HomeMy WebLinkAboutPW18-049 - Original - Integra Washington, Inc. - Riverview Park LERRD Crediting Valuation Services - 02/05/2018 140
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KENTDocument
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:
JD Edwards Number
Contract Number: I` m -()Lil
This is assigned by City Clerk's Office
Project Name: Riverview Park LERRD Crediting
Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment x Contract
❑ Other.
Contract Effective Date: 2/5/ 8 Termination Date: 5/31/18
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: Phil Anderson Department: Engineering
Contract Amount: 17 000 00
Approval Authority: X Department Director ❑ (Mayor El City Council
Detail: (i.e. address, location, parcel number, tax id, etc,):
Provide valuation services for the project.
. _
As of, 08/27/14
KENT
PROFESSIONAL SERVICES AGREEMENT
between the City of Kent and
Integra Washington, Inc.
THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation
(hereinafter the "City"), and Integra Washington, Inc. organized under the laws of the State of
Washington, located and doing business at 600 University St., Suite 310, Seattle, WA 98101, Phone:
(206) 436-1177, 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 Riverview Park LERRD
Crediting. 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 May 31, 2018.
III. COMPENSATION. The City shall pay Contractor a total amount not to exceed Seventeen
Thousand Dollars ($17,000.00) 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)
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)
1. Counter arts 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. All acts consistent with the authority of this Agreement and prior
to its effective date are ratified and affirmed, and the terms of the Agreement shall be deemed
to have applied.
CONTRACTOR. CITY Of (CENT:
By B
(Sigry t ignIture)
P a me: 't Print dame: Timothy J. LaPorte, P.E.
Its: d.T1 Its: Public Works Director
DATE: DATE:
NOTICES TO BE SENT TO: NOTICES TO BE SENT TO:
CONTRACTOR: CITY OF KENT:
Lorii Safer Timothy J. LaPorte, P.E.
Integra Washington, Inc. City of Kent
600 University St., Suite #310: 220 Fourth Avenue South
Seattle, WA 98101 Kent, WA 98032
(206) 436-1177 (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 1, 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 n%/, A r�ON 20 -
By: Vz
Far; k
Title: �J a
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
Integra neaftVnes" rCe5 600 University Street ros.90m.a70o
Scule s"^*sxn roe soanz
� Seattle,mmox10z wwwirrcont
I Llirre
|
Janumry19, 2018
Phil Anderson
Property and Acquisition Analyst
City mfKent
Public Works Engineering
400 West Gowe
Kent,VVA98832'58,9S
SUBJECT; Proposal for Valuation Services
RivemievvParkPropertima—Zapprmisa|s
Dear Mr, Anderson:
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
appraisals are retrospective values,with an effective date of September 29, 2011.
We will provide two appraisal reports for the two properties in compliance with current Uniform
Appraisal Standards for Federal Land Acquisitions standards (UASFLA, also known as the Yellow
Book).Our fee for this assignment is$17,O0&
The appraisal and reports will also 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 WnifbnnStandards gf Professional Appraisal Practice(USPAP) developed bythe
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 asan
appraiser or in any other capacity. We have not performed any services,as an appraiser or in
any other capacity, regarding the property that |s the subject wf this report within the three-year
period immediately preceding acceptance wf this assignment.
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 qr make corrections as specified by
the reviewer.Two hard copies of the reports will be provided; additional copies of the report(s)
are available atan additional cost. The current minimum cost for each additional copy is$1UO
. .
� City ofKent
| January 1g. 2O18
|
Page
per copy. The report(s)will be completed and delivered to you within 60 days once we are
authorized to begin the appraiisa| mf 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 W11 be predicated upon
| the accuracy and completeness of the information provided by the Client. In the absence of
|
some pfthis 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.
� | look forward to your favoraWeconsideration.
Sincerely,
|wrsuxx REALTY RESOURCES—SE4rrLE
Lori Safer, MAU, IVIR|CS
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.
AC4 CERTIFICATE OF LIABILITY °ATF(MWDD/YYYY)
`� TY INSURANCE 3/29/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
'iRTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
.'ePRESENTATIVE 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(a).
