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2018-123-E Planning - Animals Be Gone LLC Beaver Removal
DocuSign Envelope ID: 27010A71- 338E -4DAB- 9153- ACF241916DEC [Departmental Use Only] TITLE Beaver Removal FY 17 -18 ORANGE COUNTY CONTRACT UNDER $1,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this 13th day of April, 2018, ( "Effective Date ") by and between Orange County, North Carolina, a body politic and corporate organized under the laws of the State of North Carolina, (the "County "), party of the first part; and Animals Be Gone, LLC (the "Provider "), party of the second part; WITNESSETH: For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby contracts for the services of the Provider, and the Provider agrees to provide the following services to the County in accordance with the terms of this Agreement, time being of the essence: The services and/or materials and/or construction (hereinafter referred to collectively as "Services ") to be furnished under this Agreement are as follows: Setting of beaver traps, trapping of (up to 5) beavers, and removal of (up to 5) beavers from the site for the Historic Rogers Road Sewer Expansion Project in Chapel Hill, NC, located within and/or adjacent to the areas identified in Attachment A. Beaver trapping may occur within the 30 -ft wide sewer easement as shown on Page 2 of Attachment A and within the St. Paul AME Church properties (i.e. PIN's 9870540416, 9870543735, 9870544583, 9870545947 and 9870459243) as shown on Attachment B. Written permission from the St. Paul AME Church property owners for access to their properties for the purposes of trapping and removing beavers from the site is included as part of Attachment B. Upon completion of Services, the Provider shall provide to the County written and/or photographic documentation of the number of beavers trapped and removed from the site. The term of this agreement rendered shall be from April 13, 2018 to June 30, 2018. Provider represents and agrees that Provider is qualified to perform and fully capable of performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner to the satisfaction of the County. Provider shall be responsible for all errors or omissions, in the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the County. Provider agrees that Provider shall not sub - contract any of the services to be provided in this Agreement, nor shall Provider assign any right or responsibility granted or required by this Agreement, without the prior written approval of the County. SPECIFIC TERMS 1. Pam: The County agrees to pay at the rates specified for Services satisfactorily performed in accord with this Agreement. The amount to be paid by the County shall not exceed NINE HUNDRED SEVENTY FIVE DOLLARS, ($975.00). Payment shall be made within thirty (30) days of an invoice properly submitted to County. Should Provider fail to perform its duties under the terms of this Agreement, County may, without fault or penalty, withhold any payment associated with the work to be performed until such time as said work is completed. 2. Non — waiver: Failure by County at any time to require the performance by Provider of any of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of this Non - Waiver Clause. 