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PW16-244 - Original - Integra Realty Resources - S 228th St UPRR Grade Separation - 06/13/2016
rd s M an'a'-, 0 v KENT ( CCIIInn Wj.SHIWC'f GY kl ' CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerks Office. All portions are to be completed. If you have questions, please contact City Clerk's Office. Vendor Name: Integra Realty Resources Vendor Number: ID Edwards Number Contract Number: ' This is assigned by City Clerk's Officd Project Name S. 228Lh St. UPRR Grade Separation Description: 0 Interlocal Agreement El Change Order ❑ Amendment Contract El Other. Contract Effective bate: 6/13116 Termination Date: 12/31/16 Contract Renewal Notice (Days) Number of days required notice for termination or renewal or amendment Contract Manager: Ingrid Willms-Dixon Department: Engineering Contract Amount: 115,050.00 Approval Authority: (CIRCLE ONE) Department Director Mayor City Council Detail: (i.e. address, location, parcel num er, ax i , etc.): Provide valuation services for the project, As of: 08/27/14 KENT 00. PROFESSIONAL SERVICES AGREEMENT between the City of Kent and Integra Realty Resources THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation (hereinafter the "City"), and Integra Realty Resources organized under the laws of the State of Washington, located and doing business at 600 University St., Suite 310, Seattle, WA 98101, Phone: (206) 903-6700/Fax: (206) 623-5731, Contact: Lori Safer (hereinafter the "Contractor"). I. DESCRIPTION OF WORK. Contractor shall perform the following services for the City: The Contractor shall provide valuation services for the S. 228`h St. UPRR Grade Separation project. For a description, see the Contractor's Scope of Work which is attached as Exhibit A and incorporated by this reference. Contractor further represents that the services furnished under this Agreement will be performed in accordance with generally accepted professional practices within the Puget Sound region in effect at the time those services are performed. II. TIME OF COMPLETION. The parties agree that work will begin on the tasks described in Section I above immediately upon the effective date of this Agreement, and Contractor shall complete the work by December 31, 2016. III. COMPENSATION. The City shall pay Contractor a total amount not to exceed Fifteen Thousand, Fifty Dollars ($15,050.00) for the services described in this Agreement. The Contractor shall invoice the City monthly based on time and materials incurred during the preceding month. The hourly rates charged for Contractor's services shall be as delineated in the attached and incorporated Exhibit A. All hourly rates charged shall remain locked at the negotiated rates throughout the term of this Agreement. IV. 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 Ch. 51.08 RCW, the parties make the following representations: A. The Contractor 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. The Contractor maintains and pays for its own place of business from which Contractor's services under this Agreement will be performed. C. The Contractor has an established and independent business that is eligible for a business deduction for federal income tax purposes that existed before the City retained Contractor's services, or the Contractor is engaged in an independently established trade, occupation, profession, or business of the same nature as that involved under this Agreement. D. The Contractor 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. PROFESSIONAL SERVICES AGREEMENT - 1 ($20,000 or Less) T •1 E. The Contractor has registered its business and established an account with the state Department of Revenue and other state agencies as may be required by Contractor's business, and has obtained a Unified Business Identifier (UBI) number from the State of Washington. F. The Contractor maintains a set of books dedicated to the expenses and earnings of its business. V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party seven (7) calendar days written notice at its address set forth on the signature block of this Agreement. VI. DISCRIMINATION. In the hiring of employees for the performance of work under this Agreement or any subcontract, the Contractor, its subcontractors, or any person acting on behalf of the Contractor or subcontractor shall not discriminate against any person who is qualified and available to perform the work to which the employment relates as provided for by the City of Kent's Equal Employment Opportunity Policy. Contractor shall execute the attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement. VII. INDEMNIFICATION. Contractor shall defend, indemnify 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 the Contractor's performance of this Agreement, except for that portion of the injuries and damages caused by the City's negligence. The City's inspection or acceptance of any of Contractor's work when completed shall not be grounds to avoid any of these covenants of indemnification. The provisions of this section shall survive the expiration or termination of this Agreement. 