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HomeMy WebLinkAboutThe Door Company; 2017-09-11; PWM18-42GSTracking#: PWM18-42GS CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT FIRE STATION 4 ROLL-UP DOOR REPLACEMENT This agreement is made on the / / 't!J day of ~,e fl , , 2017, by the City of Carlsbad, California, a municipal corporation, (hereinaftercatt d"City"),and The Door Company, a sole proprietorship, whose principal place of business is 2345 Alta Vista, Vista, CA 92084 (hereinafter called "Contractor"). City and Contractor agree as follows: DESCRIPTION OF WORK. Contractor shall perform all work specified in the Contract documents for the project described by these Contract Documents (hereinafter called "Project"). PROVISIONS OF LABOR AND MATERIALS. Contractor shall provide all labor, materials, tools, equipment, and personnel to perform the work specified by the Contract Documents unless excepted elsewhere in this Contract. CONTRACT DOCUMENTS. The Contract Documents consist of this Contract, exhibits to this Contract, Contractor's Proposal, the Plans and Specifications, the General Provisions, addendum(s) to said Plans and Specifications, and all proper amendments and changes made thereto in accordance with this Contract or the Plans and Specifications, all of which are incorporated herein by this reference. When in conflict, this Contract will supersede terms and conditions in the Contractor's proposal. LABOR. Contractor will employ only skilled workers and abide by all State laws and City of Carlsbad Ordinances governing labor. GUARANTEE. Contractor guarantees all labor and materials furnished and agrees to complete the Project in accordance with directions and subject to inspection approval and acceptance by: Michael O'Brien (City Project Manager) WAGE RATES. The general prevailing rate of wages for each craft or type of worker needed to execute the Contract shall be those as determined by the Director of Industrial Relations pursuant to Sections 1770, 1773 and 1773.1 of the Labor Code. Pursuant to Section 1773.2 of the Labor Code, a current copy of the applicable wage rates is on file in the Office of the City Engineer. Contractor shall not pay less than the said specified prevailing rates of wages to all workers employed by him or her in execution of the Contract. Contractor shall be responsible for insuring compliance with provisions of section 1777.5 of the Labor Code and section 4100 et seq. of the Public Contracts Code, "Subletting and Subcontracting Fair Practices Act." The City Engineer is the City's "duly authorized officer" for the purposes of section 4107 and 4107.5. The provisions of Part 7, Chapter 1, of the Labor Code commencing with section 1720 shall apply to the Contract for work. A contractor or subcontractor shall not be qualified to bid on, be listed in a bid proposal, subject to the requirements of Section 4104 of the Public Contract Code, or engage in the performance of any contract for public work, unless currently registered and qualified to perform public work pursuant to Section 1725.5. This project is subject to compliance monitoring and enforcement by the Department of Industrial Relations. Contractor and any subcontractors shall comply with Section 1776 of the California Labor Code, which generally requires keeping accurate payroll records, verifying and certifying payroll records, and making them available for inspection. Contractor shall require any subcontractors to comply with Section 1776. FIRE STATION 4 ROLL-UP DOOR REPLACEMENT Page 1 of 6 City Attorney Approved 9/27/2016 Tracking #: PWM18-42GS FALSE CLAIMS. Contractor hereby agrees that any contract claim submitted to the City must be asserted as part of the contract process as set forth in this agreement and not in anticipation of litigation or in conjunction with litigation. Contractor acknowledges that California Government Code sections 12650 et seq., the False Claims Act, provides for civil penalties where a person knowingly submits a false claim to a public entity. These provisions include false