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HomeMy WebLinkAboutPW16-244 - Amendment - #1 - Integra Realty Resources - S 228th St UPRR Grade Separation - 11/21/2016 ri k ._ s ' K N7" `x° Document WAS HINGTON '«r+ MOM 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 Washington Inc. Vendor Number: 7D Edwards Number Contract Number: vv �u - 2 q-- 7_ This is assigned by City Clerk's Office Project Name: S. 228th St. UPRR Grade Separation Description: ❑ Interlocal Agreement ❑ Change Order ® Amendment ❑ Contract ❑ Other: P _ t t '& z�f ay\ Contract Effective Date: 11/21/16 Termination Date: 8/31/17 Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: Ingrid Willms-Dixon Department: Engineering Contract Amount: $0.00 Approval Authority: (CIRCLE ONE) Department Director Mayor City Council Detail: (i.e. address, location, parcel number, tax id, etc.): Extend the time of completion to August 31, 2017 due to project delay. As of: 08/27/14 1CNT AMENDMENT NO. 1 NAME OF CONSULTANT OR VENDOR: Integra Washington, Inc. CONTRACT NAME & PROJECT NUMBER: S. 228`h St. UPRR Grade Separation ORIGINAL AGREEMENT DATE: June 13, 2016 This Amendment is made between the City and the above-referenced Consultant or Vendor and amends the original Agreement and all prior Amendments. All other provisions of the original Agreement or prior Amendments not inconsistent with this Amendment shall remain in full force and effect. For valuable consideration and by mutual consent of the parties, Consultant or Vendor's work is modified as follows: 1. Section I of the Agreement, entitled "Description of Work," is hereby modified to add additional work or revise existing work as follows: In addition to work required under the original Agreement and any prior Amendments, the Consultant or Vendor shall The scope of work remains the same, however an amendment is needed to extend the time of completion to August 31, 2017 due to project delay. 2. The contract amount and time for performance provisions of Section II "Time of Completion," and Section III, "Compensation," are modified as follows: Original Contract Sum, $15,050.00 including applicable WSST Net Change by Previous Amendments $0 including applicable WSST Current Contract Amount $15,050.00 including all previous amendments Current Amendment Sum $o Applicable WSST Tax on this $0 Amendment Revised Contract Sum $15,050.00 AMENDMENT - 1 OF 2 Original Time for Completion 12/31/16 (insert date) Revised Time for Completion under n/a prior Amendments (insert date) Add'I Days Required (t) for this 243 calendar days Amendment Revised Time for Completion 8/31/17 (insert date) The Consultant or Vendor accepts all requirements of this Amendment by signing below, by its signature waives any protest or claim it may have regarding this Amendment, and acknowledges and accepts that this Amendment constitutes full payment and final settlement of all claims of any kind or nature arising from or connected with any work either covered or affected by this Amendment, including, without limitation, claims related to contract time, contract acceleration, onsite or home office overhead, or lost profits. This Amendment, unless otherwise provided, does not relieve the Consultant or Vendor from strict compliance with the guarantee and warranty provisions of the original Agreement. All acts consistent with the authority of the Agreement, previous Amendments (if any), and this Amendment, prior to the effective date of this Amendment, are hereby ratified and affirmed, and the terms of the Agreement, previous Amendments (if any), and this Amendment shall be deemed to have applied. The parties whose names appear below swear under penalty of perjury that they are authorized to enter into this Amendment, which is binding on the parties of this contract. IN WITNESS, the parties below have executed this Amendment, which will become effective on the last date written below. CONSULTANT/VENNROR: CITY OF KENT: B By: r Y y; By (signature) "^ �(sig ature5 Print Name --° Print Name: Timothy J. LaPorte. P.E. Its A- Its Public Works Director (tltl i (title) DATE: E 9 ✓ DATE: l( "tfl(' APPROVED AS TO FORM: (applicable if Mayor's signature required) Kent Law Department Integra-228"'UPRR Amd VWlllms-ooxon AMENDMENT - 2 OF 2 Fi ® DATE(MMIDDIYYYY) C��za CERTIFICATE OF LIABILITY INSURANCE 3i11i2016 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 DR 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, IMPDRTANT: 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 Certlticate does not confer rights to the certificate holder In hou of such endorsement(s). PRODUCER CONTACT Carrie Ovrid NAME. Conover Insurance PHONE B. . (425)455-5000 _ `Ax V,es)ssa-sssB. AC Noh 155 108th Avenue NE, Suite 725 'MAIL ezrrieo@conoverinsurance.com ADDRESS P.O. Sox 90007 IN SURER(SIAFFOROINGCOVERAGE NAICN Selle�ue WA 98004 INSURERA_Mutual Of Enun Claw Insurance 147GI INSURED INSURER a Integra Washington, Inc. , DIIP.: Integra Aealty INSURER c;_ _�______ ---- ' 600 IIniverai ty Street INSURERD: _ Suite 310 INSURER E: Seattle VIA 98101 INSURER F: COVERAGES CERTIFICATE NUMBER:16-17Ma5ter REVISION NUMBER: THIS IS TO CERI IFY THAT THE POLICIES DF 114SURANCE LISTED BELOW HAVE BEEN ISSUED TO I HE 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 AD BR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURAIJOE yMe POUCY NUMBER MMIDDIYYY` IdMrDDIYY X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE js 2,000,coo -- OAMAGETDRE T r 10 D,ODD A CLAIMS-MADE. 51 OCCUR PREMISCS_(Ca_occurrence $ X HCFDCC i3B3o5 3/14/2016 3/15/2DII MED EXP(Any one person) - S 10,000 PERSONAL S ADV INJURY $ GEIJ'L AGGREGATE U MIT APPLIES PER: _GENERAL AGGREGATE $ 4,000,000 X PDLICYF—]PRO-ECT nLOC PRODUCTS-COMPIOP AGG 5 2,000,000 J L 1 s OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY IEanccidonl $ ___ 2,D00,0o0 BODILY INJURY(Per Person) $ ANY ALL)O A AAl I-CPAUTOS MED SCHEDULED X aonoaU13B3D5 3/14/2016 3/14/201] BODILY INJURY Baraccldenl) $ - X :TIRED AUTOS X OWNED PROPERTY DAMAGE Pe.awTdsnt _ 5 AUTOS ._.. _, X UIdDRELLALIA9 X OCCUR EACH OCCURRENCE $ 1,000,000 A ( EXCESS LIAR _ CLAUAS MADE AGGREGATE 5 1,000,000 ED AN —_. I NIA H CSL 0,D ps 3/ 3/19/2019 EL DIS AIAMIDEEMPLOYE I s 2,000,000 UFO RETENTIOkS NT s 2,00I),D00 RKERB COMPENSATIONHE ED AND EMPLOYERS'LIABILITY YIN ANY PERIMEMHFR TORIEXCLUDED? UTVF. - P - DP.ndA.IMEnNIHFXCWDLD4 BDP00013030_ A (Mena atoryln NHJ If yes,describe under _ � E.L.DISEASE-POIJLY LIMIT $ a,ODD,DDD DESCRIPTION OF OPERATIONS below DESCRIPTIONOFOPERATIDh''SILOOATIDNSIVEIIICLES IACDRD 101,Add Donn Aernarks Schedule,Tay bea nie space is repn red City of Rent are i.r.cluded as Additional Tnwocda per fore PP 04 48 07 13 attached. Umbrella policy is following form over the CL and Auto. I CERTIFICATE HOLDER CANCELV+IION _ SHOULD AIJY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I City of Kent THE EXPIRATION DATE 'THEREOF, NOTICE WILL BE DELIVERED IN AGCORDANCF.W1711 THE POLICY PROVISIONS. 220 Fourth Avenue South Kent, WA 90032 - —_-- AUTHORI]RDRE PRLSCNTATIVE t Deana VI21scn/CRLN)iJ,L --- -- -- - 61988-2013ACORD CORPORATION, Al[rights reserved. I I ACORO 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1N502fi l9n5cn11 PAGE 1 MAIL MCH-M-I it Y1392 P :Fi 29, 2016 US, +® AUTOMOBILE POLICY PACKET ALLEN N SAFER 5221 PULLKAN AVE NE SEATTLE WF_ 9B105-2129 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 vour insurance needs. Required information forms are also enclosed for your review. Your Underinsured Motorists Coverage (IJIM) and Underinsured Motorists Property Damage (UIMPD) selectionlrejection remains in effect You may quote different coverage limits and make changes at any time to your policy on usaacom. 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://itcsnwaitusaa.com to watch powerful videos and take the pledge to not text and drive! Coverage exclusions apply when your vehicle s 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 pa!d by the due date indicated. To receive this document and others electronically, or manage your Auto Policy online, go to usaacom. For U.S. calls: Policy Ssnr,'ce (800) 531-8111. Claims (800) 53 —8222. 