HomeMy WebLinkAboutC14-180 Kathy Brendza Agreement AGREEMENT FOR PROFESSIONAL SERVICES
BETWEEN
EAGLE COUNTY,COLORADO
AND
KATHY BRENDZA
THIS AGREEMENT for Professional Services("Agreement")is effective as of January 1st,2014 by and
between Kathy Brendza(hereinafter"Contractor")and Eagle County,Colorado a body corporate and
politic (hereinafter"County").
RECITALS
WHEREAS,the County,through its Department of Health and Human Services("HHS")works to
promote the health, safety and welfare of County residents of all ages; and
WHEREAS,the County uses outside providers and professionals to enhance the ability of County to
promote such health,safety and welfare; and
WHEREAS, County desires to hire the Consultant to perform the Services defined below in paragraph 1;
and
WHEREAS, Consultant is authorized to do business in the State of Colorado and has the time, skill,
expertise, and experience necessary to provide the Services; and
WHEREAS,this Agreement shall govern the relationship between Consultant and County in connection
with the Services.
AGREEMENT
NOW, THEREFORE,in consideration of the foregoing and the following promises Consultant and
County agree as follows:
1. Services. Consultant agrees to diligently provide all services,labor,personnel and materials
necessary to perform and complete the Early Head Start Disabilities Coordination services described in
Exhibit A("Services")which is attached hereto and incorporated herein by reference. The Services shall
be performed in accordance with the provisions and conditions of this Agreement.
a. Consultant agrees to furnish the Services in accordance with the schedule established in
Exhibit A. If no completion date is specified in Exhibit A,then Consultant agrees to furnish the Services
in a timely and expeditious manner consistent with the applicable standard of care. By signing below
Consultant represents that it has the expertise and personnel necessary to properly and timely perform the
Services.
b. In the event of any conflict or inconsistency between the terms and conditions set forth in
Exhibit A and the terms and conditions set forth in this Agreement, the terms and conditions set forth in
this Agreement shall prevail.
c. Consultant agrees that it will not enter into any consulting or other arrangements with
third parties that will conflict in any manner with the Services.
2. County's Representative. The HHS Department's designee shall be Consultant's contact with
respect to this Agreement and performance of the Services.
3. Term of the Agreement. This Agreement shall commence upon the date first written above, and
subject to the provisions of paragraph 11 hereof, shall continue in full force and effect through the 31St
day of December,2014.
4. Extension or Modification. This Agreement may not be amended or supplemented,nor may any
obligations hereunder be waived, except by agreement signed by both parties. No additional services or
work performed by Consultant shall be the basis for additional compensation unless and until Consultant
has obtained written authorization and acknowledgement by County for such additional services in
accordance with County's internal policies. Accordingly,no course of conduct or dealings between the
parties,nor verbal change orders,express or implied acceptance of alterations or additions to the Services,
and no claim that County has been unjustly enriched by any additional services,whether or not there is in
fact any such unjust enrichment, shall be the basis of any increase in the compensation payable hereunder.
In the event that written authorization and acknowledgment by County for such additional services is not
timely executed and issued in strict accordance with this Agreement, Consultant's rights with respect to
such additional services shall be deemed waived and such failure shall result in non-payment for such
additional services or work performed.
5. Compensation. County shall compensate Consultant for the performance of the Services in a sum
computed and payable as set forth in Exhibit A. The performance of the Services under this Agreement
shall not exceed$7,000.00. Contractor shall not be entitled to bill at overtime and/or double time rates
for work done outside of normal business hours unless specifically authorized in writing by County.
a. Contractor shall submit an invoice or other documentation as may be required by County
on a monthly basis for the preceding month. All invoices shall include detail regarding the hours spent,
tasks performed,who performed each task and such other detail as County may request. If County is not
satisfied with the completeness of a submitted invoice, County may request Contractor to either revise the
invoice or provide additional information. Payment will be made for Services satisfactorily performed
within thirty(30)days of receipt of a proper and accurate invoice.