PRODUCER Carrie Ovrid
Conover Insurance PHONEFt, (425)455-5000 FAX (43SI 1S4.55S0
155 108th Avenue NE, Suite 725 IL C..carrieo�coaoverinsuraace.com
P.O. Box 90007
INSURE S AFFORDING COVERAGE NAIC 0
Bellevue WA 98004 INSURER of Enumclaw Insurance 14761
INSURED
INSURER B
Integra Washington, Inc. , DBA: Integra Realty INSURER0:
600 University Street INSURER0:
Suite 310
INSURER E
Seattle WA 98101 INSURERF:
COVERAGES CERTIFICATE NUMBER:17-18 Master GIL 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
TR TYPE OF INSURANCE wvnlUCY NUMBER EFF Y EXP
MWDLIMITS
X COMMERCIAL GENERAL UABIUTY
� EACH OCCURRENCE ; 2,000,000
A CLAIMS�IADE L�J OCCUR PR S 100,000
X SOP0001383 3/14/2017 13/14/2018 MEDEXP Art Pmson) s 10,000
PERSONAL 3 ADV INJURY $
GEML AGGREGATE LIMIT APPLIESPER: GENERAL AGGREGATE f 4,000,000
X POLICY JECT LOC PRODUCTS-COMPrOPAGO 7 2,000,000
OTHER. Nan-owned f 2,000,000
UTOMOBlLEL1ABILnY SINGLELIMIT
$ 2,000,000
s ent
A ANY AUTO BODILY INJURY(Perparsan) ;
ALL OWNED SCHEDULED BOP0001383 3 14/2017 3 14/2018 BODILY INJURY(Per 3
AUTOS AUTOS X / / ( )
X HIRED AUTOS R NON-0VMEO PRPerOPS DAMAGE
AUTOS ;
S
X UMBRELLAOCCUR EACH OCCURRENCE s 1,000 000
A EXCESSUA LAB H
B CLAIMS-MADEAGGREGATE ; 1 000 000
=
DED RETENTION$ JUMC0000555 3/14/2017 3/14/2018
WORKERS COMPENSATION AND EMPLOYERS'UABILJTY YIN T H-
ANY PROPRIETOR/PARTNERMXECUTIVE 1fA stop (yap E.L.EACH ACCIDENT $ $ 000 000
OFFICER/MEMBER EXCLUDED? ❑NIA
A tr
(Maend��NH) BOP0001303 3/14/2017 3/14/2010 E.L.DISEASE-EA EMPLOYE $ 21000,000
DE und
SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s 2,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,AddMonal Remarks Schedule,may be attached 1/more spaca is required)
City of Kent are included as Additional Insureds. The following attached form applies: Additional Insured
per form BP 044E 0713.
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.
`ent, WA 98032
AUTHORIZED REPRESENTATIVE
Carrie Ovrid/COVRID
®1g88-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS029 r?manrr
POLICY NUMBER: BOP 0001383 06 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 Persons Or Organ Ization s :
CITY OF KENT
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Section If—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. Uability And Medical Expenses
Limits Of Insurance:
3. Any person(s) or organization(s) shown in the If coverage provided to the additional insured is
Schedule is also an additional insured, but only
with respect to liability for "bodily injury", required by a contract or agreement, the most we
"property damage"or personal and advertising will pay on behalf of the additional insured is the
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 0 Insurance Services Office, Inc., 2012 Page 1 of 1
�►cofro CERTIFICATE OF LIABILITY INSURANCE DATE(MM/oo`YYY")
2/2 1 12 0 1 7
giIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
__-1.RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
I ")LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy((es) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on
this certificate does not confer r( hts to the certificate holder In lieu of such endorsements.