3. Independent Contractor: The Provider shall operate as an independent contractor, and the County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated Revised 10/17 DocuSign Envelope ID: 27010A71- 338E -4DAB- 9153- ACF241916DEC as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider. 4. Insurance: Provider shall obtain, at its sole expense, Commercial General Liability Insurance, Automobile Insurance, Workers' Compensation Insurance, and any additional insurance as may be required by County's Risk Manager as such insurance requirements are described in the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements (each document is incorporated herein by reference and may be viewed at http: / /www.orangecountync.gov /departments /purchasing division /contracts.php). If County's Risk Manager determines additional insurance coverage is required such additional insurance shall be designated here (if no additional insurance required mark N/A as being not applicable). Provider shall not commence work until such insurance is in effect and certification thereof has been received by the County's Risk Manager. 5. Indemni : The Provider agrees, without limitation, to defend, indemnify, and hold harmless Orange County from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable attorney's fees) arising from bodily injury, including death, to any person or persons or damage to or destruction of any property caused in whole or in part by any negligent or intentional act or omission on the part of the Provider in carrying out Provider's duties and obligations related to the Services to be provided in this Agreement. 6. Termination: This Agreement may be terminated at any time by mutual written agreement of the parties or by the County upon written notice to the Provider. County may suspend this Agreement upon reasonable notice to Provider. 7. Entire Agreement and Signatures: The parties have read this Agreement and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between the parties unless and until modified in writing and signed by the parties. Modifications may be evidenced by telefacsimile signature. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent of the Parties to utilize electronic signatures and the intent of the parties to comply with Article I IA and Article 40 of North Carolina General Statute Chapter 66. 8. Governing Law and Priority: Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina and Orange County. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti - discrimination laws, policies, rules, and regulations and the Orange County Non - Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http: / /www.oran ec�ountync. og v/departments /purchasing division/contracts.php.). Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147 - 86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147 - 86.81. By executing this Agreement Provider affirms Provider is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. In determining the basic services to be provided, should any documents be referenced in or attached to this Agreement, the terms herein shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. Revised 10/17 2 DocuSign Envelope ID: 27010A71- 338E -4DAB- 9153- ACF241916DEC 9. Dispute Resolution: Neither party may initiate binding arbitration. Any disputes shall be resolved by nonbinding mediation. Should either party initiate litigation to settle any dispute involving the terms of this Agreement such litigation shall be initiated in the General Court of Justice of North Carolina seated in Orange County, North Carolina. 10. Non Appropriation: Provider acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County's obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non - appropriation of public funds. [SIGNATURE PAGE TO FOLLOW] Revised 10/17 DocuSign Envelope ID: 27010A71- 338E -4DAB- 9153- ACF241916DEC IN WITNESS WHEREOF, Orange County and the Provider have signed this Agreement, effective as of the day first written above. ORANGE COUNTY PROVIDER Docusigned Spy: By: (v'4 �t-1 kd CC Q461) 0DA]CFD4C2... 1. r1LL1 L111L.11L Lll li LiLVf 200 S. Cameron St. P.O. Box 8181 Hillsborough, NC 27278 Revised 10/17 2 u5igned by: By: :r".