All invoices must be mailed or delivered in-person to the following address to ensure proper
payment. Invoices sent by fax or e-mail will not be accepted.
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Eagle County Health and Human Services
Business Office
550 Broadway
Post Office Box 660
Eagle, CO 81631
b. Any out-of-pocket expenses to be incurred by Consultant and reimbursed by County shall
be identified on Exhibit A. Out-of-pocket expenses will be reimbursed without any additional mark-up
thereon and are included in the not to exceed contract amount set forth above. Out-of-pocket expenses
shall not include any payment of salaries,bonuses or other compensation to personnel of Consultant.
Consultant shall not be reimbursed for expenses that are not set forth on Exhibit A unless specifically
approved in writing by County.
c. If,prior to payment of compensation or reimbursement for Services but after submission
to County of a request therefore by Contractor, County reasonably determines that payment as requested
would be improper because the Services were not performed as prescribed by the provisions of this
Agreement,the County shall have no obligation to make such payment. If, at any time after or during the
term or after termination or expiration of this Agreement, County reasonably determines that any
payment theretofore paid by County to Contractor was improper because the Services for which payment
was made were not performed as set forth in this Agreement,then upon written notice of such
determination and request for reimbursement from County, Consultant shall forthwith return such
payment(s)to County. Upon termination or expiration of this Agreement,unexpended funds advanced by
County, if any, shall forthwith be returned to County.
d. All funds received by Contractor under this Agreement shall be or have been expended
solely for the purpose for which granted, and any funds not so expended, including funds lost or diverted
for other purposes,shall be returned to County. Contractor shall provide the County with progress reports
upon County's request; or Contractor shall furnish progress reports as more specifically set forth in the
attached Exhibit A.
e. County will not withhold any taxes from monies paid to the Consultant hereunder and
Consultant agrees to be solely responsible for the accurate reporting and payment of any taxes related to
payments made pursuant to the terms of this Agreement.
f. Notwithstanding anything to the contrary contained in this Agreement, County shall have
no obligations under this Agreement after,nor shall any payments be made to Consultant in respect of
any period after December 31 of any year,without an appropriation therefor by County in accordance
with a budget adopted by the Board of County Commissioners in compliance with Article 25,title 30 of
the Colorado Revised Statutes,the Local Government Budget Law(C.R.S. 29-1-101 et. seq.)and the
TABOR Amendment(Colorado Constitution,Article X, Sec. 20).
6. Sub-consultants. Consultant acknowledges that County has entered into this Agreement in
reliance upon the particular reputation and expertise of Consultant. Consultant shall not enter into any
sub-consultant agreements for the performance of any of the Services or additional services without
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County's prior written consent,which may be withheld in County's sole discretion. County shall have
the right in its reasonable discretion to approve all personnel assigned to the subject project during the
performance of this Agreement and no personnel to whom County has an objection,in its reasonable
discretion, shall be assigned to the project. Consultant shall require each sub-consultant,as approved by
County and to the extent of the Services to be performed by the sub-consultant,to be bound to Consultant
by the terms of this Agreement, and to assume toward Consultant all the obligations and responsibilities
which Consultant,by this Agreement,assumes toward County. County shall have the right(but not the
obligation)to enforce the provisions of this Agreement against any sub-consultant hired by Consultant
and Consultant shall cooperate in such process. The Contractor shall be responsible for the acts and
omissions of its agents, employees and sub-consultants or sub-contractors.