PRODUCER LARealEstateCerts a' .com
rthur J. Gallagher f A.o. PHONE .818-539-1247 FAX 818-539-1804
Insurance Brokers of CA. Inc UC#0726293
5Q5 N. Brand Boulevard, Suite 600 armEE-MAIL .LARealEstateCerts@ajg.com
Glendale CA 91203
INSURERS AFFORDING COVERAGE NAIC s
INSUPERA:UnderwriterS at Lloyd's London 15792
INSURED INTEREA-03 INSURERB:APPRAISAL GUARDIAN SERIES OF FORTRE
Integra Washington, Inc. INSURER c
600 University Street#310
Seattle,WA 98101 INSURER D:
INSURER E:
INSURER F
COVERAGESCERTIFICATE NUMBER: 1182069887 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 I
POLICY EFF POIJCY EXP L TYPE OF INSURANCE IINSD 1= POLICY NUMBER LIMIT
COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S
CLAIMS-MADE OCCUR ''AMAG TO RENTED
PRE SEE a S
MED EXP( one person) $
PERSONAL&ADV INJURY f
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE f
POLICY JECTT LOC
PRODUCTS-COMP/OP AGG S
OTHER:
S
JTOMOBH.E LIABILITY
Ea aoddknt $
ANY AUTO BODILY INJURY(Per person) f
OWNED SCHEDULED
AUTOS ONLY AUTOSHIRED BODILY INJURY(Per accident) S
AUTOS ONLY AUTOS OONLYY ROPERTY GE
Peracddont S
f
it
UMBRELLA LIAR OCCUR
EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE f
DED RETENTION S f
WORKERS COMPENSATION P H-
AND EMPLOYERS'LIABILRY Y 1 N AT ER
ANY PROPRIEfOIt/PARTNER/EXECUTIVE f E.L.EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED7 ❑ N/A
(Mandatory In under
E.L.DISEASE-EA EMPLOYE S
11 yas,describea ands
DESCRIPTION OF OPERATIONS below i E.l DISEASE-POLICY LIMIT S
A Errors&Omissions MPLI531199.17
A Errors&Omissions 3/14/2017 3/14/2018 Each Claim $2,000,000
MPL1531199.17 3/14/20i7 3/14/2018 Agggregate Limit i10,000,000
B 'E&O Deductible Reimbursement 'PRFOR46APP200306922015TC 3114/2017 3/14/2018 Ea ClaimlAggrogate• $150,000
DESCRIPTIONon_ OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space b required)
Locati600 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
City of Kent THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
220 Fourth Avenue ACCORDANCE WITH THE POLICY PROVISIONS.
Kent WA 98032
USA
--^--� AUTH REPRESENTATIVE
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
PXE 1
MAIL MCH-M-I
Y1392
SERTBVBER 26, 2017
.SAA® 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 2017 TO MAY 01 2018
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.usaacom/autorecall
to learn more.
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 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://itcanwait.usaacom 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.
Please see the attached Amendment of Policy Provisions, A200WA, for changes
to your auto policy.
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
PPGE 2
THIS PAGE INTENTIONALLY LEFT BLANK
PACE 3
USAA 00140 78 56 7102 2
AUTOMOBILE POLICY PACKET CONTINUED
The Guaranteed Renewal Endorsement is no longer offered in your location.
For details, please review the enclosed Important Notice form.
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
PAGE 4
WASHINGTON INSURANCE IDENTIFICATION CARD WASHINGTON INSURANCE IDENTIFICATION CARD
UNTED SBR/ AUTOMOBILE ASSN I UNTED SERVICES AUTON OBLE ASSN
NAME OF INSURED I ORI E SAFER i NAME OF INSURED ALLM N SAFER
NTEGRA WASHIIS TON INC ; MARTIN T SAFER
POLICY NUMBER 00140 78 56U 7102 2 POLICY NUMBER 00140 78 56U 7102 2
EFFECTNEDATE 11/01/17 EXPIRATTONDATE 05/01/18 EFFECTIVEDATE 11/01/17 EXPIRATTONDATE 05/01/18
VEHICLE DESCRIP nON ; VEHICLE DESCRIP110N
YEAR MAIEM10DEL i YEAR MAKEMIODEL
2010 TOYOTA PRIUS HYB 4D 2006 &EARIJ OUTBACK
VEHICLE IDENTIFICATION NUMBER VEHICLE IDENTIFICATION NUMBER
JTDKNML AD041891 4S4131361 C367319002
