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Loaves & Fishes Centers - Use of Facility A G R E E M E N T This agreement is made and entered into between Loaves & Fishes Centers, Inc. , an Oregon non-profit corporation, hereinafter referred to as Loaves & Fishes, and City of Tigard, an Oregon Municipal Corporation, hereinafter referred to as City. Whereas, City is the owner of the Tigard Senior Center facility at 8815 S.W. O'Hara, Tigard, Oregon; Whereas, Loaves & Fishes contracts with the County to provide services to senior citizens, and desires the use of said facility; Whereas, City desires to locate Loaves & Fishes' services in said facility; Now, Therefore, in consideration of the mutual covenants and agreements herein contained, the parties agree as _follows: HOURS OF OPERATION. City provides to Loaves & Fishes use of the facility from 8:00 am to 5:00 pm, Monday through Friday. Loaves & Fishes shall have first priority for additional use of the facility. Tigard - Page Two USE. Loaves & Fishes shall use and occupy the facility for the purpose of operation of a nutrition and social service program for the elderly, including, but not limited to, congregate and. home-delivered meals, informational, educational, and recreational activities, transportation, information and referral, case management, health screening, counseling, and fund-raising -activities for the program. USE OF SPACE & EQUIPMENT BY OTHERS. City shall have the right to ' use and permit the use by others of the building and the equipment, dishes, utensils, pots, pans, etc. under the following; terms and conditions: (a) Center Manager or a designated representative will schedule all use of the facility Monday - Friday, 8:00 a.m. to 5:0.0 p.m. The City shall.. assign a designated person to schedule use of the facility for all time except 8:00 a.m. to 5:00 p.m. Monday through Friday. Such use shall not interfere with the daily use by Loaves & Fishes of the facility for the operation. of a nutrition and social service program for the elderly; Y(b) Loaves & Fishes shall assure equipment, dishes, and utensils are left in a sanitary and safe condition; (c) Loaves & Fishes will provide trained kitchen personnel (Center Monitor) to supervise the use of kitchen equipment, personnel cost to be reimbursed by the City, for any activities scheduled by the City when the kitchen is used Tigard - Page Three (d) City shall be responsible for use by such other users authorized by the City and responsible for the payment of fees necessary for supervision of the building and equipment use. Costs incurred by Loaves & Fishes resulting from other. use will be reimbursed by the City. (e) City shall be responsible ,-for-the replacement of any equipment, plates, glasses, cutlery, or utensils lost or damaged by such users as the Center/City shall discover in its use or supervision of such other use of the facility; and (f) City shall be responsible for replacement of food, cleaning. compounds, paper, and the supplies owned by Loaves & Fishes and used by such other users. FURNISHINGS AND EQUIPMENT. In the event of termination of this agreement, all such furnishings, equipment, and decorations which are permanently attached to the facility shall remain 'in the facility in good repair, with allowance for wear .and tear, occasioned by normal , use. Each of the parties hereto including the City, shall retain ownership of any equipment, pots, pans, dishes, utensils, and other personal property acquired by its own funds, by funds received