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 fees and reasonable attorneys' fees, plus the City's legal costs and fees incurred because there was a wrongful refusal on the Contractor's part. VIII. INSURANCE. The Contractor shall procure and maintain for the duration of the Agreement, insurance of the types and in the amounts described in Exhibit B attached and incorporated by this reference. IX. CONTRACTOR'S WORK AND RISK. The Contractor agrees to comply with all federal, state, and municipal laws, rules, and regulations that are now effective or in the future become applicable to Contractor's business, equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance of those services. All work shall be done at Contractor's own risk, and Contractor shall be responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. X. MISCELLANEOUS PROVISIONS. A. 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. B. 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. PROFESSIONAL SERVICES AGREEMENT - 2 ($20,000 or Less) C. 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 alternative 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 limit the City's right to indemnification under Section VII of this Agreement. D. 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 become 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. E. Assignment. Any assignment of this Agreement by either party without the written consent of the non-assigning party shall be void. F. 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 Contractor. G. 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. 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. H. Public Records Act. The Contractor acknowledges that the City is a public agency subject to the Public Records Act codified in Chapter 42.56 of the Revised Code of Washington and documents, notes, emails, and other records prepared or gathered by the Contractor in its performance of this Agreement may be subject to public review and disclosure, even if those records are not produced to or possessed by the City of Kent. As such, the Contractor agrees to cooperate fully with the City in satisfying the City's duties and obligations under the Public Records Act. I. City Business License Required. Prior to commencing the tasks described in Section I, Contractor agrees to provide proof of a current city of Kent business license pursuant to Chapter 5.01 of the Kent City Code. PROFESSIONAL SERVICES AGREEMENT - 3 ($20,000 or Less) J. Counterparts and Signatures by Fax or Email. 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 one Agreement. Further, upon executing this Agreement, either party may deliver the signature page to the other by fax or email and that signature shall have the same force and effect as if the Agreement bearing the original signature was received in person. IN WITNESS, the parties below execute this Agreement, which shall become effective on the last date entered below. CONTRACTOR: CITY OF KENT: By:— By: '—�(signature�_ s nr ure Print Name: Print Name: T-imohy J. LaPorte, P.E. Its: 'It\ Its: Public Works Director DATE: DATE: NOTICES TO BE SENT TO: NOTICES TO BE SENT TO: CONTRACTOR: CITY OF KENT: Lori Safer Timothy J, LaPorte, P.E. Integra Realty Resources City of Kent 600 University St., Suite 310 220 Fourth Avenue South Seattle, WA 98101 Kent, WA 98032 (206) 903-6700 (telephone) (253) 856-5500 (telephone) (206) 623-5731 (facsimile) (253) 856-6500 (facsimile) PROFESSIONAL SERVICES AGREEMENT - 4 ($20,000 or Less) DECLARATION CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. As such all contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with the regulations of the City's equal employment opportunity policies. The following questions specifically identify the requirements the City deems necessary for any contractor, subcontractor or 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 outlines, it will be considered a breach of contract and it will be at the City's sole determination regarding suspension or termination for all or part of the Agreement; The questions are as follows: 1. 1 have read the attached City of Kent administrative policy number 1.2. 2. During 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 written 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 acceptance of this Agreement, an adherence statement will be signed by me, the Prime Contractor, that the Prime Contractor complied with the requirements as set forth above. By signing below, I agree to fulfill the five requirements referenced above. Dated this day of 7 20 By: For: Title: M dz"Pa ,j Date: EEO COMPLIANCE DOCUMENTS - 1 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. EEO COMPLIANCE DOCUMENTS - 2 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: Title: Date: EEO COMPLIANCE DOCUMENTS - 3 EXHIBIT A Integra Realty Resources. 600 University Street T 206.901.6700 Seattle Suite 310 F 206.623.5731 Seattle,WA 98101 www.irr.com ti'm!