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Home My WebLink AboutC18-361 Alan Kokish dba Custom CateringAGREEMENT FOR SERVICES BETWEEN EAGLE COUNTY, COLORADO AND ALAN KOKISH, INC. DBA CUSTOM CATERING THIS AGREEMENT (“Agreement”) is effective as of the 1st day of January, 2019 by and between Alan Kokish, Inc. a Colorado corporation d/b/a Custom Catering (hereinafter “Contractor”) and Eagle County, Colorado, a body corporate and politic (hereinafter “County”). RECITALS WHEREAS, Contractor will provide congregate and home delivered meals for the El Jebel Healthy Aging site every Tuesday and Thursday at 11:45a.m. (the “Project”) at the Eagle County Community Center, El Jebel, CO (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 in Exhibit A (“Services” or “Work”) 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. Contractor agrees to furnish the Services in accordance with the schedule established in Exhibit A. If no completion date is specified in Exhibit A, then 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. 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. 2. County’s Representative. The Public Health 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 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 of December, 2019. 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. DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 2 Eagle County General Services Final 5/14 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. 5. Compensation. County shall compensate Contractor 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 $62,738.00. 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. 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. 29-1-101 et. seq.) and the TABOR Amendment (Colorado Constitution, Article X, Sec. 20). 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. DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 3 Eagle County General Services Final 5/14 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. i. Workers’ Compensation insurance as required by law. ii. The parties acknowledge that there will be limited driving, if any, in connection with the performance of the Services. As a result, auto coverage may be provided through a personal service insurance policy covering the driver and the vehicle. A copy of such coverage shall be provided as part of Exhibit B. Should Contractor or any of its employees drive their personal vehicles in connection with the performance of the Service under this Agreement, Contractor shall be solely responsible for any injury or damage arising out of the use and operation of such personal vehicle. iii. Commercial General Liability coverage to include premises and operations, personal/advertising injury, products/completed 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 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. v. 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 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 4 Eagle County General Services Final 5/14 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 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: Carly Rietmann 551 Broadway Post Office Box 660 Eagle, CO 81631 Telephone: 970-328-8896 E-Mail: carly.rietmann@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 CONSULTANT: Alan Kokish, Inc. d/b/a Custom Catering 50 Sunset Dr. Unit S Basalt, CO 81621 970-309-1113 alan@custom-catering.com 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 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. DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 5 Eagle County General Services Final 5/14 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 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. 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. DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 6 Eagle County General Services Final 5/14 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. l. 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 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. 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. 8-17.5-101, et. seq. If Contractor has any employees or subcontractors, Contractor shall comply with C.R.S. 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: 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 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 7 Eagle County General Services Final 5/14 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.uscis.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. e. 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] DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 8 Eagle County General Services Final 5/14 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 Through Its COUNTY MANAGER By: ______________________________ Jeff Shroll, County Manager CONSULTANT: By:________________________________ Print Name: _________________________ Title: ______________________________ DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 mr Alan kokish / Chef owner custom-catering Alan Kokish 9 Eagle County General Services Final 5/14 EXHIBIT A SCOPE OF SERVICES, SCHEDULE, FEES Custom Catering will provide senior meal services twice per week, including: A. Cook, deliver and serve meals to the El Jebel senior site by 11:45 every Tuesday and Thursday B. Send appropriate staff