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18-001 Nancy McGinnis (2)CITY OF II SERVICES AGREEMENT ($5,000 OR LESS) f 6 201/-]7 J CUPERTINO 1. Parties. This Agreement ("Agreement") is made and entered into as of February I 0, 2018 ("Effective Date") by and between the City of Cupe1iino, a municipal corporation ("City") and Nancy McGinnis , ("Contractor"), a Sole Proprietorship/Indi vi dual 2. Services. Contractor agrees to provide the programs, classes or activities ("Services") set f01ih in detail in the Scope of Services , attached and incorporated here as Exhibit A. 3. Time of Performance. This Agreement begins on the Effective Date and ends on June 30, 2018 ("Contract Time"), unless terminated earlier as provided herein. Contractor must deli ver the Services in accordance with the Schedule of Performance included or attached to Exhibit A. Time is of the essence for the perfonnance of all the Services. Contractor must have sufficient time, resources, and qualifi ed staff to deliver the Services on time. 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 exceed $_1_0_0_0 ______ _ ("Contract Price"), based upon the Scope of Services and the budget and rates included in Exhibit A. The maxi mum compensation includes all expenses and reimbursements and will remain in place even if Contractor's actual costs exceed the capped amount. Upon City approval of written invoices , Contractor w ill be p ai d as follows: (check on e; cross out others): DA lump sum amount of$ which shall not exceed the Contract Price . D At the rate of$ per hour for a total not to exceed the Contract Price . 0 Based on the payment schedule included or attached to Exhibit A which shall not exceed the Contract Price. 5. Independent Contractor . Contractor is an independent contractor and not an employee, pa1iner, or joint venture of City. Contractor is solely responsible for the means and methods of perfo1ming the Services and for the persons hired to work under this Agreement. Contractor is not entitled to health benefits, workers compensation or other benefits from the City. Contractor must have the skills and qualifications to perfo1m the Services in a competent and professional manner, and must be licen sed, registered , and/or ce1iified and have a City Business License. Contractor will supply all tools , materials and equipment required to perform the Services under this Agreement. 6. Assignment. This Agreement is not assignable. Contractor may not substitute another or transfer any ri ghts or obligations under this Agreement without prior written approval of City. Only those persons whose names are included in Exhibit A may perf01m the Services. C ity Project Facebook In stru ctio n Services Agre ement ($5 ,000)/Rev. Nov 3, 2017 Page 1 of 6 7. Indemnification. To the fullest extent allowed by law and except for losses caused by the sole and active negligence or willful misconduct of City personnel , Contractor shall ind emnify, defend , and hold haimless City, its City Council, boards and conm1issions , officers, officials, employees, agents, servants, volunteers and consultants ("Indenmitees"), tlu·ough legal counsel acceptable to City, from and against any and all liability, damages, claims , actions, causes of action, demands , charges, losses , costs and expenses (including attorney fees , legal costs and expenses related to litigation and dispute resolution proceedings), of every nature, arising directly or indirectly from this Agreement or in any manner relating to any of the following: (a) Breach of contract, obligations, representations or wananties; (b) Negligent or willful acts or omissions conunitted during perfo1mance of the Services; (c) Personal injury, prope11y damage , or economic loss resulting from the work or perfo1mance of Contractor or its subcontractors or sub-subcontractors; 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 payments may be deducted or offset to co ver any money the City lost due to a claim or counterclaim aiising out of this Agreement. 8. Insurance. Contractor shall comply with the Insurance Requirements, attached and incorporated here as Exhibit B , and must maintain the insurance for the duration of the Agreement, or longer as required by City. City will not execute the Agreement until City approves receipt of satisfactory ce11ificates of insurance and endorsements evidencing the type , amount , class of operations covered, and the effective and expiration dates of coverage. Failure to comply with this provision may result in City, at its sole discretion and without notice, purchasing insurance for Contractor and deducting the costs from Contractor's compensation or tern1inating the Agreement. 