49708-0406 ACS1 4= ( PP�3iz 4 ADDL INFO ON NEXT PACE MAIL VCH-M-1 UNITED SERVICES AUTOMOBILE ASSOCIATION RENEWAL OF (AREOIPROCALPITERINSURANCEIXCHANGE) Slate 113 14 15 Ve5 I POLICY N-WBER us � 9800 Fredericksburg Road-San Antonio,Texas 782BB WA 62 627.67. Te, 00140 78 56U 7102 2 WA.SHINGTON AUTO POLICY POUCYPERIOD: (12:01 A.M. standard time RENEWAL DECLARATIONS EFFECTIVE MAY 01 2016 TO NOV 01 2096 (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 9810E-2139 Description o e ttc e s VEH USE` - \,EH YEAF TRADEWME ivo_- 1 BODYTYPE IAN IDENTP=ICATION NUMBER SYM a` 13 10 TOYOTA PRIUS HYB 45 4 DOOR 10000 JTDKN3DU8A0041891 P 14 06 SUBARU OUTBACK Star 6000 4S4BP61C367319002 P 15 08 SUBARU B9 TRIBECA 4- DOOR 6000 4S4WX-90D584411357 P The Vehicle(s) described herein is principally garaged at the above address unless other✓ise stated. wiawawsU oa;e=e s e F�amP=awe VEH 13 SEATTLE WA 9B105-2139 VEH 15 SEATTLE WA 98105-2139 VEH 14 SEATTLE WA 98105-2139 Is po Icy provides those coverages w ere a premium Is shown below. e limits shown may be reduced by policy provisions and may not be combined regardless of the number of vehicles for which a_remium Is listed unless specificallV 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) ❑=DTD PREMIUM D=DED PREMIUIS D=DED PREMIUM D=DED PREMIUM AMOUNT MAOUN7 AMOUNI' $ MOUNT S - A. - LIABILITY .BODILY INJURY EA PER $ 500, 00 EA ACC $1, 000, 000 10B .12 82 . 44 91 . 2 PROPERTY DAMAGE EA ACC $ 100, 000 64 .76 50 . 47 55 . 3 PART B - PERSONAL TNJURY PROTECTI01 MEDICAL BENEFITS - EA PER $ IO, 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 $1, 000, 00 40 . 54 37 . 70 38 .1' TOTAL PREIT.UM - SEE FO LOWING PAG (S) �i -EH 13 ADDNL INTEREST - PERSONAL CORP INTEGRA WASHINGTON INC, SEATTLE, WA LOSS PAYEE VEH 15 USAA FEDERAL SAVINGS BANK, LEHIGH VALLEY PA 1074231315 ENDORSEMENTS : ADDED 05-01-16 - A074WA(01) REMAIN IN EFFECT (REFER TO PREVIOUS POLICY) - 7,-CCFOR (01) A099 (01) RSGPWA(C1) 5100WA(02) I'-- ORMATION FORMS : 663WA(06) 999WA(24) 00 0 4 RMM64 00 D In WITNESS WHERLOP,the Subscribers at UNITED SERVICES AU TOM- BI E ASSONATION have caused These presents to be signed by their Attorney-in-Fact on this date MARCH 25, 2016 "'� :.aura Bishop President, USAA Reciprocal Attorney-in-Fact, Inc. 5000 U of-fi G 34 61-07-1 1 I PAGE 6 g. � USAA 001a9 7B 5E 7_02 SUPPLEMENTAL INFORMATION USW EFFECTIVE MAY 01 2016 TO NOV 01 2016 The following approximate premium d'scounts or credits have already been applied to reduce your policy premium costs. (COTE: Age or senior citizen status, if allowed by your state/location, was taken into consideration when your rates were set and your premiurns have already been adjusted. VEHICLE 13 DAYTIME RLNNING LIGHTS DISCOUNT -$ 4 . 27 MULTI-CPR DISCOUNT -$ 70 . 72 OCCASIONAL CPERATOR 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 . 95 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, 20i6 PAGF. 8 USAA 00140 78 56 7102 i Personal Injury Protection Coverage in VVashington 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) 531-8111. 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. 52112-1006 663WA(D6) Rev. 10-06 Page 1 of 4 Ps.001407B56. 663WA.a7l02 i 'I 7AGE 1u USAA 00140 78 56 7132 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 Lmits displayed in this example. PERSONAL INJURY PROTECTION COVERAGE Serra—annual premiums per policy Medical & Income Loss of Funeral Hospital Expenses Continuation Services Expenses Premium ❑ S 10,ODO s200 v✓k/s10,000 max. $200 wk./$5,000 max. $2,000 $ 35. el ❑ S 10,000 $200 wk./810,000 max. $280 wk./614,600 max. $2,000 $ 36. 80 ❑ s i0,DOD $200 wk./$I0,000 max. $200 wk.1$5,000 .max. $5,000 $ 37.79 ❑ $ 25,003 $200 wk./510,000 max. s280 wkJS14,600 max. $5,000 $ 57.a6 ❑ $ 35,000 5700 wk./$35,000 max. S200 wk.155,000 max. $2,000 $ 63. 