18-001 The Cheeseballs C!'TY OF
No.
FY2018-19
�UPERTB[+1U
RECREATION SERVICES AGREEMENT
1. Parties.This contract is made and entered into as of 7/12/2018("Effective Date"),by and
between the City of Cupertino, a municipal corporation ("City"), and with THE CHEESEBALLS LLC,
10185 N.STELLING ROAD CUPERTINO,CA 95014("Contractor"), a BAND for SUMMER CONCERT.
2. Services.Contractor agrees to provide the Services included in the Scope of Work and
in accordance with the Schedule of Performance attached in Exhibit A.
3. Term. This contract begins on the Effective Date and ends on 7/12/2018 ("Contract
Time"), unless extended or terminated as provided herein. Time is of the essence and Contractor must
have sufficient time, resources, and qualified staff to deliver the Services as required. Contractor must
promptly notify City of any actual or potential delays to afford the Parties adequate opportunity to
address or mitigate such delays.
4. Compensation. City will pay Contractor for satisfactory performance of the Services an
amount that will based upon actual costs but that will be capped so as not to e�ceed$$3,000 ("Contract
Price"),based upon the Scope of Services,budget, performance schedule, and rates included in Exhibit
A. The maximum compensation includes all costs, expenses and reimbursements and will remain in
place even if Contractor's actual costs exceed the capped amount. Contractor must submit invoices and
the information required in Exhibit A in order to receive payment. City will compensate Contractor
within 30 days after approval of written invoices.
Invoices are subject to review and audit by City during regular business hours upon 24-hours'
notice. Contractor must maintain complete and accurate records of payrolls, expenditures,
disbursements and other cost items charged to City or establishing the basis for an invoice, for a
minimum of four (4) years from the date of final payment.
5. Independent Contractor.Contractor is an independent Contractor and not an employee,
partner, or joint venture of City. Contractor is solely responsible for the means and methods of
performing the Services and for the persons hired to work under this Agreement.No civil service status
or other right of employment will be acquired by virtue of Contractor's performance of the Services.
Contractor is not entitled to City's health benefits, worker's compensation or any other benefit.
Contractor must have the skills and qualifications to perform the Services in a competent and
professional rnanner. Contractor will supply all tools, materials and equipment required to perform
the Services under this Contract. Contractor is responsible for obtaining permits and licenses required
by law and must obtain a City business license.
Recreation Services Agreement/Rev. 3-27-2018
Page 1 of 6
' 6. Proprietary/Confidential Information.To the extent Contractor may have access to
private or confidential information owned or controlled by the City, Contractor agrees to treat it
confidential and use it solely to perform this Agreement. Contractor must exercise the same standard
of care to protect City information as a reasonably prudent Contractor would use to protect its own
proprietary data.
7. Ownership of Materials.To the extent Contractor prepares written material, drawings
or data in connection with this contract, City will have the property rights to those materials and all
copyrights, if any, to such work product will constitute City property.
8. Records. Contractor must maintain complete,accurate, and detailed accounting records
relating to its performance in accordance with generally accepted accounting principles and
procedures. The records must include detailed information about Contractor's services, benchmarks,
deliverables and costs/fees,and must be made reasonably available to City.The records and supporting
documents must be kept separate from other files and maintained for four years from the date of City's
final payment.
9. Assignment. This Contract is not assignable. Contractor may not substitute another or
transfer any rights or obligations under this Contract without prior written approval of City.Only those
persons whose names are included in Exhibit A may perform the Services.
10. Publicity and Signs.Any publicity generated by Contractor related to this contract or
the Services during the Contract Time and for one year thereafter must reference City contributions.
The words "City of Cupertino" shall be displayed in all pieces of publicity, including flyers, press
releases, posters, brochures, public service announcements, interviews and newspaper articles. No
signs rnay be posted, exhibited or displayed on or about City property, except signage required by law
or under this Agreement without prior written approval from City.