-, May 26, 2016 Ingrid Willms-Dixon, RWA Project Analyst City of Kent Public Works Engineering 400 West Gowe Kent, WA 98032-5895 SUBJECT: Proposal for Valuation Services 228th Street UPRR Grade Separation Project Dear Ms, Willms-Mixon: Integra Realty Resources—Seattle appreciates the opportunity to provide this proposal for valuation services for the above-captioned project, It is my understanding that the project will involve temporary construction easements and/or permanent sewer easements for five parcels located on Borth 4th Avenue,south of'South 228th Street. We will provide short forma appraisal reports in compliance with current WSDOT standards.Our fee for this assignment is shown in the following table. Parcels,Proposed Acquisition and Appraisal Fee Siteshre File Number Tax ID Number Owner Name Land Use Proposed A IVISWdn 51F Year Bit.APPrakai Fite PW2015-0131 383090-0220 Ingera/PGO croup t1C Industrial TC:E $1,78$ 2979 $2,950 PW2015-032 383090•0250 Interstate industries/Elstrom Estate Industrial TCE 47,700 1979 $2,950 PW20E.5-D34 383090.0210 YalleyMathine.Shop,Inc. Industrial TCEand/or Perm S;wrFz 60,010 1989 $2,950 PW2015-D3S 38308P0260 IDAdltive°rmaxlnvestmcnts,Int. Industrial TCE and/or Perm Swr Ez 54,098 1991 $2,950 PWIDIS-030 383090-0230 P'ietramanato Family Trust SlnPitFam}.lyTCB and Perri SwrE?. 103,205 1979 $3,,250 Total $25 050 The appraisal and reports will be prepared In conformance with and subject to,the Code of Professional Ethics and Standards of Professional Appraisal Practice of the Appraisal institute and the Uniform.Standards of Professional Appraisal Practice(USPAP)developed by the Appraisal Standards Board of the Appraisal Foundation.The Ethics Rule of USPAP requires us to disclose to you any prior services we have performed regarding the subject property within a three year period immediately preceding the acceptance of this assignment, either as an City of Kent May 26,2016 Page 2 appraiser or in any other capacity.We represent that we have not performed any services that require disclosure under this rule. We will submit an electronic copy of the report via our FRP site for initial review and we will work with the reviewer to provide additional information or make corrections as specified by the reviewer.Two hard copies of the reports will be provided; additional copies of the report(s) are available at an additional cost. The current minimum cost for each additional copy is$100 per copy. The report(s)will be completed and delivered to you within 30 days for each property once we are authorized to begin the appraisal of each parcel. In order to complete this assignment in the designated time,we will need access to pertinent documents,materials,facilities and or/personnel.Any delays in the receipt of this information or in the access to the property will automatically extend the final delivery date of the report(s) as proposed. Furthermore,the appraisal report and conclusions therein will be predicated upon the accuracy and completeness of the information provided by the Client. In the absence of some of this information,the appraisers will attempt to obtain this information from other sources and/or may require the use of Extraordinary Limiting Conditions and Assumptions within the appraisal report. Please let me know if you have any questions about this response. I look forward to your favorable consideration. Sincerely, INTEGRA REALTY RESOURCES—SEATTLE Lori Safer,MAI, MRICS Managing Director EXHIBIT B INSURANCE REQUIREMENTS FOR CONSULTANT SERVICES AGREEMENTS Insurance The Consultant shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which may arise from or in connection with the performance of the work hereunder by the Consultant, their agents, representatives, employees or subcontractors. A. Minimum Scope of Insurance Consultant shall obtain insurance of the types described below: 1. Automobile Liability insurance covering all owned, non-owned, hired and leased vehicles. Coverage shall be written on Insurance Services Office (ISO) form CA 00 01 or a substitute form providing equivalent liability coverage. If necessary, the policy shall be endorsed to provide contractual liability coverage. 2. Commercial General Liability insurance shall be written on ISO occurrence form CG 00 01 and shall cover liability arising from premises, operations, independent contractors, products-completed operations, personal injury and advertising injury, and liability assumed under an insured contract. The City shall be named as an insured under the Consultant's Commercial General Liability insurance policy with respect to the work performed for the City using ISO additional insured endorsement CG 20 10 11 85 or a substitute endorsement providing equivalent coverage. 3. Workers' Compensation coverage as required by the Industrial Insurance laws of the State of Washington. 4. Professional Liability insurance appropriate to the Consultant's profession. B. Minimum Amounts of Insurance Consultant shall maintain the following insurance limits: 1. Automobile Liability insurance with a minimum combined single limit for bodily injury and property damage of $1,000,000 per accident. 2. Commercial General Liability insurance shall be written with limits no less than $1,000,000 each occurrence, $2,000,000 general aggregate and a $1,000,000 products-completed operations aggregate limit. EXHIBIT B (Continued) 3. Professional Liability insurance shall be written with limits no less than $1,000,000 per claim and $1,000,000 policy aggregate limit. C. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following provisions for Automobile Liability and Commercial General Liability insurance: 1. The Consultant's insurance coverage shall be primary insurance as respect the City. Any Insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the Consultant's insurance and shall not contribute with it. 2. The Consultant's insurance shall be endorsed to state that coverage shall not be cancelled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. 