9. Compliance with Laws. Contractor shall comply with all laws and regulations applicable to this Agreement, included without limitation the following laws: Labor Laws. Contractor shall comply with all labor laws applicable to this Agreement. If the Scope of Services includes a "public works" component, Contractor is required to comply with prevailing wage laws under Labor Code Section 1720 and other labor laws . 0 Sole Proprietor. If Contractor is a sole proprietorship/individual, it must sign the Affidavit of No Employees included in this Agreement. Discrimination Laws . Contractor shall not discriminate on the basis of race , religious creed, color, ancestry, national origin, ethnicity, handicap, disability, marital status, pregnancy, age, sex, gender, sexual orientation, gender identity, Acquired-Inunune Deficiency Syndrome (AIDS) or any other protected classification. Contractor shall comply with all anti-disc1imination laws , including Government Code Sections 12900 and 11135, and Labor Code Sections 1735 , 1777 and 3077 .5. Consistent with City policy, Contractor understands that harassment and discrimination directed toward a job applicant, an employee, a City employee, or any other person, by Contractor or Contractor's employees or sub-contractors will not be tolerated . City Project Facebook In str uction Services Agreement ($5,000)/Rev . Nov 3, 2017 Page 2 of 6 Conflicts of Interest. Contractor shall comply with all conflict of interest laws applicable to this Agreement and must avoid any conflict of interest. Contractor wanants that no public official, employee, or member of a City board or conunission who might have been involved in the making of this Agreement, has or will receive a direct or indirect financial interest in this Agreement, in violation of California Government Code Section 1090 et seq. Contractor may be required to file a conflict of interest fonn if Contractor makes ce11ain governmental decisions or serves in a staff capacity, as defined in Section 18700 of the California Code of Regulations . Contractor agrees to abide by the City 's mies governing gifts to public officials and employees . 10. Abandonment. City may abandon or postpone the Project at any time . Contractor will be compensated for satisfactory Services perfonned tlu·ough the date of abandomnent. 11. Termination . City may te1minate this Agreement for cause or without cause at any time. City reserves the right to terminate the Agreement and the remainder of the Services offered by Consultant without notice based upon Contractor 's cancellation of a Service (i.e ., program, class or activity) without giving advance notice or obtaining written approval from City. 12. Governing Law. This Agreement is governed by the laws of the State of California. Any lawsuits filed related to this Agreement must be filed with the Superior Com1 for the County of Santa Clara, State of California. Contractor must comply with the claims filing requirements under the Government Code prior to filing a civil action in com1. If a dispute arises , Contractor must continue to provide the Services pending resolution of the dispute. If the Pm1ies elect arbitration, the arbitrator 's award must be supp011ed by law and substantial evidence and include detailed written findings of law and fact. 13. Entire Agreement. This Agreement represents the full and complete understanding of every kind or nature between the Pm1ies , and supersedes any other agreement or understanding, either oral or written , between the Pm1ies. Any changes to this Agreement will be effective only if in writing and signed by each Paiiy's authorized representative. No verbal agreement or implied covenant will be valid to amend or abridge this Agreement. If there is any inconsistency between the main Agreement and the attachments or exhibits thereto, the text of the main Agreement shall prevail. Each provision and clause required by law for this Agreement is deemed to be inse11ed and will be infened herein. 14. Services Coordinator. The Pm1ies designate the following persons as Services Coordinators for this Agreement. Contractor's designation and any substitution are subject to City approval. For Contractor: N ancy McGinnis Name Sole Prorietor Position Contact City Project Face book In structi o n For City: Amanda Hui Christine Hanel Name Recreation Coodinator Position AmandaH@ Cupeztino.org Contact Services Agreement ($5,000)/Rev. Nov 3, 2017 Page 3 of 6 15. Contract Interpretation. There are no intended third party beneficiaries of this Agreement. Neither acceptance of the Services nor payment therefor shall constitute a waiver of any contract provision. City's waiver of a breach shall not constitute waiver of another provision or breach.The headings in this Agreement are for convenience only. The Indemnification and Governing Law sections expressly survive this Agreement. 