Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Michael Alphonsus Graham d.b.a. Mike Graham Construction; 2022-06-22; PWL22-1837FAC
DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 PWL22-1837FAC Safety Training Center Concrete Repairs - 1 - City Attorney Approved 2/29/2016 CITY OF CARLSBAD PUBLIC WORKS LETTER OF AGREEMENT SAFETY TRAINING CENTER CONCRETE REPAIRS This letter will serve as an agreement between Michael Alphonsus Graham, a sole proprietorship d.b.a. Mike Graham Construction (Contractor) and the City of Carlsbad (City). The Contractor will provide all equipment, materials and labor necessary to perform concrete repairs at the Safety Training Center, per Exhibit A, B and City specifications, for a sum not to exceed $4,800. This work is to be completed within 60 working days after issuance of a Purchase Order. ADDITIONAL REQUIREMENTS 1. City of Carlsbad business license. 2. The Contractor shall assume the defense of, pay all expenses of defense and indemnify and hold harmless the City, and its agents, officers, officials, employees, and volunteers 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 this Contract or work; or from any failure or alleged failure of the contractor to comply with any applicable law, rules or regulations including those relating to safety and health; except for loss or damage which was caused solely by the active negligence of the City; and from any and all claims, loss, damage, injury and liability, howsoever the same may be caused, resulting directly or indirectly from the nature of the work covered by this Contract, unless the loss or damage was caused solely by the active negligence of the City. The expenses of defense include all costs and expenses, including attorney’s fees for litigation, arbitration, or other dispute resolution method. 3. Contractor shall furnish policies of general liability insurance, automobile liability insurance and a combined policy of workers compensation and Employers’ Liability in an insurable amount of not less than one million dollars ($1,000,000) each, unless a lower amount is approved by the Risk Manager or the City Manager. Said 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. Insurance is 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. Proof of all such insurance shall be given by filing certificates of insurance with contracting department prior to the signing of the contract by the City. 4. The Contractor shall be aware of and comply with all Federal, State, County and City Statues, Ordinances and Regulations, including Workers Compensation laws (Division 4 California Labor Code) and the “Immigration Reform and Control Act of 1986” (8USC, Sections 1101 through 1525), to include but not limited to, verifying the eligibility for employment of all agents, employees, subcontractors and consultants that are included in this Contract. 5. The Contractor may be subject to civil penalties for the filing of false claims as set forth in the California False Claims Act, Government Code sections 12650, et seq., and Carlsbad Municipal Code Sections 3.32.025, et seq. init init 6. The Contractor hereby acknowledges that debarment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor from participating in contract bidding. init init 7. 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. fv.,C, DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 PWL22-1837FAC Safety Training Center Concrete Repairs - 2 - City Attorney Approved 2/29/2016 8. 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 the Section 1770, 1773 and 1773.1 of the California Labor Code. Pursuant to Section 1773.2 of the California Labor code, a current copy of 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 the execution of the work covered by this Letter of Agreement. 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. 9. City Contact: Jason Kennedy, 442-339-5132 Contractor Contact: Mike Graham, 949-322-1371 CONTRACTOR Michael Alphonsus Graham, d.b.a. Mike Graham Construction, a sole proprietorship 12 Buttonwood Irvine, CA 92614 P: 949-322-1371 mikegraham@yahoo.com CITY OF CARLSBAD, a municipal corporation of the State of California By: Mike Graham, Owner (print name/title) Paz Gomez, Deputy City Manager, Public Works, as authorized by the City Manager By: Dated: (sign here) June 22, 2022 (print name/title) (Proper notarial acknowledgment of execution by Contractor must be attached. Chairman, president or vice-president and secretary, assistant secretary, CFO or assistant treasurer must sign for corporations. 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: Assistant City Attorney By: (sign here) DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 PWL22-1837FAC Safety Training Center Concrete Repairs - 3 - City Attorney Approved 2/29/2016 EXHIBIT A SAFETY TRAINING CENTER CONCRETE REPAIR SCOPE OF WORK AND FEES ITEM NO. DESCRIPTION QTY UNIT OF MEASURE PRICE EXTENDED TOTAL 1 Fill 2-inch diameter holes that are 12- inches in depth located on concrete masonry units (CMU) at various wall locations on the residential and commercial training structures at the Safety Training Center. Holes were drilled during construction in 2012 for the installation of rappelling anchor points. These anchor points have been removed due to safety concerns. Holes are located above window openings and at the base of the commercial training structure. Total holes to be filled: Eighteen (18). Filling material: Quickrete 4000 PSI Concrete. Contractor will closely match color of the patches to the color of the existing CMU wall areas. ***Note: Contractor will provide boom lift with necessary safety equipment and all materials for the project. 1 LS $4,800 $4,800 TOTAL* $4,800 *Includes taxes, fees, expenses, and all other costs. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 PWL22-1837FAC EXHIBIT B Lic#: 986631 Proposal Date of Proposal: 04/18/2022 Mike Graham Construction Attention: Jason Kennedy Ph: 949.322.1371 5750 Orion St 12 Buttonwood Carlsbad, CA 92010 Irvine, Ca 92614 Jason.kenned@carlsbadca.gov Mikeagraham@yahoo.com Job Location: 5750 Orion St Carlsbad, CA 92010 Scope of Work • Fill in concrete repelling anchor holes. o Two at each window and at bottom of tower and residential buildings. • Material for anchor holes: Quickrete 4000 PSI Concrete Job Includes: • Boom lift • Materials Job Total: $4,800.00 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTRINSD WVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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 policy(ies) must have ADDITIONAL INSURED provisions or 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 3/3/2022 License # 0F82764 (916) 737-2108 (916) 400-2625 38920 MICHAEL ALPHONSUS GRAHAM, DBA: MIKE GRAHAM CONSTRUCTION 12 BUTTONWOOD IRVINE, CA 92614 35378 35076 A 1,000,000 X X 0100140066-1 2/7/2022 2/7/2023 100,000 Excluded 1,000,000 2,000,000 2,000,000 1,000,000B EZXS3043092 2/7/2021 2/7/2022 1,000,000 C X 9291094-2022 2/7/2022 2/7/2023 1,000,000 1,000,000 1,000,000 City of Carlsbad/CMWD is included as Additional Insured in regards to General Liability per attached endorsement. Waiver of Subrogation applies to General Liability and Workers Compensation. RE: All operations of the named insured covered by the policy under written contract. City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services P.O. Box 947 Murrieta, CA 92564 MICHALP-01 JSANANGEL Inszone Insurance Services, LLC 2721 Citrus Road, Suite A Rancho Cordova, CA 95742 Carla Banuelos cbanuelos@inszoneins.com Kinsale Insurance Company Evanston Insurance Company State Compensation Ins Fund X X X X X X DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 ACORD" I ~ I ~ D □ ~ ~ ~ □ □ ~ ~ ~ ~ ~ ~ ~ ~ H I I 1 1 I □ I THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US-BLANKET Attached To and Forming Part of Policy Effective Date of Endorsement Named Insured 0100140066-1 02/07/2022 12:01AM at the Named Insured address shown on the Declarations Michael Alphonsus Graham Additional Premium:Return Premium: $0 $0 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE SECTION IV – CONDITIONS, 8. Transfer of Rights of Recovery against Others to Us is amended by the addition of the following: We waive any right of recovery we may have against persons or organizations because of payments we make for injury or damage arising out of “your work” done under a written contract with that person or organization wherein you have agreed to provide this waiver. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CAS4002 0110 Page 1 of 1 DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 I THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED AS REQUIRED BY WRITTEN CONTRACT Attached To and Forming Part of Policy Effective Date of Endorsement Named Insured 0100140066-1 02/07/2022 12:01AM at the Named Insured address shown on the Declarations Michael Alphonsus Graham Additional Premium:Return Premium: $0 $0 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE A. SECTION II - WHO IS AN INSURED is amended to include any person or organization you are required to include as an Additional Insured on this Policy by written contract in effect during the policy period and executed prior to the “occurrence” of the “bodily injury” or “property damage”, but only for the vicarious liability imposed on the Additional Insured provided that such liability is caused by the sole negligent conduct of the Named Insured and is proximately caused by “your work” or “your product” for the Additional Insured. However: 1.The insurance afforded to such Additional Insured only applies to the extent permitted by law; and 2.Will not be broader than that which you are required by the written contract to provide for such Additional Insured. B. The insurance provided to the Additional Insured under this endorsement is limited as follows: 1.This insurance does not apply to “bodily injury” or “property damage” arising out of “your work” or “your product” included in the “products-completed operations hazard” unless you are required to provide such coverage by written contract. If such insurance is required by written contract, the insurance provided to the Additional Insured is limited to the alleged or actual vicarious liability imposed on the Additional Insured as a result of the alleged or actual negligent conduct of the Named Insured as a result of liability solely caused by “your work” or “your product” for the Additional Insured. 2.Any insurance provided by this endorsement to an Additional Insured shall be excess with respect to any other valid and collectible insurance available to the Additional Insured unless the written contract specifically requires that this insurance apply on a primary and non-contributory basis, in which case this insurance shall be primary and non-contributory. 3.Where there is no duty to defend the Named Insured, there is no duty to defend the Additional Insured. Where there is no duty to indemnify the Named Insured, there is no duty to indemnify the Additional Insured 4.This insurance does not apply to “bodily injury” or “property damage,” arising out of the sole negligence of the Additional Insured or any employees of the Additional Insured. CAS5010 0420 Page 1 of 2 DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 I C.With respect to the insurance afforded to the Additional Insured, the following is added to SECTION III – LIMITS OF INSURANCE: The most we will pay on behalf of the Additional Insured is the amount of insurance: 1.Required by the written contract; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. D.Duties of the Additional Insured in the event of “occurrence”, claim, or “suit”: 1.The Additional Insured must promptly give notice of an “occurrence”, a claim which is made, or a ”suit” to any other insurer which has insurance for a loss to which this insurance may apply. 2.The Additional Insured must promptly tender the defense of any claim made or ”suit” to any other insurer which also issued insurance to the Additional Insured as a Named Insured or to which the Additional Insured may qualify as an Additional Insured for a loss to which this insurance may apply. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CAS5010 0420 Page 2 of 2 DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 STATE COMPE;NSATION INSURANCli FUND HOME OFFICE SAN FRANCISCO .. ,,..,vn~1.1v1,;;;1JT AGREEMENT WAIVER OF SUBROGATION EFFECTIVE FEBRUARY AND EXPIRING FEBRUARY 9291094-22 RENEWAL NF 9-97-99-76 PAGE 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME 7, 2022 AT 12.01 A.M. 7, 2023 AT 12.01 A.M. GRAHAM, MICHAEL, ALPHONSUS 12 BUTTONWOOD IRVINE, CA 92614 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF CARLSBAD CMWD WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, GRAHAM, MICHAEL, ALPHONSUS IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: FEBRUARY 28, 2022 2570 ~!.-5C PRESIDENT AND CEO SCIF FORM 10217 (REV.4·2018) OLO OP 217 MICHAEL CAMPOS 19831 YORBA LINDA BLVD STE B YORBA LINDA, CA 92886-2851 Auto Insurance Renewal farmers.com 25-8164 1-14 MICHAEL A GRAHAM 12 BUTTONWOOD IRVINE CA 92614 Your Farmers Policy Policy Number: 16411-77-63 Effective: 6/22/2022 12:01 AM Expiration: 12/22/2022 12:01 AM YourFarmersAgent Michael Campos 19831 Yorba Linda Blvd Ste B Yorba Linda, CA 92886-2851 (714) 528-3276 mcampos@farmersagent.com To file a claim log on to Farmers.com or the Farmersfi Mobile App or call 1-800-435-7764 Did you know? Farmers Friendly Review Contact your agent to learn more about the policy discounts, coverage options, and other product offerings that may be available to you. Go Paperless Save stamps, time and trees.Go Paperless! You can choose to receive your Farmers policy documents and/or billing statement electronically. Enroll at farmers.com and choose the paperless options! Go Mobile The Farmersfi Mobile App gives you 24/7 account access on the go. Text GETAPP to 29141 to download it today! 4/28/2022 Dear Michael A Graham, Thank you for choosing Farmers for your automobile insurance needs. We appreciate the opportunity to offer continued coverage for you and your family contingent upon payment toward the premium as stated below. Please review the renewal offer documents that have been enclosed: •ID cards •Renewal Billing Summary •Declaration page a summary of your insurance coverages, limits, and deductibles A summary of your premium information is shown below. Premium at-a-glance Policy Premium $531.00 Fees $0.88 Premium and Fees $531.88 If you prefer, you can log into farmers.com today to review your balance and make a payment. You can also contact us at 1-877-327-6392 or visit your agent’s office with your payment. Sincerely, Farmers Insurance Groupfi DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 ~. FARMERS INSURANCE ► D Fold here Fold here Fold here cut here cut here cut here cut here cut here Fold here Fold here Fold here cut here KEEP WITH VEHICLE Named Insured(s):Michael A Graham Your Agent: Michael Campos Agent Phone: (714) 528-3276 Policy Number: 164117763 Effective: 6/22/2022 Expiration: 12/22/2022 NAIC Number: 21652 Underwriting Company : Farmers Insurance Exchange 6301 Owensmouth Ave. Woodland Hills, CA 91367 Phone: 1-888-327-6335 California Evidence of Liability Insurance Vehicles (s):Registered Owner(s): 2005 Jeep Grand Cherokee 4D 4X2 Lar1J4GS48K05C543385 Michael Graham Listed Driver(s): Barbara Graham Beau Graham DMV REGISTRATION COPY