from grants and donations to such party for the purpose of acquiring such personal property, or such personal property as may be donated to such party. Tigard -Page Four GROUNDS & STRUCTURAL REPAIRS. The City shall be responsible for_ the repair of sidewalks, driveways, service areas, curbs, and parking areas. The City shall see that the grounds, including lawn and any other landscape features are maintained. The City shall .be responsible for making any structural repairs to `the building itself, and shall be responsible for such maintenance functions as painting, woodwork repair- , maintenance of heating, ventilation, and air conditioning systems, wiring, hot water heater, and replacement of exterior/interior lighting. Loaves & Fishes shall not make structural changes or install new equipment requiring structural changes without the approval of the City. The City will provide light bulbs and fluorescent tubes, toilet tissue, paper towels, toilet soap and such other supplies needed for daily operation. MAINTENANCE & REPAIR. The City-shall be responsible °for the repair and maintenance of all furnishings and equipment, and shall provide janitorial services for the operation of the building. Loaves & Fishes shall keep the kitchen clean, in such a way as to meet the standards of Oregon State Health Division for daily cleanliness: repairs, equipment maintenance, and seasonal cleaning are the responsibility of the. City. PERSONNEL. Loaves & Fishes shall provide all personnel for operating Loaves & Fishes' services and activities. City shall provide all personnel for all City-scheduled activities. Loaves & Fishes shall provide a Center Monitor for all activities involving food which is scheduled by or for the City. Monitor cost to be paid by the City. Tigard - Page Five LICENSES AND PERMITS. Loaves & Fishes shall be responsible for all licenses and permits which may be required for the provision of Loaves & Fishes services at the facility. UTILITIES. City shall pay all utility bills, includingelectric, gas, water, gar and sewer services REPORTS. Loaves & Fishes shall report Senior Center activities to the City at least semi-annually. INDEMNIFICATION. Either party shall indemnify and hold the other party harmless against and from any and all claims by or on behalf of any person, firm, or corporation arising from the conduct or management. or from any work or ,things whatsoever done by that party or its agents, contractors, servants, employees, or volunteer employees in or about the leased premises or the building, and shall further indemnify and hold the other party harmless against and from any and all claims arising from any breach or default on the part of that party in. the performance of any covenant or agreement on the part of that party to be performed, pursuant to the terms of this agreement or arising from any act or negligence of that party or any of its agents, contractors, servants, employees or volunteer employees, occurring during the term of this agreement in or about the Tigard - Page Six INDEMNIFICATION (continued) premises or the building, and from any and all costs, counsel fees, expenses, and liabilities incurred in or about any such claim or action or proceeding brought thereon. In case any action or proceeding be brought against any party by reason of any such claim, that party may, at its option, require that the other party resist or defend such action or proceeding at- that party's own cost and expense and by counsel reasonably satisfactory to the .other