HomeMy WebLinkAboutL16-069 - Original - Willie's Ice Cream Truck - Upland Playfields, Kent Memorial & Van Doren's Landing Parks Concessions Mobile Unit - 04/11/2016 F�,1'E('.3"1E_- IV E D
CITY CLERK
JUN 2 2 0�(.3 CITY OF KENT
KENT
W.5 N G7 0 N 220 4"' Avenue South
Kent, WA 98032
C 17(OF 1"�174T Fax: 253-856-6725
CH"I CLER< PHONE: 253-856-5725
Lease Agreement Cover Sheet
This document is to be used in lieu of the Contract Cover Sheet
SECTION I - CONTRACT PROCESSING AND TENANT SET-UP:
Contract Number: (to be completed by Clerk's Office) 0 0 U01
1. Responsible Department/Division: Parks - Recreation
2. Contact Person and Title: David HeEdt, Program Coordinator (Julie Romano,
System Support)
Telephone Extension: 5004/5001
3. Tenant (Customer) Name: Willie's Ice Crernan Truck, Willie D. Drinker
4. Tenant (Customer) Number: 607257
5. General Ledger Account Number: 10006210.56280.4210
6. King County Tax Parcel Number:
7. Address of Parcel: Kent Memorial Park, Upland Playfields, and Van
Doren's Landing, Kent
8, Type of Lease: Concession Agreement - Mobile Unit
9. Council Authorization Date:
10, Mayor Signature Date- 04-20-16 (Signed by Lori Hogan)
SECTION 2 - LEASE DURATION AND, IMPORTANT DATES:
11. Lease Start Date: 04/11/2016
12. Tenant Lease Option Renewal Notification Due Date: End of Each Term
13. Lease Termination Date: 12/31/2016
14. Lease Duration: 264 Days
SECTION 3 - RENT DETERMINATION AND DUE DATE:
15. Rent: 10% of Gross
16. Rent Due Date: 10th
Lease Agreement Cover Sheet—Page 1 of 2
17. Calculation of Rental Increase(s):
SECTION 4 — LEASEHOLD EXCISE TAX:
18. Is this lease subject to leasehold excise taxes?
❑ YES (go to Question 19)
® NO, reason:
19. Are leasehold excise taxes for this tenant centrally assessed, i.e.
directly collected from the tenant by the Washington State Department
of Revenue?
❑ YES (attach written verification received directly from DOR or indirectly
through the tenant, e.g. DOR notification letter)
® NO (go to Question 20)
20. Does Lease Rent include Leasehold Excise Tax?
(Leasehold taxes must be broken out on the invoice and coded: Business
unit.32500.0303)
❑ YES Calculate the leasehold excise tax (Stated Rent divided by
1.1284)
® NO Calculate the leasehold excise tax (Stated Rent times .1284)
SECTION 5 — APPLICABLITY OF UTILITIES:
21. Applicability of Utilities — Check all that utilities that are affected and
indicate provider (e.g. City of Kent), Account Number or basis of
exclusion.
® Does Not Apply
❑ Water:
❑ Sewer:
❑ Drainage:
❑ Garbage:
❑ Electricity/Natural Gas:
SECTION 6 — MONETARY PENALTIES AND LATE INTEREST CHARGES:
22. Monetary Penalties: 50/b
23. Late Interest: 1%
SECTION 7 — OTHER LEASE CONSIDERATIONS:
Special lease considerations, e.g. non-monetary rent, etc
® None (check box if no considerations)
Lease Agreement Cover Sheet—Page 2 of 2
CITY OF KENT
CONCESSION AGREEMENT-Upland Playfields/Kent Memorial Park/Van Doren's
Landing Park - Mobile Unit
THIS AGREEMENT is made and entered into by and between the City of Kent, a Washington
municipal corporation, (the "City"), and Willie's Ice Creman Truck (BLH-2100276),
(Willie D. Drinker, owner) 22803, 915� Way S. Apt. E203, Kent, WA 98031, (206) 372-3752,
("Concessionaire").
AGREEMENT
1. Grant of Concession. The City grants to Concessionaire the right and privilege to sale
Ice Cream sundries and beverages within the limits of Kent Memorial Park, Upland
Playfields and Van Doren's Landing Park, City of Kent, County of King, State of
Washington. This right applies to all events, with the exception, at City's sole discretion,
of certain events where park renters may be allowed to bring in additional vendors
during their own private events.
1 Term of Agreement. The term of this agreement shall commence pril , 1 210,161, and,
end DecerribeIrl,31, 20161 with an option to renew for additional one (1) year terms at the
end of each term, by mutual agreement of the parties in writing.