3. The City of Kent shall be named as an additional insured on all policies (except Professional Liability) as respects work performed by or on behalf of the Consultant and a copy of the endorsement naming the City as additional insured shall be attached to the Certificate of Insurance. The City reserves the right to receive a certified copy of all required insurance policies. The Consultant's Commercial General Liability insurance shall also contain a clause stating that coverage shall apply separately to each insured against whom claim is made or suit is brought, except with respects to the limits of the insurer's liability. D. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M. Best rating of not less than ANII. E. Verification of Coverage Consultant shall furnish the City with original certificates and a copy of the amendatory endorsements, including but not necessarily limited to the additional insured endorsement, evidencing the insurance requirements of the Contractor before commencement of the work. F. Subcontractors Consultant shall include all subcontractors as insureds under its policies or shall furnish separate certificates and endorsements for each subcontractor. All coverages for subcontractors shall be subject to all of the same insurance requirements as stated herein for the Consultant. DATE(MWDD/YYYY) ACC>RV® CERTIFICATE OF LIABILITY INSURANCE 3/11/2016 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 be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CON AMTAE:CT Carrie Ovrid Conover Insurance PHONE (425)455-5000 1 FAAX o.(425)454-5550 XtI,155 108th Avenue NE, Suite 725 -MattDDRES carrieo@conoverinsurance.com P.O. BOX 90007 INSURERS AFFORDING COVERAGE NAIC$0 Bellevue WA 98004 INSURERAMutual of Enumclaw Insurance 14761 INSURED INSURER B: Integra Washington, Inc., DBA: Integra Realty INSURERC: 600 University Street INSURERD: Suite 310 INSURERE: Seattle WA 98101 INSURERF: COVERAGES CERTIFICATE NUMBER:16-17 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL UBR POLICY NUMBER MM/DOmW MWDDNYri LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED A CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 100,000 X BOP000138305 3/14/2016 3/14/2017 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,ODD X POLICY PECTRO LOC PRODUCTS-COMP/OPAGG $ 2,000,000 J OTHER $ AUTOMOBILE LIABILITY CED Ea OMaccidBINent SINGLE LIMIT $ 2,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BOP000130305 3/14/2016 3/14/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS X NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ X UMCOOOD555 3/14/2016 3/14/2017 $ ER WORKERS COMPENSATION STATUTE X ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ NIA WA Stop Gap E.L.EACH ACCIDENT S 2,000,000 OFFICER/MEMBER EXCLUDED? A (Mandatory In NMI BOP000138305 3/14/2016 3/14/2017 E.L.DISEASE-EA EMPLOYEE $ 2,000,000 If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 21000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 11 more space Is required) City of Kent are included as Additional Insureds per form BP 04 48 07 13 attached. Umbrella policy is following form over the GL and Auto. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Kent THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 220 Fourth Avenue South ACCORDANCE WITH THE POLICY PROVISIONS. Kent, WA 98032 AUTHORIZED REPRESENTATIVE Deanna Wilson/CRUDEN ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(9nun1i POLICY NUMBER: BOP 0001383 05 BUSINESSOWNERS BP 04 48 07 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organizations : CITY OF KENT Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Section II—Liability is amended as follows: B. With respect to the insurance afforded to these A. The following is added to Paragraph C.Who Is An additional insureds, the following is added to Insured: Paragraph D. Liability And Medical Expenses Limits Of Insurance: 3. Any person(s) or organization(s) shown in the Schedule is also an additional insured, but only If coverage provided to the additional insured is with respect to liability for "bodily injury", required by a contract or agreement, the most we will pay on behalf of the additional insured is the "property damage"or"personal and advertising amount of insurance: injury"caused, in whole or in part, by your acts or omissions or the acts or omissions of those 1. Required by the contract or agreement; or acting on your behalf in the performance of 2. Available under the applicable Limits Of your ongoing operations or in connection with Insurance shown in the Declarations; your premises owned by or rented to you. whichever is less. However: This endorsement shall not increase the a. The insurance afforded to such additional applicable Limits Of Insurance shown in the insured only applies to the extent permitted Declarations. by law; and b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. BP 04 48 07 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 PASSE 1 MAIL MCH-M-I Y1392 MARCH 29, 2016 USAA® AUTOMOBILE POLICY PACKET ALLEN N SAFER 5221 PULLMAN AVE NE SEATTLE WA 98105-2139 USAA 00140 78 56 7102 2 POLICY PERIOD: EFFECTIVE MAY 01 2016 TO NOV 01 2016 IMPORTANT MESSAGES Refer to your Declarations Page and endorsements to verify that