11. Indemnification. To the fullest extent allowed by law and except for losses caused by
the sole negligence or willful misconduct of City personnel, Contractor agrees to indemnify, defend,
and hold harmless the City, its City Council, boards and commissions, officers, officials, employees,
agents, servants, volunteers and Contractors (collectively, "Indemnitees"), through legal counsel
acceptable to City, from and against any liability for damages, claims, actions, causes of action,
demands, charges, losses, costs and expenses (including attorney fees, legal costs and expenses related
to litigation, arbitrations, administrative and regulatory proceedings), of every nature, arising out of or
in any way related to Contractor's or Contractor's agents performance of this contract or the Services.
This includes but is not limited to Liability resulting in personal injury, death, property damage, or
economic losses. Contractor must pay any costs City may incur in enforcing this provision and must
accept a tender of defense upon receiving notice from City. Contractor's payrnents may be deducted or
offset to cover any money the City lost due to a claim or counterclaim arising out of this Contract.
12. Insurance. Contractor shall comply with the insurance requirements in Exhibit B. City
will not execute the Agreement until it has received and approved satisfactory certificates of insurance
and endorsements evidencing the type, amount, and dates of coverage. Alternatively, City in its sole
discretion may purchase insurance and deduct the costs from payments to Contractor,or terminate the
contract.
Recreation Services Agreement/Rev. 3-27-2018
Page 2 of 6
13. Cornpliance with Laws and Other City Requirements.
Requirements for all Contracts. This contract is subject to local, state and federal laws and
regulations prohibiting discrimination,including Title VII of the Civil Rights Act of 1964,the California
Fair Employment Practices Act,the Americans with Disabilities Act of 1990,and other laws that pertain
to fair employment and anti-discrimination practices. Contractor must comply with labor laws
pertaining to prevailing wages, working hours, overtime, payroll records, and other requirements
imposed by the Department of Industrial Relations.If Contractor does not have ernployees,it must sign
the Affidavit of No Employees, attached as Exhibit C. Contractor is responsible for verifying
employment eligibility of employees pursuant to the Immigration Reform and Control Act of 1986.
Contractor must comply with conflict of interest laws and regulations applicable to this Agreement and
avoid conflicts of interest. Contractor may be required to file a conflict of interest form for engaging in
governmental decisions or serving in a staff capacity, and is hereby advised to review the requirements
of California Political Reform Act and the California Code of Regulations. Services may only be
performed by persons who are not employed by City and who do not have a contractual relationship
with City other than this contract. Contractor agrees to abide by City policies and administrative rules
prohibiting gifts to City officials and employees.
Additional Requirements for Services Provided to Minors: Contractor and its employees
who provide services under this Agreement must comply with these additional requirements:
A. Undergo fingerprinting and a criminal background check and verify all employees
providing services under this contract have met this requirement.
B. Complete a Tuberculosis screening test as required by law and as set forth in Exhibit D.
C. Comply with the Mandatory Reporting under California Penal Code 11164-11174.3 and with
the protocols, reporting, and training required under California Health and Safety Code
Section 124235, AB2007, and other laws pertaining to concussion evaluation, removal from
play, and return to play protocols. (Refer to Center for Disease Control & Prevention,
lltt.��s:-';'_l_a:Y_ti'_�,�__tci c.,�s_��W/heai�s�a��ji�7 c��x,l-�tzn�.
D. Subrnit required forms and acknowledgments included in Exhibit D, and ensure its each
participant is provided with a concussion information sheet, signs and returns the forms to
the City as required by Health and Safety Code Section 124235.
Require coaches and administrators to successfully cornplete the concussion and head injury
education at least once either online or in person, before supervising a participant.
Contractor shall offer training, educational materials, or both to each Contractor
administrator on a yearly basis. (Training resources are available at the Center for Disease
Control &Prevention(link cited above).
E. If providing instruction, Contractor must acicnowledge and comply with all requirements
set forth in the Recreation& Community Services Instructor Manual.