9800 Fredericksburg Road San Antonio,Texas 78288 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) CONTACT US: 210-531-USAA(8722)
OR 800-531-USAA OR 800-531-USAA
i
i
- - - - -- - ----- ---- - --- -- -- - --- -- -- - --- - -- -- -- - -- ---- -- -- - ------ ---- -- - ---- - --- -
09/26/17
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
UNTIED SB:RVf>✓ES AUTOMOBLE ASSN
NAME OF INSURED A-LEN N SAFER
LCRI E SAFER
POUCYNUMBER 00140 78 56U 7102 2
EFFEC IVE DATE 11/01/17 EXPIRATION DATE 05/01/18
VEHICLE DESCRIPTION '
YEAR MAKEMODR '
2008 SURARI J 89 TRIBEGA '
VEHICLE IDENTIFICATION NUMBER i
4S4WX90D584411357
^900 Fredericksburg Road San Antonio,Texas 78288 i
i
Additional copies available at usaa.com
i
CONTACT US: 210-531-USAA(8722)
OR 800-531-USAA
PPGE 5
UNITED SERVICES AUTOMOBILE ASSOCIATION ADDL INFO ON NEXT PAGE MAIL MCH-M-1
RENEWAL OF
(A RECIPROCAL INTERINSURANCE EXCHANGE) FWA
te 13 14 15 W, PCL ICY NUN43ER
DA®US 9800 Fredericksburg Road-San Antonio,Texas 78288 62 6212621 1 Ten 00140 78 5 6 U 7102 2
WASHINGTON AUTO POLICY POLICYPERIOD: (12:01 AM. standard time)
RENEWAL DECLARATIONS EFFECTIVE NOV 01 2017 TO MAY 01 2018
(ATTACH O PREVIOUS ICY 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 VehiC e s VEH USE*
'es
VEH I YEA TRADE NAME MODEL BODYTYPEANNUAL MILEAGE
IDENTIFICATION NUMBER SYM
13 10 TOYOTA PRIUS HYB 4D 4 DOOR 10000 JTDKN3DU8A0041891 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. wlC=wmwSt d:B=Business•Ff m•P=Plessure
VEH 13 SEATTLE WA 98105-2139 VEH 15 SEATTLE WA 98105-2139
VEH 14 SEATTLE WA 98105-2139
This policy provides ONLY ose coverage where a premium is shown below. a limits shown
max a reduced by policy provisions an 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 $ NMOUNT MOUNT MOUNT $
PART A - LIABILITY
F - ILY INJURY EA PER $ 500, 00
EA ACC $1, 000, OOC 127 . 42 102 . 52 87 . 3
PROPERTY DAMAGE EA ACC $ 100, OOC 79 . 50 75 . 75 73 . 2
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 16 . 66 13 . 64 11. 03
PART C - UNDERINSURED MOTORISTS
BODILY INJURY EA PER $ 500 , 0013
EA ACC $1, 000 , 0010 46 . 12 42 . 89 42 . 8
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 11-01-17 - A200WA(01)
REMAIN IN EFFECT(REFER TO PREVIOUS POLICY) - ACCFOR(01) A402 (02) A074WA(01)
RSGPWA(01) 5100WA(02)
INFORMATION FORMS: GR(01) 663WA(06) 999WA(25)
F2
N 1s `RSM24 00 01 I I I 11 ji'. 41RMM66 00 01 I I I I I ji.v 51RMF60 00 0
n WITNESS WHEREOF,the Subscribers at UNITED SERVICES AU I OMOBILE ASSOCIATION have caused these� presents to sign by
their Attorney-in-Fact on this date SEPTEMBER 26, 2017 �j� -
WTQ-
Laura Bishop
President, USAA Reciprocal Attomey-in-Fact, Inc.
5000 U 07-11
53461-07-11
PAGE 6
UNITED SERVICES AUTOMOBILE ASSOCIATION
(A RECIPROCAL INTERINSURANCE EXCHANGES R
tate 13 14 15 Wh POLICY NUMBER
9800 Fredericksburg Road-San Antonio,Texas 78288 A 6 2 6 2 2 6 2 Terr 0 014 0 7 8 5 6U 7102 2
WASHINGTON AUTO POLICY POLI YPERIOD: (12:01 A.M.standard time)
RENEWAL DECLARATIONS EFFECTIVE NOV 01 2017 TO MAY 01 2018
(ATTACH TO PREVIOUS LICY
Named Insured and Address
ALLEN N SAFER
5221 PULLMAN AVE NE
SEATTLE WA 98105-2139
Description o e IC e s VEH USE' es
WHIYEA11 TRADE NAME MODEL BODYTYPE 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. wr�wal�,a,oa r P-P+ e
VEH 13 SEATTLE WA 98105-2139 VEH 15 SEATTLE WA 98105-2139
VEH 14 SEATTLE WA 98105-2139
This o Icy prove es t ose coverage w ere a premium Is shown ow. a limits shown
may be reduced by policy provisions N may not be combined regardless of the number of
vehicles for which a premium is listed unless specificalIv authorized elsewhere in this Dolic .