7. Insurance. Consultant agrees to provide and maintain at Consultant's sole cost and expense,the
following insurance coverage with limits of liability not less than those stated below:
a. Types of Insurance.
i. Workers' Compensation insurance as required by law.
ii. Auto coverage with limits of liability not less than$1,000,000 each accident
combined bodily injury and property damage liability insurance,including coverage for owned,hired,and
non-owned vehicles.
iii. General Liability coverage with limits of liability not less than$1,000,000..
iv. Intentionally Omitted.
v. Intentionally Omitted.
b. Other Requirements.
i. The automobile and commercial general liability coverage and such other
coverage as indicated above shall be endorsed to include Eagle County, its associated or affiliated
entities, its successors and assigns,elected officials,employees, agents and volunteers as additional
insureds.
ii. Consultant's certificates of insurance shall include sub-consultants as additional
insureds under its policies or Consultant shall furnish to County separate certificates and endorsements
for each sub-consultant. All coverage(s)for sub-consultants shall be subject to the same minimum
requirements identified above. Consultant and sub-consultants, if any,shall maintain the foregoing
coverage in effect until the Services are completed. In addition,all such policies shall be kept in force by
Consultant and its sub-consultants until the applicable statute of limitations for the Services has expired
provided that the coverage is commercially available at a reasonable premium.
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iii. Insurance shall be placed with insurers duly licensed or authorized to do business
in the State of Colorado and with an"A.M. Best"rating of not less than A-VII.
iv. Consultant's insurance coverage shall be primary and non-contributory with
respect to all other available sources. Consultant's policy shall contain a waiver of subrogation against
Eagle County.
v. All policies must contain an endorsement affording an unqualified thirty(30)
days' notice of cancellation to County in the event of cancellation of coverage.
vi. All insurers must be licensed or approved to do business within the State of
Colorado and all policies must be written on a per occurrence basis unless otherwise provided herein.
vii. Consultant's certificate of insurance evidencing all required coverage(s)is
attached hereto as Exhibit B. Upon request, Consultant shall provide a copy of the actual insurance
policy and/or required endorsements required under this Agreement within five(5)business days of a
written request from County, and hereby authorizes Consultant's broker,without further notice and
authorization by Consultant,to immediately comply with any written request of County for a complete
copy of the policy.
viii. Consultant shall advise County in the event the general aggregate or other
aggregate limits are reduced below the required per occurrence limit. Consultant, at its own expense,will
reinstate the aggregate limits to comply with the minimum limit s and shall furnish County a new
certificate of insurance showing such coverage.
ix. If Consultant fails to secure and maintain the insurance required by this
Agreement and provide satisfactory evidence thereof to County,County shall be entitled to immediately
terminate this Agreement.
x. The insurance provisions of this Agreement shall survive expiration or
termination hereof.
xi. The parties hereto understand and agree that the County is relying on,and does
not waive or intend to waive by any provision of this Agreement,the monetary limitations or rights,
immunities and protections provided by the Colorado Governmental Immunity Act, as from time to
time amended, or otherwise available to County, its affiliated entities,successors or assigns,its elected
officials,employees, agents and volunteers.
xii. Consultant is not entitled to workers' compensation benefits except as
provided by the Consultant,nor to unemployment insurance benefits unless unemployment compensation
coverage is provided by Consultant or some other entity. The Consultant is obligated to pay all federal
and state income tax on any moneys paid pursuant to this Agreement.
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8. Indemnification. The Consultant shall indemnify and hold harmless County,and any of its
officers, agents and employees against any losses, claims,damages or liabilities for which County may
become subject to insofar as any such losses,claims,damages or liabilities arise out of, directly or
indirectly,this Agreement, or are based upon any performance or nonperformance by Consultant or any
of its sub-consultants hereunder including claims for bodily injury or personal injury including death,or
loss or damage to tangible or intangible property; and Consultant shall reimburse County for reasonable
attorney fees and costs,legal and other expenses incurred by County in connection with investigating or
defending any such loss,claim, damage,liability or action. This indemnification shall not apply to claims
by third parties against the County to the extent that County is liable to such third party for such claims
without regard to the involvement of the Consultant. This paragraph shall survive expiration or
termination hereof.