Check one (if applicable):
❑ This contract requires services for children.
Recreation Services Agreement/Rev. 3-27-2018
Page 3 of 6
� � This contract currently does not require services for children. If in the future, services
for children are required, the contract will require a'written amendment'to include the
appropriate insurance coverages as required in'Exhibit B —Insurance Requirements for
Recreation Contracts', proof of finger printing and additional requirements under
Paragraph 13. The contract amendment will also require the approval of the Director of
Recreation and Community Services and City Attorney.
14. Coordination of Services. The Parties designate the following persons as Services
Coordinators with the responsibility to oversee the delivery of Services in accordance with the terms of
this Agreement. Contractor's designation and any substitution are subject to City approval.
For City: For Contractor:
Narne:Jason Bisely Name: The Cheeseballs LLC; Daniel Swan
Position: Interim Recreation Coordinator Position: Band Lead
Contact:]��c:3�z�t=_?:{=�.��ertir�t�.t��'.t�(408) 777-3127 Contact:
15. Abandonment. City may abandon or postpone the Activity or Program and will notify
Contractor as soon as possible. Contractor will be paid for satisfactory Services rendered through the
date of abandonment upon submission of final invoices approved by City.
16. Termination. City may terminate this contract for cause or without cause at any time
and will notify Contractor as soon as possible.Contractor will be paid for satisfactory services rendered
through the date of termination upon submission of final invoices approved by City.
17. Governing Law,Venue and Dispute Resolution.This contract is governed by the laws
of the State of California. Any legal actions or proceedings filed against City in connection with this
contract must comply with the government claims filing requirements and must be filed with the
Superior Court for the County of Santa Clara, State of California. At City's request, Contractor is
required to continue to provide Services pending resolution of any dispute. If the Parties elect
arbitration, the arbitrator's award must be supported by law and substantial evidence and include
detailed written findings of law and fact.
18. Attorney Fees. If City is required to pursue litigation,arbitration or other administrative
or regulatory proceeding to enforce its rights or the terms of this Agreement, the prevailing party will
be entitled to reasonable attorney fees and costs. This Section survives this Agreement.
19. Third Party Beneficiaries. There are no third party beneficiaries under this Contract.
20. Waiver.Neither acceptance of Services nor payment thereof constitutes a waiver of any
contract provision. City waiver of a breach shall not conskitute waiver of another term, provision,
covenant or condition, or a subsequent breach, whether of the same or a different character.
21. Entire Agreement. This Agreement and all referenced Exhibits are hereby attached and
incorporated into the Agreement by this reference and represent the full and complete understanding
as to those matters contained herein, and supersede any other contract or understanding, either oral or
Recreation Services A�eement/Rev. 3-27-2018
Page 4 of 6
� written,between the Parties.This Agreement may not be modified or amended except in writing signed
by both Parties. If there is any inconsistency between the main contract and any attachments or exhibits
thereto, the rnain contract shall prevail.
22. Inserted Provisions.Each provision or clause required by law or this contract is deemed
to be included and will be inferred herein. Either party may request an amendment to cure any
mistaken insertion or omission of a required provision.
23. Headings. The headings are for convenience only and are not a part of the contract or
intended to affect, limit or amplify the terms or provisions of this Agreement.
24. Severability/Partial Invalidity.If any contract term or provision, or their application to
a particular situation, is found by the court to be void, invalid, illegal or unenforceable, such term or
provision shall remain in force and effect to the extent allowed by such ruling. All other contract terms
and provisions and their application to specific situations will remain in full force and effect.
25. Survival. All provisions which by their nature must continue after the Agreement ends,
including without limitation Indemnification, Insurance, Ownership of Materials, Records, Governing
Law and Attorney Fees, will survive the expiration or termination of this Agreement.