coverages, limits, deductibles and other policy details are correct and meet your insurance needs. Required information forms are also enclosed for your review. Your Underinsured Motorists Coverage (UIM) and Underinsured Motorists Property Damage (UIMPD) selection/rejection remains in effect You may quote different coverage limits and make changes at any time to your policy on usaa.com. Or you may call us at 1-800-531-USAA (8722). TEXTING & DRIVING ... It Can Wait! Join USAA in the movement against distracted driving by going to http://itcanwait.usaa.com to watch powerful videos and take the pledge to not text and drive! Coverage exclusions apply when your vehicle is used in ride sharing. If you need coverage for ride sharing activities, we're pleased to offer Ride Share Gap Protection. Please contact us for more information or to obtain a quote. USAA considers many factors when determining your premium. Maintaining safe driving habits is one of the most important steps you can take in keeping your premium as low as possible. A history of claim or driving activity and your USAA payment history may affect your policy premium. We have provided your ID cards in this packet. You can use the cards to show proof of insurance, if necessary. This is not a bill. Any premium charge or change for this policy will be reflected on your next regular monthly statement. Your current billing statement should still be paid by the due date indicated. To receive this document and others electronically, or manage your Auto Policy online, go to usaa.com. For U.S. calls: Policy Service (800) 531-81 1 1. Claims (800) 531-8222. ACS1 49708-0406 • PAGE 2 THIS PAGE INTENTIONALLY LEFT BLANK PAGE 3 WASHINGTON INSURANCE IDENTIFICATION CARD i WASHINGTON INSURANCE IDENTIFICATION CARD UNnm SERVICES AUTOMOBILE ASSN UNITED SERVICES AUTOMOBILE ASSN NAME OF INSURED LORI E SAFER NAME OF INSURED ALLEN N SAFER INTEGRA WASHINGTON INC i MARTIN T SAFER POLICYNUMBER 00140 78 56U 7102 2 POLICYNUMBER 00140 78 56U 7102 2 EFFECTiVEDATE 05/01/16 EXPIRATIONDATE 11/01/16 EFFECPVEDATE 05/01/16 EXPIRATIONDATE 11/01/16 VEHICLE DESCRIPTION i VEHICLE DESCRIPTION YEAR MAKE/MODEL i YEAR MAK¢MODEL 2010 TOYOTA FRIUS HYB 4D 2006 SUBARU OUTI3ACK VEHICLE IDENTIFICATION NUMBER VEHICLE IDENTIFICATION NUMBER JTD)N13DU8A0041891 i 4S4BP61C367319002 9800 Fredericksburg Road San Antonio,Texas 78288 i 9800 Fredericksburg Road San Antonio,Texas 78288 Additional copies available at usaa,com Additional copies available at usaa.com CONTACT US: 210-531-USAA(8722) I CONTACT US: 210-531-USAA(8722) OR 800-531-USAA OR 800-531-USAA i -- - -- - -- - - -- - - -- - -- - --- - --- - -- - - -- - - - - - - -- - - -- - - - - - - - - - - -- - - -- - - --- - --- - - - --- 03/29/16 Automobile Insurance Identification Card We've issued an identification card as evidence of liability insurance for your vehicle(s). This card is valid only as long as liability insurance remains in force. You may be required to produce your identification card at vehicle registration or inspection, when applying for a driver's license, following an accident or upon a law enforcement officer's request Keep a copy of the ID card in your vehicle at all times. For your convenience, additional copies are available on usaa.com. 53WA3 Rev. 6-13 55084-0513_01 --- - -- - --- - --- - - -- - --- - - -- - -- - - -- - - --- WASHINGTON INSURANCE IDENTIFICATION CARD i UNITED SERVICES AUTOMOBILE ASSN NAME OF INSURED ALLEN N SAFE � LORI E SAFER POLICYNUMBER 00140 78 56U 7102 2 EFFECTIVE DATE 05/01/16 EXPIRATIONDATE 11/01/16 i VEHICLE DESCRIPTION YEAR MAKEIMODEI i 2008 SUE ARLI B9 TRIBECA VEHICLE IDENTIFICATION NUMBER i 4S4WX90D584411357 9800 Fredericksburg Road San Antonio,Texas 78288 i i Additional copies available at usaa,com CONTACT US: 210-531-USAA(8722) i OR 800-531-USAA i PPGE 4 UNITED SERVICES AUTOMOBILE ASSOCIATIONADDL INFO ON NEXT PAGE MAIL MCH-M-I � RENEWAL OF �® (A RECIPROCAL INTERINSURANCE EXCHANGE) State 13 14 15 veh PCLICY NUMBIER USA 9800 Fredericksburg Road-San Antonio,Texas 78288 WA P62P6 2 2 6 2 Ter 00140 78 5 6 U 7102 2 WASHINGTON AUTO POLICY POLICYPFRIOD: (12:01 A.M. standard time) RENEWAL DECLARATIONS EFFECTIVE MAY 01 2016 TO NOV 01 2016 ATTACH TO PREVIOUS POLICY) OPERATORS Named Insured and Address 01 ALLEN N SAFER 04 LORI E SAFER 08 MARTIN T SAFER ALLEN N SAFER 5221 PULLMAN AVE NE SEATTLE WA 98105-2139 Description of Vehicle(,$) VEH USE' VEH YEAF TRADE NAME MODEL BODYTYPE ANNUAL IDEN nRCATION NUMBER SYM es 13 10 TOYOTA PRIUS HYB 4D 4 DOOR 10000 JTDKN3DU8A0041891 P 14 06 SUBARU OUTBACK SW 6000 4S413P61C367319002 P 15 08 SUBARU B9 TRIBECA 4 DOOR 6000 4S4WX90D584411357 P The Vehicle(s)described herein is principally garaged at the above address unless otherwise stated. w�wo*rs�r,00l:tee ;FFamP=PIeasure VEH 13 SEATTLE WA 98105-2139 VEH 15 SEATTLE WA 98105-2139 VEH 14 SEATTLE WA 98105-2139 This bpo icy coverages w ere a premium is shown below. a limits shown max e reduceprove es those d by policy provisions and may not be combined regardless of the number of vehicles for which a remium is listed unless s ecificall authorized elsewhere in this policy. VEH VEH VEH VEH COVERAGES LIMITS OF LIABILITY 13 6-MONTH 14 6-MONTH 15 6-MONTH ("ACV"MEANS ACTUAL CASH VALUE) D=DED PREMIUM D=DED PREMIUM D=DED PREMIUM D=DED PREMIUM AMOUNT $ 46MOUNT MOUNT $ MOUNT $ PART A - LIABILITY BODILY INJURY EA PER $ 500 , 00 EA ACC $1, 000, OOC 108 . 