9. Ownership of Documents. All documents prepared by Consultant in connection with the
Services shall become property of County. Consultant shall execute written assignments to County of all
rights (including common law, statutory,and other rights,including copyrights)to the same as County
shall from time to time request. For purposes of this paragraph,the term"documents"shall mean and
include all reports,plans, studies,tape or other electronic recordings, drawings, sketches,estimates, data
sheets,maps and work sheets produced,or prepared by or for Consultant(including any employee or
subcontractor in connection with the performance of the Services and additional services under this
Agreement).
10. Notice. Any notice required by this Agreement shall be deemed properly delivered when(i)
personally delivered, or(ii)when mailed in the United States mail,first class postage prepaid,or(iii)
when delivered by FedEx or other comparable courier service, charges prepaid,to the parties at their
respective addresses listed below, or(iv)when sent via facsimile so long as the sending party can provide
facsimile machine or other confirmation showing the date,time and receiving facsimile number for the
transmission, or(v)when transmitted via e-mail with confirmation of receipt. Either party may change its
address for purposes of this paragraph by giving five(5)days prior written notice of such change to the
other party.
COUNTY:
Eagle County, Colorado
Attention: Toni Rozanski
551 Broadway
Post Office Box 660
Eagle, CO 81631
Telephone: 970-328-8852
Facsimile: 970-328-8829
E-mail: toni.rozanski @eaglecounty.us
With a copy to:
Eagle County Attorney
500 Broadway
Post Office Box 850
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•
Eagle, Co 81631
Telephone: 970-328-8685
Facsimile: 970-328-8699
E-Mail: atty @eaglecounty.us
CONSULTANT:
Contractor:
Kathy Brendza
Kbrendza@centurytel.net
(970)401-4821
P.O. Box 357
Gypsum, Co. 81637
11. Termination. County may terminate this Agreement, in whole or in part,at any time and for any
reason,with or without cause,and without penalty therefor with seven(7) calendar days'prior written
notice to the Consultant. Upon termination of this Agreement,Consultant shall immediately provide
County with all documents as defined in paragraph 9 hereof, in such format as County shall direct and
shall return all County owned materials and documents. County shall pay Consultant for Services
satisfactorily performed to the date of termination.
12. Venue,Jurisdiction and Applicable Law. Any and all claims,disputes or controversies related to
this Agreement,or breach thereof, shall be litigated in the District Court for Eagle County, Colorado,
which shall be the sole and exclusive forum for such litigation. This Agreement shall be construed and
interpreted under and shall be governed by the laws of the State of Colorado.
13. Execution by Counterparts;Electronic Signatures. This Agreement may be executed in two or
more counterparts, each of which shall be deemed an original,but all of which shall constitute one and
the same instrument. The parties approve the use of electronic signatures for execution of this
Agreement. Only the following two forms of electronic signatures shall be permitted to bind the parties to
this Agreement: (i) Electronic or facsimile delivery of a fully executed copy of the signature page; (ii)
the image of the signature of an authorized signer inserted onto PDF format documents. All documents
must be properly notarized, if applicable. All use of electronic signatures shall be governed by the
Uniform Electronic Transactions Act, C.R.S. 24-71.3-101 to 121.
14. Other Contract Requirements.
a. In rendering the Services hereunder, Contractor shall comply with the highest standards
of customer service to the public. Contractor shall provide appropriate supervision of its employees to
ensure the maintenance of these high standards of customer service and professionalism are maintained.
The performance of such obligation shall be determined at the sole discretion of County. In the event
County finds these standards of customer service are not being met by Contractor, County may terminate
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this Agreement, in whole or in part,upon seven(7) days' notice to Contractor.
b. Consultant shall be responsible for the completeness and accuracy of the Services,
including all supporting data or other documents prepared or compiled in performance of the Services,
and shall correct, at its sole expense,all significant errors and omissions therein. The fact that the County
has accepted or approved the Services shall not relieve Consultant of any of its responsibilities.