claims made with deliberate ignorance of the false information or in reckless disregard of the truth or falsity of the information. The provisions of Carlsbad Municipal Code sections 3.32.025, 3.32.026, 3.32.027 and 3.32.028 pertaining to false claims are incorporated herein by reference. Contractor hereby acknowledges that the filing of a false claim may subject the Contractor to an administrative debarment proceeding wherein the contractor may be prevented from further bidding on public contracts for a period of up to five years and that debarment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor or subcontracto m participati · contract bidding. Signature: Print Name: REQUIRED INSURANCE. The successful contractor shall provide to the City of Carlsbad, a Certification of Commercial General Liability and Property Damage Insurance and a Certificate of Workers' Compensation Insurance indicating coverage in a form approved by the California Insurance Commission. The certificates shall indicate coverage during the period of the contract and must be furnished to the City prior to the start of work. The minimum limits of liability insurance are to be placed with California admitted insurers that have a current Best's Key Rating of not less than "A-:VII"; OR with a surplus line insurer on the State of California's List of Approved Surplus Line Insurers (LASLI) with a rating in the latest Best's Key Rating Guide of at least "A:X"; OR an alien non-admitted insurer listed by the National Association of Insurance Commissioners (NAIC) latest quarterly listings report. Commercial General Liability Insurance of Injuries including accidental death, to any one person in an amount not less than ........ $1,000,000 Subject to the same limit for each person on account of one accident in an amount not less than ....... $1,000,000 Property damage insurance in an amount of not less than ........ $1,000,000 Automobile Liability Insurance in the amount of $1,000,000 combined single limit per accident for bodily injury and property damage. In addition, the auto policy must cover any vehicle used in the performance of the contract, used onsite or offsite, whether owned, non-owned or hired, and whether scheduled or non- scheduled. The automobile insurance certificate must state the coverage is for "any auto" and cannot be limited in any manner. The above policies shall have non-cancellation clauses providing that thirty (30) days written notice shall be given to the City prior to such cancellation. The policies shall name the City of Carlsbad as an additional insured. The full limits available to the named insured shall also be available and applicable to the City as an additional insured. WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY. Workers' Compensation limits as required by the California Labor Code. Workers' Compensation will not be required if Contractor has no employees and provides, to City's satisfaction, a declaration stating this. BUSINESS LICENSE. The Contractor and all subcontractors are required to have and maintain a valid City of Carlsbad Business License for the duration of the contract. FIRE STATION 4 ROLL-UP DOOR REPLACEMENT Page 2 of 6 City Attorney Approved 9/27/2016 Tracking #: PWM18-42GS INDEMNITY. The Contractor shall assume the defense of, pay all expenses of defense, and indemnify and hold harmless the City, and its officers and employees, from all claims, loss, damage, injury and liability of every kind, nature and description, directly or indirectly arising from or in connection with the performance of the Contract or work; or from any failure or alleged failure of Contractor to comply with any applicable law, rules or regulations including those related to safety and health; and from any and all claims, loss, damages, injury and liability, howsoever the same may be caused, resulting directly or indirectly from the nature of the work covered by the Contract, except for loss or damage caused by the sole or active negligence or willful misconduct of the City. The expenses of defense include all costs