party. INSURANCE. The City shall provide liability insurance in an. amount not less than the applicable limits of tort liability for public bodies pursuant to the Oregon Tort Claims Act. Loaves & Fishes shall provide liability insurance for its activities.. Both parties shall carry the other as an additional named insured on their respective liability policies. The City shall provide fire, theft, and all-risk insurance in an amount not -less than the appraised value of the structure and its_ . contents owned by the City. Loaves & Fishes shall provide fire, theft, and all-risk insurance in an amount not less than the appraised value of contents owned by Loaves & Fishes. Tigard - Page Seven - DURATION. This agreement shall remain in force fres ,through June 301 1991 It shall be automatically extended for additional one-year periods until such time as it renegotiated or terminated by one party or the other in the manner provided. TERMINATION OR RENEGOTIATION. Failure to provide services in accordance with the .contract to the satisfaction of the 'City or its designee shall result in written notification. Such. . notification shall be addressed to the Loaves & Fishes Center Director and shall delineate the inadequacies and provide ' specific remedies stipulating a deadline for resolution not less than -60 days from the date notification was received by the Director. Failure to remedy shall result in termination of the contract by the City. GRIEVANCES. The resolution of any grievances between the parties shall first be attempted between the City Manager and Loaves & Fishes Center Manager. THIS AGREEMENT entered into this 17TH day of September , 19 90 by the parties hereto. LOAV & FISHES CENT S, INC. CITY OFTIGARD / Exe tive Director Steering Committee Chair TIGARD L OA VES AND FISHES CENTER I C2::) Please Reply To: August 26, 19831983 Bob Jeans, City Administrator City of Tigard P. 0. Box 23397 Tigard, OR 97223 Dear Bob: On August 24, 1983, the Tigard Loaves and Fishes Senior Center Steering Committee decided-- to retain_ the present "Letter of Agreement" with the City of Tigard, with the following exception: We want to change the Agreement on page 3, 3. Duration of A�reemen.t g paragraph 1; as -fca.7 ows: "This Agreement shall remain in effect until either party requests a review." We look forward. to your early reply. Sir cera=ly; 1 Clayton Nyberg S-`eerSrig Committee Chairperson iw cc : Petty Ray Jacobs, Deputy Director SrarorIi,����� ; Sl�perv�scr C(11 j,E'z. ri,-•E-:c for •. --• OfISSUE DATE(MM/DD/YY) ® 11/01/85 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, J. B. L. & K. Insurance EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 720 S. W. Washington Suite 800 COMPANIES AFFORDING COVERAGE Portland, Oregon 97205 LETTERNY A Firemans Fund Insurance Company COMPANY B National Indemnit I"S f&AVES AND FISHES CENTER, INC. LETTER y ECEIVED COMPANY 6125 S.E. 52nd Avenue LETTER C Interstate Fire and Cas4a��y _ 198 Portland, OR 97206 COMPANY D LETTER pF TIGAR COMPANY E LETTER THIS IS TO CERTIFY THAT 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 CONDI- TIONS OF SUCH POLICIES. CO POLICY EFFECTIVE POLICY EXPIRATION LIABILITY LIMITS IN THOUSANDS LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) EACH OCCURRENCE AGGREGATE GENERAL LIABILITY BODILY A COMPREHENSIVE FORM INJURY $ $ PREMISES/OPERATIONS PROPERTY UNDERGROUND DAMAGE $ $ EXPLOSION&COLLAPSE HAZARD PRODUCTS/COMPLETED OPERATIONS CONTRACTUAL MXX 800 912 295 9/1/85 9/l/86 COMBINED $ 1,000 $ 1,000 INDEPENDENT CONTRACTORS BROAD