3. Termination of Agreement. The failure on the part of Concessionaire to comply with
any of the provisions of this agreement, or the failure to obey, perform or to comply with
local, state or federal laws, rules, regulations or requirements now existing or hereinafter
enacted, shall be grounds for the City to terminate this agreement and revoke its grant
of all rights of Concessionaire under this agreement. The City expressly reserves the
right and power to terminate this agreement upon giving Concessionaire ten (10) days
advance written notice for cause as set forth herein, and Concessionaire expressly
waives the right to claim or recover any damages on account of such termination against
the City, its officers, officials, employees, agents and volunteers. The City may order
Concessionaire to cease operations hereunder immediately at any time should the City,
in its sole discretion, determine that Concessionaire's operation is detri ental to public
safety, health or welfare. Upon expiration of this agreement or1 upon prior termination
thereof Concessionaire agrees to promptly cease to operate the point of sale concession
at the location specified' herein, without any right or claim to reimbursement,
compensation, or remuneration of any kind. Notwithstanding the foregoing, either party
may terminate this agreement with ninety (90) days' notice to the other party in writing.
4. Payment for Concession. Concessionaire shall pay to City 0/6' of its monthly gross
receipts from the concession privileges granted by this agreement as described in
Section 1.
Concessionaire shall make payment to the City for each calendar month of operation,
said payment being due and payable no later than the tenth (101h) of the following,
accompanied by a signed and certified written report for the prior calendar month period
of all Gross Receipts for such period in a form reasonably approved by the City. All
payments shall be paid or delivered to:
City of Kent Finance Department
Customer Services Division
220 Fourth Avenue South
Kent, WA 98032-5895
In addition, a copy of the written report shall be delivered to the City of Kent Parks
Department at the above noted address by the tenth (10'h) of each month.
If any payment due under this Agreement is, not paid to the City within ten (10) days
after the date specified, a one-time late charge of five percent (5%) of the payment due
shall be added to the payment as a penalty, and the total sum shall become immediately
due and payable. Any amount remaining unpaid by the first day of the month following
the due date for payment (i.e. approximately 20 days late) shall bear interest at the rate
of one percent (1%) per month.
The Concessionaire shall maintain records respecting that activity which truly,
completely, and accurately disclose all information necessary to determine the
Concessionaire's rent liability hereunder during each reporting period. Such records
shall be kept and maintained for a period of not less than three (3) years.
All books, records, and other items required to be kept and maintained under this
section shall be subject to, and immediately made available for inspection and audit at
any time, with or without notice, at the place where such records are kept upon the
demand of the finance director or his or her designee.
Any amount due and unpaid under this Agreement and all penalties, service charges,
or fees shall constitute a debt to the city. The city may, pursuant to Chapter 19.16
RCW, use a collection agency to collect outstanding debts, or it may seek collection by
court proceedings, which remedies shall be in addition to all other existing remedies.
5. Rules Governing Concession Operation. Concessionaire agrees to comply with the
following provisions. Violation of any of these provisions, in City's sole discretion shall
constitute cause to terminate the agreement with ten (10) days' notice pursuant to
Section 3 Termination of Agreement:
a. The location of Concessionaire's point(s) of sale, methods of sale, and prices
charged for commodities sold under this agreement are subject to the supervision,
direction and approval of the City. The City expressly reserves the right to make
rules, regulations and requirements relating to the management of any and all of
the locations operated by the Concessionaire under this agreement, including the
regulation and prices at which commodities handled or dispensed by the
Concessionaire shall be sold to the public.
b. Concessionaire shall pay a $200.00 cleaning deposit fee to the City. The cleaning
deposit fee will be returned to Concessionaire within 14 days of termination of this
agreement, provided Concessionaire cleans the concession area to the satisfaction
of the City. Any cleaning or waste disposal deemed necessary to be performed by
the City will be at Concessionaire's sole expense. Concessionaire will be required
to timely reimburse the City for any cleaning or disposal expense it incurs, and the
City may retain Concessionaire's cleaning deposit to offset any such expense.
c. Concessionaire shall not establish any point of sale that interferes with on-field
events or spectator viewing of events.
d. Concessionaire shall furnish all necessary equipment to store, prepare, cook and
hold all items of a perishable nature in accordance with King County Health
Department rules and regulations.