and expenses including attorneys' fees for litigation, arbitration, or other dispute resolution method. JURISDICTION. The Contractor agrees and hereby stipulates that the proper venue and jurisdiction for resolution of any disputes between the parties arising out of this agreement is San Diego County, California. Start Work: Contractor agrees to start within five (5) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within one ( 1) working days after receipt of Notice to Proceed. CONTRACTOR'S INFORMATION. Ill Ill Ill Ill Ill Ill Ill The Door Company (name of Contractor) 740956 (Contractor's license number) C-61 I D28; B 9130117 (license class. and exp. date) 1000023636 (DIR registration number) 6130118 (DIR registration exp. date) FIRE STATION 4 ROLL-UP DOOR REPLACEMENT Page 3 of 6 2345 Alfa Vista (street address) Vista, CA 92084 ( citylstatelzi p) 760-917-5194 (telephone no.) NIA (fax no.) joe@innovationdoors.com (e-mail address) City Attorney Approved 912712016 Tracking#: PWM18-42GS AUTHORITY. The individuals executing this Agreement and the instruments referenced in it on behalf of Contractor each represent and warrant that they have the legal power, right and actual authority to bind Contractor to the terms and conditions of this Agreement. CONTRACTOR THE DOOR COMPANY, a sole proprietorship By~ (sign here ~ =~o= (print name/title) By: (sign here) (print name/title) CITY OF CARLSBAD, a municipal corporation of the State of California By: Elaine Lukey/. ic Works Director as authorized by the City Manager If required by City, proper notarial acknowledgment of execution by Contractor must be attached. !f..E. corporation, Agreement must be signed by one corporate officer from each of the following two groups: Group A Chairman, President, or Vice-President Group B Secretary, Assistant Secretary, CFO or Assistant Treasurer Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation. APPROVED AS TO FORM: CELIA A. BREWER, City Attorney BY:cd:a~ Deputy City Attorney FIRE STATION 4 ROLL-UP DOOR REPLACEMENT Page 4 of 6 City Attorney Approved 9/27/2016 Tracking #: PWM18-42GS EXHIBIT A LISTING OF SUBCONTRACTORS BY GENERAL CONTRACTOR Set forth below is the full name and location of the place of business of each sub-contractor whom the Contractor proposes to subcontract portions of the Project in excess of one-half of one percent of the total bid, and the portion of the Project which will be done by each sub-contractor for each subcontract. NOTE: The Contractor understands that if it fails to specify a sub-contractor for any portion of the Project to be performed under the contract in excess of one-half of one percent of the bid, the contractor shall be deemed to have agreed to perform such portion, and that the Contractor shall not be permitted to sublet or subcontract that portion of the work, except in cases of public emergency or necessity, and then only after a finding, reduced in writing as a public record of the Awarding Authority, setting forth the facts constituting the emergency or necessity in accordance with the provisions of the Subletting and Subcontracting Fair Practices Act (Section 4100 et seq. of the California Public Contract Code). If no subcontractors are to be employed on the project, enter the word "NONE." SUBCONTRACTORS Portion of Project to Business Name and Address DIR Registration License No., %of be Subcontracted No. Classification & Total Expiration Date Contract c0 r Total% Subcontracted: The Contractor must perform no less than fifty percent (50%) of the work with its own forces. FIRE STATION 4 ROLL-UP DOOR REPLACEMENT Page 5 of 6 City Attorney Approved 9/27/2016 Tracking#: PWM18-42GS EXHIBIT B Contractor will furnish and install a new Cookson barrel rolling steel door asssembly and four steel curtains for the rear door at Fire Station 4 located at 6885 Batiquitos Lane in Carlsbad. Replacment components will be comperable in dimentions and technical details to the original rolling compenents being replaced. Repair includes, but not limited to: removing and recycling existing/damaged rolling door