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HomeMy WebLinkAboutC18-062 Jerry CheneyAGREEMENT FOR SERVICES BETWEEN EAGLE COUN'T'Y, COLORADO AND JERRY CHENEY THIS AGREEMENT ("Agreement") is effective as of 03/12/2018 by and between Jerry Cheney a sole proprietor (hereinafter "Contractor") and Eagle County, Colorado, a body corporate and politic (hereinafter "County"). RECITALS WHEREAS, County desires to retain Contractor to assist the Facilities Management Department in the daily maintenance and oversight of the El Jebel Community Center, located at 0020 Eagle County Road, El Jebel, CO 81623 (the "Property"); and WHEREAS, Contractor is authorized to do business in the State of Colorado and has the time, skill, expertise, and experience necessary to provide the Services as defined below in paragraph 1 hereof; and WHEREAS, this Agreement shall govern the relationship between Contractor and County in connection with the Services. AGREEMENT NOW, THEREFORE, in consideration of the foregoing and the following promises Contractor and County agree as follows: 1. Services or Work. Contractor agrees to diligently provide all services, labor, personnel and materials necessary to perform and complete the services or work described below ("Services" or "Work"). The Services shall be performed in accordance with the provisions and conditions of this Agreement. MAINTENANCE AND OVERSIGHT SERVICES: 1. Check the building daily. These duties will include: a) Check condition of meeting rooms, clean if necessary and report findings. b) Check janitorial work, contact contractor if not complete and report findings. c) Check snow removal work, contact contractor if not complete and report findings. 2. Keep grounds free of litter. 3. Routine maintenance repairs such as minor plumbing, change light bulbs, change HVAC filters, hang signs, move furniture and boxes and other duties as requested. 4. Contact Facilities Management Department for larger or specialized needs. 5. Complete and forward a daily report of findings and activities to Facilities Management. 6. Respond to after hour calls concerning alarms, plumbing, etc. as requested. 7. Contractor must maintain during the course of the Agreement reliable transportation, tools and insurance as required. a. Contractor agrees to furnish the Services in a timely and expeditious manner consistent with the applicable standard of care. By signing below Contractor represents that it has the expertise and personnel necessary to properly and timely perform the Services. C18-062 2. County's Representative. The Facilities Management Department's designee shall be Contractor's contact with respect to this Agreement and performance of the Services. 3. Term of the Agreement. This Agreement shall commence on the 4th day of April, 2018, and subject to the provisions of paragraph 11 hereof, shall continue in full force and effect for a period of one year. 4. Extension or Modification. This Agreement may be extended for up to three additional one year terms upon written agreement of the parties. Any amendments or modifications shall be in writing signed by both parties. No additional services or work performed by Contractor shall be the basis for additional compensation unless and until Contractor 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, Contractor'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. S. Compensation. County shall compensate Contractor for the performance of the Services in a sum computed and payable as set forth in Exhibit A. Prior to commencement of any additional services at the Property, outside the Scope of Services provided in paragraph 1 hereof, Contractor shall first provide County with a written estimate which shall include an estimate of the labor, materials without any mark up and any additional costs necessary to perform the additional services at the Property. Each estimate must be approved by County's Representative prior to commencement of the additional services by Contractor and all rates shall be in accordance with the fee schedule set forth in Exhibit A The performance of the Services and any additional services allowable under this Agreement shall not exceed fifty thousand dollars ($50,000). Contractor shall be entitled to bill at overtime rates for work done outside of normal business hours in accordance with the fees established in Exhibit A. a. Payment will be made for Services satisfactorily performed within thirty (30) days of receipt of a proper and accurate invoice from Contractor. All invoices shall include detail regarding the hours spent, tasks performed, who performed each task and such other detail as County may request. b. If, at any time during the term or after termination or expiration of this Agreement, County reasonably determines that any payment made 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, Contractor 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. C. County will not withhold any taxes from monies paid to the Contractor hereunder and Contractor 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. d. 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 Contractor 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. 29-1-1O1 et. seq.) and the TABOR Amendment (Colorado Constitution, Article X, Sec. 20). 