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Home My WebLink About1989-133 I' I Ii I' 1 II I, ,I 2 I' I 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RESOLUTION NO. 89-133 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE DIRECTOR OF PARKS, RECREATION AND COMMUNITY SERVICES DEPARTMENT TO MAKE APPLICATION FOR AND ACCEPT A GRANT FROM "ACTION" IN THE AMOUNT OF $201,941 FOR THE SENIOR COMPANION PROGRAM FOR THE PERIOD JULY I, 1989 THROUGH JUNE 30, 1990. BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO AS FOLLOWS: SECTION 1. The Director of Parks, Recreation and Community Services Department of the City of San Bernardino is hereby authorized and directed to submit an application to, and accept on behalf of the City a grant from, "ACTION" in the amount of $201,941 for the Senior Companion Program for the period July I, 1989 through June 30, 1990. I HEREBY CERTIFY that the foregoing resolution was duly adopted by the Mayor and Common Council of the City of San Bernardino at a regular meeting thereof, held on the following vote, to wit: 15th day of May , 1989, by the AYES: Council Members Estrada, Flores, Maudsley, Minor, Pope-Ludlam NAYS: ABSENT: None Council Members Reilly, Miller 1~@/?~--1~ / City Cl erk The foregoing resolution is hereby approved this /?eh day of May , 1989. Approved as to form and legal content: Ci~~ . 2."PPLJ. a. NUMBER 3. STATE a. NUMBER I' FEDERAL ASSISTANCE CANT'S APPLI. , APPLI. CATION I. TYPE CATION 95-(>00072 IDENTI. OF o NOTICE OF INTENT IDENTJ. b. DATE FIER b. DATE , (OPTIONAL) F1ER NOTE TO BE f SUBMISSION r"D' _lit tloy ASSIGNED y,.. ..",nth dl1.~ ,Jlorltop. o PREAPPLlCA TlON 1989-3-24 ASSIGNED , BY STATE 19 ~lOlr IX APPLICATION .... ....,. BlGnA a. FEDERAL $ 201; 941.00 a. APPLICANT b.APPLICANT 5U,432.00 36 c. STATE -0-.00 15. PROJECT START DATE YfOT -,It day d. LOCAL 7,387.00 e. OTHER -0-.00 f. Total $ 259,760.00 18. ~~VEA'J:?"",CY . 19 89".!'fi-'T'" do, 19. FEDERAL AGENCY TO RECEIVE REQUEST ACTION a. ORGANIZATIONAL UNIT (IF APPROPRIATE) I b. ADMINISTRATIVE CONTACT (IF KNOWN) Los Angeles Office I Lowell Brinson c. ADDRESS Federal Bldg, Room 14218, 11000 Wilshire Blvd., Los An2eles, CA 90024 ~ 22. ,............__.....''''..... a. YES,TlDSNOTICE OF INTENTIPREAPPLICATlON/APPLICATlON WAS MADE AVAlLABLE 1= THE in Ohi. ........."...pp.'""~ ~ "'" TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON: ~ APPLICANT and oorreet, the doeument hall t-n duly DATE 'CERTIFIES .uthorized by the aovenUJli body C#tbe ap- THAT ... plicaDt aDd dill! IIpPlicant 'IIri1I comply with tbeau..chedMllU'8JXl!liftheusiltanoeil owvnd. b. NO, PROGRAM 15 NOT COVERED BY E.O. 12372 0 OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW 0 ~ 23 . TYPED NAME AND TITLE b'/Z.GN ~-"""""\ E C~G Annie F. Ramos, Director ,,-" "=-TIVE Parks, Recreation & Comm. Svs. Dept. '.. ~ .