26. Notices.All notices and instrurnents pertaining to material provisions of this contract or
significant disputes which are required by law or under this contract to be in writing must be sent to
the persons listed below. The notices will be deemed effective on the date of personal delivery or the
date confirmed by a reputable overnight delivery service, on the fifth calendar day after deposit in the
United States Mail, postage prepaid, registered or certified, or the next business day following
electronic submission.
To City of Cupertino: To Contractor:
Office of the City Manager 10185 N. Stelling Road Cupertino, CA 95014
10300 Torre Ave., Cupertino CA 95014 cc: Representative/Coordinator:
cc: Representative/Coordinator: The Cheeseballs LLC
Jason Bisely Email:
Email: JasonB@Cupertino.org
27. Validity of Contract. This contract is valid and enforceable only if it complies with the
provisions of Cupertino Municipal Code Chapters 3.22 and 3.23, is signed by the City Manager or
authorized designee, and is approved for form by the City Attorney's Office.
28. Execution. The person executing this contract on behalf of Contractor represents and
warrants that Contractor has full right, power, and authority to execute this contract and to carry out
all actions and services required. This contract constitutes a legally binding obligation of Contractor,
and may be executed in counterparts, each one of which is deemed an original and all of which, taken
together, constitute a single binding instrument.
Recreation Services Agreement/Rev. 3-27-2018
Page 5 of 6
IN WITNESS WHEREOF,the parties have caused this contract to be executed.
CONTRACTOR CITY OF CUPERTINO
The Cheeseballs LLC A Municipal Corporation
By $y �-�.--�,..-
Name'�e��A�4�wo-vt -�p✓'1 �t. ��cCSeba,��s Name t.�'ZIs7-S�hc_..� !(��`,.s
Title '�ioc�k��v�� I�q�{' Title �,�� /i/��'�''
Date ��$'1 L i� Date • � � "-1�
Tax I.D. No.: �3—U����l �
VED AS TO FORM: ATTEST:
, �� �f�',%;�
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DOLPH STEVENSON HOM GRACE SCHMIDT ,,.� � C �''
Cupertino City Attorney City Clerk
ContractlEncacmbered Amount:
Account No.:
Recreation Services Agreement/Rev. 3-27-2018
Page 6 of 6
+ EXHIBIT A
SCOPE OF WORK,PERFORMANCE AND PAYMENT SCHEDULES
The CONTRACTOR will provide SUMMER CONCERT in,but not limited to,the following:
BAND PERFORMANCE JULY 12, 2018
Location and Time of CONTIZACTOR Services:
Refer to the Recreation Schedule dated SUMMER 2018 for agreed upon dates, times, and class
locations. The City, at its sole discretion, may change the agreed terms.
Compensation for CONTRACTOR Services:
Contractor shall be compensated for services performed pursuant to this Agreement. Compensation
shall consist of the following: $3,000. The total compensation to the Contractor shall not exceed
$3,000.
If less than the required minimum number of participants enroll in and pay for a particular class as
identified in the schedule before the class is scheduled to start, the City may cancel the particular class
and/or terminate this Agreement without additional notice or payment to Contractor.
List of all Band Members working f.or the City of Cupertino (if no Members,identify"self"):
E,�c Cal�v r� 2 e k.i� _ V��ke �sr2✓s � �r� °
�I i iab�- �ac�d 5o�d�c. BvU wK L�,-�G.e,�vt,c a v� i�.t i I�.e L��a-�-K.ca�
Performance of CONTRACTOR Services:
In the case Contractor unilaterally cancels performance of a class, camp, activity or service without
City approval, City reserves the right to immediately and without notice cancel the remainder of
programs/services offered and or performed by Contractor.
The Contractor shall follow all guidelines pertaining to registration procedures as listed in the
quarterly recreation schedule. Participants may not take part in the program unless they are listed on
the class roster or can show proof of enrollment. All participants and volunteers need to complete the
City's Waiver of Liability form prior to taking part in the program. If applicable, contractors who are
responsible for supervising minors must remain with the class until a parent of legal guardian has
arrived and all minors are released to them.