assembly and damaged four (4) curtain slats; installing new Cookson barrel and spring assembly and four (4) steel curtain slats, any and all equpment rental, parts and labor required to complete the work on the west facing rolling steel door. All replacement work will be performed in agreeance with Cookson Door Technical Details. Parts and labor are guaranteed for one (1) year. JOB QUOTATION ITEM UNIT QTY DESCRIPTION PRICE; NO. 1 LS 1 Provide and replace rear rolling steel door barrel $7,495 assembly and four curtiain slats at Fire Station 4 with a new Cookson barrel rolling door com pents. TOTAL* $7,495 *Includes taxes, fees, expenses and all other costs. FIRE STATION 4 ROLL-UP DOOR REPLACEMENT Page 6 of 6 City Attorney Approved 9/27/2016 ACORD® CERTIFICATE OF LIABILITY INSURANCE I DA TE (MM/ODIYYYY) ~ 07/18/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy{les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1,;0N1A1,;T Eric Bock NAME: ACW GROUP, LLC dba: AKAMINE CHRISTMAN WALL INSURANCE PHONE 760-625-7816 I r:i~ Nol: 760-262-3673 IA/C No Ext\: 79-220 Corporate Center Drive Suite 102F E-MAIL ebock@acwgroup.com ADDRESS: La Quinta, CA 92253 INSURER(SJ AFFORDING COVERAGE NAIC# INSURER A: Security National Insurance Company 19879 INSURED INSURERB: JOSEPH VEL TON JEZISEK INSURERC: 2345 AL TA VISTA DRIVE INSURERD: INSURERE: Vista CA 92084 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE AuuL <>UC>~ POLICY EFF POLICY EXP LIMITS LTR "'"" ""'" POLICY NUMBER tMM/00/YYYYl tM M/OD/YYYYl A COMMERCIAL GENERAL LIABILITY NA 105898404 05/20/17 05/20/18 EACH OCCURRENCE $ 1,000,000 ~ ~ CLAIMS-MADE [Kl OCCUR ""'."'A\,t:_ I u c<t:NTt:D 100,000 PREMISES (Ea occurrence\ $ MED EXP (Any one person) $ 5,000 ~ PERSONAL & ADV INJURY $ 1,000,000 ~ 2,000,000 GEN"L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ ~ DPRO-DLOC PRODUCTS -COMP/OP AGG $ 2,000,000 POLICY JECT OTHER $ / AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) - ANY AUTO BODILY INJURY (Per person) $ -~ -ALL 0\1\JNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ --NON-OV'vNED FROPERTY DAMAGE HIRED AUTOS AUTOS Per acCJdenU $ --$ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED I I RETENTION $ $ WORKERS COMPENSATION I PER I I OTH- AND EMPLOYERS' LIABILITY STATUTE ER Y/N ANY PROPRIETORIPARTNERIE.l(ECUTI VE D EL. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) EL. DISEASE -EA EMPLOYEE $ If yes. describe under DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The following entity is listed as an additional insured with respects to general liability insurance per attached company blanket form 49-0108 07 11 Project Description: Door installation, service and repair Project Location: Various locations through out San Diego County CERTIFICATE HOLDER CANCELLATION The City of Carlsbad SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1635 Faraday Avenue TME EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Carlsbad, CA 92008 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ~~ © 1988-2014 ACORD CORPORATION. All nghts reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART / SCHEDULE Policy Number: NA105898404 Endorsement Effective: 5/20/2017 12:01 a.m Named Insured CouITTeffi;f ,J t~~ JOSEPH YELTON JEZISEK, DBA: JOSEPH VELTON JEZISEK SCHEDULE Name of Person or Oraanization:t th d -d -bl. t db ·rt f itt t t · A'ny person or orgamzat1on tna e name insure Is o Iga e y vI ue o a wr en con rac or agreement to provide insurance such as is afforded by this policy. Location: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II -Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project C. The words "you" and "your'' refer to the Named Insured shown in the Declarations. D. "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. Primary Wording If required by written contract or agreement Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization 49-0108 07 11 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission ACSC • 7/19/2017 2:25:56 PM PAGE 4/010 Fax Server lnterinsurance Exchange of the Automobile Club Automoblle Insurance Polley Coverages and Limits Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send a1 least the minimum payment on or before the due date. Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy. If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the lnterlnsurance Exchange reserves the right to apply any refund due to your outstanding balance. NAM ED INSURED (Item 1.) AUTO POLICY NUMBER: CAA on174270 POLICY PERIOD (PACIFIC STANDARD TIME) JEZISEK, KERRY AND JEZISEK, JOSEPH 2345 ALTA VISTA DR POLICY EFFECTIVE DATE: 11-02-16 12:01 AM. VISTA CA 92084-7026 POLICY EXPIRATION DATE: 11-'>2-17 12 01 AM VEHICLES VEH. YEAR MAKE MODEL IDENTIFICATION NO. NUMBER 1 2007 TYTA TUNDRA LN VS 5TFLV52127X005140 2 1925 FORD MODEL T 14673114 6 2011 FORD RANGER SUPER 1FTLR4FE8BPA18799 7 2013 NSSN QUEST JN8AE2KP1D9068177 COVERAGES AND LIMITS Coverage is not in effect unless a premium or the word "included" ie shown. COVERAGES LIMITS OF LIABIUTY Llabll/ty Bodllylnjury $1,000,000 each person/ $1,000,000 each occurrence Property Damage $500,000 each occurrence Medfr:a/ Physical Damage (Actual Cuh Value unlen otherwiH 1t1t1d, len doductible) Comprehensive (Less Deductible) Collision (Less Deductible) car Rental Expense Vehicle 1 Vehicle 2 Vehicle 6 Vehicle 7 ACV No Coverage ACV ACV $1000 No Coverage $1000 $1000 ACV No Coverage ACV ACV $1000 No Coverage $1000 $1000 (Per Day) No Coverage No Coverage No Coverai;ie No Coverage Unjnsured Motorist Bodily Injury-$30,000 each person/ $60,000 each accident Uninsured & Underlnsured Vehicles Unlneured Deductible Waiver Uninsured Collision Total Premium Vehicle VEHICLE GARAGE ANNUAL"" VERIFIED USE ZIP CODE MILES MILEAGE COMMUTE 92084 12,501 -15,000 NO PLEASURE 92084 1 • 500 NO BUSINESS 92084 7,501 -10,000 NO PLEASURE 92084 7,501 -10,000 NO ANNUAL PREMIUMS Vehicle 1 Vehicle 2 Vehicle 6 Vehicle 7 $ 676 S 373 $126 $ 62 $ 373 $ 191 S 270 $136 I I I I I I I I I :No Coverage:No Coverage:No Coverage:No Coverage: I I I I ' ' ' $81 !No coverage! S 54 $ 51 ' ' ' ' S 431 :No coverage: S 297 S 270 ' ' ' I I I I :No Coverage:No Coverage:No Coverage No Coverage: SM $~ $~ S~ ' ' ' ' ' : Included :No Coverage: Included , Included : :No Coverage;No Coverage;No Coverage;No Coverage: $ 1645 $ 213 $ 958 $ 765 SALVAGE NO NO NO Vehicle PREMIUM Cll8COUNTS "No Coverage" indicates coverage not purchased. Please refer to the enclosed document entitled "Premium Discounts Applied to Your Au!O'Tloblle Polley." * If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5% per month of the balance outstanding will apply as explained in your billing statements, which are part of these declarations. ** To see the annual mileage for your expiring policy, please refer to the "Notice of Annual MIieage" page contained in your renewal package. PROCESS DATE 09-23-16 PLEASE ATTACH TO YOUR POLICY Total Annual Premium" $ 3581 (Includes all 11pplc11ble discounts.) Less Pollcyholder Savings Dividend $ 361 Net Premium* $ 3220 (SEE REVERSE) ACSC 7/19/2017 2:25:56 PM PAGE 3/010 Fax Server AUTO POLICY NUMBER: CAA 077174270 POLICYHOLDER SAVINGS DIVIDEND STATEMENT We are pleased to announce that our auto policyholders will once again receive money back through the payment of a POLICYHOLDER SAVINGS DIVIDEND. While auto dividends are not guaranteed, qualifying auto policyholders have received a Policyholder Savings Dividend in each year since 1990 and now you have the opportunity to get money back just for insuring your car INith us. For years our auto policyholders have enjoyed the benefit of quality insurance, caring customer service, great discounts and also the opportunity to receive money back through a Policyholder Savings Dividend. Not all insurance companies can say that Giving money back to our auto policyholders through dividends is another way we're always with you. The amount of the Policyholder Savings Dividend that you will receive upon completion of your current policy period is displayed below. Your dividend amount is based on your current policy premium. Since dividends are paid at the end of your current policy term, the good news is