehicle includes an underinsured motor vehicle as defined in subdivision (p) of Section
11580.2 of the Insurance Code.
Uninsured motorists coverage includes protection for damages an insured person is legally entitled to recover
from an underinsured auto. An underinsured auto is a motor vehicle which has a bodily injury liability bond,
self insurance or bodily injury liability insurance in effect and applicable at the time of the accident, but in an
amount less than the Uninsured Motorists limits carried on your policy.
THE OPTIONS AVAILABLE TO YOU
Uninsured Motorists Insurance is available to you at a variety of limits up to your policy's Bodily Injury
Liability Insurance Limits. You can:
- Select Uninsured Motorists Insurance equal to your Bodily Injury Liability limits,
- Select Uninsured Motorists Insurance at limits lower than your Bodily InJJ' Liability limits, but not lower
than the minimum financial responsibility limit of $15,000 per person, $3000 per accident (15/30), or
Reject Uninsured Motorists Insurance entirely.
Uninsured Motorists Insurance for Bodily Injury
{ X } I'd like to purchase Uninsured Motorists Insurance for Bodily Injury at one of the following coverage
limits:
{ X } $15,000/$30,000 { } $30,000/$60,000
{ } $20,000/$40,000 { } Other
{ } $25,000/$50,000 { } Equal to my Bodily Injury Liability limits
+ 914499187ZZZZZZ64789AUR953CAl +
{ } I choose to reject Uninsured Motorists Insurance for Bodily Injury entirely.
I understand that these actions will apply to all future renewals, continuations, and changes in my policy unless
I notify you otherwise.
914499187
Policy or Application No.
Br o ar02
O'Z
Signature of Named Insured/Applicant
BRETT KOONTZ
Named Insured/Applicant
Mar 12,2015
Date
OFFER OF WAIVER OF COLLISION COVERAGE DEDUCTIBLE
AND
UNINSURED MOTORISTS INSURANCE FOR PROPERTY DEDUCTIBLE
We are required by California law to offer you coverage for damage to an insured auto that you are legally
entitled to recover from the owner or operator of an uninsured motor vehicle.
The following options are available for each insured auto under your policy:
- If you are insuring an auto you own for Auto Collision Insurance, we are offering a Waiver of Collision
Coverage Deductible to apply when the auto is damaged in an accident caused by an uninsured motor vehicle.
- If you are not insuring an auto for Auto collision Insurance and are insuring it for Uninsured Motorists
Insurance for bodily injury, we are offering you the opportunity to extend your Uninsured Motorists Insurance
to cover property damage up to $3,500.
- You have the option of rejecting either the Waiver of Collision Coverage Deductible or Uninsured Motorists
Insurance for property damage, or both coverages.
Payment will not include damage to personal property or loss of use of a covered auto and will not exceed the
smaller of-
- The amount of the collision deductible
- The actual cash value of the covered auto, or
- $ 3,500
Once again, the law also permits you to reject these coverages completely.
914499187ZZZZZZ64789AUR953CA2
Select your choice of these options for each insured auto by putting an "X" in the appropriate box below -refer to
your schedule of covered auto(s) you own to identify vehicle(s):
{X} I have selected Auto Collision Insurance for the following auto(s) and want to add the Waiver of Collision
Coverage Deductible to the covered auto(s) as indicated.
{X} Vehicle 1
{ } Vehicle 2
{ } Vehicle 3
{ } Vehicle 4
{ } I have not selected Auto Collision Insurance but have selected Uninsured Motorists Insurance for the
following covered auto(s) and want to extend Uninsured Motorists Insurance to include property damage
up to $3,500 for the covered auto(s) as indicated:
{ } Vehicle 1
{ } Vehicle 2
{ } Vehicle 3
{ } Vehicle 4
{ } I reject both the Waiver of Collision Coverage Deductible and Uninsured Motorists Insurance for property
damage for the following covered auto(s):
{ } Vehicle 1
{ } Vehicle 2
{ } Vehicle 3
{ } Vehicle 4
I understand that these actions will apply to all future renewals, continuations, and changes in my policy unless
I notify you otherwise.
914499187
Policy or Application No.
Br ho Mar m5
Signature of Named Insured/Applicant
Allstate Northbrook Indemnity Company
BRETT KOONTZ
Named Insured/Applicant
Mar 12, 2015
Date
914499187ZZZZZZ64789AUR953CA3