to serve each meal C. Purchase all raw food D. Follow the grant approved menu each month. Any substitutions should be cleared by the Healthy Aging Coordinator and/or grant contracted dietician E. Provide an edited Eagle/Minturn menu each month by the 10th day of each month F. Manage all temperature and food and appliance logs for Tuesday/Thursday meals and turn in at the end of each month G. Maintain regular communication with the El Jebel Healthy Aging Coordinator H. Accommodate basic modified diets needs (vegetarian) I. Handle disposal and washing of all serving pieces supplied by Custom Catering J. If Custom Catering is unavailable on a meal day; Custom Catering will notify El Jebel Healthy Aging Coordinator at least 48 hours before the absence so that the Healthy Aging Coordinator can arrange for alternate plans, such as an alternate catered meal option. Eagle County will: A. Provide disposable take out meal containers for congregate participants B. Provide Custom Catering with a grant approved menu for editing each month C. Provide and store all beverages for meal days D. Provide warming cart or warming trays at El Jebel site every Tuesday/Thursday E. Communicate an accurate meal count, including congregate and home delivered meals (HDM), to Custom Catering every Monday/Wednesday F. Provide all delivery containers for home delivered meal participants G. Communicate any modified diet needs to Custom Catering no later than the day before the meal day H. Handle all intake paperwork for congregate and HDM participants I. Conduct re-assessments for all HDM participants J. Find and coordinate meal day volunteers K. Provide all cleaning supplies for El Jebel kitchen L. Provide cups, silverware, dishes, etc. for each meal day and wash all at the end of each meal M. Set up and take down dining room each meal day N. Maintain all appliances in El Jebel kitchen O. Store any extra food in El Jebel’s pantry, freezer or Fridge if needed Financial Compensation: A. During the term of January 1, 2019 through December 31, 2019, Eagle County will compensate Custom Catering for the performance of the Services at the rate of $57,980.00 which covers 50 meals per day. If more than 50 meals are served in a day, Eagle County will compensate Custom Catering $9.15 per meal up to 5 additional meals or a total of $4,758. Compensation will go towards funding personnel, raw food, and other operating expenses. Compensation for the performance of Services under this Agreement during the term shall not exceed $62,738.00 for project period January 1, 2019 through December 31, 2019. B. Invoices should be submitted once or twice per month to phinvoices@eaglecounty.us and mandi.dicamillo@eaglecounty.us and should be billed up to $603.25 per meal day. Breakdown of total is as follows: DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 10 Eagle County General Services Final 5/14 104 approximate meal days in project period 50 contracted meals per day $11.15 cost per meal $11.15 x 50 = $557.50 $557.50 x 104 = $57,980.00 Additional 5 meals per day as needed: $9.15 x 5 = $45.75 $45.75 x 104 = $4,758 Per meal day total: $557.50 + $45.75 = $603.25 (as needed) Annual total: $57,980 + $4,758 = $62,738.00 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 11 Eagle County General Services Final 5/14 EXHIBIT B INSURANCE CERTIFICATE DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 WLTR005 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 December 4, 2018 EAGLE COUNTY PUBLIC HEALTH AND ENVIRONM PO BOX 660 EAGLE CO 81631-0660 Account Information: Policy Holder Details :ALAN KOKISH, INC DBA CUSTOM CATERING Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone:(866) 467-8730 Fax:(888) 443-6112 Email:agency.services@thehartford.com Website:https://business.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder.Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/04/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATIONIS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER PETER J MARTIN INSURANCE 34343628 995 COWEN DRIVE SUITE 202 CARBONDALE CO81623 CONTACT NAME: PHONE (A/C, No, Ext): (866) 467-8730 FAX (A/C, No): (888) 443-6112 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURER A :The Hartford Fire Insurance Company 19682 INSURED ALAN KOKISH, INC DBA CUSTOM CATERING 216 W SOPRIS CREEK RD BASALT CO 81621 INSURER B :The Twin City Fire Insurance Company 29459 INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS B COMMERCIAL GENERAL LIABILITY 34 SBM IJ4032 12/01/2018 12/01/2019 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence)$1,000,000 X General Liability MED EXP (Any one person)$10,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $2,000,000 POLICY PRO- JECT X LOC PRODUCTS - COMP/OP AGG $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS-MADE EACH OCCURRENCE AGGREGATE DED RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/ A 34 WEC CC2531 12/01/2018 12/01/2019 X PER STATUTE OTH- ER Y/N E.L. EACH ACCIDENT $100,000 E.L. DISEASE -EA EMPLOYEE $100,000 E.L. DISEASE - POLICY LIMIT $500,000 B EMPLOYMENT PRACTICES LIABILITY 34 SBM IJ4032 12/01/2018 12/01/2019 Each Claim Limit Aggregate Limit $10,000 $10,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION EAGLE COUNTY PUBLIC HEALTH AND ENVIRONMENT PO BOX 660 EAGLE CO 81631-0660 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 