Page 2
e. Concessionaire shall not permit any lewd or immoral conduct in or about the
concession area. All persons working in the concession area shall present a neat
and clean appearance.
f. Concessionaire shall keep the general area around the designated point of sale
clean; i.e., keep all bottles, cans, papers and refuse picked up from the area. Upon
any failure to do so, after written notice by the City, the City reserves the right to
clean the area and charge labor costs to the Concessionaire.
g. Concessionaire shall permit any authorized officer or employee of the City to have
free access to the concession area at any and all times to ensure compliance with
the agreement.
h. Concessionaire shall not serve, handle or otherwise possess or store alcoholic
beverages or tobacco products of any kind in the concession area.
i. A radio or musical device for entertainment may be used by the Concessionaire in
the point of sale area; provided, however, that any radio or musical device shall be
operated at reduced volume so it cannot be heard at a distance of more than 100
feet from the concession area.
j. All deliveries of merchandise shall be made at a time so as not to disrupt scheduled
activities.
k. Concessionaire shall devote as much time to this concession as may be necessary
to provide first-class service to the patrons. Concessionaire shall be open for
business seven days per week, while scheduled activities are in progress. All
closures, regardless of the circumstances, must be approved by the City; provided,
however, that approval shall not be required when any scheduled event has been
canceled due to any local, state, or national disaster or force of nature.
I. Calling out of wares shall be done in such a manner so as to not interfere with the
scheduled event in progress, and no unnecessary loud noises will be permitted. No
advertisement, sign, notice, poster or other advertising of any kind or character
whatsoever shall be placed, affixed, distributed and/or used in the concession area
without prior approval of the City.
6. Independent Contractor. The parties intend that an Independent Contractor-
Employer Relationship will be created by this agreement. By their execution of this
agreement, and in accordance with Chapter 51.08 RCW, the parties make the following
representations:
a. Concessionaire has the ability to control and direct the performance and details of
its work, the City being interested only in the results obtained under this
agreement.
b. Concessionaire has an established and independent business that is eligible for a
business deduction for federal income tax purposes that existed before the City
retained Concessionaire's services and is a service other than that furnished by the
City, or Concessionaire is engaged in an independently established trade,
occupation, profession, or business of the same nature as that involved under this
agreement.
c. Concessionaire is responsible for filing as they become due all necessary tax
documents with appropriate federal and state agencies, including the Internal
Revenue Service and the state Department of Revenue.
Page 3
r
d. Concessionaire has registered its business and established an account with the state
Department of Revenue and other state agencies as may be required by
Concessionaire's business, and has obtained a Unified Business Identifier (UBI)
number from the State of Washington.
e. Concessionaire has a valid contractor registration pursuant to Chapter 18.27 RCW
or an electrical contractor license pursuant to Chapter 19.28 RCW.
f. Concessionaire maintains a set of books dedicated to the expenses and earnings of
its business.
7. Indemnification. Concessionaire agrees to indemnify, defend and hold the City, its
officers, officials, employees, agents and volunteers harmless from any and all claims,
injuries, damages, losses or suits, including all legal costs and attorney fees, arising out
of or in connection with Concessionaire's performance of this agreement, except for that
portion of injuries and damages caused by the City's negligence.
IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE
INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE CONTRACTOR'S WAIVER OF
IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE
PURPOSES OF THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT
THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER.
In the event Contractor refuses tender of defense in any suit or any claim, if that tender
was made pursuant to this indemnification clause, and if that refusal is subsequently
determined by a court having jurisdiction (or other agreed tribunal) to have been a
wrongful refusal on the Contractor's part, then Contractor shall pay all the City's costs for
defense, including all reasonable expert witness fess and reasonable attorneys' fees, plus
the City's legal costs and fees incurred because there was a wrongful refusal on the
Contractor's part.
The provisions of this section shall survive the expiration or termination of this
Agreement.
8. Discrimination. In the hiring of employees for the performance of work under this
agreement or any sub-contract, Concessionaire, its sub-contractors, or any person acting
on behalf of Concessionaire or its sub-contractor shall not, by reason of race, religion,
color, sex, age, sexual orientation, national origin or the presence of any sensory, mental
or physical disability, discriminate against any person who is qualified and available to
perform the work to which the employment relates.
Concessionaire shall execute the attached City of Kent Equal Employment Opportunity
Policy Declaration, Comply with City Administrative Policy 1.2, and upon completion of
this agreement, file the attached Compliance Statement.
9. Permits and Insurance. It shall be the responsibility of the Concessionaire to obtain
all food handling permits as required by the King County Health Department.
Concessionaire shall obtain a comprehensive liability insurance policy with limits of not
less than $1,000,000 for bodily injury, and $1,000,000 property damage and shall have
a certificate of insurance issued to the CITY OF KENT naming the City as an additional
insured. Such certificate shall cover all activities of the Concessionaire with respect to
this agreement. The CITY OF KENT shall be provided with thirty (30) days notice prior to
termination of such coverage by the insurer.