COVERAGES LIMITS OF LIABILITY 13 6-MONTH 14 6-MONTH 15 6-MONTH
("ACV"MEANS ACTUAL CASH VALUE) D=DED I PREMIUM D=DED PREMIUM D=DED PREMIUM D=DED PREMIUM
MOUNT $ MOUNT $ MOUNT $ MOUNT $
PART C - UNDERINSURED MOTORISTS
- ROPERTY DAMAGE EA ACC $ 10, 000 5 . 53 5 . 14 5 .14
l: :r D - PHYSICAL DAMAGE COVERAGE
COMPREHENSIVE LOSS ACV LESS D 300 51 . 76D 300 23 . 60D 300 24 .2
COLLISION LOSS ACV LESS D 500 131 .71D 500 90 . 18D 500 92 . 0
RENTAL REIMBURSEMENT
STANDARD CLASS 12 . 50 12 . 5
EHICLE TOTAL PREMIUM. 471.20 353 . 72 348 . 3
6 MONTH PREMIUM $ 1173 . 30
PREMIUM DUE AT INCEPTION. THIS IS NOT A BILL, STATEMENT 10 FOLLOW.
EARNED ACCIDENT FORGIVENESS APPLIES WITH FIVE YEARS CLEAN DRIVING WITH US AA.
THE PREMIUM ON YOUR RENEWING POLIO IS $ 103 . 80 MORE 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 LABOR
VEH 15 - TOWING AND LABOR
E-pf3j RSM24POOPOI I I I I 101 RMM66 00 0 H 51 RMF60 00 0
n WITNESS WHEREOF,the Subscribers at UNITED SER ICES AUTOMOBILE ASSOCIATION have caused these presents to De signed by
their Attorney-in-Fact on this date SEPTEMBER 26 , 2017
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
US/a1A® EFFECTIVE NOV 01 2017 TO MAY 01 2018
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 . 64
MULTI-CAR DISCOUNT -$ 73 . 78
OCCASIONAL OPERATOR DISCOUNT -$ 64 . 66
OPERATOR 08
PASSIVE RESTRAINT DISCOUNT -$ 2 .45
PREMIER DRIVER LEVEL DISCOUNT -$ 73 . 78
VEHICLE 14
ANNUAL MILEAGE DISCOUNT -$ 23 . 56
DAYTIME RUNNING LIGHTS DISCOUNT -$ 2 . 35
MULTI-CAR DISCOUNT -$ 55 . 25
PASSIVE RESTRAINT DISCOUNT -$ 1 . 92
PREMIER DRIVER LEVEL DISCOUNT -$ 55 . 25
VEHICLE 15
ANNUAL MILEAGE DISCOUNT -$ 22 . 22
DAYTIME RUNNING LIGHTS DISCOUNT -$ 2 .41
MULTI-CAR DISCOUNT -$ 52 .12
PASSIVE RESTRAINT DISCOUNT -$ 1 .46
PREMIER DRIVER LEVEL DISCOUNT -$ 52 . 12
SUPDECCW Rev. 7-95 SEPTEMBER 26, 2017
PAGE 8
USAA 00140 78 56 7102
AMENDMENT OF POLICY PROVISIONS
This Amendment forms a part of the auto policy to which it is attached, and it modifies that policy as
follows:
DEFINITIONS
The following definition P. is added:
P. Diminution in value means the actual or
perceived loss in market or resale value,
which results from a direct and accidental
loss.
PART C - UNDERINSURED MOTORISTS COVERAGE
(referred to as UIM Coverage)
EXCLUSIONS
The following exclusion is added:
E. We do not provide PD Coverage sustained
by any insured for diminution in value
for your covered auto.