LR 00 09 04 18 Page 1 of 1 ALAN KOKISH DIANA KEYSER 216 W SOPRIS CREEK RD BASALT CO 81621-9152 AMERICAN FAMILY INSURANCE COMPANY827RAILROADAVERIFLECO81650-3511 August 27,2018 Regarding your Family Car Policy Our offer to renew your insurance policy is enclosed Your renewal bill will be sent separately Policy number Billing account number Renewal Date 41008-73653-71 644-021-742-23 9/30/2018 Thank you for choosing American Family Insurance.We truly value you as our customer.Enclosed is our offer to renew the policy noted above and your new proof of insurance cards. For a summary of the policy coverage and limits provided,please see the enclosed Renewal Declarations. If you would like a more detailed explanation of the coverage,please refer to your policy and endorsements.We have also included other important and/or state specific notices relating to this policy. Please review all of the enclosed information carefully.Contact your agent if you would like to make changes to your policy. This renewal offer is only available to you if the premium for the prior term has been paid in full.To accept our renewal offer and to maintain continuous coverage,we must receive payment by the date shown on your renewal billing notice. Your renewal bill will be sent separately from this notice. Thank you for placing your trust in American Family Insurance.If you have questions about this information,please contact your agent listed below or call us at 1-800-MY AMFAM (1-800-692-6326). AMERICAN FAMILY INSURANCE COMPANY Your American Family Agent is: Jim Lord Agency,Inc.jlor1@amfam.com 827 Railroad Ave Rifle CO 81650-3511 100 Elk Run Dr Ste 122 Basalt CO 81621-9241 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 PV 89 01 03 13 Page 1 of 4 AMERICAN FAMILY INSURANCE COMPANY827RAILROADAVERIFLECO81650-3511 Colorado Insurance Card Insured:Alan Kokish,Diana Keyser Policy Number: 41008-73653-71 Effective Date: 9/30/2018 Expiration Date: 9/30/2019 Vehicle Description: 2005 Toyota Highlander 4d 4wd Vehicle Identification Number: JTEEP21A450088266 Coverage: BI PD ME UM/UIM COMP COLL ERS Agent: James T Lord Producer ID: Agent Phone: 1-970-625-4742 5639 Colorado Insurance Card Insured:Alan Kokish,Diana Keyser Policy Number: 41008-73653-71 Effective Date: 9/30/2018 Expiration Date: 9/30/2019 Vehicle Description: 2005 Toyota Highlander 4d 4wd Vehicle Identification Number: JTEEP21A450088266 Coverage: BI PD ME UM/UIM COMP COLL ERS Agent: James T Lord Producer ID: Agent Phone: 1-970-625-4742 5639 Colorado Insurance Card Insured:Alan Kokish,Diana Keyser Policy Number: 41008-73653-71 Effective Date: 9/30/2018 Expiration Date: 9/30/2019 Vehicle Description: 2005 Toyota Sienna Van 2wd Vehicle Identification Number: 5TDZA22C75S281404 Coverage: BI PD ME UM/UIM COMP COLL ERS Agent: James T Lord Producer ID: Agent Phone: 1-970-625-4742 5639 Colorado Insurance Card Insured:Alan Kokish,Diana Keyser Policy Number: 41008-73653-71 Effective Date: 9/30/2018 Expiration Date: 9/30/2019 Vehicle Description: 2005 Toyota Sienna Van 2wd Vehicle Identification Number: 5TDZA22C75S281404 Coverage: BI PD ME UM/UIM COMP COLL ERS Agent: James T Lord Producer ID: Agent Phone: 1-970-625-4742 5639 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 PV 89 01 03 13 Page 2 of 4 THIS CARD MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND.THE COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. To report a claim,call: 1-800-MY AMFAM (1-800-692-6326) American Family Insurance Company 6000 American Parkway Madison WI 53783 NAIC # 10386 THIS CARD MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND.THE COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. To report a claim,call: 1-800-MY AMFAM (1-800-692-6326) American Family Insurance Company 6000 American Parkway Madison WI 53783 NAIC # 10386 THIS CARD MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND.THE COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. To report a claim,call: 1-800-MY AMFAM (1-800-692-6326) American Family Insurance Company 6000 American Parkway Madison WI 53783 NAIC # 10386 THIS CARD MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND.THE COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. To report a claim,call: 1-800-MY AMFAM (1-800-692-6326) American Family Insurance Company 6000 American Parkway Madison WI 53783 NAIC # 10386 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 PV 89 01 03 13 Page 3 of 4 AMERICAN FAMILY INSURANCE COMPANY827RAILROADAVERIFLECO81650-3511 Colorado Insurance Card Insured:Alan Kokish,Diana Keyser Policy Number: 41008-73653-71 Effective Date: 9/30/2018 Expiration Date: 9/30/2019 Vehicle Description: 2003 Toyota Tacoma Pu Dbl Cab Sh 4x4 Vehicle Identification Number: 5TEHN72N73Z280686 Coverage: BI PD ME UM/UIM ERS Agent: James T Lord Producer ID: Agent Phone: 1-970-625-4742 5639 Colorado Insurance Card Insured:Alan Kokish,Diana Keyser Policy Number: 41008-73653-71 Effective Date: 9/30/2018 Expiration Date: 9/30/2019 Vehicle Description: 2003 Toyota Tacoma Pu Dbl Cab Sh 4x4 Vehicle Identification Number: 5TEHN72N73Z280686 Coverage: BI PD ME UM/UIM ERS Agent: James T Lord Producer ID: Agent Phone: 1-970-625-4742 5639 Colorado Insurance Card Insured:Alan Kokish,Diana Keyser Policy Number: 41008-73653-71 Effective Date: 9/30/2018 Expiration Date: 9/30/2019 Vehicle Description: 1994 Dodge Truck Grand Caravan 