we have applied your dividend to your renewal premium to reduce your premium balance and your minimum due. This means less money coming out of your pocket to renew your policy. YOUR POLICYHOLDER SAVINGS DIVIDEND THIS YEAR Policyholder Savings Dividend Amount: $361 Dividend applied to renewal premium for auto policy period: (Refer to the enclosed Renewal Billing Statement for your premium balance) 11-02-16 to 11-02-17 YOUR POLICYHOLDER SAVINGS DIVIDEND HISTORY Total savings received from dividends within the last five years: $1,610 Call (B77) 422-2100 I Click AAA.com/myaccount to access your I Visit or call your local Auto Club branch policy and pay your bill online AAA.com/branches Insurance provided to qualified Auto Club members by the lntemsurance Exchange of the AutomobDe Club. ACSC 7/19/2017 2:25:56 PM PAGE 5/010 Fax Server lnterinsurance Exchange of the Automobile Club Automoblle Insurance Policy Coverages and Limits Renewal Declarations (continued) AUTO POLICY NUMBER: CAA 077174270 POLICY EFFECTIVE DATE: 11-02-2016 DRIVE RS (Coverage ma differ for each driver. Please .see each section of the polic contract for the detin/tion of "Persons In.sured".) DRIVER NUMBER NAME 1 JEZISEK, KERRY A 2 JEZISEK, JOSEPH V 3 JEZISEK, PETER J -EXCLUDEOW GENDER FEMALE MALE MALE MARITAL STATUS MARRIED MARRIED SINGLE YEAR FIRST LIO NSE 1980 1983 * IMPORTANT: NO COVERAGE IS PROVIDED BY THIS POLICY WHILE ANY VEHICLE IS BEING OPERATED BY AN EXCLUDED DRIVER. PLEASE READ THE "EXCLUSION OF DESIGNATED PERSON ENDORSEMENT" AGREEMENT PREVIOUSLY PROVIDED TO YOU. (Endorsement No. 2184.) DRIVING RECORD RATED DRIVER NUMBER OF I NUMBER OF TRAFFIC CONVICTIONS DRIVER STATUS VEHICLE NUMBER PRINCIPALLY 1 2 3 AT-FAULT ACCIDENTS I ENDORSEMENTS AND CERTIFICATES NUMBER I TITLE MINOR I SERIOUS I MAJOR I 2011 MEMBER'S AUTOMOBILE POLICY -POLICY NUMBER CHANGE 2052 LOSS PAYABLE -NOTICE TO LIENHOLDER 2184 EXCLUSION OF DESIGNATED PERSON 2231 GUARANTEED RENEWAL 2298 SELECTION OF UMIUIM COVERAGE ENDORSEMENT 2367 AMENDATORY ENDORSEMENT SEVERE I SUSPENSIONS SPECIAL EQUIPMENT"• VEH. CAMPER/ OlHER NO. VANCONV. 1 2 6 7 PRIMARY PRIMARY EXCLUDED NUMBER 1 6 SOUND EQllPM ENT""' '2rWAY TELE-RADIO QTI,ER RADIO PHONE -Coverage is indicated by a "YES' in the appropriate equipment column Coverage limitations apply unless cove~e was purchased specifically for certain equipment ANY PHYSICAL DAMAGE LOSS MAY BE MADE PAYABLE TO YOU AND ANY INTEREST LISTED BELOW: VEH NO. 6 LOAN NO. 8151760818 WELLS FARGO DEALER SERVICES PO BOX5075 CORAOPOLIS PA 15108 PERSON DESIGNATED TO RECEIVE NONPAYMENT OF PREMIUM NOTICES: An individual designated by a policyholder t0 receive notice of lapse, tsrmina~on, f!IXp/mUon, nonf!lnewal, or cancsllatlon of tt,e policy ror nonpayment of premium daf!IS not have any rights, whether es 11n 11ddltlon11I Insured or othetwfse, to any benefits under the policy, ether than the right to receive notice. CA/>020C8 E20150722 002316 Click AAA.com/myaccount to access your policy information online, pay your bill or print additional proof of insurance cards ACSC 7/19/2017 2:25:56 PM PAGE 6/010 Fax Server • lnterinsurance Exchange of the Automobile Club P.O. Box 25448, Santa Ana, CA 92799-5448 AAA.cam 1-877-422-2100 AUTOMOBILE RENEWAL BILLING STATEMENT THIS BILLING STATEMENT AND THE INFORMATION IT CONTAINS ARE PART OF YOUR INSURANCE POLICY DECLARATIONS INSURANCE BILLING STATEMENT JEZISEK, KERRY AND JEZISEK, JOSEPH 2345ALTA VISTA DR POLICY NUMBER: CAA 077174270 POLICY EFFECTIVE DATE: 11-02-2016 VISTA CA 92084 BILLING DATE: 09-23-2016 11-02-2016 1. 2. 3. 4. 5. 6. CAPD781A E20131206 119'2316 RENEWAL PREMIUM: $ LESS PRIOR PAYMENT: $ PREVIOUS BALANCE: $ AMOUNT FINANCED: $ 3581.00 0.00 er 0.00 3581.00 DUE DATE: Your Policyholder Savings Dividend has been used to reduce the minimum due necessary to renew your policy: Minimum Amount Due: $ 397.88 LESS POLICYHOLDER SAVINGS DIVIDEND: $ 361.00 er Less Pollcyholder Savings Dividend: $ 361.00 er TOTAL BALANCE: 3220.00 Minimum Due Recuired to Renew: $ 36.88 Future payments will vary from $4D3.86 to $434.72 if there are no chani;ies in premium and installments are paid as billed.