12 82 .44 91 . 2 PROPERTY DAMAGE EA ACC $ 100, OOC 64 . 76 50 . 47 55 . 3 PART B - PERSONAL INJURY PROTECTIOIS MEDICAL BENEFITS - EA PER $ 10, 00 INCOME CONTINUATION - $200 PER WEEK LOSS OF SERVICES BENEFITS - $40/DAY MAX, $200/WK MAX, $5, 000 MAXIMUM TOTAL FUNERAL EXPENSE - $2, 000 14 . 96 11 . 04 9 . 8 PART C - UNDERINSURED MOTORISTS BODILY INJURY EA PER $ 500, 00 EA ACC $1, 000, OOC 40 . 54 37 . 70 38 . 1 TOTAL PREN IUM - SEE FO LOWI G PAG (S) EH 13 ADDNL INTEREST - PERSONAL CORP INTEGRA WASHINGTON INC, SEATTLE, WA LOSS PAYEE EH 15 USAA FEDERAL SAVINGS BANK, LEHIGH VALLEY PA 1074231315 ENDORSEMENTS : ADDED 05-01-16 - A074WA(01) REMAIN IN EFFECT (REFER TO PREVIOUS POLICY) - ACCFOR(01) A099 (01) RSGPWA(01) 5100WA(02) INFORMATION FORMS : 663WA(06) 999WA(24) E3 „ 1131 RSM23 00 0 41 RMM64 00 0 H 5 RMF58 )00001111 ri 15V1 In WITNESS WHEREOF,the Subscribers at UNITED SERVICES AUTOMOBILE ASSOCIA I ION have caused these presents to De signed y their Attorney-in-Fact on this date MARCH 29, 2016 " Laura Bishop President, USAA Reciprocal Attomey-in-Fact, Inc. 5000 U 07-11 53461-07-11 PAGE 5 UNITED SERVICES AUTOMOBILE ASSOCIATION (A RECIPROCAL INTERINSURANCE EXCHANGE) RW �F-6 314 15 veh POLICYNUMBER IJSAA® 9800 Fredericksburg Road-San Antonio,Texas 78288 2 6 2 2 6 2 rBrt 00140 7 8 5 6 U 710 2 2 WASHINGTON AUTO POLICY POUICYPERIOD: (12:01 A.M.standard time) RENEWAL DECLARATIONS EFFECTIVE MAY 01 2016 TO NOV 01 2016 ATTACH TO PREVIOUS POLICY Named Insured and Address ALLEN N SAFER 5221 PULLMAN AVE NE SEATTLE WA 98105-2139 Description of Vehicle(s) VEH USE' es VEH I YEN4 TRADE NAME MODEL BODYTYPE ME IDENTIFICATION NUMBER SYM 13 10 TOYOTA PRIUS HYB 4D 4 DOOR 10000 JTDKN3DUBA0041891 P 14 06 SUBARU OUTBACK SW 6000 4S4BP61C367319002 P 15 08 SUBARU B9 TRIBECA 4 DOOR 6000 4S4WX90D584411357 P The Vehicle(s)described herein is principally garaged at the above address unless otherwise stated.V w/c--wo«wsdmd;B=Bushmp P=FaTmP=P1easure VEH 13 SEATTLE WA 98105-2139 VEH 15 SEATTLE WA 98105-2139 VEH 14 SEATTLE WA 98105-2139 This po icy .provides those coverages w ere a premium is shown a ow. a limits shown max be reduced by policy provisions and may not be combined regardless of the number of vehicles for which a premium is listed unless specifically authorized elsewhere in this Policy. COVERAGES LIMITS OF LIABILITY 13 6-MONTH 14 6-MONTH 15 6-MONTH ("ACV"MEANS ACTUAL CASH VALUE) D=DED PREMIUM D=DED PREMIUM D=DED PREMIUM D=DED PREMIUM MOUNT $ NMOUNT $ MOUNT $ MOUNT $ PART C - UNDERINSURED MOTORISTS PROPERTY DAMAGE EA ACC $ 10, 00C 4 . 90 4 . 55 4 . 6 PART D - PHYSICAL DAMAGE COVERAGE COMPREHENSIVE LOSS ACV LESS D 300 52 . 71D 300 29 . 23D 300 30 . 5 COLLISION LOSS ACV LESS D 500 150 . 33D 500 85 . 02D 500 84 . 2 RENTAL REIMBURSEMENT $ 30 A DAY/$ 900 MAXIMUN 13 . 87 13 . 8 EHICLE TOTAL PREMIUM 450 . 19 300 .45 327 .66 6 MONTH PREMIUM $ 1078 .30 PREMIUM DUE AT INCEPTION. THIS IS NOT A BILL, STATEMENT TO FOLLOW. EARNED ACCIDENT FORGIVENESS APPLIES WITH FIVE YEARS CLEAN DRIVING WITH US AA. THE PREMIUM ON YOUR RENEWING POLIO IS $ 20 . 94 LESS THAN CN YOUR EXPIRING FOLICY. THE FOLLOWING COVERAGE (S) DEFINED IN THIS POLICY ARE NOT PROVIDED FOR: VEH 13 - TOWING AND LABOR VEH 14 - RENTAL REIMBURSEMENT, T WING AND LAB DR VEH 15 - TOWING AND LABOR N1131 RSM23 00 0 H 4 RMM64POOPO TN 5 RMF58 00 0 In WITNESS HEREOF,the Subscribers at UNITED SERVICES AUTOMOBILE ASSOCIATION have caused these presents to be signed by their Attorney-in-Fact on this date MARCH 29, 2016 ��' U Laura Bishop President, USAA Reciprocal Attorney-in-Fact, Inc. 5000 U 07-11 53461-07-11 PAGE 6 USAA 00140 78 56 7102 SUPPLEMENTAL INFORMATION USAA® EFFECTIVE MAY 01 2016 TO NOV 01 2016 The following approximate premium discounts or credits have already been applied to reduce your policy premium costs. NOTE: Age or senior citizen status, if allowed by your state/location, was taken into consideration when your rates were set and your premiums have already been adjusted. VEHICLE 13 DAYTIME RUNNING LIGHTS DISCOUNT -$ 4 .27 MULTI-CAR DISCOUNT -$ 70 . 72 OCCASIONAL OPERATOR DISCOUNT -$ 62 . 71 OPERATOR 08 PASSIVE RESTRAINT DISCOUNT -$ 2 •20 PREMIER DRIVER DISCOUNT -$ 30 . 18 VEHICLE 14 ANNUAL MILEAGE DISCOUNT -$ 19. 94 DAYTIME RUNNING LIGHTS DISCOUNT -$ 2 . 25 MULTI-CAR DISCOUNT -$ 46 . 75 PASSIVE RESTRAINT DISCOUNT -$ 1 . 51 PREMIER DRIVER DISCOUNT -$ 19 . 94 VEHICLE 15 ANNUAL MILEAGE DISCOUNT -$ 17 .76 DAYTIME RUNNING LIGHTS DISCOUNT -$ 2 •23 MULTI-CAR DISCOUNT -$ 49 . 11 PASSIVE RESTRAINT DISCOUNT -$ 1•29 PREMIER DRIVER DISCOUNT -$ 20 . 95 SUPDECCW Rev. 7-95 MARCH 29, 2016 PAGE 7 USAA 00140 78 56 7102 PERSONAL CORPORATION ENDORSEMENT -WASHINGTON The coverage provided by this Endorsement is subject to all the provisions of the policy and amendments except as they are modified in this Endorsement. This endorsement is added at the request of This Endorsement applies only to a Personal the named insured. It forms a part of the auto Corporation the stock of which is wholly policy to which it is attached. It is effective owned by: from the policy effective date or from the date shown on the amended Declarations. 1. You; or We agree that the Personal Corporation shown 2. You and family members; or on the Declarations is a covered person under Part A — Liability Coverage of this policy. 