California Evidence of Liability Insurance Named Insured(s):Michael A Graham Your Agent: Michael Campos Agent Phone: (714) 528-3276 Policy Number: 164117763 Effective: 6/22/2022 Expiration: 12/22/2022 NAIC Number: 21652 Underwriting Company : Farmers Insurance Exchange 6301 Owensmouth Ave. Woodland Hills, CA 91367 Phone: 1-888-327-6335 Vehicles (s):Registered Owner(s): 2005 Jeep Grand Cherokee 4D 4X2 Lar 1J4GS48K05C543385 Michael Graham Listed Driver(s): Barbara Graham Beau Graham DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 Fold here cut here cut here Fold here Fold here Fold here Fold here Fold here cut here cut here cut here cut here Contact Farmers Claim Department or Roadside Assistance 24 hours a dayat (800) 435-7764Para Espaæol, llame al (877) 732-5266Report a claim at www.farmers.com, via the Farmersfi MobileApp or Contact your Farmersfi AgentAt the scene of an accident:1. Obtain the following: Name, address, and phone number of each driver, passenger,and witness. Obtain a drivers license number for each driver. License plate number, insurance company, and policynumber of each involved vehicle. Photos of vehicle damage and accident scene.2. Report the accident to the proper authorities.3. Do not admit fault. An investigation may later reveal you werenot responsible for the accident.This policy complies with Section 16056 of the California Vehicle CodeKEEP THIS CERTIFICATE IN YOUR VEHICLE AT ALL TIMES.25-5973 1-19Contact Farmers Claim Department or Roadside Assistance 24 hours a dayat (800) 435-7764Para Espaæol, llame al (877) 732-5266Report a claim at www.farmers.com, via the Farmersfi MobileApp or Contact your Farmersfi AgentAt the scene of an accident:1. Obtain the following: Name, address, and phone number of each driver, passenger,and witness. Obtain a drivers license number for each driver. License plate number, insurance company, and policynumber of each involved vehicle. Photos of vehicle damage and accident scene.2. Report the accident to the proper authorities.3. Do not admit fault. An investigation may later reveal you werenot responsible for the accident.PRESENT THIS COPY WHEN REGISTERING YOUR VEHICLE.25-5973 1-19DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 farmers.com 25-5983 2-18 Auto Insurance Billing Summary Auto Policy 16411-77-63 Billing Account D287267219 Your Farmers Agent Michael Campos 19831 Yorba Linda Blvd Ste B Yorba Linda,CA 92886-2851 (714) 528-3276 mcampos@farmersagent.com Billing Questions? 1-877-327-6392 7:00 am - 11:00 pm (CT) Mon - Fri 8:00 am - 8:00 pm (CT) Sat - Sun 4/28/2022 Michael A Graham, Your renewal balance is due by your renewal date - 6/22/2022. You can pay now with the options displayed below or an itemized billing statement will be sent on 5/23/2022. Your Account Summary Current term remaining balance $0.00 Renewal Premium and Fees $531.88 Account balance $531.88 This is a summary and actual billed amount may change based on payment activity and future transactions. Changes made after April 28, 2022, will reflect on your statement. Payment Options Save time and never forget a bill with automatic payments. Sign up at farmers.com or contact your agent to set up automatic payments. Your payment due will be automatically debited on your due date. Pay online. Visit us at farmers.com. Pay by phone. Call 1-877-327-6392 or contact your agent. Pay your agent directly. Your agent can accept payment in a variety of methods. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 ~. FARMERS INSURANCE Manage your account: Go to www.farmers.com to access your account any time! Policy No. 16411-77-63 56-6176 2nd Edition 3-19 4/28/2022 farmers.com Auto Insurance Declaration Page Page 1 of 3 Questions? Callyour agent Michael Campos at (714) 528-3276 or email mcampos@farmersagent.com Premiums/Fees Policy Premium $531.00 Fees (*also see Information on Additional Fees below) $0.88 PolicyPremium and Fees $531.88 This is not a bill. Policy Number:16411-77-63 Effective:6/22/2022 12:01 AM Expiration:12/22/2022 12:01 AM Named Insured(s):Michael A Graham 12 Buttonwood Irvine,CA 92614 barbarajograham@yahoo.com Underwritten By:Farmers Insurance Exchange 6301 Owensmouth Ave. Woodland Hills,CA 91367 Household Drivers All persons who drive or will occasionally be driving any of the cars on the policy should be listed below. If anyone is missing or needs to be added, such as a newly licensed driver, you should contact your agent or the company to add that person before they begin to drive any of the cars covered on the policy. Name Driver Status Name Driver Status Michael Graham Covered Barbara Graham Covered Beau Graham Covered Vehicle Information Veh. # Year/Make/Model/VIN LimitCoverageDeductible 1 2005 Jeep Grand Cherokee 4D 4X2 Lar Comprehensive: Not Covered 1J4GS48K05C543385 Collision: Not Covered Additional Equipment:Not Covered Coverage Information Premiums by VehicleLimitsCoverage(applicable to all vehicles)Vehicle 1 Bodily Injury Liability $250,000 each person $500,000 each accident $212.00 Property Damage Liability $100,000 each accident $241.00 Permissive User Limit of Liability** Full (See Permissive User Limit of Liability in your policy) Included Medical Coverage Not Covered Uninsured Motorist Bodily Injury $250,000 each person $500,000 each accident $69.00 Comprehensive Not Covered Collision Not Covered Additional Equipment Not Covered DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 ~. FARMERS INSURANCE ► farmers.com Page 2 of 3 Policy No. 16411-77-63 Questions? Callyour agent Michael Campos at (714) 528-3276 or email mcampos@farmersagent.com Manage your account: Go to www.farmers.com to access your account any time! Declaration Page (continued) 56-6176 2nd Edition 3-19 Premiums by VehicleLimitsCoverage(applicable to all vehicles)Vehicle 1 Uninsured Motorist Property Damage without Collision $3,500 $9.00 Uninsured Motorist Property Damage with Collision Not Covered Towing and Road Service Not Covered Total Premium Per Vehicle $531.00 Policy Premium $531.00 Fee Detail Vehicle 1 Total Anti-Fraud Fee $0.88 $0.88 Fees $0.88 PolicyPremium and Fees $531.88 Discounts Discount Type Applies to Vehicle(s) Discount Type Applies to Vehicle(s) Multiple Car All Good Driver All Safe Driver All Anti-Lock Brakes All Group - Firefighter All Auto/Home All Rating Information Details Vehicle 1 Garaging Zip 92614 Renewal Term 12-Month Mileage 7,500 Expiring Term 12-Month Mileage 7,500 Vehicle Usage Other Use Years of Driving Experience 44-48 Policy and Endorsements This section lists the policy form number and any applicable endorsements that make up your insurance contract. Any endorsements that you have purchased to extend coverage on your policy are also listed in the coverages section of this declarations document: 56-5684 1st ed.; 25-4501 8-11; 25-8531 10-12; CA125 2nd ed. Other Information •**YOUR POLICY INCLUDES THE FULL PERMISSIVE USER LIMIT OF LIABILITY. PLEASE SEE PERMISSIVE USER LIMIT OF LIABILITY IN YOUR POLICY FOR FURTHER INFORMATION. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 ► ► ► farmers.com Page 3 of 3 Policy No. 16411-77-63 Questions? Callyour agent Michael Campos at (714) 528-3276 or email mcampos@farmersagent.com Manage your account: Go to www.farmers.com to access your account any time! Declaration Page (continued) 56-6176 2nd Edition 3-19 •You may be eligible for a different rate but with different coverage from Farmers Specialty Insurance Company. Please contact your Farmersfi agent to discuss your options. •You have the right to designate an additional third party to receive any notice of cancellation for nonpayment of your premium for this policy. Please contact your Farmersfi agent if you would like to add, change, or remove a designee. •Go Green by logging onto Farmers.com or contacting your Farmers Agent. •Farmers Friendly Reviews are a great way to make sure you are receiving all the discounts for which you qualify, and identify any potential gaps in coverage. Contact your agent to learn more about the policy discounts, coverage options, and other product offerings that may be available to you. *Information on Additional Fees The "Fees" stated in the "Premiums/Fees" section on page 1 apply on a per-policy, not an account basis. The following additional fees also apply: 1. Service Charge per installment (In consideration of our agreement to allow you to pay in installments): - For Recurring Electronic Funds Transfer (EFT): $0.00 (applied per account) - For Recurring Credit/Debit Card plans: $5.00 (applied per account) - For all other payment plans: $7.00 (applied per account.) If this account is for more than one policy, changes in these fees are not effective until the revised fee information is provided for each policy. 2. Late Fee: $15.00 (applied per account) 3. Returned Payment Charge: $25.00 (applied per check, electronic transaction, or other remittance which is not honored by your financial institution for reasons including, but not limited to, insufficient funds or a closed account) 4. Reinstatement Fee: $18.40 (applied per vehicle, 20% discount will apply for Good Drivers) One or more of the fees or charges described above may be deemed a part of premium under applicable state law. Countersignature Authorized Representative DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 farmers.com Policy No. 16411-77-63 Page 1 of 6 Policy Notices (Continued Next Page) Explanation of Rating Plan California law requires that we explain how traffic violation convictions and chargeable accidents„ can affect your insurance premium. By law, mandatory California rating factors must be considered by an insurer in determining your premium. One of these rating factors is your public driving safety record, including the nature and number of your traffic violation convictions,2 and the nature and number of your chargeable accidents, within the past three years. Traffic violation convictions which generally involve the safe operation of a motor vehicle, and chargeable accidents, are considered by Farmers in the premium calculation process through a standardized Driver Points System (DPS), which generates a DPS score. Your DPS score affects your premium for Bodily Injury and Property Damage Liability coverage, Uninsured Motorist Bodily Injury coverage, Medical Payments coverage, and Comprehensive and Collision coverages. Based upon your driving safety record, you may be eligible for a Good Driver Discount. Eligibility for this discount is defined by law. You have the right to be informed, upon request, of any increase in your premium, in whole or in part, charged by virtue of your involvement in any accident or conviction by you or any operator of your insured motor vehicle. „In California, an accident is chargeable if the driver was found at least 51% responsible for the accident, and either the accident resulted in bodily injury or death or, for an accident that resulted only in damage to property, the total loss or damage caused by the accident exceeded $1000 (or $750 if the accident happened before December 11, 2011). †We define a minor traffic violation as a violation for which one (1) negligent point is assigned to you by California Vehicle Code. We define a major violation as a violation for which two (2) negligent operator points are assigned to you by the California Vehicle Code. 25-4501 8-11 Notice of Information Practices California Why did we send you this notice? The State of California requires all insurance companies to tell customers about their information practices. Information practices include things companies do to gather and share information about customers. Insurance companies need information to make decisions. They make all sorts of day-to-day decisions: who to insure, how much to charge, how to handle claims, and others. What are your rights? Our information practices extend to applicants and policyholders (past and present). State and federal laws give you certain rights when you take part in transactions having to do with insurance for yourself, your family, or your household. We send our customers a notice called the "Farmers Privacy Notice." The Farmers Privacy Notice does not limit any rights you may have - as a consumer, claimant, or beneficiary. Your state gives you additional protections. They are explained in this notice. How do we collect the information? You give us most of the information we need when you apply for insurance. Much of it is made up of common, practical facts: your employment information, your driving record, your age, where you live, and other things like that. Many times, we need more information. Or we may need to verify information you’ve given us. When that happens, we normally ask for a report from an outside source. That source can be a consumer reporting agency or an insurance support organization. Both provide information in the form of consumer reports. Most insurance companies use these; it’s a common industry practice. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 ~. FARMERS INSURANCE farmers.com Policy No. 16411-77-63 Page 2 of 6 Policy Notices (continued) (Continued Next Page) Sometimes one of these outside sources needs to gather information before they can prepare an investigative consumer report. This could be done as part of a fraud investigation, for example. They might then contact you, another adult member of your household, or a neighbor by phone or in person. If this happens, you can, as the Named Insured, ask us to interview you or your spouse as well. We will make every effort to honor your request. What types of information do we collect? Auto - While taking your application for insurance and to service policies covering your personal vehicles, we may obtain information about ·How you use your vehicle(s), including annual mileage ·Age, personal habits, and characteristics of drivers ·Credit information ·History of accidents, driving violations, arrests or convictions, and claims ·Previous insurance experience Property - While taking your application for insurance and to service policies covering your real and personal property, we may obtain information about ·Type of construction and square footage of dwelling ·Heating system and other physical characteristics of the property ·Care and maintenance of the property ·Credit information ·Claims history ·Previous insurance experience ·Personal habits and characteristics of the property’s occupants What do we do with the information? We use the information we collect about you to perform insurance functions. This includes ·Underwriting and servicing your policy ·Processing claims (we may obtain information relating to health and employment) ·Investigating potential fraud ·Other activities permitted by state and federal law Here’s an example: If you ask us to set up a payment by electronic funds transfer, we may obtain financial information for a particular bank account. We may also disclose information to other parties. The law permits us to do this without your prior authorization when the information goes, for example, to these parties: 1. Your Farmers fi agent - to service your policy. 2. Persons who need this information to perform normal business functions for us. 3. Persons conducting actuarial or research studies on our behalf. 4. Another insurance company or an insurance support organization - to perform an insurance transaction, or to detect or prevent criminal activity or fraud in connection with an insurance transaction. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 farmers.com Policy No. 16411-77-63 Page 3 of 6 Policy Notices (continued) (Continued Next Page) 5. A medical professional or medical care institution - to verify insurance coverage or benefits or to inform an individual of a medical problem the individual may not know about. 6. An insurance regulatory authority. 7. Law enforcement or other governmental authority. 8. A group policyholder - to report claims experience or conduct an audit of our operations, but only as needed to conduct the review or audit. 9. Affiliates, as permitted by law. The law allows us to share your financial information with our affiliates to market products or services to you, and does not allow customers to restrict that disclosure. 10.Persons that perform marketing services on our behalf, as permitted by law. 11.Other non-affiliated third parties, as permitted by law. 12.A party to a proposed or consummated sale, transfer, merger, or consolidation of all or part of the company underwriting your policy. An insurance support organization that prepares a report may keep information it gathers and disclose that information to other persons, but only to the extent permitted by federal and state law. How can you see or make corrections to your personal information? You have these rights: ·To know what personal information about you we have in our records. That includes reports from outside sources. ·To get a copy of your personal information. ·To request that we correct, change, or remove any information you feel is incorrect. To use these rights, you must send us a written request. Your Farmers fi agent can give you the appropriate service center address. If you request that we correct, change, or remove incorrect information, we’ll check our records and make the changes if we can. We’ll let you know in writing what we decide. If we cannot make a change you asked for, you can file a statement. Write down the reasons you disagree with our decision. We’ll include the statement in our records. That way, anyone who looks at the disputed personal information will also see your statement. From then on, if we disclose your information to another party, we’ll include your statement. We will also send a copy to anyone who has gotten your personal information from us in the past two years. Just tell us who you would like us to send it to. There are some types of information for which these rights do not apply: ·Information we collect to process an actual or anticipated claim ·Information we collect for an actual or anticipated civil or criminal proceeding ·Specific items of privileged information when an applicant or policyholder is suspected of fraud, material misrepresentation, or material nondisclosure We’ll keep you informed. As required by law, we will keep you up to date on our information practices. We reserve the right to modify our practices at any time, when permitted by law. If you have questions about this notice, please call your Farmers fi agent. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 farmers.com Policy No. 16411-77-63 Page 4 of 6 Policy Notices (continued) (Continued Next Page) This notice is sent on behalf of the Farmers Insurance Group of Companies, whose members include, but are not limited to: Farmers Insurance Exchange, Fire Insurance Exchange, Truck Insurance Exchange, Mid-Century Insurance Company, Farmers New Century Insurance Company, Farmers Insurance Company, Inc. (A Kansas Corp.), Farmers Insurance Company of Arizona, Farmers Insurance Company of Idaho, Farmers Insurance Company of Oregon, Farmers Insurance Company of Washington, Farmers Insurance of Columbus, Inc., Farmers Texas County Mutual Insurance Company, Illinois Farmers Insurance Company, Mid-Century Insurance Company of Texas, Texas Farmers Insurance Company, Civic Property and Casualty Company, Exact Property and Casualty Company, and Neighborhood Spirit Property and Casualty Company. 25-8531 10-12 Did you know? Farmers Insurance Exchange and Mid-Century Insurance Company (collectively Farmers) offer a selection of insurance coverages that may be attractive to a broad range of customers. This message describes Auto policy discounts available from Farmers Insurance Exchange and Mid-Century Insurance Company in California for which certain customers will be eligible, as well as Auto policy surcharges that could also be applicable. It also describes uninsured motorist coverage. We provide this information to help you learn about the Farmers Auto policy discounts for which you may be eligible, to give you an overview of Farmers Auto policy surcharges that may affect your insurance premium, and to inform you about uninsured motorist coverage. This information can help you make informed choices about your Auto insurance coverage. If you have any questions about discounts or surcharges, or about your insurance coverage, please contact your Farmers agent. Important note: This message provides general information about Farmers insurance discounts and surcharges and about uninsured motorist coverage in California. Additional terms and restrictions may apply; you should consult your agent for details. This message is not an offer of insurance, and it is not a part of your policy. If there is any discrepancy between this message and your policy, the terms of the policy take precedence. Discounts The discounts discussed below may help you save money on your Auto insurance premiums. If you have a question about your eligibility for any of the discounts shown below, your Farmers agent will be able to help you. •Drivers with a safe driving record will be eligible for the Good Driver Discount. State law defines a safe driving record; your Farmers agent can provide you with the details. •The Multiple Car Discount will be available to eligible persons who have insured two or more cars with Farmers. Vehicles classified as "storage use" will not be counted toward this discount. •A Multi-line Discount may be available to eligible persons who have purchased an Auto insurance policy and also have purchased a qualifying Homeowners, Renters, CEA, Umbrella or Life policy with Farmers. These persons may also be eligible for this discount if they have purchased both a Farmers Auto insurance policy and a qualifying policy on a mobile home insured with Foremost Insurance Company (which is one of the Farmers Insurance Group of Companies). •A Safe Driving Discount is available to eligible drivers. Your record of traffic violation convictions and chargeable accidents determines your eligibility for this discount. Drivers who have had no more than one minor traffic violation conviction in the past three years, no chargeable accidents for the past five years, and no convictions for driving under the influence of alcohol or drugs for the past five years may qualify for the Safe Driving Discount. Please contact your Farmers agent for more information. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 farmers.com Policy No. 16411-77-63 Page 5 of 6 Policy Notices (continued) (Continued Next Page) •Business and Professional Group Discounts may be available to eligible persons employed in certain occupations and to members of qualifying groups (associations and organizations). Your agent will ask you for proof of eligibility, and there are some restrictions. Your Farmers agent can provide you with the details. •An Anti-Theft Discount may be available for eligible persons with vehicles with an approved Theft Recovery System. •Passive Restraint Discounts may be available for eligible persons with vehicles with qualifying passive restraint devices, such as air bags and automatic seat belts. •The Antilock Brake Discount may be available for eligible persons with vehicles with a factory-installed antilock braking system that controls braking on all four wheels. •An Alternative Fuel Vehicle Discount may be available for eligible persons with electric-and-gasoline hybrid vehicles and for dedicated-fuel vehicles using a qualifying alternative fuel, including electricity, ethanol, methanol, propane, hydrogen or compressed natural gas. •The Electronic Stability Control Discount may be available for eligible persons with vehicles with an Electronic Stability Control System that is factory installed as a standard feature to help prevent a driver from losing control of the vehicle during high-speed maneuvers or on slippery roads. •The Senior Defensive Driver Discount may be available to eligible drivers age 55 or older, who have successfully completed a prescribed safe driving course. The course must be approved by the Department of Motor Vehicles. •The Good Student Discount may be available to eligible full-time students who maintain a grade point average of at least "B" or its equivalent. •Driver Training Discount may be available to eligible drivers with less than nine years of driving experience who have not had a traffic violation conviction or a chargeable accident in the past three years. Successful completion of a program covering insurance and driver safety is also required. •The Distant Student Discount may be available to eligible licensed single drivers who have less than 9 years of driving experience and are a child of a primary named insured driver. The driver must attend a school that is at least 100 miles away and not have regular access to a vehicle while at school. Surcharges Insurance companies sometimes charge an additional amount of premium where the customer has historically had an unusual number of traffic violation convictions or chargeable accidents, or where the customer has an unusual risk profile. This additional premium is called a surcharge, and it may be applied in some of the following conditions and situations. You may wish to consider these and discuss them with your Farmers agent. •A Vehicle History Surcharge may be applied on a vehicle with adverse vehicle history. Uninsured Motorist Coverage Uninsured motorist coverage will compensate an insured person for bodily injury or wrongful death caused by the owner or operator of an uninsured motor vehicle. The limits of uninsured motorist coverage will be equal to the limits of your bodily injury liability coverage unless you reject this coverage completely or unless you purchase this coverage with reduced limits. By law, you cannot purchase uninsured motorist coverage with limits less than the minimum financial responsibility limits. Additionally, you can purchase uninsured motorist coverage, but provide that it does not apply when your insured motor vehicle is operated by a certain person or persons designated by name. If you purchase uninsured motorist coverage for bodily injury or wrongful death, your policy will also provide uninsured motorist coverage for property damage. This coverage will compensate you for property damage to an insured motor vehicle caused by the owner or operator of an uninsured motor vehicle, in an amount not to exceed the actual cash value of the insured motor vehicle or $3,500, whichever is less. If you purchase both uninsured motorist coverage for property damage and collision coverage, and you are DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 farmers.com Policy No. 16411-77-63 Page 6 of 6 Policy Notices (continued) involved in an accident with an uninsured motorist, your uninsured motorist property damage coverage will pay your deductible under your collision coverage. As with uninsured motorist coverage for bodily injury, you may reject uninsured motorist coverage for property damage, or you may purchase the coverage and provide that it does not apply when your insured motor vehicle is operated by a certain person or persons designated by name. 25-8813 5-17 DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 Subscription Agreement Notice farmers.com 25-3031 2-14 Subscription Agreement Notice (Please keep for your records) By payment of the policy premium, you acknowledge that you have received and read the Farmers Insurance Exchange Subscription Agreement (the terms of which are provided below) and that you agree to be bound to all of the terms and conditions of the Subscription Agreement. Under the Subscription Agreement, you appoint Farmers Underwriters Association (the Association) to act as the attorney-in-fact. The Association has acted in this capacity since 1928. The Subscription Agreement provides for payment of compensation to the Association for its becoming and acting as attorney-in-fact. This compensation consists of a membership fee and a percentage of premiums on all policies of insurance or reinsurance issued or effected by the Exchange. These fees are included in your policy payment and are not an additional fee. We reserve the right to request that you provide us with a signed Subscription Agreement and if you fail to do so, your coverage may be terminated. Subscription Agreement For and in consideration of the benefits to be derived therefrom the subscriber covenants and agrees with Farmers Insurance Exchange and other subscribers thereto through their and each of their attorney-in-fact, the Farmers Underwriters Association, to exchange with all other subscribers policies of insurance or reinsurance containing such terms and conditions therein as may be specified by said attorney-in-fact and approved by the Board of Governors or its Executive Committee for any loss insured against, and subscriber hereby designates, constitutes and appoints Farmers Underwriters Association to be attorney-in-fact for subscriber, granting to it power to substitute another in its place, and in subscribers name, place and stead to do all things which the subscriber or subscribers might or could do severally or jointly with reference to all policies issued, including cancellation thereof, collection and receipt of all monies due the Exchange from whatever source and disbursement of all loss and expense payments, effect reinsurance and all other acts incidental to the management of the Exchange and the business of interinsurance; subscriber further agrees that there shall be paid to said Association, as compensation for its becoming and acting as attorney-in-fact, the membership fees and twenty per centum of the Premium Deposit for the insurance provided and twenty per centum of the premiums required for continuance thereof. The remaining portion of the Premium Deposit and of additional term payments made by or on behalf of the subscriber shall be applied to the payment of losses and expenses and to the establishment of reserves and general surplus. Such reserves and surplus may be invested and reinvested by a Board of Governors duly elected by and from subscribers in accordance with provisions of policies issued, which Board or its Executive Committee or an agent or agency appointed by written authority of said Executive Committee shall have full powers to negotiate purchases, sales, trades, exchanges, and transfers of investments, properties, titles and securities, together with full powers to execute all necessary instruments. The expenses above referred to shall include all taxes, license fees, attorneys fees and adjustment expenses and charges, expenses of members and governors meetings, agents commissions, and such other specified fees, dues and expenses as may be authorized by the Board of Governors. All other expenses incurred in connection with the conduct of the Exchange and such of the above expenses as shall from time to time be agreed upon by and between the Association and the Board of Governors or its Executive Committee shall be borne by the Association. The principal office of the Exchange and its attorney-in-fact shall be maintained in the City of Los Angeles, County of Los Angeles, State of California. This agreement can be signed upon any number of counterparts with the same effect as if the signatures of all subscribers were upon one and the same instrument, and shall be binding upon the parties thereto, severally and ratably as provided in policies issued. Wherever the word subscriber is used the same shall mean members of the Exchange, the subscriber hereto, and all other subscribers to this or any other like agreement. Any policy issued hereon shall be non-assessable. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 ~. FARMERS INSURANCE Privacy Policy farmers.com Page 1 of 425-7660 12-19 This notice describes our privacy policies and procedures in safeguarding information about customers and former customers that obtain financial products or services for personal, family or household purposes. Please note that if state law is more protective of an individual’s privacy than federal privacy law, we will protect information in accordance with state law while also meeting federal requirements. Information We Collect We may collect the following categories of information for the purposes identified below. Please note that the examples are not an exhaustive list and may fall into multiple categories. Categories and specific pieces of information collected may vary depending on the nature of your relationship with us. Category Purpose of Use What may be included inthis category Some examples Internal Authenticate your identity; create, maintain and secure your account with us; maintain your preferences. Knowledge and Belief, Authenticating, Preference Passwords, PIN, mothers maiden name, individual interests Historical Complete a transaction or provide a service for which the personal information was collected; conduct analytics and modeling. Personal history Past claims, prior insurance carriers, prior addresses, medical history, criminal history Financial Process your billing; make payments; complete a transaction or provide a service for which the personal information was collected. Account, Ownership, Transactional, Credit Credit card number, bank account, records of real or personal property, credit, income, loan records, taxes External Identify information to verify you; complete a transaction or provide a service for which the personal information was collected; deliver product offerings that may be relevant to you; conduct analytics. Identifying, Ethnicity, Gender, Demographic, Medical and Health, Physical Characteristics Name, username, government issued identification, social security number, gender, browsing behavior, age range, income bracket, physical and mental health, medical records Social Establish your communication preferences; complete a transaction or provide a service for which the personal information was collected; process your policy, account or claim. Professional, Criminal, Public Life, Family, Social Network, Communication Job titles, work history, school attended, convictions, charges, marital and family status, email, telephone recordings Tracking Contact you; provide relevant information; provide a location-based product or service requested by you; conduct analytics. Computer or Mobile Device, Contact, Location IP Address, geolocation, email address, physical address, telephone number, country We collect certain information ("nonpublic personal information") about you and the members of your household ("you") from the following sources: ·Information you provide on applications or other forms, such as your social security number, assets, income, and property information; ·Information about your transactions with us, our affiliates or others, such as your policy coverage, premiums, and payment history; DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 ~. FARMERS INSURANCE Page 2 of 4 farmers.com 25-7660 12-19 ·Information from your visits to the websites we operate, use of our mobile sites and applications, use of our social media sites, and interaction with our online advertisements; ·Information we receive from consumer reporting agencies or insurance support organizations, such as motor vehicle records, credit report information and insurance claims history; and ·If you obtain a life, long-term care or disability product, information we receive from you, medical professionals who have provided care to you and insurance support organizations, regarding your health. How We Protect Your Information Our customers are our most valued assets. Protecting your privacy is important to us. We restrict access to personal information to those individuals, such as our employees and agents, who provide you with our products and services. We require individuals with access to your information to protect it and keep it confidential. We maintain physical, electronic, and procedural safeguards that comply with applicable regulatory standards to guard your nonpublic personal information. We do not disclose any nonpublic personal information about you except as described in this notice or as otherwise required or permitted by applicable law. Information We Disclose We may disclose the nonpublic personal information we collect about you, as described above, to our affiliates, to companies that perform marketing services on our behalf or to other financial institutions with which we have joint marketing agreements, and to other third parties, all as permitted by law and for our everyday business purposes, such as to process your transactions and maintain your accounts and insurance policies. Many employers, benefit plans or plan sponsors restrict the information that can be shared about their employees or members by companies that provide them with products or services. If you have a relationship with Farmers or one of its affiliates as a result of products or services provided through an employer, benefit plan or plan sponsor, we will follow the privacy restrictions of that organization. We are permitted to disclose personal health information: (1) to process your transaction with us, for instance, to determine eligibility for coverage, to process claims or to prevent fraud; (2) with your written authorization, and (3) otherwise as permitted by law. When you are no longer our customer, we continue to share your information as described in this notice. Sharing Information with Affiliates The Farmers Insurance Groupfi of Companies includes affiliates that offer a variety of financial products and services in addition to insurance. Sharing information enables our affiliates to offer you a more complete range of products and services. We may disclose nonpublic personal information, as described above in Information We Collect, as permitted by law to our affiliates, which include: ·Financial service providers such as insurance companies and reciprocals, investment companies, underwriters and brokers/dealers. ·Non-financial service providers, such as data processors, billing companies and vendors that provide marketing services for us. We are permitted by law to share with our affiliates information about our transactions and experiences with you. In addition, we may share with our affiliates consumer report information, such as information from credit reports and certain application information, received from you and from third parties, such as consumer reporting agencies and insurance support organizations. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 Page 3 of 4 farmers.com 25-7660 12-19 IMPORTANT PRIVACY CHOICES You have choices about the sharing of some information with certain parties. These choices may differ based on the particular affiliate(s) with which you do business. For 21st Century customers: We are offering you an Opt-Out opportunity which is included with your policy documents. If you prefer that we not share your consumer report information with Farmers you may opt-out of such disclosures that is, you may direct us not to make those disclosures --other than as otherwise permitted by law. You may do so by following the procedure explained in the Opt-Out Form. You may opt-out only by returning the Opt-Out Form. We will implement your request within a reasonable time. If it is your decision not to opt-out and to allow sharing of your information with the Farmers affiliates, you do not need respond in any way. For Bristol West customers: If you prefer that we not share consumer report information with our affiliates, except as otherwise permitted by law, you may use the Opt-out form included with your policy documents. Please verify that your Bristol West policy number is listed. If not, please add the policy numbers on the form and mail to the return address printed on the form. We will implement your request within a reasonable time after we receive it. Any policyholder may opt-out on behalf of other joint policyholders. An opt-out by any joint policyholder will be deemed to be an opt-out by all policyholders of the policy. If it is your decision not to opt-out and to allow sharing of your information with our affiliates, you do not need to request an Opt-Out or respond to us in any way. For Farmers customers: If you prefer that we not share consumer report information with our affiliates, except as otherwise permitted by law, you may request an Opt-Out Form by calling toll free, 1-800-327-6377, (please have all of your policy numbers available when requesting Opt-Out Forms). A form will be mailed to your attention. Please verify that all of your Farmers policy numbers are listed. If not, please add the policy numbers on the form and mail to the return address printed on the form. Any policyholder may opt out on behalf of other joint policyholders. An opt-out by any joint policyholder will be deemed to be an opt-out by all policyholders of the policy issued by the affiliates listed on the Farmers Privacy Notice. We will implement your request within a reasonable time after we receive the form. If you decide not to opt-out or if you have previously submitted a request to opt-out on each of your policies, no further action is required. --- Additionally, under the California Consumer Privacy Act (CCPA), California residents have the right to opt out of the sale of personal information to certain third parties. Although we do not currently share personal information in a manner that would be considered a sale under CCPA, you may still submit a request to opt out by calling us at 1-855-327-6548 or submitting a request through our CCPA Web Form at https://www.farmers.com/california-consumer-privacy/. Modifications to our Privacy Policy We reserve the right to change our privacy practices in the future, which may include sharing nonpublic personal information about you with other nonaffiliated third parties. Before we make any changes, we will provide you with a revised privacy notice and give you the opportunity to opt-out of, or, if applicable, to opt-in to that type of information sharing. Website and Mobile Privacy Policy Our Enterprise Privacy Statement includes our website and mobile privacy policies which provides additional information about website and mobile application use. Please review those notices if you transmit personal information to us over the Internet through our websites and/or mobile applications. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139 Page 4 of 4 farmers.com 25-7660 12-19 Recipients of this Notice While any policyholder may request a copy of this notice, we are providing this notice to the named policyholder residing at the mailing address to which we send your policy information. If there is more than one policyholder on a policy, only the named policyholder will receive this notice. You may receive more than one copy of this notice if you have more than one policy with us. You also may receive notices from affiliates, other than those listed below. More Information about these Laws? This notice is required by applicable federal and state law. For more information, please contact us. Signed Farmers Insurance Exchange, Fire Insurance Exchange, Truck Insurance Exchange, Mid-Century Insurance Company, Farmers Insurance Company, Inc. (A Kansas Corp.), Farmers Insurance Company of Arizona, Farmers Insurance Company of Idaho, Farmers Insurance Company of Oregon, Farmers Insurance Company of Washington, Farmers Insurance of Columbus, Inc., Farmers Insurance Hawaii, Inc., Farmers New Century Insurance Company, Farmers Services Insurance Agency, Farmers Specialty Insurance Company, Farmers Texas County Mutual Insurance Company, Farmers Financial Solutions, LLC (a member of FINRA and SIPC)*, FFS Holding, LLC, Illinois Farmers Insurance Company, Mid-Century Insurance Company of Texas, Texas Farmers Insurance Company, Civic Property and Casualty Company, Exact Property and Casualty Company, and Neighborhood Spirit Property and Casualty Company, American Federation Insurance Company, 21st Century Advantage Company, 21st Century Assurance Company, 21st Century Auto Insurance Company of New Jersey, 21st Century Casualty Company, 21st Century Centennial Insurance Company, 21st Century Indemnity Insurance Company, 21st Century Insurance & Financial Services, Inc., 21st Century Insurance Company, 21st Century Insurance Company of Southwest, 21st Century North America Insurance Company, 21st Century Pacific Insurance Company, 21st Century Premier Insurance Company, 21st Century Superior Insurance Company, Hawaii Insurance Consultants Ltd., American Pacific Insurance Company, Inc., Bristol West Casualty Insurance Company, Bristol West Holdings, Inc., Bristol West Insurance Company, Bristol West Insurance Services of California, Inc., Bristol West Insurance Services, Inc. of Florida, Bristol West Preferred Insurance Company, BWIS of Nevada, Inc.; Coast National Holding Company, Coast National Insurance Company; Foremost County Mutual Insurance Company, Foremost Insurance Company Grand Rapids, Michigan, Foremost Lloyds of Texas, Foremost Property and Casualty Insurance Company, Foremost Signature Insurance Company, and Security National Insurance Company (Bristol West Specialty Insurance Company in TX). The above is a list of the affiliates on whose behalf this privacy notice is being provided. It is not a comprehensive list of all affiliates of the companies comprising the Farmers Insurance Group of Companies. *For more background information on Farmers Financial Solutions, LLC (FFS) or its registered representatives/Agents, visit FINRAs BrokerCheck at www.finrabrokercheck.com or call the BrokerCheck toll free hotline at (800) 289-9999. You may obtain information about the Securities Investor Protection Program (SIPC) including the SIPC brochure by contacting SIPC at (202) 371-8300 or via the internet at www.sipc.org. FFS is registered with the US Securities and Exchange Commission and the Municipal Securities Rulemaking Board (MSRB). The MSRB website is accessible at www.msrb.org and includes an Investor Brochure that describes the protections that may be provided by the MSRB and how to file a complaint with the appropriate regulatory authority. DocuSign Envelope ID: 49EB0D3F-74CA-4E35-B4A9-68E564904139