— WaikV Title: 85AC2 r5 DSCr 3-'iss... Tim Walker, Owner, Animals Be Gone, LLC 4104 Hawkins Road Hurdle Mills, NC 27541 w— QI— w LU T _ t m -- n Q 0 0 N 3. x N LL 10 N w Q a. W co tr c _ W � � ri v s T� J_ w, r d - - LL z H S. � S 8 Sit C ` e 5igc A i •� W _ � p 5 Y c Q'lrt ri � N pp3 E5a 7 Is s _ � I � r. 1P'96} •Ill �+rw c IYW'Af�I .CTi +Ht� I � r1aY 4 {m e Xad30 nw rXe 9 � 3 I � f 1 re. res Nr -X�s � spry � �iiw�•nrow - ' e rm +n rtsc - zs tr�['R3133HS33S 3N! I N NC❑ o E O1 9 QI NJ 7 � N } a m DP c1 � LL lt-a L yin L 'L a - ula9M s 3 N Sld /dC1F ncc-a c,a xrsr ®.,.. VM a3x3s acv a3rvM 3sNvW & u a O 11P Irre1J 1Y ml �H!�I1 u4SLi mnlw ®l m1Y -qn5 +O Yc%'d ��o n-}d 11114f V nvilf14 _ 311..+Dbd 7R NVld UW35 ON 'kLNP dl 30kvw i'7 ©ISi^irJd7S3 b3A53$ au�lulaa ksnti angEnandan,]SZl:7 OVON S�BOOb OINOi$IH W _ 1d7F71. — Q a �e � u � _ a v v o v LU o ❑ gg LLJ 3 L'C fil @ N tit CCCC ED7 O LL 'g w $:` e kag J FV� x e =� r• --r « ull :9 h 9 6 Q Q J_ w, r d - - LL z H S. � S 8 Sit C ` e 5igc A i •� W _ � p 5 Y c Q'lrt ri � N pp3 E5a 7 Is s _ � I � r. 1P'96} •Ill �+rw c IYW'Af�I .CTi +Ht� I � r1aY 4 {m e Xad30 nw rXe 9 � 3 I � f 1 re. res Nr -X�s � spry � �iiw�•nrow - ' e rm +n rtsc - zs tr�['R3133HS33S 3N! I N NC❑ o E O1 9 QI NJ 7 � N } a m DP c1 � LL lt-a L yin L 'L a O_ 6 E a Ln a :E- C: co c N O a a `o °7 U .0 N 0 U c O � U 7 c Q O O (6 L O `O a E 6 47 O_ yL� O O E a n O L U c a . O a - c o .o a � o U `o E N a O N O O O d N w c O o Q � _T O s U O N o N L a O Q c U cn � N � T 73 � c O O O O O O U o o � - c E E o Z3 O uN m 2 3 E 'c T wNN. Q o_ Q'U O O d U Q Q O 6 .Q o '° E c cn O O c N a � m c L L 7 .• O O O N L-. L a a H m w ny N O c O i O O O � Ocy) O O G) O N 00 O �— w w w w p� Z p p p p Ja J J Q Q Q Q Q O� U 0 >1w>wla- z < C) X C J m Q D m J J_ 2 L J N w CO � Q 00 d- o U LL Q U- J w = O OU cn cn m w Lu Pw : o N w O J w Cnp ��—m� � T U U � co °- Q S I`m U m w o E U N r Q c�aY OJ E `o p w LO Q a- 00 Z) am U) p J J_ w 2 Z 0 co (Y) d Cn w O LL w J a w J � w N Q 0 Q U Z 00 Z N N Cj i a p E �� w UN p N O Z U O O p p Q U Q Q oc c �_ u r ! N LLI u m M LO ° ° C) 0O O i O O O � Ocy) O O G) O N 00 O �— w w w w p� Z p p p p Ja J J Q Q Q Q Q O� U 0 >1w>wla- z < C) X C J m Q D m J J_ 2 L J N w CO � Q 00 d- o U LL Q U- J w = O OU cn cn m w Lu Pw : o N w O J w Cnp ��—m� � T U U � co °- Q S I`m U m w o E U N r Q c�aY OJ E `o p w LO Q a- 00 Z) am U) p J J_ w 2 Z 0 co (Y) d Cn w O LL w J a w J � w N Q 0 Q U Z 00 Z N N Cj i N a �coU) w wCnCn �� w UN p N Z Z w w w J U O O p p Q U Q Q U J DocuSign Envelope ID: 27010A71- 338E -4DAB- 9153- ACF241916DEC ATTACHMENT B ST. PAUL AME CHURCH PROPERTY (PAGE 2 OF 3) From: burnice hackney To: Christopher Sandt Cc: Rose Snipes Subject: RE: Beaver Impoundment at Historic Rogers Road Sewer Project Date: Friday, April 06, 2018 11:11:11 AM Mr. Sandt In response to your email I am a authorized representative of St. Paul AME Church. As Trustee President ProTem I authorize Orange County's contractor to enter the church property to remove beavers to expedite the Roger's Road sewer project My phone is 919 942 -5588 if you need to contact me.. Sent from Mail for Windows 10 From: Christopher Sandt Sent: Tuesday, April 3, 2018 6:04 PM To: Rose Snipes Cc: brhackneyl (@gmail.com; ischreyack Subject: RE: Beaver Impoundment at Historic Rogers Road Sewer Project Hi Dr. Snipes, Hope you had a nice Holiday. Just an update here; Orange County is finally processing our contract with Animals Be Gone for removal of beavers from the Historic Rogers Road sewer project and the St. Paul AME Church property. Sorry for the formality, but is there any way you could resend an e-mail response to me (or expand on your e -mail below) stating clearly that you and /or Mr. Hackney are authorized representatives of the St. Paul AME Church? Our Risk Management and Legal folks will want to ensure that there is no miscommunication regarding our beaver removal contractor accessing Church