In the event of an injury occurring to a participant, the Contractor will notify the City within 1 hour
and complete an Incident Report in the form approved by the City. The Incident Report must be
submitted to the City within 24 hours of the injury occurring.
' Exhibit B i
Insuf•ance Requif•e�ie�zts foN Rec�eation Cont�°acts
As required by Section 12 of the Agreement, Contractor shall procure and maintain the following insurance
for the duration of the contract against claims arising from or in connection with Contractor, its agents,
representatives, employees or subcontractors Services under this Agreement.
Minimum Scope and Limit of Insurance. Coverage shall Ue at least as broad as:
1. Commercial General Liability (CGL): Insurance Services Office Form CG 00 O1 covering CGL on an
"occurrence" basis, including property damage, bodily injuiy and personal & advei�tising injury with
liinits no less than $1,000,000 per occurrence. If a general aggregate limit applies, it must apply
separately to this project/location(CG 25 03 or 25 04) or be twice the required occurrence limit.
2. Automobile Liability: ISO CA 0001 covering Code 1 (any auto), or if Contractor has no owned autos,
Code 8 (hired) and 9 (non-owned), with limits no less than$1,000,000 per accident for bodily injury and
property damage.
❑ Required if automobile is used to perform wo�Iz under^this contract.
�f Otherwise, p�^oof of Contracto�'s pe�sonal auto insurance with limits Nequired by state law
suffices. Contractor shall not transpor^t or use its personal vehicle to t�ansport participants ov�
perform woi^k unde�this contract.
3. Workers' Compensation: As required by the State of California, with Statutory and Employer's
Liability Insurance limits of no less than$1,000,000 per accident for Uodily injury or disease.
❑ Requi�ed if Contracto�has employees.
� If no en2ployees, Cont�actoN�Zust sign Affidavit of No Employees.
4. Sexual Abuse/Molestation: Insurance or the equivalent as required for activities/seivices involving
minors, (i.e., after school activities, recreational programs, athletics, study/training events and
transportation of minors). Coverage may be included under General Liability or be obtained in a separate
policy, such as Educators Legal Liability (ELL) policy, with a limit of no less than $1,000,000 per
occurrence. If a general aggregate linut applies, it must apply separately to this contract or Ue twice the
required occurrence limit.
❑ Requirecl if Contract involves services to children.
Insurance coverage required may be satisfied by a combination of Primary and Excess/LTmbrella insurance.
Self-bzsutecl Reteratio�zs: Self-insured retentions must be approved Uy City. City may require Contractor to
provide proof of ability to pay losses and related investigations, claim administration, and defense
expenses within the retention. The policy language must provide, or be endorsed to provide, that the self-
insured retention may be satisfied by either the named insured or City.
Acceptability of Insu�^ers:Insurance must be issued by insurers acceptable to City and licensed to do business
in the State of California,with an A.M. Best's financial strength rating of"A" or better and a financial size
rating of"VII"or better.
OTHER INSURANCE PROVISIONS: The CGL policy must contain, or be endorsed to contaul, the
following provisions:
1. The City, its City Council, Uoards and commissions, officers, officials, employees, agents, servants
and volunteers are to be covered as additional insureds with respect to liability arising out of work or
Exh.B InsuraT�ce for Recreation Contracts Updated 3-26-18
1
EXHIBIT C
AFFIDAVIT OF NO EMPLOYEES
State of California
County of Santa Clara
City of Cupertino
I, the undersigned, declare as follows:
I am an independent contractor and the owner of 'r�° ��S��a<<�
I wish to enter into a services contract with the City of Cupertino. I am fully aware of the
provisions of section 3700 of the California Labor Code, which requires every employer to
provide Workers' Compensation coverage for employees in accordance with the provisions
of that Code. I am also aware that I must provide proof of workers' compensation insurance
to the City of Cupertino for any and all employees I may have, pursuant to Section 12 of the
City of Cupertino's contract.