95 ❑ 5 50,000 $700 wk./S35,000 max. 6280 wk./514,600 max. $2,000 $ 75 91 ❑ $ 75,000 $700 wk./S35,000 max. $200 wk./S5,000 max. $5,000 $ 95.92 ❑ $100,000 $700 wk.1s35,000 max. $280 wk./$14,600 max. $5,000 S 95.93 Loss of Services: $ 5,000 has a $40 per day, $200 per week maximum s 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 $ $ / "a $ $ �❑ 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—BR77 or mail it to the following address: USAA., 9800 Fredericksburg Road, San Antonio, Texas 78288 If this forte is sent by facsimile machine (fax), the sender adepts 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.(O6) Rev. 10- 08 In Page 3 of 4 PS.co14o7856.663WA-07102 L PACE 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, .hen 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 Ulm 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 rnimmurn 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 tray 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 999WA(24) Rev. 2-08 � Page 1 of 4 PS.D01407856.999WA.07102 Ac�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD1YVl Y7 2/24/2016 3 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS tTIFICATE 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 endorsements. PRODUCER NAMEACT LA Rea l EstateCerts a .com Arthur J. Gallagher& Co. PHONE —"- Fax-- Insurance Brokers of CA. Inc LIC#0726293 �a 318-539-1247 IAiG,Nn. 818-539-1804 EMAIL .LARealEstateCerts a com _ 505 N. Brand Boulevard, Suite 600 _.- @ J9� _ Glendale CA 91203 _ INSURER(S)AFFORDING COVERAGE NAICp INSURERA:LLOYD'S OF LONDON SYNDICATE 3624 INSURED INTEREA-03 INSURER B:APPRAISAL GUARDIAN SERIES OFFORTRE Integra Washington, Inc. INSURERC: I Integra Realty Resources Inc. 1133 Ave of Americas -_- - _-- - ---_ - 27th Floor 600 University Street, Suite 310 INSURER O: Seattle WA 98101 INSURERE: NSURERF: COVERAGES CERTIFICATE NUMBER:612604032 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. InTE TYPE OF INSURANCE AINSD WVD POLICYNUMBER 1d MIDDV/YYY1' MrnIDpY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ $ _ J GIRPdS-MADE u OCCUR DAMAGE TO RENTED PREMISES Ea..whence $ MED EXP(Any one person) $ PERSONAL&ADVINJLIRY $ GEN L AGGREGATE LIfdIT APPLIES PER: GENERALACG_REGATE S POLICY JEM LOC PRODUCTS-CON FADE ADD $ OTHER_ _-. $ ' C MBINEOSIN LELI AUTOMOBILE LIABILITY E. de.nl) j$ ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident) $ ' NON-0WNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per aradent $ __...... UMBRELLA LIAR OCCUR _EACH OCCURRENCE $ EXCESS LIAB CLAII0S-'MADE AGGREGATE 5 DED RETENTION$ $ ;WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/P.ARTNERIEXECUTIVE NIA L_E FACIACCIDENT /M S OFFICEREMBER EXCLUDED? r� (Mandatory In NH) EL DISEASE-EA EMPLOYE $ If yes,descnba under DESCRIPTION OF OPERATIONS below E.I DISEASE-PDLICY LIMIT $ A Errors&Omissions MPL1531199.16 3/14/2016 3/14/2017 Each Claim $2 000,000 A Errors&Omissions MPL1531199.16 3/14/2016 3/14/2017 Aggregate Limit S10,000,000 B *E&O Deductible Reimbursement 'PRFDR4BAPP200306922015TC V14/2016 3/14/2017 Ea Claim/Aggregate` $150,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,Additional Remarks Schedule,may be attached It more space is required) Location: 600 University Street, Ste 310, Seattle, WA 98101 Evidence only. *Policy is subject to$25,000 Self Insured Rentention/Deductible payable by local office. This certificate of insurance is not a policy of insurance and does not affirmatively or negatively amend, extend or alter the coverage afforded by the policy to which the certificate of insurance makes reference. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Certificate As Evidence ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD PX3E 1 MAIL MCH-M-1 Y1392 SEPiE 3ER 24, 2016 USAX AUTOMOBILE POLICY PACKET ALLEN N SAFER 5221 PULLMAN AVE NE SEATTLE WA 98105-2139 USAA 00140 78 56 7102 2 POLICY PERIOD: EFFECTIVE NOV 01 2016 TO MAY 01 2017 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. Check your vehicle for a safety recall today! Visit www.usaa.com/autorecall to learn more. Your Rental Reimbursement Coverage has changed. Please see your Declarations, Amendatory Endorsement A402, and the form "New Features are Now Available" for information about this change. With this renewal, your premium has increased due to a rate change in your state or because of your policy's individual risk characteristics. See your Declarations for the new premium. Contact us if you have any questions. 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.usaacom to watch powerful videos and take the pledge to not text and drivel 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. 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) 531-8111. Claims (800) 531-8222. ACS1 49708-0406 PX3E 2 THIS PAGE INTENTIONALLY LEFT BLANK PAGE 3 USAA 00140 78 56 7102 2 AUTOMOBILE POLICY PACKET CONTINUED 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. ACS2 PX3E 4 WASHINGTON INSURANCE IDENTIFICATION CARD i WASHINGTON INSURANCE IDENTIFICATION CARD UNITED SERVICES AUTOMOBILE ASSN UNITED SEWCES AUTOMOBILE ASSN NAMEOFINSURED I-OR E SAFER NAMEOFINSURED ALEN N SN$2 INTEGRA WASHINGTON INC , MARTIN T SAFER POLICYNUMBER 00140 78 55U 7102 2 POLICYNUMBER 00140 78 56U 7102 2 EFFECTNEDATE 11/01/16 EXPIRATIONDATE 05/01/17 i EFFECTNEDATE 11/01/16 EXPIRATION DATE 05/01/17 VEHICLE DESCRIPTION i VEHICLE DESCRIPTION YEAR MAKEMODEL i YEAR MAKSMODEL 2010 TOYOTA PRIUS HYB 40 2006 SUB4U CUTBACK VEHICLE IDENTIFICATION NUMBER ' VEHICLE IDENTIFICATION NUMBER JTDKN3DU8AO041891 4S4BP61C367319002 9800 Fredericksburg Road San Antonio,Texas 78288 i 9800 Fredericksburg Road San Antonia,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 -- - - - - - - -- - - - - - - - - - - - - - - - - - - -- -- - - - - - - - - - - - - - -- - - - - -- - - - - - -- - - - - - - - - - - - - - - - - - • 09/24/16 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 UNITED SERVICES AUTOMOBILE ASSN NAME OF INSURED AU-EN N SAFER LOH E SAFER POLICYNUMBER 00140 78 56U 7102 2 EFFECTNEDATE 11/01/16 EXPIRATIONDATE 05/01/17 VFIHICLEDESCRIPION ' YEAR MNIE/MODEL ' 2008 SUBARU B9 TFSECA VEHICLE IDENTIFICATION NUMBER i 4S4WX9OD584411357 9800 Fredericksburg Road San Antonio,Texas 78288 1 Additional copies available at usaa.com i CONTACT US: 210-531-USAA(8722) ' OR 800-531-USAA ' i i PAGE 5 UNITED SERVICES AUTOMOBILE ASSOCIATION ADDL INFO ON NEXT PAGE MAIL MCH-M-I % RENEWAL OF W-11 (ARECIPROCAL INTERINSURANCE EXCHANGE) slate 13 14 15 Vdi I POLICY NUMBER USAW 9800 Fredericksburg Road-San Antonio, Texas 78288 WA P62 62262 Terr 00140 78 56U 7102 2 WASHINGTON AUTO POLICY POUCYPERIOD: (12:01 A.M. standard time) RENEWAL DECLARATIONS EFFECTIVE NOV 01 2016 TO MAY 01 2017 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 o e IC e(s) VEH USE" wcRtea�cx. VEH TRADENAME MODEL BODYTYPE MILEAGE IDENTIFICATION NUMBER SYM 13 10 TOYOTA PRIUS HYB 4D 4 DOOR 10000 JTDKN3DU8AO041891 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..wic-wo"d,od;B�usln ;r Pan ;P�hsue VEH 13 SEATTLE WA 98105-2139 VEH 15 SEATTLE WA 98105-2139 VEH 14 SEATTLE WA 98105-2139 This o Icy provides those coverages where a premium is shown below. a limits shown may � we 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. 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 [MOUNT $ MOUNT $ AMOUNT $ PART A - LIABILITY BODILY INJURY EA PER $ 500, 00 EA ACC $1, 000, OOC 117 . 56 89 . 67 78 . 3 PROPERTY DAMAGE EA ACC $ 100, OOC 73 . 10 65 .43 63 . 7 PART B - PERSONAL INJURY PROTECTIO 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 15 . 02 11 . 5E 9 . 52 PART C - UNDERINSURED MOTORISTS BODILY INJURY EA PER $ 500 , 00 EA ACC $1, 000, 00 36 . 89 34 . 3 34 . 