Consultant shall perform the Services in a skillful,professional and competent manner and in accordance
with the standard of care, skill and diligence applicable to Consultants performing similar services. This
paragraph shall survive termination of this Agreement.
c. Consultant represents and warrants that it has the expertise and personnel necessary to
properly perform the Services and covenants that its professional personnel are duly licensed to perform
the Services within Colorado.
d. Consultant agrees to work in an expeditious manner,within the sound exercise of its
judgment and professional standards,in the performance of this Agreement. Time is of the essence with
respect to this Agreement.
e. This Agreement constitutes an agreement for performance of the Services by Consultant
as an independent contractor and not as an employee of County. Nothing contained in this Agreement
shall be deemed to create a relationship of employer-employee,master-servant,partnership,joint venture
or any other relationship between County and Consultant except that of independent contractor.
Consultant shall have no authority to bind County.
f. Consultant represents and warrants that at all times in the performance of the Services,
Consultant shall comply with any and all applicable federal and state laws,codes,rules and regulations.
g. Contractor shall comply with the Civil Rights Act of 1964 and Section 504,
Rehabilitation Act of 1973, concerning discrimination on the basis of race, color, sex,age,religion,
political beliefs,national origin or handicap.
h. This Agreement contains the entire agreement between the parties with respect to the
subject matter hereof and supersedes all other agreements or understanding between the parties with
respect thereto.
i. Consultant shall not assign any portion of this Agreement without the prior written
consent of the County. Any attempt to assign this Agreement without such consent shall be void.
j. This Agreement shall be binding upon and shall inure to the benefit of the parties hereto
and their respective permitted assigns and successors in interest. Enforcement of this Agreement and all
rights and obligations hereunder are reserved solely for the parties,and not to any third party.
k. No failure or delay by either party in the exercise of any right hereunder shall constitute a
waiver thereof. No waiver of any breach shall be deemed a waiver of any preceding or succeeding breach.
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I. The invalidity,illegality or unenforceability of any provision of this Agreement shall not
affect the validity or enforceability of any other provision hereof.
m. Consultant shall maintain for a minimum of three years, adequate financial and other
records for reporting to County. Consultant shall be subject to financial audit by federal, state or county
auditors or their designees. Consultant authorizes such audits and inspections of records during normal
business hours,upon 48 hours' notice to Consultant. Consultant shall fully cooperate during such audit or
inspections.
n. The signatories to this Agreement aver to their knowledge,no employee of the County
has any personal or beneficial interest whatsoever in the Services or Property described in this
Agreement. The Consultant has no beneficial interest, direct or indirect,that would conflict in any manner
or degree with the performance of the Services and Consultant shall not employ any person having such
known interests.
o. The Consultant, if a natural person eighteen(18)years of age or older,hereby swears and
affirms under penalty of perjury that he or she(i) is a citizen or otherwise lawfully present in the United
States pursuant to federal law, (ii)to the extent applicable shall comply with C.R.S. 24-76.5-103 prior to
the effective date of this Agreement.
15. Prohibitions on Government Contracts.
If Consultant has any employees or subcontractors,Consultant shall comply with C.R.S. 8-17.5-101,
et. seq.,regarding Illegal Aliens-Public Contracts for Services,and this Agreement. By execution of
this Agreement,Consultant certifies that it does not knowingly employ or contract with an illegal alien
who will perform under this Agreement and that Consultant will participate in the E-verify Program
or other Department of Labor and Employment program("Department Program")in order to confirm
the eligibility of all employees who are newly hired for employment to perform Services under this
Agreement.
a. Consultant shall not:
i. Knowingly employ or contract with an illegal alien to perform Services under
this Agreement; or
ii. Enter into a subcontract that fails to certify to Consultant that the subcontractor
shall not knowingly employ or contract with an illegal alien to perform work under the public contract for
services.
b. Consultant has confirmed the employment eligibility of all employees who are newly
hired for employment to perform Services under this Agreement through participation in the E-Verify
Program or Department Program, as administered by the United States Department of Homeland
Security. Information on applying for the E-verify program can be found at:
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http://www.dhs.gov/xprevprot/programs/gc_1185221678150.shtm
c. Consultant shall not use either the E-verify program or other Department Program
procedures to undertake pre-employment screening of job applicants while the public contract for services
is being performed.