~. 24. APPLICA. Y_ _"" do, 25. FEDERAL APPLICATION IDEN1':'NO. 26. FEDERAL GRANT IDENTIFICATION 1l.9A:""'D ,. . 27. ACTION TAKEN 28. 3 :J a. AWAllDED ;:: Z D b. REJECTED EE Gc.~:R 100( 0" ErURNED FOR E>- t.O. 12372 SUBMISSlON Z~ BV APPLICANT TO 0" STATE ~~ C e. DEFERRED t :J f. wmIDRAWN 4. LEGAL APPLlCANTIRECIPIENT e. Applicant Name ; City of San Bernardino b.Organiution Unit : Parks, Recreation & Comm. Svs. Dept. c. StreetlP.o. Box' : 300 North "D" Street d. City : San Bernardino e. County San Bernardino f. State : CA g. ZIP Code. 92418 :: h. Contact Person (Nom" Betty Lewison i! . T.".....N.. : (714) 384-5100 ~ 7. TITLE OF APPLICANT'S PROJECT mee _ion IV of Ibis fonn to provide e aummary Ii: clea<ription of Ibe project.) ~ 5 ~ c .! ~. I Senior Companion Program 9. AREA OF PROJECT IMPACT (Na_ o(cWn. ftlUntin. &tau.. m.) 10. ESTIMATED NO. OF PERSONS BENEFITING 300 Inland Empire 12. PROPOSED FUNDING 13. CONGRESSIONAL DISTRICT OF: b. PROJECT 36 16. PROJECT DURATION 1989-7-1 12J1Qnth. FUNDING 5. EMPLOYER IDENTIFICATION NUMBER (EIN) 6. PRO. GRAM a.NUMBER I ~I"I I^I^I DI L.lJ.1L..:::I.Q fFrom CFDAI MULTIPLE 0 b. TITLE SCP 8. TYPE OF APPLICANTIRECIPIENT A-State G-Special Purs-- ()UItrict. B-lnat.nUte H-Camrnunity Ad.ian Atency C-Sultituw I-Higher Educat.ionallnRtitution Orpnization J-Indian Tribe D-County K-Other fSpmfrJ: E-City F--School Diarid [i) EnkT appropriate letter 11. TYPE OF ASSISTANCE A-Basic Gnnt D-llUlwuce B-Supplemrntal Gr.nt E-Other C-Loan EIUtr appropt'itJU' 1Itkri,} [ill 14. TYPE OF APPLICATION A-Nf''''' C-Rr.rision E-AUI(IIM!ntation B-Renewal O-Continuation ~ ElINr appropriDk IrUt'1" L!!J 17. TYPE OF CHANGE rFor 141" or J4~1 A-iner'eue Dollan F-Other fSpmfyJ B--~ Dollars C-bK2'eue Duration D-Decreue Duration E--Caneellation [III E~tJPP'O' Drialtltttnfl) 20. EXlSTING FEDERAL GRANT WENT. NO. t. ~Ii-QO 17 21. REMARKS ADDED Dyes []I No YftU IIIOnth Ga)" 30. YftU fMfllh dol., S1:.MlTlNG DATO: 19 32. YftJr month date ENPING DATE 19 83. REMARKS ADDED e. FEDERAL b. APPLICAN: c. STATE d. LOCAL e. OTHER f. Total 29. ACTION DATE~ 19 .00 31. CONTACT FOR ADDmONAL .00 INFORMA nON (NOIIU' aM ~/,qJhtJM /Wmbt'TJ .00 .00 .00 .00 $ $ Dyes D No PAGE I Pre.cribed by OMS CirelolKv A.J02 "a > C'l tIl ~ ,.. ~ .,.. ,.. ;r !" ,.. ~ !'o !' :r !' po !" I- !A to :" i 1 ~ - I l 9 &l 't f ':1 :l ;p ~ ~ " " ~ ! " j 'it ~ [ i " t ~ " '" 1 ii i!. ': i1 l> n _ji t f &; '<l :J &; 2 i1 [ i 0 &1 l = " ;' !!. " " - p a " ;a &1 J !t ("l :J . ~ .. z " i ~ l " :I. ~ .. " .... N ~"I . 0 0 ij'!!.l co -.i i ~ .. .. .. .. ..., ..., N "a 0 0 ..., en :oJ ~ . . '" . . i ~ > a- a- '" .... 0 a- " - := .... .... a- 0 N 0 '" 1 l a> a:i I '" .... I .... N I I 0 ~ en 0 0 :oJ >of 0 . . 