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Home My WebLink AboutPW18-058 - Original - A Touch of Magic - H2O 2018 Water Festival - 01/03/2018 %' Records M , /n � e me, DENT Document . WASH I I O TO N' / CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerics Office., All portions are to be completed. If' you have questions, please contact City Clerk's office. Vendor Name: A Touch of Magic Vendor Number: JD Edwards Number Contract Number: m _ qc This is assigned by City Clerk's Office Project Name: H2O - 2018 Water Festival Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment x Contract ❑ Other: Contract Effective bate: 2/12/18 Termination mate: 3/30/18 Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: Gina Hun erford Department: Engineering Contract Amount: 2,500.00 Approval Authority: X Department Director ❑ Mayor ❑ City Council Detail: (i.e. address, location, parcel number, tax id, etc.): Present up to six presentations at the festival. As of: 08/27/14 CITY OF KENT PERFORMANCE AGREEMENT THIS AGREEMENT is dated January 3, 2018, and is between Steffan Soule, A Touch of Magic ("Presenter") and THE CITY OF KENT, a Washington municipal corporation ("City"). In consideration of the covenants and agreements set forth herein, the parties agree as follows: 1. DESCRIPTION. The Presenter agrees to present up to six 20 to 25-minute presentations at Kent's H2O-2018 Water Festival at Green River Community College, 12401 SE 320t" Street, Auburn, WA 98092-3622 on March 27, 2018 ("Presentation"). The Presentation is described in the Scope of Work, attached as Exhibit A and incorporated by this reference. 2. COMPENSATION. The City shall pay Presenter the total sum of Two Thousand, Five Hundred Dollars ($2,500.00) for the work to be performed under this Agreement, upon satisfactory completion of all services and requirements specified in this Agreement. 3. LOCATION. The City agrees, at its own expense to provide the location for the Presentation. 4. IMPOSSIBILITY OF PERFORMANCE. The parties agree that the Presentation shall take place rain or shine. The Presenter shall be under no liability for failure to appear or perform in the event that such a failure is caused by or due to acts or regulations of public authorities, labor difficulties, civil tumult, strike, epidemic, or if such failure is caused by a "superior force"(s) defined under Washington law. 5. NOTICES. Any notice or information required or permitted to be given to the parties under this Agreement may be sent to the following addresses unless otherwise specified: a. CITY OF KENT b. Attn: Timothy J. LaPorte, P.E. c. 220 Fourth Avenue South d. Kent, WA 98032 e. PRESENTER f. Steffan Soule, A Touch of Magic. 6. INDEMNIFICATION. Presenter 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 Vendor's performance of this Agreement, except for that portion of the injuries and damages caused by the City's negligence. 7. INSURANCE. The Vendor shall procure and maintain for the duration of the Agreement, insurance of the types and in the amounts described in Exhibit B. 8. WORK PERFORMED AT PRESENTER'S RISK. Presenter shall take all necessary precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the performance of the contract work and shall utilize all protection necessary for that purpose. All work shall be done at Presenter's own risk, and Presenter 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. 9. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party thirty (30) calendar days' written notice at its address set forth in Section 5. 10. 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 Presenter. 11. ENTIRE AGREEMENT. This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof. No prior or contemporaneous representation, inducement, promise, or agreement between or among the parties which relate to the subject matter hereof which are not embodied in this Agreement shall be of any force or effect. 12, GOVERNING LAW. This Agreement shall be governed by and construed in accordance with the laws of Washington. 13. COUNTERPARTS AND SIGNATURES BY FAX OR EMAIL. This Agreement may be executed in any number of counterparts, each of which shall constitute an original, and all of this 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 THEREOF the parties hereto have executed this agreement. C$Y PRESENTE R F E R 10 41;Z1 � -Z Signed Oate Sigited ate Michael Mactutis, P.E., Environmental Engineering Manager C— PP ON S1W k/A 220 Fourth Avenue South, Kent, WA 98032 'OoX Address (253)856-5500 C%< Phone i EXHIBIT A Steffan Soule _\1 A Touch 2452-60th Ave SE Mercer Island, WA 98040 17j) ' (206) 232-9129 o f Magic 12/19/2017 Scope for 20180327 Gina Hungerford Public Works Department 220 Fourth Avenue South Kent, WA 98032 ghungerford@KentWa.gov Dear Gina, This is in response to your request for the Scope of Work. If you require more from us, please let me know. WHO: A Touch of Magic, Inc - 2452 60th Ave SE, Mercer Island, WA 98040, Tax ID #91-1653793; Phone: 206-232-9129, email: magic@steffansoule.com. WHAT: Steffan Soule Performs one and up to six 20-25 minute magical presentations entitled "Environmental Magic" at the 2018 Planet Protectors Summit, hosted by the City of Kent at Green River Community College on March 27, 2018. COST: Total is $2500.00 for the one day event, all inclusive. The Magic Presentation teaches students about the value of water, recycling and earth science in a fun and entertaining way. During the presentation, students learn that we are Caretakers of the Planet and how to care for our water and our materials that can be recycled including compost. The audience primarily observes and several volunteers participate on stage (3-6 students) in each session; all safety precautions are taken; approx. 