property, and that we have clear written authorization from the Church. We hope to get the Contractor out there within two weeks. Please call if any questions. Regards, Christopher J. Sandt, PE Staff Engineer Oranae Countv Plannina and Insaections DeDartment Engineering /Stormwater Division 131 W. Margaret Lane (P.O. Box 8181) Hillsborough, NC 27278 (919) 245 -2583 (W) (512) 590 -0359 (M) csandt e orangecountync.gov NOTE: Pursuant to North Carolina General Statute 132, DocuSign Envelope ID: 27010A71- 338E -4DAB- 9153- ACF241916DEC ATTACHMENT B ST. PAUL AME CHURCH PROPERTY correspondence sent and received from this accoun (PAGE 3 OF 3) public record and may be disclosed to third parties. From: Rose Snipes [mailto:relainegun @aol.com] Sent: Monday, February 26, 2018 3:24 PM To: Christopher Sandt Cc: brhackneyl @gmail.com; Allison Reinert (areinert @owasa.org); jschreyack Subject: Re: Beaver Impoundment at Historic Rogers Road Sewer Project Mr. Hackney and I have discussed (along with our engineer Janine Schreyack ) we are agreeing to the beaver trapping on our property in the best interest of the sewer project. Regards, Rose Snipes, MD On Feb 26, 2018, at 1:18 PM, Christopher Sandt <csandt(cDorangecountync.gov> wrote: Hi Ms. Snipes, Thanks for your time on the phone today. As discussed, Orange County would like to move forward with trapping and removing the beavers that are inhabiting the area near our Historic Rogers Road sewer project. This beaver trapping work will involve our hiring of a private contractor to set traps in the general vicinity of our sewer project, which will include the setting of traps within the St. Paul AME Church property (PIN #9870540416). Orange County anticipates starting the beaver trapping activities by mid -March 2018, as we must first contract with a licensed service provider for this work. The costs for this beaver trapping and removal work (at this location) will be covered by Orange County. Please reply to this e -mail at your earliest convenience. Your affirmative response to this e-mail will ensure that Orange County has a record of written documentation that the St. Paul AME Church is in agreement with allowing our private contractor access to begin beaver trapping activities on the St. Paul AME Church property. Thanks for working with us on this project. Please call if you have any questions. Regards, Christopher J. Sandt, PE Staff Engineer Orange County Planning and Inspections Department Engineering /Stormwater Division 131 W. Margaret Lane (P.O. Box 8181) Hillsborough, NC 27278 (919) 245 -2583 (W) (512) 590 -0359 (M) csandt a orangecountync.gov NOTE: Pursuant to North Carolina General Statute 132, DocuSign Envelope ID: 27010A71- 338E -4DAB- 9153- ACF241916DEC ANIMBEC OP ID: SLS An° CERTIFICATE OF LIABILITY INSURANCE 703/08/2018 E (MM /DDYYYY) 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 SUBROGATION IS 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 Phone: 919-286-7473 CONTACT NAME, Dominick Huckabee Noblin Trent Fax: 919 - 286 -5170 Insurance Agency PHONE FAX A/C No Ext : A/C, No): E -MAIL ADDRESS: POBox 52239 Durham, NC 27717 -2239 05/12/2018 EACH OCCURRENCE Sherry Sloan INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Penn National Insurance 14990 PERSONAL & ADV INJURY INSURED Animals Be Gone c/o Tim Walker 4104 Hawkins Rd INSURERB: INSURERC: $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 7 PRO 7 LOC EC� PRODUCTS - COMP /OP AGG Hurdle Mills, NC 27541 INSURER D: $ INSURER E: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS 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 SUBR POLICY NUMBER YYY MM DD YE MM DD /YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 7�r7 OCCUR X GL 9 0664609 05/12/2017 05/12/2018 EACH OCCURRENCE $ 1,000,000 DAMAGE ( RENTED PREMISES S Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 7 PRO 7 LOC EC� PRODUCTS - COMP /OP AGG $ 2,000,00 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCL D? UDE F—] (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Exterminators CERTIFICATE HOLDER CANCELLATION © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Planning and THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Inspections Department PO Box 8181 AUTHORIZED REPRESENTATIVE 131 W. Margaret Ln Hillsborough, NC 27278 © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: 27010A71- 338E -4DAB- 9153- ACF241916DEC National General �� IANIMALS'BE GONE LLC Auto, Home & Health Insurance 4104 Hawkins Rd PO Box 3199 • Winston Salem, NC 27102 -3199 Hurdle Mills, NC 27541 Orange County Planning And Inspections Department 131 W Margaret Lane Hillsborough, NC 27278 CERTIFICATE HOLDER: Orange County Planning And Inspections Department POLICY NUMBER: 2005913004 POLICY EFF DATE: 1211812017 POLICY EXP DATE: 112118120118 UNDERWRITING COMPANY: Integon General Insurance Corporation Date: 03/2012018 CERTIFICATE OF INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY BELOW. This is to certify that the policy of insurance shown above has 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 policy described herein is subject to all the terms, exclusions and conditions of such policy. Limits shown may have been reduced by paid claims. Email: CVService @NGIC.com • Fax: 1- 800 - 405 -4302 • Phone: 1- 877 - 468 -3466 Visit us at www.MyNatGenPolicy.com 10316 {02012016) Page 1 of 2 Type of Insurance Auto Liability: Scheduled Auto Limits of Liability Provided $300,000 Combined Single Limit Property Damage NIA Auto Physical Damage Coverage Provided 2006 FORD F150 1FTRF12226NB89577 Collision Lessor of ACV or Stated Amount Subject to nla Deduction From Each Loss El Comprehensive Lessor of ACV or Stated Amount Subject to nla Deduction From Each Loss Specific Perils Lessor of ACV or Stated Amount Subject to nla Deduction From Each Loss 2016 FORD F150 1FTMFIC81GKD26945 Collision Lessor of ACV or Stated Amount Subject to $250 Deduction From Each Loss Comprehensive Lessor of ACV or Stated Amount Subject to $100 Deduction From Each Loss Specific Perils Lessor of ACV or Stated Amount Subject to nla Deduction From Each Lass Email: CVService @NGIC.com • Fax: 1- 800 - 405 -4302 • Phone: 1- 877 - 468 -3466 Visit us at www.MyNatGenPolicy.com 10316 {02012016) Page 1 of 2 DocuSign Envelope ID: 27010A71- 338E -4DAB- 9153- ACF241916DEC Cancellation: Should the above described policy be cancelled before the expiration date thereof, we will mail written notice of cancellation that complies with state statutes to the certificate holder named above, but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives. Authorized Representative 0312012018 Issue date: 10316 (02012016) Page 2 of 2 2015 FORD F150 SUP 1FTEX1C87FFC45294 ® Collision Lessor of ACV or Stated Amount Subject to $250 Deduction From Each Loss ® Comprehensive Lessor of ACV or Stated Amount Subject to $100 Deduction From Each Loss D Specific Perils Lessor of ACV or Stated Amount Subject to nla Deduction From Each Loss 2013 FORD F150 SUP 1 FTEX1 CM3DKG20079 Collision Lessor of ACV or Stated Amount Subject to $250 Deduction From Each Loss 0 Comprehensive Lessor of ACV or Stated Amount Subject to $100 Deduction From Each Loss ❑ Specific Perils Lessor of ACV or Stated Amount Subject to nla Deduction From Each Loss Cancellation: Should the above described policy be cancelled before the expiration date thereof, we will mail written notice of cancellation that complies with state statutes to the certificate holder named above, but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives. Authorized Representative 0312012018 Issue date: 10316 (02012016) Page 2 of 2