16. Severability. If a te1m or provision of the Agreement or its application to a paiticular situation is found by the comt to be void, invalid, illegal or unenforceable, such tenn/ provision shall remain in effect to the extent allowed by such rnling . All other te1ms and provisions of this Agreement or their application to specific situations shall remain in full force and effect. 17. Notices. All notices, demands, requests and approvals must be sent to the persons below in w1iting , and will be considered effective on the date of personal delivery, upon confinnation of delivery by a reputable overnight delivery service, on the fifth calendar day after deposit thereof in the United States Mail , postage prepaid, registered or ce1tified , or the next business day following electronic submission: To City of Cupe1tino: 10300 ToITe Ave., Cupe1tino, CA 95014 Attention: Amanda Hui ------------- Email : AmandaH @Cupertino.org To Contractor:Na nc y McGinnis 38 Putnam St. San Francisco , CA 94110 Attention: Na nc y McGinnis Email: 18. Validity of Contract. This Agreement is valid and enforceable only if (a) it complies with the contract provisions of Cupe1tino Municipal Code Sections 3.22 and 3 .23, (b) is signed by the City Manager or an autho1ized designee, and (c) is approved for f01m by the City Attorney 's Office . 19. Execution. Contractor's signatory wairnnts that he or she is autho1ized to execute the Agreement and to legally bind Contractor. This Agreement may be executed in counterpaits, each one of which is deemed an original and all of which, taken together, constitute a single binding instrnment. City Project Facebook In stru ction Services Agreement ($5,000)/Rev. Nov 3, 2017 Page 4 of 6 IN WITNESS WHEREOF, the Patties have caused the Agreement to be executed as of the Effective Date written above. CONTRACTOR Nancy McGinnis By <l__Afl_-__ ,_\ _____________ _ Name: N ancy McGinnis Title: Instructor Tax 1.D . No .: By: __ \.----____.,"-------=-,;C-X----"--'"-------- RAN Cupe1tino City Attorney ATTEST: City Project Facebook In struction CITY OF CUPERTINO A Municipal Corporation Name: Christine Hanel Title: Assistant Director of Recreation Services Agreement ($5,000)/Rev. Nov 3, 2017 Page 5 of 6 Contractor's 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 /\/llc,10:( "-tc C,, ,-1,.,-iJ I wish to enter into a services contract w ith the City of Cupe11ino. 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 Cupe11ino for any and all employees I may have, pursuant to Section 12 of the City of Cupe11ino 's contract. I hereby ce11ify that I do not have any employees nor will I have any employees working for me or my business during the tenn of any service contract with the City of Cupe11ino. I am not required to have Workers' Compensation insurance . I declare under penalty of pe1jury under the laws of the State of Ca li fornia that the foregoing is tlue and co1Tect. Executed on this~ day of JiA..s14,ra.4 201~ , WH, at ____ C£C._,~e~11._,._,_..to ____ , California. City Project Facebook In struction Services Agreement ($5,000)/Rev. Nov 3, 2017 Page 6 of 6 EXHIBIT A CONSULT ANT SERVICES TO BE PERFORMED The CONSULT ANT will provide FACEBOOK INSTRUCTION in, but not limited to, the following programs: FACEBOOK CLASSES: A SERIES OF THREE, ONE HOUR CLASSES. FOR SENIOR ADULTS, NO CHILDREN INVOLVED. Compensation: Consultant shall be compensated for services performed pursuant to this Agreement. Compensation shall consist of the following: EIGHTY PERCENT (80%) OF EACH REGISTERED PARTICIPANT. A TWENTY-FIVE ($25) DOLLAR ADMINISTRATION FEE WILL BE DEDUCTED FROM THE FIRST PAYMENT. CONSULTANT SHALL PROVIDE ALL TEACHING SUPPLIES SUCH AS, BUT NOT LIMITED TO, DRY ERASE MARKERS, ERASERS, AND HANDOUTS. CONSULTANT PAYS FOR COPY SERVICE AT THE SENIOR CENTER AT $0.10 PER PAGE. The total compensation to the Consultant shall not exceed ONE THOUSAND DOLLARS ($1,000). Location and Time of CONSULT ANT Services: Refer to the Recreation Schedule dated JANUARY/FEBRUARY 2018 (PUBLISHED 12/18/17); MARCH/APRIL 2018 (PUBLISHED 2/16/18); MAY/JUNE 2018 (PUBLISHED 4/2018), for agreed upon dates, times, and class locations. By the mutual agreement of both parties, class schedule may change. Eligible Participant Minimum and Maximums for CONSULTANT Services: Minimum: 5 Maximum: 10 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 Consultant. Performance of CONSULT ANT Services: In the case Consultant unilaterally cancels performance of a class, camp or activity without City approval, City