2 WAMylContiwl FbmIDin RsVerryCheney�20I&krryChe�y.EllebeI Community Cc nter.CLEAN.022118.d6cx 6. Subcontractors. Contractor acknowledges that County has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the performance of any of the Services or additional services without 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. Contractor shall require each subcontractor, as approved by County and to the extent of the Services to be performed by the subcontractor, to be bound to Contractor by the terms of this Agreement, and to assume toward Contractor all the obligations and responsibilities which Contractor, by this Agreement, assumes toward County. County shall have the right (but not the obligation) to enforce the provisions of this Agreement against any subcontractor hired by Contractor and Contractor shall cooperate in such process. The Contractor shall be responsible for the acts and omissions of its agents, employees and subcontractors. 7. Insurance. Contractor agrees to provide and maintain at Contractor's sole cost and expense, the following insurance coverage with limits of liability not less than those stated below: a. Types of Insurance. 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. Commercial General Liability coverage to include premises and operations, persona I/ad vert i s ing injury, prod uctslcompleted operations, broad form property damage with limits of liability not less than $1,000,000 per occurrence and $1,000,000 aggregate limits. b. Other Requirements. i. The automobile and commercial general liability coverage 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. A certificate of insurance consistent with the foregoing requirements is attached hereto as Exhibit B. ii. Contractor's certificates of insurance shall include subcontractors, if any as additional insureds under its policies or Contractor shall furnish to County separate certificates and endorsements for each subcontractor. iii. The insurance provisions of this Agreement shall survive expiration or termination hereof. iv. 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. 3 WAMylCa punct FbmI ❑inRsVerry Cheney�20 I&krry Cheesy. El lebe l Cam mi y 0eiwer.CLEAN.022118.dwx Contractor is not entitled to workers' compensation benefits except as provided by the Contractor, nor to unemployment insurance benefits unless unemployment compensation coverage is provided by Contractor or some other entity. The Contractor is obligated to pay all federal and state income tax on any moneys paid pursuant to this Agreement. 8. Indemnification. The Contractor 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 Contractor or any of its subcontractors hereunder; and Contractor 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 Contractor. This paragraph shall survive expiration or termination hereof. 9. Ownership of Documents. All documents (including electronic files) and materials obtained during, purchased or prepared in the performance of the Services shall remain the property of the County and are to be delivered to County before final payment is made to Contractor or upon earlier termination of 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: Facilities Management Department 590 Broadway Post Office Box 850 Eagle, CO 81631 Telephone: 970-328-8881 Facsimile: 970-328-8782 E -Mail: ron.siebert@eaglecounty.us With a copy to: Eagle County Attorney 500 Broadway Post Office Box 850 Eagle, CO 81631 Telephone: 970-328-8685 Facsimile: 970-328-8699 E -Mail: atty@eaglecounty.us CONTRACTOR: Jerry Cheney 2496 Hwy 133 4 WAMyCo illi l FbmIDin RsVerryCheney�20I&krryChe�y.EllebeI Cam mi y 0eiwer.CLEAN.022118.dwx Carbondale, CO 81623 Telephone: 970-274-0457 Facsimile: 970-963-3496 E -Mail: jcheney@sopris.net H. 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 Contractor. Upon termination of this Agreement, Contractor 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 Contractor 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. B. 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. 24-71.3401 to 121. 14. Other Contract Requirements and Contractor Representations. a. Contractor has familiarized itself with the nature and extent of the Services to be provided hereunder and the Property, and with all local conditions, federal, state and local laws, ordinances, rules and regulations that in any manner affect cost, progress, or performance of the Services. b. Contractor will make, or cause to be made, examinations, investigations, and tests as he deems necessary for the performance of the Services. C. To the extent possible, Contractor has correlated the results of such observations, examinations, investigations, tests, reports, and data with the terms and conditions of this Agreement. d. To the extent possible, Contractor has given County written notice of all conflicts, errors, or discrepancies. e. Contractor shall be responsible for the completeness and accuracy of the Services and shall correct, at its sole expense, all significant errors and omissions in performance of the Services. The fact that the County has accepted or approved the Services shall not relieve Contractor of any of its responsibilities. Contractor shall perform the Services in a skillful, professional and competent manner and in accordance with the standard of care, skill and diligence applicable to contractors performing similar services. Contractor represents and warrants that it has the expertise and personnel necessary to properly perform the Services and shall comply with the highest standards of customer service to the public. Contractor shall provide appropriate supervision to its employees to ensure the Services are performed in accordance with this Agreement. This paragraph shall survive termination of this Agreement. 