800-1000 students will sit in on these fun, educational sessions during the one day event. I Thank you, Steffan Soule President A Touch of Magic i i EXHIBIT B INSURANCE REQUIREMENTS FOR PERFORMANCE 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 Commercial General Liability insurance shall be endorsed to provide the Aggregate Per Project Endorsement ISO form CG 25 03 11 85. There shall be no endorsement or modification of the Commercial General Liability insurance for liability arising from explosion, collapse or underground property damage. 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. 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, $1,000,000 general aggregate and a $1,000,000 products-completed operations aggregate limit. EXHIBIT B (Continued) 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 Consultant before commencement of the work. F. Subcontractors Consultant shall include all subcontractors as insureds under its policies or shall furnish separate certificates and endorsements for each subcontractor. All coverages for subcontractors shall be subject to all of the same insurance requirements as stated herein for the Consultant. DATE(MM/DD/YYYY) ncoRb? CERTIFICATE OF LIABILITY INSURANCE 01l29l201 8 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the Certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Kimberly Rice HMK Insurance PHONE (610)868-8507 (610)868-7604 10'No. Ext: AlC No): 54 South Commerce Way E-MAIL-ADDRE s: Suite 150 INSURER($)AFFORDING COVERAGE NAIC M Bethlehem PA 18017 INSURER A: Atlantic Specialty Insurance Company 27154 INSURED INSURER B: Intemational Brotherhood of Magicians and INSURER C: Steffan Soule INSURER D: 2452 60th Ave SE INSURER E: Mercer Island WA 98040 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1772134545 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. IINSLTR TYPE OF INSURANCE INSD AULJLrU V POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS x COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1.000,000 CLAIMS-MADE a OCCUR PREMISES Ea occurrence S 100,000 MED EXP(Any oneperson) S 5,000 A GLO1057-08 08/15/2017 08/15/2018 PERSONAL&AOV INJURY S 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 7 ECT LOC PRODUCTS-COMP/OPAGG S 1,ODQ000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Me accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAG $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE s EXCESS LIAB HCLAIMS-MADE AGGREGATE S DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STAT TE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) Additional Insured: The City of Kent Effective Date: 0 112 9/2 01 8 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Kent Attn: Timothy J LaPorte PE ACCORDANCE WITH THE POLICY PROVISIONS. 220 4th Avenue S AUTHORIZED REPRESENTATIVE Kent WA 98032 71Wmao R 1 j r / a(1` i f 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) ACORN CERTIFICATE OF LIABILITY INSURANCE 01/29/201 B THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Kimberly Rice HMK Insurance PHONfE o.Ext. (610)868-8507 FAXA/C No: (610)868-7604 54 South Commerce Way ADDRESS: Suite 150 INSURER(S)AFFORDING COVERAGE NAIC f Bethlehem PA 18017 INSURER A: Atlantic Specialty Insurance Company 27154 INSURED INSURER B: International Brotherhood of Magicians and INSURER C: Steffan Soule INSURER D: 2452 60th Ave SE INSURER E: Mercer Island WA 98040 INSURER F. COVERAGES CERTIFICATE NUMBER: CL1772134545 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. TR TYPE OF INSURANCE INSD p POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence S 100,000 MED EXP(An one person) $ 5,000 A GLO1057-08 08/15/2017 08115/2018 PERSONAL&ADV INJURY s 1,000,000 AGGRE GATE GENERAL AGGREGATE $ 2,000,000 POLICY F PRO-JECT LOC PRODUCTS-COMPIOPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMA E $ AUTOS ONLY AUTOSONLY Peraccident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DEO I I RETENTION$ $ OTH- WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N J A E.L.EACH ACCIDENT s OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Additional Insured: The City of Kent Effective Date: 01/29/2018 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Kent Attn: Timothy J LaPorte PE ACCORDANCE WITH THE POLICY PROVISIONS. 