6 TOTAL PRE IUM - SEE FO LOWI G PAG (S) VEH 13 ADDNL INTEREST - PERSONAL CORP INTEGRA WASHINGTON INC, SEATTLE, WA LOSS PAYEE VEH 15 USAA FEDERAL SAVINGS BANK, LERIGH VALLEY PA 1074231315 ENDORSEMENTS : ADDED 11-01-16 - A402 (02) REMAIN IN EFFECT (REFER TO PREVIOUS POLICY) - ACCFOR(01) A074WA(01) A099 (01) RSGPWA (01) 5100WA(02) INFORMATION FORMS : FEAFLRR(02) 663WA(06) E2 1 fl131 RSM23POO1001 I I I 11 Jx 41 RMM65 00 0 -51 RMF59 0000 In WITNESS WHEREOF,the Subscribers at UNITED ERVICES AUTOMOBILE ASSOCIATION have caused these presents to be signed by their Attorney-in-Fact on this date SEPTEMBER 24, 2016 Laura Bishop President, USAA Reciprocal Attorney-in-Fact, Inc. 5000 U 07.11 53461-07-11 PAGE 6 1 % UNITED SERVICES AUTOMOBILE ASSOCIATION (ARECIPROCALIVrERINSURANCEE(CHANGE) State 13 14 15 u� PCUCYNUMBER USAW 9800Fredeicksburg Road-San Antonio, Texas 78288 A 62 62262 Tad 00140 78 56U 7102 2 WASHINGTON AUTO POLICY POUCYPERIOD: (12:01 A.M.standard time) RENEWAL ➢ECLARATIONS EFFECTIVE NOV 01 2016 TO MAY 01 2017 ATTACH TO PREVIOUS POLICY Named Insured and Address ALLEN N SAFER 5221 PULLMAN AVE NE SEATTLE WA 98105-2139 Description o e is e s VEH USE* fly as \,Eli TRADENAME MODEL BODYTYPE N,y�GE IDENTIFICATION NUMBER SYM 13 10 TOYOTA PRIUS HYB 4D 4 DOOR 10000 JTDKN3DU8AO041891 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 w1C--woksd,00r 13=13m a F=Fam:P=Pl�sure VEH 13 SEATTLE WA 981OS-2139 VEH 15 SEATTLE WA 98105-2139 VEH 14 SEATTLE WA 98105-2139 This ppolicy provides ONLY those coverages where a premium is shown below. The limits shown maX be reduced by policy provisions and may not be combined regardless of the number of vehicles for which a remium is listed unless specifically authorized elsewhere in this policy. 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 I PREMIUM D=DED PREMIUM AMOUNT $ MOUNT 5 AMOUNTI $ MOUNT $ PART C - UN➢ERINSURED MOTORISTS PROPERTY DAMAGE EA ACC $ 10, 00C 4 .43 4 . 12 4 . 16 PART D - PHYSICAL DAMAGE COVERAGE COMPREHENSIVE LOSS ACV LESS D 300 52 . 71D 300 23 .46D 30C 24 .2 COLLISION LOSS ACV LESS D 500 137 . 92D SOO 89 . 52 SOC 89 . 6 RENTAL REIMBURSEMENT STANDARD CLASS 12 . 50 12 . 5 VEHICLE TOTAL PREMIUM 450 . 13 318 . 09 316 . 8 6 MONTH PREMIUM $ 1085 . 07 PREMIUM DUE AT INCEPTION. THIS IS NOT BILL, STATEMENT 0 FOLLOW. EARNED ACCIDENT FORGIVENESS APPLIES WITH FIVE YEARS CLEAN DRI ING WI H US THE PREMIUM ON YOUR RENEWING POLIO IS $ 6 . 77 MORE THAN YO R EXPI ING OLICY. THE FOLLOWING COVERAGE (S) DEFINED N THIS POLIO ARE NOT P OVID D FOR: VEH 13 - TOWING AND LABOR VEH 14 - RENTAL REIMBURSEMENT, TOWING AND LAB R VEH 15 - TOWING AND LABOR 1131 RSM23 0000 41 RMM65 00 0 51 RMF59 0000 In WITNESS WHEREOF,the Subscribers at UNITED SERVICES AUTOMOBILE ASSOCIATION have caused these presents to be signed by their Attorney-in-Fact on this date SEPTEMBER 24, 2016 !/*" &A8P Laura Bishop President, USAA Reciprocal Attorney-in-Fact, Inc. 5000 U 07.11 53461-07-11 PAGE 7 USAA 00140 78 56 7102 ® SUPPLEMENTAL INFORMATION USAW EFFECTIVE NOV 01 2016 TO MAY 01 2017 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 -$ 3 . 89 MULTI-CAR DISCOUNT -$ 71 . 08 OCCASIONAL OPERATOR DISCOUNT -$ 63 . 79 OPERATOR 08 PASSIVE RESTRAINT DISCOUNT -$ 2 .21 PREMIER DRIVER LEVEL DISCOUNT -$ 71. 08 VEHICLE 14 ANNUAL MILEAGE DISCOUNT -$ 21 . 30 DAYTIME RUNNING LIGHTS DISCOUNT -$ 2 .40 MULTI-CAR DISCOUNT -$ 49 . 97 PASSIVE RESTRAINT DISCOUNT -$ 1 . 60 PREMIER DRIVER LEVEL DISCOUNT -$ 49 . 97 VEHICLE 15 ANNUAL MILEAGE DISCOUNT -$ 17 . 20 DAYTIME RUNNING LIGHTS DISCOUNT -$ 2 . 40 MULTI-CAR DISCOUNT -$ 47 . 55 PASSIVE RESTRAINT DISCOUNT -$ 1 . 24 PREMIER DRIVER LEVEL DISCOUNT -$ 47 . 55 SUPDECCW Rev. 7-95 SEPTEMBER 24, 2016 PAGE 8 USAA 00140 78 56 7102 AMENDATORY ENDORSEMENT The coverage provided by this Endorsement is subject to all the provisions of the policy and amendments except as they are modified as follows. PART D - PHYSICAL DAMAGE COVERAGE INSURING AGREEMENT b. If Rental Reimbursement Coverage is afforded, the vehicle class for Paragraph A. is replaced in its entirety by the transportation expenses is the following: vehicle class shown on the Declarations for Rental A. Comprehensive Coverage (excluding Reimbursement for that vehicle. collision). Paragraph C. is replaced in its entirety by the 1. Physical damage. We will pay for loss following: caused by other than collision to your covered auto, including its equipment, C. Rental Reimbursement Coverage (for loss and personal property contained in your other than total theft). covered auto, minus any applicable deductible shown on the Declarations. 