4wd Vehicle Identification Number: 1B4GK54L3RX339783 Coverage: BI PD ME UM/UIM ERS Agent: James T Lord Producer ID: Agent Phone: 1-970-625-4742 5639 Colorado Insurance Card Insured:Alan Kokish,Diana Keyser Policy Number: 41008-73653-71 Effective Date: 9/30/2018 Expiration Date: 9/30/2019 Vehicle Description: 1994 Dodge Truck Grand Caravan 4wd Vehicle Identification Number: 1B4GK54L3RX339783 Coverage: BI PD ME UM/UIM ERS Agent: James T Lord Producer ID: Agent Phone: 1-970-625-4742 5639 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 PV 89 01 03 13 Page 4 of 4 THIS CARD MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND.THE COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. To report a claim,call: 1-800-MY AMFAM (1-800-692-6326) American Family Insurance Company 6000 American Parkway Madison WI 53783 NAIC # 10386 THIS CARD MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND.THE COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. To report a claim,call: 1-800-MY AMFAM (1-800-692-6326) American Family Insurance Company 6000 American Parkway Madison WI 53783 NAIC # 10386 THIS CARD MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND.THE COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. To report a claim,call: 1-800-MY AMFAM (1-800-692-6326) American Family Insurance Company 6000 American Parkway Madison WI 53783 NAIC # 10386 THIS CARD MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND.THE COVERAGE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. To report a claim,call: 1-800-MY AMFAM (1-800-692-6326) American Family Insurance Company 6000 American Parkway Madison WI 53783 NAIC # 10386 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 PV 80 26 03 14 Page 1 of 4 Index:CO 41008-73653-71 American Family Insurance Company 6000 American Parkway Madison WI 53783 For customer service and claims service 24 hours a day,7 days a week 1-800-MY AMFAM (1-800-692-6326) amfam.com Renewal Declarations Family Car Policy Please read your policy Named Insured(s) Alan Kokish Diana Keyser 216 W Sopris Creek Rd Basalt CO 81621-9152 Policy Information Policy number Policy period Billing account number 41008-73653-71 9/30/2018 to 9/30/2019 644-021-742-23 Vehicles Insured by This Policy Year Make Model Series VIN/Serial Number Premium 2005 Toyota Highlander 4d 4wd V6/V6 Limited JTEEP21A450088266 $667.30 2005 Toyota Sienna Van 2wd Xle/Xle Limited 5d 5TDZA22C75S281404 $485.80 2003 Toyota Tacoma Pu Dbl Cab Sh 4x4 V6 5TEHN72N73Z280686 $234.80 1994 Dodge Truck Grand Caravan 4wd Le 1B4GK54L3RX339783 $162.50 Subtotal $1,550.40 Policy Level Premium Uninsured or Underinsured Motorist -Bodily Injury $163.90 Total premium with discounts applied $1,714.30 Total Premium with Customer Full Pay Discount $1,628.50 Discounts Applied to this Policy . Vehicle related discounts Auto Safety Equipment Discount --2005 Toyota Highlander 4d 4wd Low Mileage Discount --2005 Toyota Highlander 4d 4wd,2005 Toyota Sienna Van 2wd,2003 Toyota Tacoma Pu Dbl Cab Sh 4x4,1994 Dodge Truck Grand Caravan 4wd Other policy discounts AutoPay Discount Loyalty Discount Multi-Product Discount Multi-Vehicle Discount Steer into Savings Discount These discounts reduced your total premium by $830.70 Drivers Drivers are individuals who are used to rate this policy. Name(s) Alan Kokish Diana Keyser DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 41008-73653-71 PV 80 26 03 14 Page 2 of 4 Index:CO Policy Forms These forms apply to the entire policy. Form Number Name(s) PV 80 05 03 14 Medical Expense Coverage -Colorado PV 82 02 03 14 Cancellation and Nonrenewal Endorsement-Colorado PV 81 02 03 15 Colorado Changes LR 00 09 04 18 Renewal Cover Letter PV 89 01 03 13 Proof of Insurance Cards PV 84 05 03 13 Emergency Roadside Service Coverage PV 80 26 03 14 Declaration Form PLM-32252 05 17 Privacy Notice PV 83 02 03 14 Uninsured or Underinsured Motorists -Bodily Injury Coverage -Colorado PV 80 01 03 14 Family Car Form UF 00 10 01 18 Summary Disclosure statement AL 00 04 05 17 American Family Mutual Insurance Company,S.I.Amendatory Endorsement State and Policy Information The percentage of fault in an auto accident may impact the extent of recoverable damages based on Colorado law. An asterisk (*)next to a coverage in the Coverage,Endorsements and Other Charges section of this Declarations indicates an optional coverage or limit you have purchased.Contact your agent if you have any questions about this coverage.State law requires you to have Bodily Injury Liability limits of at least $25,000 per person and $50,000 per occurrence and Property Damage Liability limits of $15,000 per occurrence. Higher coverage limits are available and recommended. Agent Information Jim Lord Agency,Inc.jlor1@amfam.com 827 Railroad Ave Rifle CO 81650-3511 100 Elk Run Dr Ste 122 Basalt CO 81621-9241 Declarations are effective on the date shown.