Page 4
10. Taxes, Fees and Permits. The Concessionaire shall obtain and at all times maintain a
current City of Kent business license. The Concessionaire shall promptly pay all taxes
and fees for its operations to the appropriate collecting agencies. These taxes and fees
include, but are not limited to, sales tax and any other taxes imposed by governmental
agencies pertaining to the Concessionaire's operations under this Agreement.
11. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City
requires its contractors and consultants to use recycled and recyclable products
whenever practicable. A price preference may be available for any designated recycled
product.
12. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any
of the covenants and agreements contained in this agreement, or to exercise any option
conferred by this agreement in one or more instances shall not be construed to be a
waiver or relinquishment of those covenants, agreements or options, and the same shall
be and remain in full force and effect.
13. Resolution of Disputes and Governing Law. This Agreement shall be governed by
and construed in accordance with the laws of the State of Washington. If the parties are
unable to settle any dispute, difference or claim arising from the parties' performance of
this agreement, the exclusive means of resolving that dispute, difference or claim shall
only be by filing suit exclusively under the venue, rules and jurisdiction of the King
County Superior Court, King County, Washington, unless the parties agree in writing to
an alternate dispute resolution process. In any claim or lawsuit for damages arising from
the parties' performance of this agreement, each party shall pay all its legal costs and
attorney's fees incurred in defending or bringing such claim or lawsuit, including all
appeals, in addition to any other recovery or award provided by law; provided, however,
nothing in this paragraph shall be construed to limited the City's right to indemnification
under Section 7 of this agreement.
14. Written Notice. All communications regarding this Agreement shall be sent to the
parties at the addresses listed on the signature page of the agreement, unless notified to
the contrary. Any written notice hereunder shall be effective three (3) business days
after the date of mailing by registered or certified mail, and shall be deemed sufficiently
given if sent to the addressee at the address stated in this agreement or such other
address as may be hereafter specified in writing.
15. Assignment. Any assignment of this agreement by either party without the written
consent of the non-assigning party shall be void. If the non-assigning party gives its
consent to any assignment, the terms of this agreement shall continue in full force and
effect and no further assignment shall be made without additional written consent.
16. Modification. No waiver, alteration or modification of any of the provisions of this
agreement shall be binding unless in writing and signed by a duly authorized
representative of the City and Concessionaire.
17. Entire Agreement. The written provisions and terms of this agreement, together with
any exhibits attached hereto shall supersede all prior verbal statements of any officer or
other representative of the City, and such statements shall not be effective or be
construed as entering into or forming a part of or altering in any manner this agreement.
All of the above documents are hereby made a part of this agreement. However, should
any language in any of the exhibits to this agreement conflict with any language
contained in this agreement, the terms of this agreement shall prevail.
Page 5
18. Compliance with Laws. Concessionaire agrees to comply with all federal, state and
municipal laws, rules and regulations that are now effective or in the future become
applicable to Concessionaire's business, equipment and' personnel engaged in operations
covered by this agreement or accruing out of the performance of those operations.
19. Counterparts. This agreement may be executed in any number of counterparts, each
of which shall constitute an original, and all of which will together constitute this
Agreement.
This agreement shall become effective on the last date entered below.
CONCESSIONAIRE CITY OF KENT
B By: Lori Hoga
I Its: Parks Superi end t
-
D)Mate. ,,' Date, q 2-
Notices to be sent to Concessionaire: Notices, to be sent to the City:
Address: Address:
Willie D. Drinker City of Kent Parks, Recreation &
22803 915t Way S. Apt. E203 Community Services
Kent, WA 98031 Attn: Lori Hogan, Parks Superintendent
220 4 th Avenue South
Kent, WA 98032
Page 6
. .
DECLARATION
CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY
The City of Kent is committed to conform to Federal' and State laws rega!rding equal
opportunity. As such all contractors, subcontractors and suppliers who perform work with
relation to this agreement shall comply with the regulations of the Oty's equal employment
opportunity policies.
The following questions specifically identify the naqu|narnemts the City deems necessary for any
contractor, subcontractor ur supplier on this specific Agreement to adhere to. An affirmative
response is required on all of the following questions for this Agreement to be valid and
binding. If any contractor, subcontractor or supplier willfully misrepresents themselves with
regard to the directives outlined, it will be considered a breach of contract and it will be at the
City'sso|e determination regarding suspension or termination for all or part uf the Agreement;
The questions are as follows:
1. I have read the attached City of Kent administrative policy number 1.2.
2. [)odng the time of this Agreement I will not discriminate in employment on the basis of
sex, race, color, national origin, age, or the presence of all sensory, mental or physical
disability.