0 0 . . a :oJ 5 J ~ - 0 I 0 0 I I 0 I 0 0 0 = 0 0 0 0 0 0 0 0 I l :z g= ~ i > ! .. .. i ~ .. .. ~ .... .... t:: .... f 8 .... .... .... ..,. ~ ~ .... .... .... 0 :oJ i ~ ~ . . . . " Q:~ N N ~ a- .... 1 = ("l a- a- a- 0 I f l> -a, I ..,. 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I=' ~ I IlII .0 0 0 := 0 0 i 00 0 00 z 0 0 I:ll 0 0 I I > ~ ~ ~ .. ." ~ .. .. .. .. ~ N ~ ': I 0 0 ... V> 00 00 ~ i ... 0 it ..... ..... . . 0 * . . . . w w ... ... w w . V> V> i 'IJ V> 00 t 00 00 V> V> ~ V> V> ..... ..... I 0 0 ~ ~ ~ 0 0 0 0 0 0 >, 0 0 0 0 ~ ~ .. .e .. .. .. .. N ... ': ... V> V> V> ... ... ! ~ ... 0 t ..... ..... ! ... . * . . Ie., . . w ; ... ... 00 i w 00 V> 00 I ... ... 00 N ... '" '" '" N ~ . . . 0 0 0 0 0 0 0 0 0 0 0 0 ellANT 'to. _Do 110. ellAN'l'lI OIlGMIIAT_ 'AIlT 1-IUDGET'LAN . 1. VOLUNftIIlIUl'POllT .xPI_ -. """"1 PEIIIONNEL m lit 01 "I III ClI .llPE.1S ......... .~ T... ....... ............... .... .....' .. ... _.;r- .,... III" ...... C. ....Jl'... ....~... a1 - r C.h.~ Director 128,938. 100. 128,938. 125,690. 1 3,248. 1 Clerk/Typist 14,867. 70% 10,407. -0- 10,407. Coordinator of Volunteers 15,600. 50% 7,800. -0- 7,800. Accountant 30,000. 20% 6,000. -0- 6,000. TCnAL PlIlSONNEL IlIPENSIS 189,405. . 1 53,145. I 25,690. 127,455. I .. 'RINGE IENEFI1I 9,976. 3,UUU. 7,UOZ. I C. hI GMNTEE ITAFF LOCAL TflAVEL 825. 425. 400. C. III GAANTEIITAFF LONG DlSTANCI TflAVEL 500. 50u. -0- D. IQIMMENT I. IUPPLlU 250. 100. 150. F. CONTRACTUAL IERVICE G. OTHEIl: Postage 200. 200. -0- CalNnuniclti_ Phone 720. 4b:l. Z51S. Prin,... 500. 300. ZOO. ap.., Mainentance & Utilities 5,359. -U- 5,359. M. lNDlllECT COSTS TOTAL VOLUNTEER IlMORT EXPENSEI 71,501. 30,677 . 40,824. -0- a. VOLUNTEER EllPENIEI -. PlIlIDNNEL EllPENSEI Itiponds 140,104. 14U,lU4 -U- ...,.. AlII.. 1 _ hdol...- AII_ ......, Ledgi.. AII_ .. FRINGE .ENEFI1I ...... 20.862 16,800. -0- 4,062. FICA Unl_ -- Z50. Z50. -0- Other: Recognition 1,400. 610. 790. Physical Exams Z,135. -U- 2,135. e. TflAVEL Z3,508 13,5UU. W,UUIS. D. lOU_EHY IE. .WPLlB ,. CONTRACTUALIERVICE I G. OTHER . TOTAL VOLUNTEER EXPENSEI 188,259.00 171,264.00 12,933.00 4,062.00 . TOTAL COSTS 1259,760.00 1201,941.00 153,757.00 14.062.00 . a. fERCENTAGI ,.... 78% 21% 2% .. VOLUlllTIIIlITIlENG1H: .1L....AIld Val"".., tMnhOUfl: 'ltqtr 15 , 921 2ndqtr15.921 :InIqtr15.921 ... ....15 . 9Z 1 .......lOd _. 01 oorvtoo-= 61 ~ Irft... A..'IA__ ..." _.01 VOLUNTEER SUPPORT EXPENSES A. Grantee Personnel Expenses Salaries and fringe benefits are based on grantee's salary schedules established by resolution of the Mayor and Common Council. 1. Project Director (100% time) $13.9125 per hr x 80hrs x 26 pay periods $28.938.00 $25.690.00 $ 3.248.00 2. Clerk/Typist (70% time) $7.15 per hr x 80hrs x 26 pay periods x 70% -0- 10.407.00 SENIOR COMPANION PROGRAM BUDGET JUSTIFICATION Grant U 436-9017 July 1. 1989 thru June 30. 