1. We will reimburse you for expenses The deductible will be waived for loss you or any family member incurs to to window glass that can be repaired rent a substitute for your covered rather than replaced. In cases where the auto. This coverage applies only if: repair proves unsuccessful and the window glass must be replaced, the full a. Your covered auto is withdrawn amount of the deductible, if any, must from use due to a loss, other than a be paid. total theft, to that auto; and 2. Transportation expenses. We will also b. The loss is covered under pay Comprehensive Coverage or caused by collision, and the cause of loss a. The reasonable amount for is not otherwise excluded under Part transportation expenses incurred by D of this policy. you or any family member, but no more than the cost of renting an 2. We will reimburse you only for that Economy Class vehicle, as defined period of time reasonably required to under Rental Reimbursement repair or replace your covered auto. If Coverage. This applies only in the we determine your covered auto is a event of a total theft of your total loss, the rental period will end no covered auto. We will pay only later than seven days after we have transportation expenses incurred made a settlement offer. during the period beginning 48 hours after the theft and ending when your covered auto is LIMIT OF LIABILITY returned to use or, if not recovered or not repairable, up to seven days Paragraph A. of the Limit of Liability section is after we have made a settlement replaced in its entirety by the following: offer. 126836-0314 02 A402(02) Rev. 05-14 Page 1 of 3 PAGE 9 USAA 00140 78 56 7102 A. Total loss to your covered auto. Our limit D. Under Rental Reimbursement Coverage, our of liability under Comprehensive Coverage maximum limit of liability is the reasonable and Collision Coverage is the actual cash amount necessary to reimburse you for value of the vehicle, inclusive of any expenses incurred to rent a vehicle in the custom equipment, and the cost to applicable class shown on the Declarations: transfer or replace any equipment, furnishings or parts designed to assist 1. Economy Class. For purposes of this disabled persons. endorsement, Economy Class means ,.mini," small or compact 2— and 4—door 1. The maximum amount we will include cars that are not considered sports or for loss to custom equipment in or on luxury vehicles and are not the station your covered auto is $5,000. wagon type. 2. We will declare your covered auto to 2. Standard Class. For purposes of this be a total loss if, in our judgment, the endorsement, Standard Class means cost to repair it would be greater than standard and full size 2— and 4—door its actual cash value minus its salvage cars that are not considered sports or value after the loss. luxury vehicles and are not the station wagon type. 3. If Car Replacement Assistance is shown on the Features Declarations for this 3. Multipassenger/Truck Class. For your covered auto, we will pay an purposes of this endorsement, additional 20% of the actual cash Multipassenger/Truck Class means: value of the vehicle at the time of a total loss. This additional amount: a. Sports, convertible and luxury cars of any size; a. Is separate from the limit available for loss to your covered auto b. Station wagons; under Comprehensive Coverage or Collision Coverage; and c. Minivans; b. Is available if the total loss is paid: d. Mid—size cargo and passenger vans; (1) Under this policy's e. Pickup trucks; and Comprehensive Coverage or Collision Coverage; or f. "Mini," small and midsize sport utility (2) Because of the PD by or on vehicles (SUVs) that are not behalf of persons or considered luxury SUVs. organizations who may be legally responsible. 