3. During the time of this Agreement the prime contractor will provide a vvhttom statement
to all new employees and subcontractors indicating commitment as an equal
opportunity employer.
4. During the time of the Agreement I, the prime contractor, will actively consider hiring
and promotion of women and minorities.
5. Before acceptemoa of this Agreement, an adherence statement will be signed by me,
the PMrnp Contractor, that the Prime Contractor complied with the requirements as set
forth above.
By signing below, I agree tofulfill the five raqu|marneo1s referenced above.
;Dated h| , �Q. .
CITY OF KENT
ADMINISTRATIVE POLICY
NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998
SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996
CONTRACTORS APPROVED BY Jim White, Mayor
POLICY:
Equal employment opportunity requirements for the City of Kent will conform to federal and
state laws. All contractors, subcontractors, consultants and suppliers of the City must
guarantee equal employment opportunity within their organization and, if holding Agreements
with the City amounting to $10,000 or more within any given year, must take the following
affirmative steps:
1. Provide a written statement to all new employees and subcontractors indicating
commitment as an equal opportunity employer.
2. Actively consider for promotion and advancement available minorities and women.
Any contractor, subcontractor, consultant or supplier who willfully disregards the City's
nondiscrimination and equal opportunity requirements shall be considered in breach of contract
and subject to suspension or termination for all or part of the Agreement.
Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public
Works Departments to assume the following duties for their respective departments.
1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these
regulations are familiar with the regulations and the City's equal employment
opportunity policy.
2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines.
Page 8
CITY OF KENT
EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT
This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded
the Agreement.
I, the undersigned, a duly represented agent of
Company, hereby acknowledge and declare that the before-mentioned company was the prime
contractor for the Agreement known as that was entered
into on the (date), between the firm I represent and the City
of Kent.
I declare that I complied fully with all of the requirements and obligations as outlined in the
City of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment
Opportunity Policy that was part of the before-mentioned Agreement.
Dated this day of 20
By
For: Ate-
V I
Title:
Date: YA?
Page 9
CERTIFICATE OF LIABILITY INSURANCE DATE(MMMvA*YY)
_ _ 0413M16
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXPEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
IEPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the po[lcy(les)must have ADDITIONAL INSURED provisions or be epdorsed.
If SUBROGATION IS WAIVED,subject to the tame 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 endorsemen s.
PRODUCER N ul KELLI CLAWSON
Stateftm CRAIG ROMNEY I'MO 253-859-0810 F No
24266104TH AVE SE &MAIL
e KENT WA 98030
INSU S AFFORDING COVERAGE NAIL#
INSURER A: State Farm Fire and Casualty Company 25143
INSURED
INSURER B•
WILLIE DRINKER INSU 0:
22803 91 ST WAYS APT E203 NOUR D:
KENT, WA 98031 INSURER E.
INS ER F:
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,
ILTR NSR I TYPE OF INSURANCE POLICY EFF POLICY p
POUCYNUMBER MUM LIMITS
COMMERCIAL GENERAL LIANLITY EACH CURRENCE S 1.000,000
CLAIMS-MADE OCCUR D GETORENTED $ 3001000
MED EXP ft ono Demon) S 5,000
98-SX-C221.8 04/1%2016 041132017` PERsoNALBADvwuRY a 1.000.000
61=ML AGGREGATE L.WAPPLIES PER GENEM A13OREGATE $ 2,000,000
POLICY❑jpeT LOC
PRODUCTS-CONfPlOP AGG $
OTHER; S
AUTOMOMLE LIABILITY COMB112
D S NGLE LOMrr $
ANY AUTO BODILY INJURY(Per poreon) S
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Peraeeiderd) S
HIRED NOWOVMED PRO
PE DAMAGE
AUTOS ONLY AUTOS ONLY Pcr2rMl ft $
B
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESSU" HCLAIM54AADE AGGREGATE $
DFO I I RETENTIONS $
WORKERS COMPENSATION J PER
AND EMPLOYERS'UABIUTY
ANY FROPRIETORlPARTNERI>�CUrIVE YIN E.L,EACH ACCIDENT S
OFROC IMEMSER EXCLUDED. NIA
If(Mandatory ndbe NH)and E.L.DISEASE-EA gmpLOY S
If Yee.deaCl6e under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPEERATIONS I LOCATIONS I VEHICLES(ACORD 101.AddMonal Remwi(a SChedule,maybe attached If m rc space 1&required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
hT ACCORD CE WITH THE POLICY PROVISIONS.
525 4V KW N.
._ ra-
REPM T1VEI(w[ WA-98032
® -20 S ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registe ed marks of ACORD e
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