3. You and other persons, all of whom are However, this applies only to the extent that eligible for auto insurance with USAA, the Personal Corporation qualifies as a covered USAA—CIC, USAA—GIC, or Garrison person under Paragraph 3. of the definition of insurance. covered person in Part A of this policy. If any stock of the Personal Corporation is Our inclusion of the Personal Corporation does issued or transferred to persons other than not operate to increase the limits shown on the those listed above, the coverage afforded by Declarations. this Endorsement shall cease automatically as of the date of such change. The Personal Corporation is not responsible for the payment of any premiums. Any premiums The named insured is authorized to act for the returned and any dividend we may declare will Personal Corporation in all matters pertaining to be paid to the named insured. this insurance. Coverage under this policy does not apply to BI We will not provide any written notice of: or PD sustained by any person arising out of or in the course of that person's employment by 1. Cancellation initiated by the named the Personal Corporation. insured; 2. Nonrenewal; or 3. Policy changes: to the Personal Corporation. If we decide to cancel the policy, we will give the same advance notice of cancellation to the Personal Corporation as we give to the named insured shown in the Declarations. Copyright, USAA, 2014. All rights reserved. Includes copyrighted material of Insurance Services Office, used with permission. 128794-0814_01 A074WA(01) 10-14 Page 1 of 1 PAGE 8 USAA 00140 78 56 7102 Personal Injury Protection Coverage in Washington Below, you will find a brief explanation of Personal Injury Protection coverage. Please remember that this is designed to be a simple overview. Coverage is subject to all the provisions and exclusions described in your insurance policy. The decision you make regarding the level of coverage in this area may affect your insurance premium. When purchasing this coverage, it is important to understand that you will be reimbursed only for reasonable and necessary medical expenses. Bills are audited, and amounts charged which are not reasonable, or charges incurred for treatment which is not necessary, will not be reimbursed. Any amounts not qualifying for reimbursement are your responsibility. Please see your policy for details. If you have further questions, feel free to contact a member service representative by calling (800) 531-81 1 1. Coverage Description Personal Injury Protection Coverage (PIP): • Is optional. • Written rejection is required. If rejected, future renewals will remain the same. • Provides a death benefit. • Provides an income continuation benefit, for up to one year, beginning 14 days from the date of the automobile accident, subject to the lesser of 85% of the actual income lost or the limit selected. • Provides Loss of Services Disability Benefits of $40 per day, subject to the limit selected. y= 52112-1006 663WA(06) Rev. 10-06 Page 1 of 4 PS.001407856.663WA.07102 PAGE 9 USAA 00140 78 56 7102 THIS PAGE INTENTIONALLY LEFT BLANK 663WA(06) Rev. 10-06 Page 2 of 4 PS.001407856.663wA.07102 PAGE 10 USAA 00140 78 56 7102 Rejection/Selection Form If you do not wish to make any changes to your current policy, no action is required. If you would like to make changes to your policy, please complete, sign and return the form below. The premiums below reflect the total premium for this coverage for all vehicles insured on your policy. The coverage-limit combinations displayed in this form are examples. You can create other combinations of the coverage limits displayed in this example. PERSONAL INJURY PROTECTION COVERAGE Semi-annual premiums per policy Medical & Income Loss of Funeral Hospital Expenses Continuation Services Expenses Premium ❑ S 10,000 $200 wk./$10,000 max. $200 wk./S5,000 max. $2,000 $ 35.81 ❑ $ 10,000 $200 wk./S10,000 max. $280 wk./$14,600 max. $2,000 $ 36.80 ❑ $ 10,000 $200 wk./S10,000 max. $200 wk./S5,000 max. $5,000 $ 37.79 ❑ S 25,000 $200 wk./$10,000 max. $280 wk./S14,600 max. $5,000 $ 57.86 ❑ $ 35,000 $700 wk./$35,000 max. $200 wk./S5,000 max. $2,000 $ 65.95 ❑ $ 50,000 $700 wk./835,000 max. $280 wk./S14,600 max. $2,000 $ 75.91 ❑ $ 75,000 $700 wk./S35,000 max. $200 wk./$5,000 max. $5,000 $ 85.92 ❑ $100,000 $700 wk./S35,000 max. $280 wk./S14,600 max. $5,000 $ 98.93 Loss of Services: $ 5,000 has a $40 per day, $200 per week maximum $ 14,600 has a $40 per day, one year maximum Note: Your current limit selection is: Medical & Income Loss of Funeral Hospital Expenses Continuation Services Expenses Premium ❑ I reject Personal Injury Protection Coverages for this policy and all subsequent renewals, supplemental policies or replacement policies. USAA Number Signature of Named Insured Home Phone Alternate Phone Date Please fax your completed form to (800) 531-8877 or mail it to the following address: USAA, 9800 Fredericksburg Road, San Antonio, Texas 78288 If this form is sent by facsimile machine (fax), the sender adopts the document received by USAA as a duplicate original and adopts the signature produced by the receiving fax machine as the sender's original signature. 