220 4th Avenue S AUTHORIZED REPRESENTATIVE Kent WA 98032 7ht maa 14cnfz % r` 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: GLO1057-08(IBM) COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s): The City of Kent Re: Steffan Soule Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for"bodily injury", "property If coverage provided to the additional insured is damage or personal and advertising injury' required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement; or or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the insured only applies to the extent permitted by Declarations. law; and 2. 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. CG 20 26 0413 C Insurance Services Office, Inc., 2012 Page 1 of 1 PEMCO 1300 Dexter Avenue N PEMCO Auto Policy Insurance Seattle,WA 98109.3571 Renewal Declarations PEMCO Mutual Insurance Company Policy Number CA 1227577 EFFECTIVE DATE EXPIRATION DATE Valued Customer Since 12/23/17 12/23/18 2009 12:01 A.M. PACIFIC STANDARD TIME Named Insureds: This is your Auto insurance renewal.Your proofof-insurance and identification cords are enclosed. STEFFAN SOULE Thank you for choosing PEMCO. BARBARA A. HALLIDAY PMB 526 316 SE PIONEER WAY OAK HARBOR WA 98277-5716 t Please verify all information. Make your changes on line at pemco.com or call 1-800-GO-PEMCO (1-800-467-3626). 2005 CHEVROLET ASTRO VIN 1GNELl9XX5B127120 COVERAGES Limits/Deductible Premium Bodily Injury $250,000 each person/$500,000 each occurrence $137.94 Property Damage Liability $100,000 each occurrence $86.19 Underinsured Motorist Bodily Injury $250,000 each person/$500,000 each occurrence $93.66 Underinsured Motorist Property Damage $100,000 each occurrence $8.78 Personal Injury Protection $10,000 $53.26 Loss of Income $200 max per week/$10,400 max per occurrence each person Included Collision Deductible: $500 $89.43 Comprehensive Deductible: $100 $67.44 Auto Loan/Lease Not Selected Towing $100 $9.18 Rental Reimbursement $30 per day/$900 per occurrence $20.48 Stereo/Communication Equipment Not Selected Customized Equipment Not Selected Rideshore Not Applicable Vehicle Premium $566.36 Garaging Address:760 Lo Cana St,Coupeville, WA 98239-9787 Estimated Annual Mileage: 8,000-9,999 1997 BUICK LESABRE CUSTOM VIN 1G4HP52K6VH526308 COVERAGES Limits/Deductible Premium Bodily Injury $250,000 each person/$500,000 each occurrence $119.21 Property Damage Liability $100,000 each occurrence $70.95 Underinsured Motorist Bodily Injury $250,000 each person/$500,000 each occurrence $78.05 Underinsured Motorist Property Damage $100,000 each occurrence $7.31 Personal Injury Protection $10,000 $30.47 Loss of Income $200 max per week/$10,400 max per occurrence each person Included Collision Not Selected Comprehensive Deductible: $100 $35.22 Auto Loan/Lease Not Selected Towing Not Selected Rental Reimbursement Not Selected Auto Declarations 12/2016 Questions?Check our Customer Support site at pemco.com,make your changes online or call 1-800-GO-PEMCO(1-800.467-3626). Page 1 of 3 COVERAGES (continued) Limits/Deductible Premium Stereo/Communication Equipment Not Selected Customized Equipment Not Selected Rideshore Not Applicable Vehicle Premium $341.21 Garaging Address: 760 Lo Cana St, Coupeville,WA 98239-9787 Estimated Annual Mileage: 8,000-9,999 Vehicle Discounts:Airbag Both Driver and Passenger 2005 DODGE GRAND CARAVAN SE VIN 1 DAGP24R25B231947 COVERAGES Limits/Deductible Premium Bodily Injury $250,000 each person/$500,000 each occurrence $127.73 Property Damage Liability $100,000 each occurrence $79.80 Underinsured Motorist Bodily Injury $250,000 each person/$500,000 each occurrence $78.05 Underinsured Motorist Property Damage $100,000 each occurrence $7.31 Personal Injury Protection $10,000 $61.86 Loss of Income $200 max per week/$10,400 max per occurrence each person Included Collision Not Selected Comprehensive Deductible: $100 $48.87 Auto Loan/Lease Not Selected Towing Not Selected Rental Reimbursement Not Selected Stereo/Communication Equipment Not Selected Customized Equipment Not Selected Rideshare Not Applicable Vehicle Premium $403.62 Garaging Address: 760 La Cana St,Coupeville,WA 98239-9787 Estimated Annual Mileage: 8,000.9,999 Previous policy premium $1,369.07 Total Policy Premium $1,311.19 THE FOLLOWING DISCOUNTS ARE BEING APPLIED TO THIS POLICY Airbag Both Driver and Passenger Auto Plus Homeowner Homeownership Loyal Auto Customer Multiple Car DRIVER AND HOUSEHOLD INFORMATION Drivers Rated on This Policy Steffan Soule Qualifies for Accident Forgiveness Qualifies For Minor Ticket Forgiveness Barbara A. Halliday Qualifies for Accident Forgiveness Qualifies for Minor Ticket Forgiveness POLICY FORMS AND ENDORSEMENTS Edition Form date Endorsement Vehicle PAE-04 09/15 Ridesharing and Corsharing Endorsement All 14.95 09/17 Auto Policy Contract All All existing endorsements and exclusions remain in effect. Auto Declarations 12/2016 Questions?Check our Customer Support site at pemco.com,make your changes online or call 1-800-GO-PEMCO(1-800-467-3626). Page 2 of 3 o Representative:Skyway Security Insurance,Jim Hale,206-232-7355 Executive: Stan McNaughton PEMCO President and CEO Auto Declarations 12/2016 Questions?Check our Customer Support site at pemco.com,make your changes online or call 1.800-00-PEMCO(1-800-067-3626). Page 3 of 3