FORM PROPERTY DAMAGE 1 000 PERSONAL INJURY PERSONAL INJURY $ f Broadening Endorsement AUTOMOBILE LIABILITY BODILY A fiptodfied Autos MXX 800 912 295 9/1/85 9/1/86 (ERRPPERSON) $ ALL OWNED AUTOS(PRIV. PASS.) BODILY OTHER THAN INJURY ALL OWNED AUTOS(OTHER PASS. (PER ACCIDENT) $ HIRED AUTOS PROPERTY NON-OWNED AUTOS DAMAGE $ GARAGE LIABILITY B Specified Autos BP1813-52 11/5/85 11/5/86 COMBINED $ 1,000 EXCESS LIABILITY C UMBRELLA FORM 551037486 11/26/8 11/26/86 COMBINED $ 3,000 $3,000 OTHER THAN UMBRELLA FORM WORKERS'COMPENSATION STATUTORY AND $ (EACH ACCIDENT) EMPLOYERS'LIABILITY $ (DISEASE-POLICY LIMIT) $ (DISEASE-EACH EMPLOYEE) OTHER 1,368,038 Blkt. Bldgs. Property - Various MXX 800 912 295 9/1/85 9/1/86 t Property @ 90% Locations oinsurance DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Certificate holder is an Additional Insured as respect contract between Loaves & Fishes Centers, Inc and City of Tigard for provision of meals, nutrition, outreach, transportation recreation leisure and referral, this includes the activities of any and all Loaves anti Fishes a io ees. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX- CITY OF TIGARD PIRATIgn DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO Cit Hall MAIL U DAYS WRITTEN NOTICE TO TH�ERTIFICATE HOLDER NAMED TO THE City LEFT,BUT FAILURE TO MAIL SUCH NOTICEAHALL IMPOSE TION Oh`LIABILITY Tigard, Oregon OF ANY KIND UPON THE.COMPANY,IT AGENTS ATIVES. AUTHORIZED REPRESENTATIVE I M BRI - crwck . . NAME AND ADDRESS.OF AGENCY INSURANCE PLANNING SERVICE COMPANIES AFFORDING COVERAGES LLOYD'BUILDING SUITE 396 GY A AIU. INSURANCE CO. PORTLAND., OR. 97232 LETTERETTER COMPANY ® .. LETTER U ST. PAUL FIRE AND. MARINE INS.. CO NAME AND ADDRESS OF INSURED - LOAVES & FISHES CENTERS, INC. ETER"Y C .6125 ' S. E. 52ND PORTLAND•, OR. 97206 LETER"Y ® ' COMPANY LETTER This is to certify.That policies of insurance listed below have been issued to the insured named above and are in force at this time: Notwithstanding any requirement;term or condition of any contractor other document with respect to which this certificate may be issued ormay pertain,the insurance afforded by the policies described herein is subject to all the terms,exclusions and conditions of such-policies. COMPANY Poilcv Limits:of Liability in Thousands ) LETTER TYPE OF INSURANCE POLICY NUMBER EXPIRATION DATE - EACH AGGREGATE OCCURRENCE GENERAL LIABILITY BODILY INJURY $ $ COMPREHENSIVE FORM p - - A PREMISES' OPERATIONS AIU-X. 242-43-52 0.9-01-82 PROPERTY DAMAGE $ $ ❑ EXPLOSION AND COLLAPSE - HAZARD - ❑UNDERGROUND HAZARD PRODUCTS/COMPLETED OPERATIONS HAZARD BODILY INJURY AND 300 - 300 FOCONTRACTUAL INSURANCE _ - PROPERTY DAMAGE $ - $ BROAD FORM PROPERTY COMBINED DAMAGE ❑.INDEPENDENT CONTRACTORS PERSONAL INJURY _ PERSONAL INJURY $ '3 O O AUTOMOBILE LIABILITY BODILY INJURY A - (EACH PERSON) $ ' COMPREHENSIVE FORM AIU—X 242-43-52 Og='01-82 BODILY INJURY $ OWNED (EACH ACCIDENT) HIRED - PROPERTY DAMAGE $ BODILY INJURY AND .NON-OWNED - PROPERTY DAMAGE .' 500. COMBINED EXCESS LIABILITY BODILY INJURY AND 1300000 B UMBRELLA FORM 1-82 11,000 $ 1,000 � 587XB3163 09-0 PROPERTY DAMAGE ❑ OTHER THAN UMBRELLA COMBINED FORM WORKERS'COMPENSATION STATUTORY and EMPLOYERS'LIABILITY $- (EACn ACCIDENT) OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES CERTIFICATE HOLDER IS AN ADDITIONAL NAMED INSURED AS RESPECTS CONTRACT BETWEEN LOAVES & FISHES CENTERS, INC. AND CITY OF TIGARD FOR PROVISION OF MEALS, NUTRITION, OUTREACH, TRANSPORTATION, RECREATION AND LIESURE AND REFERRAL, THIS INCLUDES THE