reserves the right to immediately and without notice cancel the remainder of programs offered by Consultant The Consultant 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. In the event of an injury occurring to a participant, the Consultant 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. EXHIBITB INSURANCE REQUIREMENTS For Special Events, Contractors/Coaches or Activities Involving Children Contractor shall procure and maintain for the duration of the contract insurance against claims for injuries to persons or damage to prope1iy arising from or in connection with Contractor's performance of the Services or the results of that work by Contractor, its agents, representatives , employees or subcontractors. The coverage must include the policy types and limits specified below. Minimum Scope and Limit of Insurance Coverage shall be at least as broad as: 1. Commercial General Liability (CGL): Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis , including property damage, bodily injury and personal & adve1iising injury with limits no less than $1,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this project/location (ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit. 2. Sexual Abuse/Molestation insurance or the equivalent are required for any and all activities/services involving children, including without limitation, after school activities, recreational programs, athletics , studies and transpo1iation of students. Coverage must be included under General Liability or obtained in separate policies in an amount of not less than $1,000,000 per occurrence ($2,000,000 aggregate) and $3,000,000 excess/umbrella coverage. D Required only if Contract involves services to childre n. 3. Automobile Liability: Insurance Services Office Forn1 Number 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 prope1iy damage. D Above required only if auto is used in pe,formance of work. !81 Otherwise, proof of Contractor's auto insurance in compliance with minimum state la w requirements suffices. 4. Workers' Compensation: As required by the State of California, with Statutory Limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. D Required only if Contractor has emplo yees. ~ Jfno emp loyees, Contractor must sign Affidavit of No Emplo yees. Insurance coverage required may be satisfied by a combination of Primary and Excess/Umbrella insurance. Self-Insured Retentions Self-insured retentions must be declared to and approved by the 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 shall provide, or be endorsed to provide, that the self-i nsured retention may be satisfied by either the named insured or City. Acceptability of Insurers Insurance must be issued by insurers acceptable to City and licensed to do business in the State of California , and each insurer must have an A.M . B es t 's financial strength rating of "A" or better and a financial size rating of"VII" or better. Other Insurance Provisions The genera l liability policy is to contain, or be endorsed to contain, the following provisions: 1 EXHIBIT B 1. The City, its City Council, boards 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 operations performed by or on behalf of the Contractor including materials, pai1s or equipment furnished in connection with such work or operations . 2. For any claims related to this contract, the Contractor's insurance coverage shall be primary insurance coverage at least as broad as ISO CG 20 01 04 13 as respects the City, its officers, officials, employees, agents, and volunteers . 3. The Insurance Company agrees to waive all rights of subrogation against the City, its elected or appointed officers, officials, agents, and employees for losses paid under the te1ms of any policy which arise from work perf01med by the Contractor for the City. This provision also applies to the Contractor 's Workers' Compensation policy. 4. Each insurance policy required above shall provide that coverage shall not be canceled, except with notice to the City. Primary Coverage The Additional Insured coverage under Contractor's policy shall be primary non-contributory and at least as broad as ISO CG 20 01 04 13 as respects the City and all the insureds/indemnitees. If the limits of Insurance required in this Agreement are satisfied in part by Umbrella/Excess Insurance, the Umbrella/Excess Insurance shall contain or be endorsed to contain a provision that such coverage shall also apply on a "primaiy and non-cont1ibut01y" basis for the benefit of City/Additional Insureds before City's own insurance is triggered in way. Notice of Cancellation Each insurance policy shall provide that coverage shall not be canceled or allowed to expire without