d.' If Consultant obtains actual knowledge that a subcontractor performing work under the
public contract for services knowingly employs or contracts with an illegal alien, Consultant shall be
required to:
i. Notify the subcontractor and County within three (3) days that Consultant has
actual knowledge that the subcontractor is employing or contracting with an illegal alien; and
ii. Terminate the subcontract with the subcontractor if within three days of receiving
the notice required pursuant to subparagraph (i) of the paragraph (d) the subcontractor does not stop
employing or contracting with the illegal alien; except that Consultant shall not terminate the contract
with the subcontractor if during such three (3) days the subcontractor provides information to establish
that the subcontractor has not knowingly employed or contracted with an illegal alien.
e. Consultant comply with any reasonable request by the Department of Labor and
Employment made in the course of an investigation that the department is undertaking pursuant to its
authority established in C.R.S. 8-17.5-102(5).
f. If Consultant violates these prohibitions, County may terminate the Agreement for breach
of contract. If the Agreement is so terminated specifically for breach of this provision of this Agreement,
Consultant shall be liable for actual and consequential damages to County as required by law.
g. County will notify the Colorado Secretary of State if Consultant violates this provision
of this Agreement and County terminates the Agreement for such breach.
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IN WITNESS WHEREOF,the parties have executed this Agreement the day and year first set forth
above.
COUNTY OF EAGLE, STATE OF COLORADO, by
and thro 'ts COUNTY MANAGER
By: L?aAko
eith P. Montag, Co ty Manager
CONSULTANT:
By: AL .LL----- 5/4.1,11
Print Name:' J—l�e 2 0 1 I` ' ) {e Y16]?L.c'-,
Title: i.S,\-).9. 1 -I-.i-t..- Coop ,1 c:,
11
EXHIBIT A
SCOPE OF SERVICES, SCHEDULE,FEES
Description of Services: The Services to be provided under this Agreement and shall commence
upon execution of this Agreement, and subject to the provisions set forth in paragraph 11 hereof, shall
continue until December 31,2014. Contractor shall perform the following Early Head Start Disabilities
Coordination Services in accordance with the Head Start Performance Standards and the Head Start Act
as amended December 12,2007:
1. Disabilities Coordination
A. Work with parent educators through the Child Find referral process and services
coordination
B. Audit and monitor disabilities data in client charts and PROMIS data base
C. Provide support to families in Early Head Start who need disability services/coordination
of services
D. Train staff on disability screening tools(ASQ)and the referral process
E. Attend Chart Reviews and staff meetings as requested by staff
F. Oversee implementation of the disabilities service plan
Payment and Fee Schedule: County will compensate Contractor for Early Head Start Disabilities
Coordination Services satisfactorily performed at the rate of$70.00 per hour.