5 GAAiidyY'o iliwl FbmIDin RsVerryCheney�20I&krryCheney.El]ebeI Cam mky 0eiwer.C1EAN.022118.d6cx f. Contractor 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. g. This Agreement constitutes an agreement for performance of the Services by Contractor 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 Contractor except that of independent contractor. Contractor shall have no authority to bind County. h. Contractor represents and warrants that at all times in the performance of the Services, Contractor shall comply with any and all applicable laws, codes, rules and regulations. i. 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. j. Contractor 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. k. 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. 1. 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. M. The invalidity, illegality or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of any other provision hereof. 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 Contractor has no beneficial interest, direct or indirect, that would conflict in any manner or degree with the performance of the Services and Contractor shall not employ any person having such known interests. o. The Contractor, 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 citinn 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. ProhibitionsQn Government Contracts. As used in this Section 15, the term undocumented individual will refer to those individuals from foreign countries not legally within the United States as set forth in C.R.S. 5-17.5-101, et, seq. If Contractor has any employees or subcontractors. Contractor shall comply with C.ILS. 8-17.5-101, et. seq., and this Agreement. By execution of this Agreement, Contractor certifies that it does not knowingly employ or contract with an undocumented individual who will perform under this Agreement and that Contractor 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. Contractor shall not: 5 GAAiidyY'o iliwl FbmI Din n.OuryCheney�20I&krryCheney.El]ebeI Cam mky Ceiwer.C1EAN.022118.d6cx i. Knowingly employ or contract with an undocumented individual to perform Services under this Agreement; or ii. Enter into a subcontract that fails to certify to Contractor that the subcontractor shall not knowingly employ or contract with an undocumented individual to perform work under the public contract for services. b. Contractor 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: https://www.usris.gov/e-verify C. Contractor 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 Contractor obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an undocumented individual, Contractor shall be required to: i. Notify the subcontractor and County within three (3) days that Contractor has actual knowledge that the subcontractor is employing or contracting with an undocumented individual; 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 undocumented individual; except that Contractor 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 undocumented individual. C. Contractor shall 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 Contractor 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, Contractor shall be liable for actual and consequential damages to County as required by law. g. County will notify the Colorado Secretary of State if Contractor violates this provision of this Agreement and County terminates the Agreement for such breach. [REST OF PAGE INTENTIONALLY LEFT BLANK] 7 GAAiidyV'o punct FbmI ❑inRsVerry Cheney�20 I&krry Cheney. El]ebe l Cam mky 0eiwer.C1EAN.022118.d6cx IN WITNESS WHEREOF, the parties have executed this Agreement the day and year first set forth above. COUNTY OF EAGLE, STATE OF COLORADO, B y and Through Its COUNTY MANAGER By: Kelley Collier, Deputy County Manager CONTRACTOR: .TERRY CHENEY Print Name: Jerry Cheney Title: Own5r GAAiidyV'o iliwl FbmI ❑inRsVerry Cheney120I&krry Cheney. El lebe I Cam mky 0eiwer.C1EAN.022118.dwx Proposal to Eagle County for Maintenance Services at: El Jebel Community Center 0024 Eagle County Road M Jebel CO 81623 Jerry Cheney, as an Independent Contractor, proposes to provide maintenance services to Eagle County for the El Jebel Community Center as outlined in request for proposal, and other services to be defined later. Contractor to provide labor, tools, transportation and insurance as required at an hourly rate of $50Jhr.(includes labor, insurance and mileage ) material and supplies to be purchased or supplied by Eagle County. After hours and weekend calls will be billed at a time and half charge. Availability or unavailability for evening and weekend calls will be provided to Bill Beasley with sufficient notice for other arrangements to be made I have worked as a sub contractor for Prince Creek Construction and performed electrical maintenance And other services for the Social Security Administration in Glenwood_ Springs numerous times. I have managed and maintained a personal rental property in Carbondale the past 2 years. I have no lawsuits, tax liens or potential claims pending at this time. EXHIBIT A --1 Ak—. o CERTIFICATE OF LIABILITY INSURANCE WITE w*IDay" 03!08!2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES SOW. THIS CERTIFICATE OF INSURANCE DOES HOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERISj, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDM IMPORTANT: If the certificate holder is an ADDITIONAL INSURER