PART D - PHYSICAL DAMAGE COVERAGE
DEFINITIONS EXCLUSIONS
The following definition is amended: The following exclusion is added:
D. "Loss" means direct and accidental damage 14.Loss to your covered auto,
to the operational safety, function, or non-owned auto, or trailer, for
appearance of, or theft of, your covered diminution in value.
auto or personal property contained in
your covered auto. Loss includes a total
loss, but does not include any damage other
than the cost to repair or replace. Loss
does not include any loss of use, or
diminution in value that would remain
after repair or replacement of the damaged
or stolen property.
130590-0316_01
A200WA(01) 06-16 Page 1 of 1
PAGE 9
USAA 00140 78 56 7102
IMPORTANT NOTICE
Thank you for trusting us with your auto insurance needs. We're writing to let you know that the
Guaranteed Renewal endorsement is no longer available in your location. Because we want to continue
offering a competitively priced auto product for all members and to be the provider of choice for
auto insurance, USAA has made the decision to not offer this endorsement in your location.
No action is needed on your part, but if you have questions about your policy or this change, please
call us at 210-531-USAA (8722), our mobile shortcut #8722 or 800-531-8722.
As always, we appreciate the opportunity to serve you.
131823-0817_01
GR(01) 08-17 Page 1 of 1
PAGE 10
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.
` 52112-1006
663WA(06) Rev. 10-06 �R Page 1 of 4
PS.001407856.663WA.07102
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)
s
663WA(06) Rev. 10-06 Page 2 of 4
PS.001407856.663WA.07102
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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
❑ $ 10,000 $200 wk./$10,000 max. $200 wk./$5,000 max. $2,000 $ 41.33
❑ $ 10,000 $200 wk./$10,000 max. $280 wk./$14,600 max. $2,000 $ 42.49
❑ $ 10,000 $200 wk./$10,000 max. $200 wk./$5,000 max. $5,000 $ 43.64
0 $ 25,000 $200 wk./$10,000 max. $280 wk./$14,600 max. $5,000 $ 67.08
❑ $ 35,000 $700 wk./$35,000 max. $200 wk./$5,000 max. $2,000 $ 76.54
❑ $ 50,000 $700 wk./$35,000 max. $280 wk./$14,600 max. $2,000 $ 88.18
❑ $ 75,000 $700 wk./$35,000 max. $200 wk./$5,000 max. $5,000 $ 99.86
❑ $100,000 $700 wk./$35,000 max. $280 wk./$14,600 max. $5,000 $ 115.07
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 .d" Page 3 of 4
PS.001407856.663WA.07102
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1
663WA(06) Rev. 10-06 Page 4 of 4
PS.001407856.663WA.07102
PAGE 14
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 210-531-USAA (8722), our mobile shortcut #8722 or
800-531-8722. 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.
53652-0217_03
999WA(25) Rev. 12-16 Page 1 of 4
PS.001407856.999WA.07102
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r
999WA(25) Rev. 12-16 Page 2 of 4
PS.001407856.999WA.07102
• PAGE 16
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 $ 60.24 ❑ $ 300,000/$ 500,000 $ 121.66
❑ $ 50,000/S 100,000 $ 80.70 ❑ S 500,000/S 500,000 S 130.70
❑ S 100,000/$ 200,000 $ 110.83 ❑ $ 500,000/$1,000,000 $ 131.90
❑ $ 100,000/S 300,000 $ 111.42 ❑ $ 1,000,000/S 1,000,000 $ 152.38
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
In order to provide for an informed decision of the potential consequences of rejecting
underinsured motorist coverage; the undersigned acknowledges that by rejecting underinsured
motorist coverage there is exposure to the risk of not being sufficiently insured for injury
and/or damages when involved in an accident with a driver of an underinsured vehicle.
USAA Number Signature of Named Insured
Home Phone Alternative Phone Date
999WA(25) Rev. 12-16 Page 3 of 4
PS.001407856.999WA.07102
p LAST PAGE 17
USAA 00140 78 56 7102
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(25) Rev. 12-16 Page 4 of 4
PS.001407856.999WA.07102