ACTIVITIES OF ANY AND ALL LOAVES AND FISHES 3s Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing com- pany will endeavor to mail _.EL days written notice to the below named certificate holder; but failure to mail such notice shall impose no obligation or liability of any kind upon the company. NAME AND ADDRESS OF CERTIFICATE HOLDER: RECIMCD 11/2/81 LH/eg CITY OF TIGARI7 DATE ISSUED: CITY HALL NOV:13 981 TIGARD, OREGON CITY OF TI 'AR - AUTHO IZED ArPRESENTATIVE aI ills; IM NAME AND ADDRESS OF AGENCY INSURANCE PLANNING SERVICE COMPANIES AFFORDING COVERAGES LLOYD BUILDING — SUITE396 CIMIA PORTLAND, OREGON 97232 LETTERNY A AIU INSURANCE COMPANY COMPANY B LETTER NAME AND ADDRESS OF INSURED COMPA ■/� Ep LOAVES & FISHES CENTERS, INC. LETTER C SEP - `R 6125 S.E. 52ND COMPANY D CIS 8� PORTLAND, OREGON 97206 LETTER N R COMPANY E RD LETTER This is to certify that policies of insurance listed below have been issued to the insured named above and are in force at this time. 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. COMPANY POLICY Limits of Liability in Thousands( 0 TYPE IS LETTER TYOF POLICY NUMBER EXPIRATION DATE EACH AGGREGATE OCCURRENCE GENERAL LIABILITY BODILY INJURY $ $ A ®COMPREHENSIVE FORM p ®PREMISES—OPERATIONS AIUX 243-30-01 9-1-83 PROPERTY DAMAGE $ $ ❑EXPLOSION AND COLLAPSE HAZARD ❑UNDERGROUND HAZARD ®PRODUCTS/COMPLETED OPERATIONS HAZARD BODILY INJURY AND ®CONTRACTUAL INSURANCE PROPERTY DAMAGE $ 300 $300 ® BROAD FORM PROPERTY _ COMBINED DAMAGE ❑ INDEPENDENT CONTRACTORS ® PERSONAL INJURY PERSONAL INJURY $3 00 AUTOMOBILE LIABILITY BODILY INJURY $ (EACH PERSON) A ® COMPREHENSIVE FORM BA 245-72-16 BODILY INJURY $ ® OWNED BA 245-72-17 9-1-83 (EACH ACCIDENT) ® HIRED PROPERTY DAMAGE $ FKIBODILY INJURY AND NON-OWNED PROPERTY DAMAGE $ 500 COMBINED EXCESS LIABILITY BODILY INJURY AND ❑ UMBRELLA FORM PROPERTY DAMAGE $ $ ❑ OTHER THAN UMBRELLA COMBINED FORM WORKERS'COMPENSATION STATUTORY and EMPLOYERS'LIABILITY $ (EACH ACCIDENT) OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES RESPECTS CONTRACT BETWEEN LOAVES & FISHES CENTERS, INC. AND CITY OF TIGARD FOR PROVISION OF MEALS, NUTRITION, OUTREACH, TRANSPORTATION, RECREATION AND LEISURE AND REFERRAL, THIS INCLUDES THE ACTIVITIES OF ANY AND ALL LOAVES AND Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing com- pany will endeavor to mail 30 days written notice to the below named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the company. NAME AND ADDRESS OF CERTIFICATE HOLDER: DATE ISSUED: 8-31-82 LH4dd CIT — CITY OF TIGARD CITY HALL TIGARD, OREGON AU 'ORIZED REPRE TA IK' ACORD 25(1.79) RECEIVED LOAVES & FISHES CENTERS, INC. OCT 15 19°0 CIN OF n= -.October 19, 1990 1989/90 BOARD OF DIRECTORS ROSTER ' Phil Adamsak,ChairGr Phil"Bogue,Vice Chair Hugh Gallagher,Secretary Q Bob Brunmeier,Treasurer oI�IS;nOV1 J Bob Allenbrand Gwin Barham Catherine Wheatley Nancy Delbrueck Jim Durkheimer City Recorder Karen Gates City Of Tigard Ott Girtler PO Box 23397 Charlie Green Marc Grignon Tigard, OR 97223 John Hakanson Marilyn Hopfer Dear Ms. Wheatley,:. - Robert Hughes Wilbert Lolley Larry McIntyre Enclosed,'please find,one signed copy of the Agreement Helen Potampa between the City of Tigard and Loaves 9' Fishes Charl es- Beth Wessinger concerning the .Tigard Senior. Center facility. Dean Wilkins ALTERNATES We have kept one copy for our records. Nancy Howard _ Mary Biggs Sincerely Dan Paris - Andy Myers Bob Coltrane Director of Program operations ADVISORY BOARD Dr.Joseph Blurnel B C/r m Gwyneth Gamble Booth Mary Clark Maurie Clark End. Nick Collins Charles Crookham Elizabeth Crookham Betsy Johnson.Helm Elizabeth Hirsch John Huisman Dr.Peter Kohler Elizabeth Johnson Lasselle Fred Macdonald Maybelle Clark Macdonald Robert Mitchell Oran Robertson Anne Swindells Sherry Vaughan Tom Vaughan Bruce Willison Anne Kelly Feeney, Executive,Director 6125 S.E.52nd Avenue • Portland,Oregon 97206 • (503)M-2424 �. :::.: •;�:.: ::. .::.: ,> r .:.: �.:::::: : .::.