the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the temTs and conditions of the policy, certain policies may require an endorsernem A statement on this certificate does not confer tights to the certificate holder in Ileu of such endorsement[sk F*O ucER Insurance Strings, CO 61602 Haywood Gen INSURED Je Chen 2496 Highway 133 INSURERS; Carbondale, C081623 I"'RI e INSURER D: INSUReg E. INSURER F COVERAGES CERTIFICATE NUMBER: 1 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF WSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POL1C1E6 LUXTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM INSR LTR TYPE OF WSIIRAHCE AUM im SUM vM POLICY NUMBER POLICY Err LUM A X COMYEMAL GENERAL uAsurY ❑X OCCUR X 8KS56035378 03► 0117 031Y01201$mr�j EACH OCCURRENCE s 1.000.01 WROCLAAIsaMM S 300,01 MM EXP (ANON cananl S 16.01 PERSONAL s ADV INJMY S 1,800,41 GEtERAI AGGREGATE S 2,BBD,01 OENL AGGREGATE LIMIT APPLIES PER jC POLICY � 0 LOC PRODUCT'S - COUPIOP AGO S 2X0.01 S OTHER- A"OBILE LIABILITY CO&URNED SINGLE LAAn S ANY AUTO BODILY INJURY IPerPenanl s ALL OYMD SCHEDULED AUTOS AUTOS BODILY INJURY IPR aee+dRey i HIRED AUTOS AU ON SVMIED f S UlAaF ELLA LIAROCCUR HCLANA54AADE EACH OCCURRENCE s EXCESS LIAC A,GCQEGATE S OED I I RETENTIONf I S WORKERSCONPINSATM AND EIPLOYEW LIAIIILITY vim ANY PROPRIETORIPAR7 MMEWtIVE OFFIEAIBEREXCLUDED? NIA EL EACH ACCICEHT s E L. DISEASE • EA EeePLO S et'[Iu N OF OPERAT KM 0, F L DISEASE • POLICY I -Of s DESCRWTM oP OPQtATTONS I LOCATKM I VVUCU!E IACORD 7x11, Add cam& PA= is SClndrk, mey be ad&UM h nmM spice b IY W W) Ider is included as Additional Insured under Genera I Liab€lity only and my In respect to ongoing operations performed lay the insured on behalf of holder. I j_Ttir-Jr-Vi Eagle County, Colorado Facilities Management dept PO Sox 860 Eagle, CO 81631 SHOULD ANY OF THE ABOVE QESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NORM WILL BE DELIVERED IN ACCORDANCE mTH THE POLICY PROVIMONS. 0 ISM2014 ACORD ACORD 26 t2014AH j Tile ACS name and logo sae registered marks of ACID IT State Farm Mutual AutornoNle Insurance Comparry u PO Box 653922 State Farm RkfreNsonrl,IX7X 75�8�39FP AT2 000243 oaoa A-1997 CHENEY. JERRY & SUSAN 2496 HIGHWAY 133 CARBONDALE CO 81623-9206 ON IIIIII1t111111111111g11111111:,111111111111111111111111111161111 Policy Number: C75 4271 -F17 -46L Policy Period- Decamber 17, 2017 to June 17, 2418 Vehicle: 2414 CHEVROLET K1500 Principal Driver: JERRY C CHENEY A This policy expires on the data due if premium is not paid Based an your driving record, you have our Accident -Fres Discount for preferred customers. When you provide a check as payment, you authorize us either to use information from your check to make a ons -time electronic fund transfer from Your account or to POcy Number C75427t-F17.ML Prepared Octobar 25, 2017 ID045M AUTO RENEWAL AMOUNT DUE; $373.10 Payment Is due by December 17, 2017 Your State Fane Agent TODD FUGATE,CPCU Office: 970-953.5610 Address; 590 HIGHWAY 133 CARBONDALE, CO 01623-1644 ff)w haw a rf ordffim r ew, haus added ffW& rcm orhm nmwd. Pk=0=wf%x process the payment as a check transaction. When we use information from your check to maks an 91ectronb fund transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will not receive your check back from your financial institution. i Please fold and tear here + Page number 1 of 5 t1GM Mi 11At.m15 DRIVER INFORMATION Other Household Driver(s) In addition to the Principal Drlver(s) and Assigned Drivar(s), your premum may be influenced by the drivers shown below and other individuals permitted to drive your vehicle. This list does not extend or expand coverage beyond that contained In this automobile policy. The drivers listed below are the drivers reported to us that most frequently drive other vehicles in your household SUSAN B CHENEY PrincipaI Driver & Assigned Drivers For each automobile, the Principal Driver is the individual who most frequently drives it. Each driver is designated as an Assigned Driver on the household automobile that he or she mast frequently drives IMPORTANT NOTICE REGARDING YOUR PREMIUM State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile insurance is determined by many factors such as the coverages you have, where you live, the kind of car you drive, haw your car is used, who drives the car, and information from consumer reports. WeFar Your premium may be influenced by the information shown for these drivers. You have the right to request, no more than once during a 12 -month period, that your policy -be re -rated using a current credit -based insurance score. The resuItklg Impact due to the credit pardon of the re -raked Insurance score will not Increase your pramiumr howeve(, your overall prey jWrn may decrease, remain the same, or increase due to other factors impacting your total premium. COVERAGE AND LIMITS Seeyowrpolkyforen expferishhn of these coverages A Liand.Iy Badly lnlury 1,D90.00011,MD.CW PraperiyDamage 1,000,000 $152.39 G Medcal_Ppyrnents 5.000 $7.60 0 10D Deductible Comprehensive S1 D0.95 G 250 iDeducW* Golhs!on sh t 68 H Emergency Road Service $3.95 $375.47 CoWmdu The Prevention Authority pee S050 i Mwnt Dun s37S.g7 The clalm experience on your make and model of vehlcie has resulted in an Increase to your vehlde rating group for comprehensive coverage - Policy Number C75 4271TI7-ML Prepared April 20, 2017 If any coverage you carry Is changed to give broader prolection with no additional premium charge, we will give (continued on next page) Pegs nurribm 3 of 5 U