I hereby certify that I do not have any employees nor will I have any employees working for
me or my business during the term of any service contract with the City of Cupertino. I am
not required to have Workers' Compensation insurance.
I declare under penalty of perjury under the laws of the State of California that the foregoing
is true and correct.
Executed on this � day of I�IG� 2018, at J California.
�Gv�le.I Swak '�v � �P�Se�bal�5
PRINT NAME
SIGNATURE
EVANSTON 1NSURANCE COMPANY
CERTIFICATE NO.: -
CERTIFICATE OF INSURANCE
SPECIAL EVENT LIASILITY PROGRAM
PRODUCER PUBLIC ENTITY(ADDITIONAL INSURED)
Alliant Insurance Services,Inc.in conjunction with
Apex Insurance Services
P. O.Box 6450
Newport Beach,CA 92658
License No:OC 36861
NAMED INSURED(EVENT HOLDER): EVENT INFORMATION:
City of Cupertino,Its City Council,Soards and Commissions, TYPE: 2018 Summer Concert Series
Officers,Officials,Employees,Agents,Servants,Volunteers DATE(S): June 7,14,21,28,2018&
and Consultants July 4,5,12,2018
10185 North Stelling Road LOCATION: Memorial Park,21121 Stevens Creelc
Cupertino,CA 95014 Blvd,Cunertino CA 95014
*Liquor Liability Yes❑ No�
**Liquor LiaUility after 12 am ends before 2 am ❑
This is to certify that the insurance policy listed below has been issued to the above insured nanled(event holder)far the policy
period indicated. The insurance described herein is suUject to all the terms,exclusions and conditions of such policy(ies)unless
amended as described in Special Conditions.
INSURANCE CARRIER:Evanston Inst�rance Coinpany
MASTER POLICY NUMBER: SEP41026
MASTER POLICY DATES: EFFECTIVE: JANUARY 1,2018 EXPIRATION:JANUARY 1,2019
COMMERCIAL G�NERAL LIABILITY OCCURRENC�FORM DEDUCTIBLE: NON�
General Aggregate Limit $2,000,000
Products&Completed Operations 1,00a,000 SP�CIAL CONDITIONS:
Persoual&Advertising Lijury 1,000,000 The followiug endorsemeuts attached to
Each Occurreuce Limit 1,000,000 the Master Policy do not apply to this
Dainage To Premises Rented To You(Any One Premises) 100,000 Ce�tificate Of Insurliice:
Medical Payments(Any One Person) 5,000 MEGL643
Liquor Liability (If purchased) 1,000,000
Optional Limits Purchased
❑ $1,000,000/$3,000,000
❑ $2,000,000/$2,000,000
Damage To Property(If purchased)
The liinits of insurauce apply separately to each event insured by this policy as if a separate policy of insurauce has been issued for that event.
OTHER ADDITIONAL INSUREDS
CANCELLATION: Should tlie above descriUed policy Ue cancelled before the expiration date thereof,notice will be delivered in accordance with the policy
provisions.
�✓"�*� �-�✓IL.+�vx,.x..�e-�u....sk.�.�..
AUTHORIZ�D REPRESENTATNE:
DATE ISSUED: 5/25/18
POLICY NUMBER: SEP41026 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):
City of Cupertino, Its City Council, Boards and Commissions, Officers,
Officials, Employees,Agents, Servants,Volunteers and Consultants
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 covera e rovided to the additional insured is
damage" or "personal and advertising injury" g p
caused, in whole or in part, by your acts or required by a contract or agreement, the most we
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 �nsurance 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
Declarations.
insured only applies to the extent permitted by
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 04 13 O Insurance Services Office, Inc., 2012 Page 1 of 1
Renewal auto policy declarations
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Your policy effective date is April 25,2018 Ynu're in gcaod hands.