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 REPRESENTATIVE President Secretary DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 41008-73653-71 PV 80 26 03 14 Page 3 of 4 Index:CO Policy Level Coverage The policy level coverage shown below applies to a vehicle when coverage is displayed under Vehicle Coverage,Endorsements and Other Charges for the vehicle.The policy limit shown is the maximum available for each person or each occurrence and may not be added,combined or stacked if coverage is displayed for more than one vehicle insured under this policy. Coverage Policy Limit Bodily Injury Liability $500,000 Per Person $500,000 Per Occurrence Property Damage Liability $500,000 Per Occurrence Medical Expense $10,000 Each Person Uninsured or Underinsured Motorist -Bodily Injury $500,000 Per Person $500,000 Per Accident Vehicle #1 Coverage,Endorsements and Other Charges Year Make Model Series VIN/Serial Number 2005 Toyota Highlander 4d 4wd V6/V6 Limited JTEEP21A450088266 Name Premium Bodily Injury Liability *$500,000 Per Person $500,000 Per Occurrence $346.70 Property Damage Liability *$500,000 Per Occurrence $63.60 Medical Expense *$10,000 Each Person $13.70 Uninsured or Underinsured Motorist - Bodily Injury * $500,000 Per Person $500,000 Per Accident Policy Level Premium Comprehensive *$500 Deductible $66.50 Collision *$500 Deductible $161.40 Emergency Roadside Service *$14.40 Colorado Auto Theft Prevention Fee $1.00 Vehicle premium with discounts applied $667.30 Address where vehicle is kept 216 W Sopris Creek Rd Basalt CO 81621-9152 Vehicle #2 Coverage,Endorsements and Other Charges Year Make Model Series VIN/Serial Number 2005 Toyota Sienna Van 2wd Xle/Xle Limited 5d 5TDZA22C75S281404 Name Premium Bodily Injury Liability *$500,000 Per Person $500,000 Per Occurrence $127.40 Property Damage Liability *$500,000 Per Occurrence $62.20 Medical Expense *$10,000 Each Person $13.80 Uninsured or Underinsured Motorist - Bodily Injury * $500,000 Per Person $500,000 Per Accident Policy Level Premium Comprehensive *$500 Deductible $90.00 Collision *$500 Deductible $177.00 Uninsured Motorist -Property Damage *Rejected Emergency Roadside Service *$14.40 Colorado Auto Theft Prevention Fee $1.00 Vehicle premium with discounts applied $485.80 Address where vehicle is kept 216 W Sopris Creek Rd Basalt CO 81621-9152 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 41008-73653-71 PV 80 26 03 14 Page 4 of 4 Index:CO Vehicle Coverage,Endorsements and Other charges (continued) Vehicle #3 Coverage,Endorsements and Other Charges Year Make Model Series VIN/Serial Number 2003 Toyota Tacoma Pu Dbl Cab Sh 4x4 V6 5TEHN72N73Z280686 Name Premium Bodily Injury Liability *$500,000 Per Person $500,000 Per Occurrence $133.20 Property Damage Liability *$500,000 Per Occurrence $75.30 Medical Expense *$10,000 Each Person $10.90 Uninsured or Underinsured Motorist - Bodily Injury * $500,000 Per Person $500,000 Per Accident Policy Level Premium Uninsured Motorist -Property Damage *Rejected Emergency Roadside Service *$14.40 Colorado Auto Theft Prevention Fee $1.00 Vehicle premium with discounts applied $234.80 Address where vehicle is kept 216 W Sopris Creek Rd Basalt CO 81621-9152 Vehicle #4 Coverage,Endorsements and Other Charges Year Make Model Series VIN/Serial Number 1994 Dodge Truck Grand Caravan 4wd Le 1B4GK54L3RX339783 Name Premium Bodily Injury Liability *$500,000 Per Person $500,000 Per Occurrence $86.20 Property Damage Liability *$500,000 Per Occurrence $47.00 Medical Expense *$10,000 Each Person $13.90 Uninsured or Underinsured Motorist - Bodily Injury * $500,000 Per Person $500,000 Per Accident Policy Level Premium Uninsured Motorist -Property Damage *Rejected Emergency Roadside Service *$14.40 Colorado Auto Theft Prevention Fee $1.00 Vehicle premium with discounts applied $162.50 Address where vehicle is kept 216 W Sopris Creek Rd Basalt CO 81621-9152 DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 AL 00 04 05 17 Page 1 of 1 Index:CO 41008-73653-71 AMERICAN FAMILY MUTUAL INSURANCE COMPANY, S.I. AMENDATORY ENDORSEMENT A.When used in the policy,the words American Family Mutual Insurance Company now means American Family Mutual Insurance Company,S.I. B.The following provision is added: 1.MEMBERSHIP AND VOTING While this policy is in force,each insured named in the Declarations is considered an owner or policyholder and a member of the American Family Insurance Mutual Holding Company (AFIMHC)of Madison, Wisconsin.As a member,you are entitled to one vote at all meetings either in person or by proxy.You can only cast one vote regardless of the number of policies or coverage you purchased.If two or more persons qualify as a member under a single policy,they are considered one member for purposes of voting.The owner of a group policy will have one vote regardless of the number of persons insured or coverage purchased.Fractional voting is not allowed.If you are a minor,any vote will be given to your parent or legal guardian. 2.ANNUAL MEETINGS The Annual Meetings are held at the Home Office:6000 American Parkway,Madison,Wisconsin,on the first Tuesday of March at 2:00 P.M.Central Standard Time.Notice in this policy shall be sufficient notification. 3.DIVIDENDS If any dividends are declared,you will share in them according to law and under conditions set by the Board of Directors. All other terms,agreements,conditions,and provisions remain unchanged. DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 PLM-32252 Rev. 5/17 PLM-32252 FACTS WHAT DOES AMERICAN FAMILY INSURANCE DO WITH YOUR PERSONAL INFORMATION? Why? Financial companies choose how they share your personal information. Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. What? The types of personal information we collect and share depend on the product or service you have with us. This information can include: • Social Security number and income • Account balances and payment history • Credit history and credit based insurance scores • Drivers license records and claims history When you are no longer our customer, we continue to share your information as described in this notice. How? All financial companies need to share customers' personal information to run their everyday business. In the section below, we list the reasons financial companies can share their customers' personal information; the reasons American Family Insurance chooses to share; and whether you can limit this sharing. Reasons we can share your personal information Does American Family Insurance share? Can you limit this sharing? For our everyday business purposes— such as to process your transactions, maintain your account(s), respond to court orders and legal investigations, or report to credit bureaus Yes No For our marketing purposes— to offer our products and services to you Yes No For joint marketing with other financial companies Yes No For our affiliates' everyday business purposes— information about your transactions and experiences Yes No For our affiliates' everyday business purposes— information about your creditworthiness Yes Yes For our affiliates to market to you Yes Yes For nonaffiliates to market to you Yes Yes To limit our sharing Call 1-888-312-2263 – when prompted you will be asked to provide your first name, middle initial (if applicable), last name, address, city, state and at least one of your policy numbers. Please also indicate if you are requesting to limit sharing for others on your policies. Please indicate their full names. Please note: If you are a new customer, or receiving this notice from us for the first time, we can begin sharing your information 30 days from the date we sent this notice. When you are no longer our customer, we continue to share your information as described in this notice. However, you can contact us at any time to limit our sharing. Questions? Please go to our website at www.amfam.com/privacy-security Who we are Who is providing this notice? This privacy notice is provided by American Family Mutual Insurance Company, S.I. and the affiliates as listed under the "Other important information" section of this notice (referred to collectively as "American Family Insurance"). DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 PLM-32252 Page 2 What we do How does American Family Insurance protect my personal information? To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured files and buildings. How does American Family Insurance collect my personal information? We collect your personal information, for example, when you • Apply for insurance • Give us your contact information • Pay insurance premiums • Use your credit or debit card • File an insurance claim Why can't I limit all sharing? Federal law gives you the right to limit only • sharing for affiliates' everyday business purposes—information about your creditworthiness • affiliates from using your information to market to you • sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharing. (See below for more on your rights under state law.) What happens when I limit sharing for an account I hold jointly with someone else? Your limit-sharing request will only apply to the names received in your request. Definitions Affiliates Companies related by common ownership or control. They can be financial and nonfinancial companies. • The affiliates of American Family Mutual Insurance Company, S.I. include the companies identified under the "Other important information" section of this notice, and other affiliated companies within Homesite Group Incorporated and PGC Holdings Corp. Nonaffiliates Companies not related by common ownership or control. They can be financial and nonfinancial companies. • Nonaffiliates we share with can include our sales agents, mortgage companies and direct marketing companies. Joint marketing A formal agreement between nonaffiliated financial companies that together market financial products or services to you. • Our joint marketing partners include other financial services companies and insurance companies. Other important information For Nevada residents only. You have the right to place your telephone number on American Family Insurance’s internal do not call list, which means we can contact you by telephone only in response to a specific request from you for information or in order to service any existing American Family Insurance business. For additional information about the Nevada do not call requirements, or to add your telephone number to our internal do not call list, contact American Family Insurance at 1-877-216-9232. For information on the Nevada state do not call law, contact the Nevada Bureau of Consumer Protection, Office of the Nevada Attorney General, 555 E. Washington St., Ste. 3900, Las Vegas, NV 90101, Phone: 1-702-486-3132, email: BCPlNFO@ag.state.nv.us For Vermont residents only. We will not disclose information about your creditworthiness to our affiliates and will not disclose your personal information, financial information, credit report, or health information to nonaffiliated third parties to market to you, other than as permitted by Vermont law, unless you authorize us to make those disclosures. Additional information concerning our privacy policies can be found at