* Your Minimum Due of I $36.88 I will be deducted from your bank account with the last four digits of 0807 on the Due Date / 11-02-2016 I *After the inilia/ renewal installment, each subseqvent instaHment will include a finance charge. Thank you for selecting our AAA Auto Pay plan. This convenient plan allows your monthly payments to be withdrawn automatically from your bank account. Your bank account with the last four digits of 0807 will be debited with the Minimum Due on the Due Date indicated above. For questions on this bill please call (877) 422-21 oo (option 1) DO NOT PAY THIS BILL-YOUR AUTOMATIC PAYMENT HAS BEEN SCHEDULED -See reverse for details - ACSC Number of Pa')fflents 09 ANNUAL PERCENTAGE RATE The cost of your credit as a yaartyrate. 15.80% 7/19/2017 2:25:56 PM PAGE 7/010 SEND ANY QUESTIONS REGARDING THIS BILL TO: ACSC Attn: CORPORATE RECEIVABLES A313 P.O. Box 25001, Santa Ana, CA 92799-5001 Phone: 1-877-422-2100 ru m en In! T th. L d' l n orma 10n or 01c11: I f t' f p I' CAA 077174270 Fl rst Payn, ant Due Date First Payment Amount 01her Payments are due each succeeding month on this date 11-2-16 $36.88 2ND FINANCE CHARGE Amount Financed Total of Payments The dollar amount the The amount of credit pra.-ided to The amount you will have paid credit will cost you. you or on )':)Ur behalf. after \IOU have made all payments as scheduled. $179.21 $3,581 .oo $3,760.21 There is no prepayment penalty. Fax Server 01her Payments WIii vary from $403.86 to $434.72 Total Sale Price The total cost of your purchai.e on credit. $3,760.21 The full balance or at least the Minimum Due is payable by the due date. You must pay the outstanding balance in full to avoid paying any finance charges. After the first renewal payment, each subsequent billing will include a finance charge. Payments received wlll be applied first to any fees or charljles due. The remainder of your payment will be applied to the premium due. All returned payments, whether by check, electronlc transaction, or other form of payment, may be re-presented electronically for payment. Each late payment is subject to a $7 fee and each returned payment is subject to a $15 fee. Installment payment plans and all fees are subject to change without notice. An adverse payment record (such as a late payment, a returned payment, or a nonpayment) may reduce the number of remaining Installments and Increase the minimum due, or result in a request to pay the entire balance of the policy bill in full. Whenever a payment is returned by your financial institution, we may, at our option, notify you in writing that the entire outstanding premium balance is immediately due and payable in cash or by cashier's check or bank money order at one of the Auto Club's district offices. In addition, the payment record during the current policy period will determine the payment terms offered at the next policy renewal. The finance charge periodic rate will be 1 % per month (12% ANNUAL PERCENTAGE RATE) on that portion of the Balance exceeding $1,000 and 1.5% (18% ANNUAL PERCENTAGE RATE) on that portion of the Balance that is $1,000 or less. ACSC • 7/19/2017 2:25:56 PM PAGE 8/010 Fax Server lnterinsurance Exchange of the Automobile Club Premium Discounts Applied to Your Automobile Policy Auto Policy Number: CAA 077174270 The following automobile premium discounts are available from the lnterinsurance Exchange. If you meet the discount requirements, an "X" will appear in the box next to the discount name and you will receive a premium reduction on all coverages that qualify for the discount. D MULTI-POLICY IX] MUL Tl-VEHICLE D SELECT PROFESSIONALS & GROUPS IX] LOYALTY D DRIVINO COURSE D MAT\JRE DRIVER D STUDENT AWAY D GOOD STUDENT IX] GOOD DRIVER JEZISEK, JOSEPH V 00 ANTI-THEFTW: ELECTRONIC LOCATOR OTHER 2007 TYTA TUNDRA LN VS 2011 FORD RANGER SUPER 2013 NSSN QUEST IX] AIRBAGS** 2007 TYTA TUNDRA LN VS 2011 FORD RANGER SUPER 2013 NSSN QUEST D GARAGE PARKING * D VERIFIED MILEAGE Anti-Theft Device and Garage Parking -Discount applies if Comprehensive