4. Large SUV Class. For purposes of this endorsement, Large SUV Class means However, Car Replacement Assistance luxury SUVs of any size, large SUVs, does not apply to total loss to any any private passenger vehicle equipped nonowned vehicle. to assist the disabled (when available) and large cargo or passenger vans. Paragraph D. is replaced in its entirety by the following: A402(02) Rev. 05-14 Page 2 of 3 PAGE 10 USAA 00140 78 56 7 10 2 PART E - GENERAL PROVISIONS OUR RIGHT TO RECOVER PAYMENT The Our Right to Recover Payment section is amended to add the following: Our rights in this section do not apply with respect to amounts paid in excess of the actual cash value of your covered auto because of Car Replacement Assistance. Copyright, USAA, 2013. All rights reserved. A402(02) Rev. 05-14 Page 3 of 3 i PAGE 11 USAA 00140 78 56 7102 9800 Frede[ickshurg Road �[�^' �I San Antonio,Texas78288 UJ New Auto Policy Features Available for Purchase At USAA, we continuously look for ways to improve features and benefits of your insurance policy. We're pleased to let you know about two new auto policy features that can help you if you're involved in an accident: 1) Rental Reimbursement Coverage by vehicle class and 2) Car Replacement Assistance. • Rental Reimbursement Coverage Rental Reimbursement Coverage has changed. The current option of dollar limits per day for Rental Reimbursement Coverage is being replaced by vehicle class. The vehicle—class choices are: • Economy • Standard • Multipassenger/Truck • Large SUV How this change affects your current Rental Reimbursement Coverage Effective with this renewal, the Rental Reimbursement Coverage applicable to each vehicle on your policy has been converted as follows: • $30 per day to a maximum of $900 — Standard Class • $50 per day to a maximum of $1,500 — Multipassenger/Truck Class Please see your Declarations for the vehicle class that applies to your Rental Reimbursement Coverage. You may change the vehicle class at any time. • Car Replacement Assistance Regardless of the year and model of your car, Car Replacement Assistance will pay an additional 20% of the actual cash value of your vehicle at the time of a total loss. Please read the Amendatory Endorsement included with this renewal for more details about Rental Reimbursement Coverage and Car Replacement Assistance. Change the Rental Reimbursement Coverage vehicle class or purchase Car Replacement Assistance on usaa.com using the Change Coverage option once your renewal is in effect. If you prefer, you can make these changes to your policy by calling 210-531—USAA (8722), our mobile shortcut #8722 or 800-531-8722. It's our pleasure to help you with all your financial needs. 127562-0215 01 FEAFLRR(02) Rev. 04-15 PAGE 12 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) 531-8111. 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. N 52112-1006 663WA(06) Rev. 10-06 Page 1 of 4 P5.001407856.663WA.07102 PAGE 13 USAA 00140 78 56 7102 THIS PAGE INTENTIONALLY LEFT BLANK 663WA(06) Rev. 10-06 �h Page 2 of 4 PS.001407856.663WA.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. 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 ❑ 5 10,000 $200 wk./$10,000 max. $200 wk./$5,000 max. $2,000 $ 36.12 ❑ 5 10,000 $200 wk./$10,000 max. $280 wk./$14,600 max. $2,000 $ 37.12 ❑ S 10,000 $200 wk./510,000 max. $200 wk./S5,000 max. $5,000 $ 38.12 ❑ S 25,000 $200 wk./510,000 max. $280 wk./$14,600 max. $5,000 $ 58 .41 ❑ S 35,000 $700 wk./$35,000 max. $200 wk./$5,000 max. $2,000 $ 66 .60 ❑ S 50,000 $700 wk./$35,000 max. $280 wk./$14,600 max. $2,000 $ 76.66 ❑ $ 75,000 $700 wk./S35,000 max. $200 wk./55,000 max. $5,000 $ 86.77 ❑ S100,000 $700 wk.1S35,000 max. $280 wk./$14,600 max. $5,000 $ 99.94 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 M Page 3 of 4 PS.001407856.663WA.07102 LAST PAGE 15 USAA 00140 78 56 7102 THIS PAGE INTENTIONALLY LEFT BLANK 663WA(06) Rev. 10-06 Page 4 of 4 PS.001407856.663WA.07102