Page 1 of 3
Information as of March 5,2018
TOt7l A1110U11t �Ue for the Policy Period
Please review your insured vehicle and verify its VIN is correct. SUmmary
Vehicle covered Identification Number(Vlld) Premium Named Insured(s)
$612,24 Michael Leatherman
California Fraud Assessment Fee 0.88 Mailing address
Total* $673.12
i Morgan Hill CA 95037-9637
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*Yourb►ll will be mailed separately.Before making a payment,please refer fo your Polic number
lafest b►ll,which mcludes paymenf options and instal/ment fee in formafion,►f you do 937107 839
not payin fuU,you wi!!be charged an instal►ment fee(s). Your policy provided by
See the Important payment and coverage information section for details about Allstate Northbrook Indemnity
installment fees. Company
Policy period
Beginning April 25,2018 through
�ISCOU11tS (included in your total premium) October 25,2078 at 12:01 a.m.standard
Good Driver(20%) $135.35 Multiple Policy $44.34 time
Distinguished $107.90 Anti-theft $1.49 Your Allstate agency is
Driver Maureen Harris Ins
TO#dl dISCOU11tS 17200 Monterey#A
�a89'08 Morgan Hill CA 95037
._.....,, ... _ . ... .,. ....... (408)778-1298
MaureenHarris@al lstate.com
Discounts per vehicle '
$289,�$ Some or all of the information on your
Good Driver(20%) $135.35 Multiple Policy $44.34 Policy Declarations is used in the rating
Distinguished $107.90 Anti-theft $1.49 of your policy or it could affect your
eligibility for certain eoverages.Please
Driver notify us immediately if you believe that
any information on your Policy
Listed driver on your policy Declarations is incorrect.We will make
Michael Leatherman corrections once you have notified us,
and any resulting rate adjustments,will
be made only for the current policy
Excluded drivers from your policy period or for future policy periods.
None Please also notify us immediately if you
believe any coverages are not listed or
are inaccurately listed.
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Renewal auto policy declarations Page 2 of 3
Pol i cy num ber: 937107 839
Policy effective date: April 25,2018
Coverage detail for
Coverage Limifs Deductible Premium
Automobile Liability Insurance Not applicable $269.24
Bodily Injury $100,000 each person
$300,000 each occurrence
� Property Damage $100,000 each occurrence
��' Auto Collision Insurance Actual cash value $250 $207.20
Waiver of deductible applies
� Auto Comprehensive Insurance Actual cash value $100
$28.45
�' Rental Reimbursement up to$30 per day for a maximum of 30 Not applicable $23.31
days
� Towing and Labor Costs $100 each disablement Not applicable $5.84
Uninsured Motorists Insurance for Bodily $100,000 each person Not applicable $51.87
Injury $300,000 each accident
�� Automobile Medical Payments $5,000 each person Not applicable $26.33
Coordinated Medical Protection Not purchased*
Lease/Loan Gap Notpurchased*
Repair or Replacement Cost Option Not purchased*
Sound System Not purchased*
Tape Notpurchased*
To#al premium for 2009 Toyota Sienna $612.24
*This coverage can provide you wifih valuable protection. To help you stay
current with your insurance needs,contact your Allstate agent to discuss
coverage options and other products and services that can help protect
you.
Rating information
Your premium is determined based on certain information, m
including the following: o
� This vehicle is driven 10-20 miles to work/school,unmarried �
male licensed 35 years.
Allstate uses mileage informafion as one factor to help determine your premium amount. N
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Important Note:The annual mileage figure applicable to this vehicle for the expiring policy period was:14,500-14,999.The o
annual mileage figure applicable to this vehicle for the eurrent policy period is:74,500-74,999. o
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The following odometer information was used to determine your annual mileage for current policy period: o
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Odometer Reading:69,964 Odometer Reading:83,966 �
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Date:07/10/2075 Date:06/20/2016 0
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If any of the information shown above is incorrect,missing or changes in the future,please contact your Allstate o
representative.Please keep in mind that a change in any of the information may result in an adjustment to your premium. �
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