www.amfam.com/privacy-security or call 1-800-692-6326. For our customers in AK, AZ, CA, CT, GA, IL, ME, MA, MN, MT, NV, NJ, NC, OH, OR, SC and VA only. You have the right to review information in your file. You may do so by writing to us at the address at the end of this section and providing us with your complete name, address, date of birth, and all policy numbers under which you are insured. Within 30 days of receipt of your request, we will contact you and inform you of the nature of recorded information that can be reasonably located and retrieved about you in our files. If you believe there is information in our file that is incorrect, you have the right to notify us and request that it be corrected, amended or deleted from your file. Use this address for requesting information in your file or for questions about the information in your file: American Family Insurance, Attn: Consumer Affairs Department, 6000 American Pkwy., Madison, Wisconsin 53783-0001. American Family Insurance Legal Entities: In addition to American Family Mutual Insurance Company, S.I., this privacy notice is provided by the following companies, which are all affiliates of American Family Mutual Insurance Company, S.I.: American Standard Insurance Company of Wisconsin, American Family Life Insurance Company, American Family Brokerage, Inc., American Family Insurance Company, American Standard Insurance Company of Ohio, and Midvale Indemnity Company. All companies are collectively referred to as "American Family Insurance" in this notice. DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 UF 00 10 01 18 Page 1 of 3 Index:CO 41008-73653-71 American Family Insurance Company 6000 American Parkway Madison WI 53783 For customer service and claims service 24 hours a day,7 days a week 1-800-MY AMFAM (1-800-692-6326) amfam.com Special Notice to Policyholders Private Passenger Automobile Insurance Summary Disclosure Please read your policy COLORADO PRIVATE PASSENGER AUTOMOBILE INSURANCESUMMARYDISCLOSUREFORM This summary disclosure form is a basic guide to the major coverages and exclusions in your policy.It is a general description.It is not a policy of any kind.All coverage is subject to the terms,conditions,and exclusions of your policy and all applicable endorsements. PLEASE READ YOUR POLICY FOR COMPLETE DETAILS.THIS SUMMARY DISCLOSURE FORM SHALL NOT BE CONSTRUED TO REPLACE ANY PROVISION OF THE POLICY ITSELF. Complete details include,but are not limited to,information on the method we use to calculate your unearned premium (e.g.,pro rata or short rate),if you should cancel your policy before the next renewal.This summary disclosure form also provides some of the factors considered for cancellation,nonrenewal and increase-in-premium. These factors are general in nature.They do not represent the only reasons a policy may be cancelled or changed. Please contact us or your agent for further information. Unless you have purchased the appropriate endorsement,your policy excludes coverage for livery conveyance.If you are a driver for a transportation network company please verify you have purchased appropriate coverage. I.REQUIRED COVERAGE -Liability Colorado law requires you to have liability coverage on your automobile.This coverage pays bodily injury to another person and property damage to anothers property that are the result of an accident in which you are found to be at-fault. Coverage is not provided for any automobile owned by you or a resident relative that is not insured for liability under your policy.There is no coverage for intentional acts. Please read your policy for other conditions and exclusions. II.OTHER COVERAGES A.Uninsured and Underinsured Motorist Coverage Uninsured and underinsured motorist coverage will be included in your policy unless you reject it in writing. Uninsured Motorist coverage pays for your bodily injury damages that are the result of a not at fault accident with an uninsured or hit and run driver. Underinsured Motorist coverage pays for your bodily injury damages that are the result of a not at fault accident with an underinsured driver.A motorist is considered underinsured if his or her liability coverage is not enough to pay the full amount you are legally allowed to recover as damages. Please read your policy for other conditions and exclusions. B.Physical Damage Coverage -Collision and Comprehensive You must be offered collision coverage. Collision coverage pays for damage to your own automobile when it collides with another automobile or object.It also pays if your automobile overturns. Comprehensive coverage pays for damage to your automobile from causes such as fire, theft,vandalism,hail,and falling objects. Collision and comprehensive coverage may be written with a deductible.A deductible is that part of a loss you will pay.We will pay the balance of covered repairs subject to your policy provisions.A lender may require you purchase both collision and comprehensive coverage. Unless you have purchased the appropriate endorsement,coverage does not apply to losses that occur while your automobile is rented or leased to others.There is no coverage for wear,tear,freezing,mechanical failure or breakdown,or road damage to tires. Please read your policy for other conditions and exclusions. C.Medical Expense Coverage Medical Expense coverage of $5,000 will be included in your