>: .>: :.:::• .;. T ...PRODUCERCJ B L & K INSURANCE AND CONFERS NO RIGHTS UPON THE CERTIFICATE R. THIS CERTIFICATE DOES NOT AMEND, EXTENDOR PHONE# 222-1831 ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. 220 N W SECOND AVE COMPANIES AFFORDING COVERAGE PORTLAND OR 97209 COMPANY A ST PAUL INS CO INSURED COMPANY LOAVES & FISHES CENTERS, INC. B COMPANY 6125 S.E. 52ND AVE. C PORTLAND, OR. 97206 COMPANY D ............................. • • . �::.�.....................>...>...>..>..>...>.?.:............>..>.....:..:....:..::.::.:..:..:..:...:.:..E.EE.:..:.::.:.:.:.:.::.'•.:.iE.:.;.:.::::::::s >:.si:;`•:>:;:? ..................... THISIS TOCERTIFYTHAT E:'>#:>:>:>::::>::::::::::>::::>:«:::»::>::::>:::::::::>::':::::::<:::::::»..::.:#.:.::..ii..::.:i.:.:.::..E:.::..:.:.:?.:.:.::...;:..;:.;:..;'•.;:..#.;:..#.;'•..?'•.::.>.:<.:.>.::.::.::.>.:<.:.:>.:.:»...«..:>.:.: 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. CO TYPEOF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY C K 0 8 7 0112 8 07/01/95 07 01/96 GENERAL AGGREGATE s2, 000, 000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGO s2, 000, 000 CLAIMS MADE I A. I OCCUR PERSONAL At ADV INJURY $1, 000, 000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $1, 000, 000 FIRE DAMAGE(Any one fire) $ 100, 000 MED EXP(Any one person) $ 5, 000 AUTOMOBILE LIABILITY CK 0 8 7 0112 8 07/01/95 07 01 96 1, 000, 000 X ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ........................................ ........................................ ........................................ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY CK 0 8 7 0112 8 07/01/95 07 O1 96 EACH OCCURRENCE x 4, 0 0 0, 0 00 X UMBRELLA FORM AGGREGATE s4, 000, 000 OTHER THAN UMBRELLA FORM $ ........................................ ........................................ WORKERS COMPENSATION AND STATUTORY LIMITS EMPLOYERS'LIABILITY EACH ACCIDENT $ THE PROPRIETOR/ INCL DISEASE-POLICY LIMIT $ PARTNERS/EXECUTIVE OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $ OTHER CK08701128 07/01/95 07/01/96 LI SPECIAL FORM—R C BLKT BLDGS/EQUIP $858, 400 $1000 DED 1, 114 , 007 $ 250 DED DESCRIPTION OF OPERATIONS/LOCAMONS/VE®CLESMMCIAL ITEMS HOLDER IS ADD'L. INSD. AS RESPECTS CONTRACT WITH THE INSURED FOR PROVISION OF MEALS, NUTRITION, OUTREACH, TRANSPORTATION, RECREATION, LEISURE & REFERRAL. THIS INCLUDES LOAVES & FISHES EMPLOYEE ACTIVITIES. .. ............................................. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY OF TIGARD EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TWA1L 0 DAYS wRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THEFT, CITY HALL BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OBAABH,ITY T I GARD, OR. 97223 OF ANY RIND UMN THE COMPANY ITS NTS OR REPRESENTATIVES, AUTHORIZED A :y:;:.::::::::::::::::::::::::::::::.::::::::: . . �Y CH A �7.!Q:::::- ::;;:;:i::ii::is�:>::i::i:::iii:::::52;:�:::;:i:::i:::::::;::;:;:r;::;:i;;:f::;::::::::iii:;:::;::::;;:::::::::::::i::;:::::;::;::;;::i:;i;::;::;:;;:::::::::::;::;::<:::S:;:i:;:;, ;•;;�::y�:.;,�:-y::•:-;:•::.:::.;:::::.;..:•.:•.::::i'i'-:�.:�-::