The maximum amount of compensation under this Agreement shall not exceed$7,000.00
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EXHIBIT B
Insurance Certificate
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DECLARATIONS
COLORADO HOMEOWNERS POLICY-CONDO-UNIT FORM 6(ED 06/94)CO
NON-ASSESSABLE POLICY ISSUED BY AMERICAN FAMILY MUTUAL INSURANCE COMPANY
A MEMBER OF THE AMERICAN FAMILY INSURANCE GROUP, MADISON,WI
PLEASE READ YOUR POLICY
POLICY NUMBER 05PL-1831-01
MORTGAGEE
REFERENCE NUMBER: 3555775
PNC BANK NA
ITS SUCCESSORS AND/OR ASSIGNS ATIMA
PO BOX 7433
SPRINGFIELD,OH 45501-7433
NAMED INSURED
BRENDZA,JOHN&KATHY EFFECTIVE
PO BOX 357 FROM 3/22/2014 TO 3/22/2015
GYPSUM,CO 81637-0357 ACCT 504-249-803-33
COVERAGES AND LIMITS PROVIDED
001 FAMILY FRAME DWELLING IN TOWN CLASS 6
SECTION I LIMITS
REAL PROPERTY $721,900
PERSONAL PROPERTY ON PREMISES $158,700
PERSONAL PROPERTY OFF PREMISES 100%SUBJECT TO POLICY LIMITATION
LOSS OF USE-ACTUAL LOSS SUSTAINED WITHIN 12 MONTHS OF THE LOSS $500
DEDUCTIBLE AMOUNT-ALL PERIL
SECTION II
PERSONAL LIABILITY $500,000
MEDICAL EXPENSE $1,000
ADDITIONAL PROTECTION/ENDORSEMENTS
OPTION 18-GOLD STAR CONDO-UNIT COVERAGE
OPTION 2-EXTENDED COVERAGE ON JEWELRY,WATCHES AND FURS
OPTION 14-PERSONAL PROPERTY REPLACEMENT COVERAGE
BACK-UP SEWER COV(END 466 ED 10/97)-$5000 LIMIT- 1000 DED
ENVIRONMENTAL/PERSONAL POLLUTION DAMAGE COV(END 523 ED 9/94)
FUNGI OR BACTERIA EXCLUSION(END 595 ED 6/02)
AMENDATORY HOMEOWNERS CONDO(END 422 ED 10/06)
ACTUAL CASH VALUE WOOD ROOF SURFACE LOSS SETTLEMENT(END 596A ED 11/08)
COLORADO AMENDATORY HOMEOWNERS(END 584D(CO)ED 10/13)
CUSTOMER LONGEVITY DISCOUNT HAS BEEN APPLIED
HOME&AUTO DISCOUNT HAS BEEN APPLIED
HOME AND UMBRELLA DISCOUNT HAS BEEN APPLIED
TOTAL PREMIUM $2,036.00
LATEST PERSONAL PROPERTY COST INDEX IS 212
Declarations effective on the date shown above.These declarations form a part of this policy and replace all other
declarations which may have been issued previously for this policy. If these declarations are accompanied by a new
policy,the policy replaces any which may have been issued before with the same policy number.
AUTHORIZED c C7 �-
REPRESENTATIVE President Secretary
AGENT 169-307 PHONE (970)949-4465
Mike Deacon Agency
P.O.Box 3259
140 Beaver Creek Blvd. Ste B106
Avon,CO 81620-3259
Form No.HO-47C 1 of 2 Stock No.23281
•
DECLARATIONS
COLORADO HOMEOWNERS POLICY-CONDO-UNIT FORM 6(ED 06/94)CO
NON-ASSESSABLE POLICY ISSUED BY AMERICAN FAMILY MUTUAL INSURANCE COMPANY
A MEMBER OF THE AMERICAN FAMILY INSURANCE GROUP, MADISON,WI
PLEASE READ YOUR POLICY
POLICY NUMBER 05PL-1831-01
LOCATION OF RISK: 65 A BLACKBEAR GYPSUM CO 81637
MORTGAGEE
REFERENCE NUMBER: 000355576
PNC BANK NA ITS SUCCESSORS AND/OR ASSIGNS ATIMA PO BOX 7433 SPRINGFIELD,OH
45501-7433
LATEST PERSONAL PROPERTY COST INDEX IS 212
Declarations effective on the date shown above.These declarations form a part of this policy and replace all other
declarations which may have been issued previously for this policy. If these declarations are accompanied by a new
policy,the policy replaces any which may have been issued before with the same policy number.
AUTHORIZED Lea.C� '? r� J
REPRESENTATIVE President Secretary
AGENT 169-307 PHONE (970)949-4465
Mike Deacon Agency
P.O.Box 3259
140 Beaver Creek Blvd. Ste B106
Avon,CO 81620-3259
Form No.HO-47C 2 of 2 Stock No.23281