coverage is purchased. "" Air Bags -Discount applies if Medical Payments and/or Uninsured Motorist Bodily Injury coverage is purchased (refer to page one of the declarations). If you need addltlonal Information about any of the above discounts, please refer to the Available Automoblle Premium Discounts insert included with your renewal offer (or the insert provided with your application). If you have additional questions about premium discounts or your auto policy, please call us at 1-877-422-2100. B;iJ, Ed. 06-13 ACSC • 7/19/2017 2:25:56 PM PAGE 9/010 Fax Server lnterinsurance Exchange of the Automobile Club Policy Number: CAA 077174270 NOTICE OF ANNUAL MILEAGE Pursuant to section 2632.5 (c) of the California Insurance Code of Regulations, we are providing you with the annual mileage figures for your vehicle(s). Vehicle Vehicle Vehicle No. Year Make 1 2007 TYTA 2 1925 FORD 6 2011 FORD 7 2013 NSSN Vehicle Identification No. 5TFLV52127X005140 14673114 1FTLR4FE8BPA18799 JN8AE2KP1 D9068177 Annual Miles Expiring Polley 12,801 -115,000 1 -500 7,501 -10,000 7,801 -10,000 8217 Ed. 09-2008 ACSC • 7/19/2017 2:25:56 PM PAGE 10/010 Fax Server lnterinsurance Exchange of the Automobile Club GUARANTEED RENEWAL ENDORSEMENT Effective 11-02-2016 12:01 A.M. Pacific Standard Time Forming a part of Policy No. CAA 077174270 issued by the INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB. We agree not to cancel or refuse to renew your policy, provided the premium is paid when due. However, this agreement shall become void upon the occurrence of any of the events listed below, and we may then cancel or refuse to renew your policy for any reason not prohibited by law. This agreement shall become void if: 1. Fraud or materlal misrepresentation has been committed affecting the pollcy or Insured. 2. Any vehicle insured under your policy is used for commercial purposes. 3. You do not have a valid membership in the Automobile Club of Southern California. 4. Your primary residence is outside the state of California. 5. You have failed to provide to us, within 30 days of our reasonable written request, information necessary to accura1ely underwrite your policy or determine your premium. 6. During the 36 months before the expiration date of the policy period shown on your most recent declarations, you or any other primary or additional driver insured under your policy has had: a. a driver's license suspended or revoked for any reason: or b. any of the following: (1) one or more convictions for: (a) any felony arising out of the ownership, maintenance or use of a motor vehicle; or (b) homicide or assault arising out of the ownership, maintenance or use of a motor vehicle; or (c) any drug or narcotics-related traffic violations; or (d) any speed contest: or (2) two or more convictions for any alcohol-related traffic violations; or (3) three or more convictions for any traffic violations we classify as "major" for additional premium purposes: or (4) two or more at-fault automobile accidents which result in bodily injury; or (5) three or more at-fault automobile accidents which result in physical damage only; or (6) three or more convictions for minor traffic violations. 7. Any primary or additional driver is added to your policy who is not a statutory good driver because of his/her driving record. All provisions of your policy not affected by this endorsement remain unchanged. ACSC Management Services, Inc. ATTORNEY-IN-FACT 2231 E20Cl:lD9 CERTIFICATE OF EXEMPTION WORKERS' COMPENSATION/EMPLOYERS' LIABILITY INSURANCE has no employees and is not required by law to maintain workers' compensation or employers' liability insurance. Should __ , _l~t~d:£ ..... -__ ~_,.,\=~',...,O~C=iI::-· _,_/,._, ··1~,,::~11/4,~'"~+-',. ~-.<:~1 '-+/-employ any person during the term [name of company] \ of the Agreement with the City of Carlsbad for __________________ _ [ description of project or work that is being contracted] then workers' compensation and employers' liability insurance will be obtained. [Title and name of company or corporation] 06/15/2006 25