written notice to City 30 days in advance or 10 days in advance if due to non-payment of premiums. Such notice must be sent to City via email or ce11ified mail addressed to the attention of the City Manager. Waiver of Subrogation Contractor grants City a waiver of any right to subrogation which any insurer of said Contractor may acquire against the City by virtue of the payment of any loss under such insurance. Contractor agrees to obtain any endorsement that may be necessaiy to affect this waiver of subrogation, but this provision applies regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer. Verification of Coverage Contractor shall furnish the City with original ce11ificates and amendato1y endorsements effecting coverage required by this clause. All ce11ificates and endorsements are to be received and approved by the City before work commences. The City reserves the right to require complete, ce11ified copies of all required insurance policies, including endorsements affecting the coverage required by these specifications, at any time. At a minimum Contractor must provide acceptable copies of the policy declarations and endorsement page verifying the required msurance coverages . Homeowner's Insurance Contractor's homeowner's liability insurance may provide coverage sufficient to meet these requirements . Contractor should provide these requirements to his or her agent to confirm and provide verification to the City. Special Events Coverage Insurers may provide special events coverage for a reduced fee , or City may be able to offer this coverage . Contractor should contact City for more info1mation or assistance. Special Risks or Circumstances City reserves the right to modify these requirements based on the nature of the risk, prior expe1ience , insurer, coverage, or other special circumstances. The City reserves the right to modify or waive insurance requirements for ce11ain low risk recreational activities. 2 EVANS TON INSURANCE COMP ANY CERTIFICATE NO.: 636S.12825080841231 CE RTIFICATE OF INSURANCE SPE CIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) A lli a nt Insurance Services , Inc. in conju nction with Apex Insurance Services City of Cupertino P . 0 . Bo x 6450 Newport Beach , CA 92658 Licen se No : OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION : Nancy McGinnis TYPE: Various Ins tructio na l Classes DATE(S): 01/11/2018 -12/31/2018 LOCATION : Cupertino Senior Center, 2 1251 Stevens Creek Blvd, Cupertino, CA 95014 *L iqu o r L iabi li ty YesO No{!) **Liquor Liab ility after 12 am end s before 2 am D This is to ce1tify that the insurance policy li sted below has been issued to the above insured named ( event ho ld er) for the policy period indicated. The in s ura nce described herein is subject to all the terms , exclusions and conditio ns of such policy(ies) unl es s amended a s de scribed in Special Co nditions . INSURANCE CARRIER: E vanston In s urance Company MASTER POLICY NUMBER: SEP41026 MASTER POLICY DATES : EFFECTIVE: January 01 , 2018 EXPIRATION : J a nuary 01, 20 1 9 COMME RCIAL GENE RAL LI ABILI TY Ge neral OCCURR ENCE FORM DEDUC TIBL E: NONE Agg rega te Limit S 2,000,000 Pro du cts & Comp leted Operati ons 1,000 ,0 00 SPEC IAL CON DITIO NS : Perso nal & Adv erti sin g lnju1y 1,000 ,000 The fo ll ow in g end orse men ts att ac hed to Each Occ uJTence Limit 1,00 0 ,000 the Mas ter Policy do not apply to thi s Damage To Premi ses Rented To Yo u (A ny One Pre mi ses) !00,0 00 Ce rtifi ca te Of Ins ur ance: Me di ca l Pay ment s (An y On e Perso n) 5,000 MEGLI643 Liquor Liability (If purchased) 1,000 ,000 Optional Limits Purchased D $1,000,0001$3,ooo ,ooo D $2,o oo ,0001$2,000 ,000 Property Damage (If purchase d) No Property Damage Coverage The limit s of in suran ce appl y se para tely to each eve nt in sur ed by thi s poli cy as ifa se para te poli cy of in suran ce has bee n iss ued for th at eve nt. OTHE R ADDITIONAL INSUREDS City of Cupertino, Its City Council, Boards and Commissions, Officers, Officials, Employees, Agents, Servants, Volunteers and Consultants CANCELLAT ION: Sh ould th e above desc rib ed poli cy be can ce ll ed befo re th e ex pira ti on date th ereof, noti ce will be de li ve red in acco rd ance with th e po licy provis ions. AUTHORIZED REPRESENTATIVE :----------------------------- DATE ISSUED : _0_1/_1 _1/_20_1_8 ________________________________ _ POLICY NUMBER: SEP41026 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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 For Certificate No.: 636512825080841231 Information required to complete this Schedule, if not shown above , wi ll be shown in the Declarations. A. Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongo ing operations; or 2. In connection with your premises owned by or rented to you . However: 1. The insurance afforded to such additional 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 . 8. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement , the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations ; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 0413 © Insurance Services Office , Inc ., 2012 Page 1 of 1 Jan 12 18 12 :03p State Fa rm Mu tu al Auto mobile Ins urance Ccmpany 900 Old River Road Bskersfield, CA 93311 AT1 A-0177 MCG INNI S, NANCY Pol icy Number : 240 8621-E29-05C Pol icy P:ir icd: No vem ber 29, 20 17 to May 29, 20 18 Ve hicl e: Principal Driver: NANCY MCG INNIS A When you provide a chec k as paym ent, yo u aut ho ri ze us eithe r to use in for mati on from yo ur check to make a one-t ime electro nic fund transfer fro m yo ur accou nt or to proc ess the paymen t as a chec k transac tion . Whe n we use information f,om you r che ck to ma ke an elect ron ic fund Po liC'I' Number: 240 8621-E2 9-05C Prep~red Oc tober 2A, 2017 100458: f;;:: '~1~1r;'·-~-· p.2 ~State Farm AUTO RENEvVAL PREMIUM PAID: $784 .92 DO NOT PAY. Your premium is billed through the Stale Farm Payme nt Plan State Farm Payment Pian Numbe r: 1053062902 Your State Farm Agent JOS H IN BRUG UER A INS AGGY INC Offi ce: 415-821-36DO Address: 399 CO RT LAND AVE SAN FRA NC ISCO, CA 94110-5 535 If you ham a llBW or diiferent Ccr, have addec! any drivero, or hJ,e roo~d. p!eaSf! con/ad yo ur agent. tra nsfe r, fu nds may be wit hdrawn from yo ur acco unt 3S soo n as th e sa me cay we rece iv e \'O ur pay ment , and you wil l not receive your chec k bac k from your fina ncia l inst itu tion . Pa:ie number 1 of 4 14)562 20 ; 11-12-20 1·1 ), It's What You Know. ~~{~;!. -J .. , . . ~~H t,, I • • ll?I~:t.'.~},,,. :; .. .:.··:. ,,~'l'j '-..i .:;~T. \ Your auto insurance premium is $7 84.92 . Did you know you may qual ify for a discou nt? Ca ll St ate Fa rm® Ag ent JOSH IN BRUGUERA INS AGGY INC 2t 415 -82 1-3600 ~lbr at,' dt sccu nts a n} aviJlJJ [JfL, m ,:svu ry s!ate • .-u,d d,'f.c cun t .. u.,100 11!~ may l'tlry t.iy S~J:e. Jan 121812:03p p.3 ~State Farm VEHICLE INFOR MA TIO N Review your po li cy in forma ti on ca refully. If any th ing is incorrect. or if there are any changes, please let us know ri ght away . Veh icle Descri pt ion Ve hicl e Ide nti ficati on Nu mber (VI N) Who pr inci pall y driv es th is vehi cle ? How is this vehicl e norm ally used? Naiional ave"ags: 12, OOG rr.Res dn\-en an nually pe r vehfc.'e NANCY MC GIN NIS, a single fe male, who To Work, Sc'lool or Pleasure. Drive n ever will have 61 ye ars of drl·ling ex perience as 7,50 0 mi les ann uall y. cf Ncverrber 29 , 2G 17. Wit h Dr ive Safe & Save 11", mileage inforn1ation fror.i your vehicle is used to determine yo ur discount. You r ca lcu lated annu al mileage is 16,900 . Prem ium Adj ustment Eac h year, we rev iew ou r med ica l p3yme nts and pe rs::ina l injur/ pro tection coverages claim experience to det er mine the ve hic!e safe ty di scount tha t is a;:ip lied to eac h ma~e and DRI VER IN FO RM ATION Assi gne d Drive r(s) The follow ing driver(s) are assigned to the ve hicle(sj on this po li cy . model. In addition. we review the co mp rehens ive, collision, bodily inj ury an d property dama ge cla im ex per ience annua ll y to de termi ne wh ich makes and mode ls ha•:e ea rn ed decre ases or increases from Sta te Fa rm's standa rd ra,es. If any changes resu lt from ou r rev iews , ad justments are re nected in the rates shown on this renewa i not ice. Driv er Name Driv ing Experie nc e as of Y.arit al Record ___ __!'i!!!_embe r 29, 2_01_7 ____ G_en_d_e_r _s_1a_t_us ____ Le_v_e1 _______ , ___ _ NA IJCY MCGltJNIS Fem ale 02 Princip al Driv er & Assign ed Driv ers For eac h automo bile, the Principal Dr iver is the indiv idu al who most freque ntly drives it. Each drive r :s des igna te d as an Assign ed Dr ive r on the household au tomo bi le that he or she mos t fr equently drives. Your pre mi um may be infl uen ced by the inform3tio1 shovm for thes e dr ive rs. COVERA GE AND LIM ITS See yo ur pof;cy for a,1 e~pianation ofthes e c::images. Liabi lity Bod ily Injury 250 ,0J0/5 JO,OOO Property Damage 100,000 C Medi cal Pay ment s 5,00 0 D ,OJ Deduc t1b'e Compre hens ive G '.O QO Deductible Cc !l is ,Jn H Eme rge ncy Road Se rvic e R1 Ca r Rental & Travel Expense $2 5 pg r Day, $600 Max u Unin sured Mo :or Vehic le Bod ily Injury 250 ,000/:00,000 U1 Unin sured Mo '.or Veh icle Prcperty Oamafe Total .Premium Poli(;)' Nu mber. 240 862' -E2 9-05C Prepa red Octobe r 24, 20 17 $26 1/,4 S15.89 $119.8~ $297.99 $15.60 $63.22 $784.92 Page noll'b er 2 of 4