663WA(06) Rev. 10-06 Page 3 of 4 PS.001407856.663WA.07102 PAGE 11 USAA 00140 78 56 7102 THIS PAGE INTENTIONALLY LEFT BLANK may: • 663WA(06) Rev. 10-06 Page 4 of 4 Ps.0014O7856.663WA.07102 PAGE 12 USAA 00140 78 56 7102 Underinsured Motorists Coverage in Washington Below, you will find a brief explanation of Underinsured Motorists coverage. Please remember that this explanation is only an overview, and it does not replace or supplement any of the provisions of your policy. Please see your policy for details because the policy controls all issues of coverage. The decisions you make regarding the amount of coverage will affect your insurance premium. If you have questions, please call Policy Service at 1-800-531-USAA (8722). You may complete this form online at usaa.com. Coverage Descriptions Underinsured Motorists (UIM) Coverage: • Protects you and your family if injured in a motor vehicle accident caused by an underinsured or hit—and—run motorist who is at—fault. • Pays if you are injured by an at—fault motorist whose Bodily Injury (BI) Liability limits are less than the amount of damages you are legally entitled to recover from the at—fault motorist. The at—fault motorist's policy pays its BI Liability limits first, then your UIM Coverage pays the lesser of: • any remaining loss, or • your UIM Coverage limits. • Must be issued with UIM Coverage limits equal to your BI Liability limits unless you reject UIM Coverage or select lower UIM Coverage limits by completing, signing and returning the Rejection/Selection Form by mail or at usaa.com. • Your rejection of UIM Coverage or selection of lower UIM Coverage limits will remain in effect on this policy and on future renewals until you request otherwise in writing. Underinsured Motorists Property Damage (UIMPD) Coverage: • Pays for damage to your vehicle that you are legally entitled to recover from an at—fault underinsured motorist or hit—and—run motor vehicle because of property damage (including loss of use) sustained in an auto accident. • Is issued with UIMPD Coverage limits equal to the minimum limits required by Washington unless you reject UIMPD Coverage for one or more vehicles by completing, signing, and returning the Rejection/Selection Form by mail or at usaa.com. • You may select higher UIMPD Coverage limits for one or more vehicles by completing, signing, and returning the Rejection/Selection Form by mail or at usaa.com. • Your rejection of UIMPD Coverage will remain in effect on this policy and on future renewals until you request otherwise in writing. • Vehicle damage is subject to a $100 deductible. However, vehicle damage caused by a hit—and—run or phantom vehicle is subject to a $300 deductible. r= 53652-0612_01 999WA(24) Rev. 2-08 Page 1 of 4 PS.001407856.999WA.07102 PAGE 13 USAA 00140 78 56 7102 THIS PAGE INTENTIONALLY LEFT BLANK 999WA(24) Rev. 2-08 Page 2 of 4 PS.001407856.999Wa.07102 PAGE 14 USAA 00140 78 56 7102 Rejection/Selection Form If you do not wish to make any changes to your current policy, no action is required. TO MAKE CHANGES TO YOUR POLICY, PLEASE COMPLETE THIS FORM, SIGN, AND RETURN IT TO US. The premiums below reflect the total premium for this coverage for all vehicles insured on this Policy. Underinsured Motorists (UIM) Coverage Bodily Injury Semi-annual premium per policy To make a change to your current policy, you must check one of the following boxes: Limit Premium Limit Premium per person/per accident per person/per accident ❑ $ 25,000/$ 50,000 $ 53 .13 ❑ $ 300,000/$ 500,000 $ 107.31 ❑ $ 50,000/$ 100,000 $ 71.19 ❑ $ 500,000/$ 500,000 $ 115.29 ❑ $ 100,000/$ 200,000 $ 97.76 ❑ $ 500,000/$1,000,000 $ 116.35 ❑ $ 100,000/$ 300,000 $ 98.29 ❑ $ 1,000,000/$1,000,000 $ 134.40 Property Damage The available Underinsured Motorists Property Damage (UIMPD) limits per accident are: $10,000 $100,000 $25,000 $300,000 $50,000 UIM Coverage limits and UIMPD Coverage limits cannot exceed your BI and PD Liability limits. You may reject both UIM Coverage and UIMPD Coverage for all vehicles, or you may reject only UIMPD Coverage for one or more vehicles. You cannot carry UIMPD Coverage unless you also carry UIM Coverage. ❑ I reject UIM Coverage and UIMPD Coverage for all vehicles for this policy and all subsequent renewals until I request otherwise in writing. ❑ I reject only UIMPD Coverage for the following vehicles for this policy and all subsequent renewals until I request otherwise in writing. YR/MAKE/MODEL YR/MAKE/MODEL DO NOT SIGN UNTIL YOU READ USAA Number Signature of Named Insured Home Phone Alternative Phone Date Please complete this form and fax it to 1-800-531-8877 or mail it to USAA, 9800 Fredericksburg Road, San Antonio, Texas 78288; or complete this form on usaa.com. If this form is sent by facsimile machine (fax), the sender adopts the document USAA receives as a duplicate original and adopts the signature receiving fax machine produces as the sender's original signature. 999WA(24) Rev. 2-08 Page 3 of 4 PS.001407856.999WA.07102 LAST PAGE 15 USAA 00140 78 56 7102 THIS PAGE INTENTIONALLY LEFT BLANK 999WA(24) Rev. 2-08 Page 4 of 4 PS.001407856.999WA.07102 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 Integra Washington, Inc. Company, hereby acknowledge and declare that the before-mentioned company was the prime contractor for the Agreement known as S. 2281h St. UPRR Grade Separation that was entered into on the June 1 (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. By: For: U I Title: k'(Q- Date: C1 EEO COMPLIANCE DOCUMENTS - 1