policy unless you reject it.You may reject the coverage in writing or in the same method in which you applied for the policy. DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 UF 00 10 01 18 Page 2 of 3 Index:CO 41008-73653-71 Medical Expense coverage is not required to be offered on motorcycles,low-power scooters, off-road vehicles or other miscellaneous vehicles. Medical Expense coverage pays for you and your passengers reasonable health care expenses incurred for bodily injury caused by an automobile accident. If you are in an automobile accident,your Medical Expense coverage will pay before your health insurance coverage. Medical Expense coverage will apply toward health insurance coverage coinsurance or deductible amounts. We must prioritize the payment of your benefits in a manner consistent with Colorado insurance law. Injuries to you that are the result of an at-fault accident will not be paid,under an automobile insurance policy,unless Medical Expense coverage is purchased. Please read your policy for other conditions and exclusions. D.Uninsured Motorist Property Damage Coverage This coverage pays for damages to your automobile caused by an at-fault owner of an uninsured automobile. This is an optional coverage you can request if you do not have collision coverage on your automobile. This coverage will not apply if the automobiles do not make physical contact. This coverage only pays actual cash value of your automobile or cost of repair or replacement,whichever is less. Please read your policy for other conditions and exclusions. III.CANCELLATION,NONRENEWAL,AND INCREASE IN PREMIUM A.Cancellation During the first 59 days we may cancel your policy for any reason not prohibited by law. After your policy has been in effect for more than 59 days,we may cancel your policy for any of the following reasons: 1.Nonpayment of policy premium;or 2.Knowingly making a false statement on your application for automobile insurance; or 3.A drivers license suspension or revocation;or 4.Knowingly and willfully making a false material statement on a claim under the policy. B.Nonrenewal We may choose to nonrenew your policy. Some examples of reasons for nonrenewal include,but are not limited to: 1.An unacceptable number of traffic convictions; 2.An unacceptable number of at-fault accidents; 3.Conviction of a major violation such as drunk driving or reckless driving;or 4.Knowingly and willfully making a false material statement on a claim under the policy. C.Increase in Premium We may increase your premiums.Some examples of reasons for increased premium include,but are not limited to: 1.Change of garage location of the automobile; 2.Change of automobile(s)insured; 3.Addition of a driver; 4.Change in use of your automobile; 5.A general rate increase.This results from the loss experience of a large group of policyholders rather than from a single policyholder.A general rate increase applies to everyone in the group,not just those who had a loss. The above list of reasons is not all inclusive. There may be other changes that result in an increased premium. We may add a surcharge or remove a discount because of an at-fault accident or traffic conviction. Under this circumstance you will receive a notice of your statutory right to file a complaint with the Colorado Division of Insurance. IV.LOWERING YOUR COSTS Although the general classifications used by insurance companies to set rates may be beyond your control,it is possible to reduce the cost of your automobile insurance without giving up necessary protection.Here are some tips: A.Maintain a Good Driving Record Traffic convictions and at-fault accidents usually result in higher premiums. B.Consider the Highest Deductible You Can Afford Insurance should protect you from major losses.Choosing a higher deductible may result in lower premiums. C.Check With Your Insurance Agent or Company Before You Buy or Lease a New Automobile Insurance rates are higher for some makes and models of automobiles than for others. DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3 UF 00 10 01 18 Page 3 of 3 Index:CO 41008-73653-71 D.Consider the Age and Condition of Your Automobile Some optional coverage may not be practical for an older automobile. E.Ask if You Are Eligible for Discounts Some discounts that may be offered are Good Driving Discount,Auto Safety Equipment Discount,Multi-Product Discount,Multi-Vehicle Discount,Customer Full Pay and Loyalty Discount. V.SPECIALIZED PRODUCTS A.KnowYourDrive American Familys usage-based insurance product,KnowYourDrive,is easy to use, promotes safety by notifying drivers of dangerous driving habits,and can result in savings for good drivers. B.Semi autonomous vehicle coverage Owners of semi autonomous vehicles can purchase the Semi-Autonomous Vehicle Coverage endorsement which provides additional coverages and coverage limits for vehicles with enhanced safety features. C.Transportation Network Company Drivers who work for a ridesharing service can purchase the Transportation Network Company Gap Coverage endorsement which provides limited coverage for the period when you are driving your insured vehicle,signed in to the companys online application and available for carrying passengers or property but have not yet been matched with a passenger or delivery request. DocuSign Envelope ID: E4693100-D41A-47AA-AFFA-EE4AA110DFC3