1990 1. FEDERAL 3. Coordinator of volunteers (50% time) $7.50 per hr x 80hrs x 26 pay periods x 50% 4. Accountant (20% time) $14.42 per hr x80hrs x 26 pay periods x 20% -0- -0- -0- NON-FEDERAL EXCESS NON-FED. -0- -0- 7.800.00 -0- 6.000.00 -0- TOTAL PERSONNEL EXPENSES $25.690.00 $27.455.00 B. Fringe Benefits 1. Project Director: $28.938.00 x 22% 2. Clerk Typist: $10.407.00 x 22% 3. Coordinator of Volunteers: U.I.: $7.800.00 x.25% - $20.00 W.C.: $7.800.00 x .08% = $6.00 4. Accountant: $6.000.00 x 22% 3.000.00 -0- -0- -0- 3.366.00 2.290.00 -0- -0- 26.00 1.320.00 -0- -0- TOTAL FRINGE BENEFITS -0- $ 3.000.00 $ 7,002.00 C. Grantee Staff - Local Travel: The Project Director will travel an average of 150 mi. per month x 12 mos. @ 25~ per mi. - 450.00 The Coordinator of Volunteers will travel an average of 125 mi. per month x 12 mos. @ 25~ per mi.- $375.00 425.00 -0- D. Grantees Staff - Long Distance Travel The Project Director will attend one ACTION Training Conference: 1 R.T. airfare @ $200.00 3 days @ $100.00 per diem = $300.00 (Includes room. meals and other related expenses.) 500.00 25.00 -0- 375.00 -0- -0- -0- 'VOLUNTEER SUPPORT EXPENSES (Continued) E. Supplies Consumable desk-top supplies are estimated to cost $250.00 G. Other: 1. Postage Postage costs are estimated at $200.00 2. Telephone Phone costs are estimated at $600.00 per mo x 12 ~ $720.00 3. Printing' and Photocopying Based on actual cost: 834 pages @5C x12 mo. ~ $500.00 4. Space (Maintenance & Utilities) SCP is housed in the City's Senior Citizens Center and utilizes 1,032 sq. ft. of space, which is 8% of the total building space of 13,000 sq. ft. Custodial Service = $35,988.00 Utility Costs = 31,000.00 $66,988.00 $66,988.00 x 8% = $5,359.00 FEDERAL $ 100.00 200.00 462.00 300.00 -0- NON-FEDERAL $ 150.00 -0- 258.00 200.00 5,359.00 EXCESS NON-FED. -0- -0- -0- -0- -0- -0- TOTAL VOLUNTEER SUPPORT EXPENSES $30,677.00 $40,824.00 . . 2 . VOLUNTEER EXPENSES A. PERSONNEL EXPENSES Stipends: 61 volunteers x 1044 hrs. @ $2.20 per hr. B. Fringe Benefits: 1 . Meals 61 volunteers x 228 working days @ $1.50 per day 2. Insurance Accident: 61 volunteers x $1.10 = $67.00 P.L.: Minimum premium = $45.00 Excess Auto: 50 vol. @ $2.75 = $138.00 3. Recognition 61 volunteers @ $10.00, plus sponsor and community donations for additional meal costs, door prizes, decorations, etc. in the amount of $790.00 4. Physical Exams 61 volunteers @ $35.00 C. Travel 50 volunteers will drive their own vehicles and are limited to $35.00 per month = 50 x 12 x $35.00 11 volunteers use public trans- portation @ $1.00 per day x 228 working days = 11 x $1.00 x 228 days TOTAL VOLUNTEER EXPENSES TOTAL VOLUNTEER SUPPORT EXPENSES TOTAL BUDGET FEDERAL $140,104.00 16,800.00 250.00 610.00 -0- 13,500.00 -0- NON-FEDERAL -0- -0- -0- 790.00 2,135.00 7,500.00 2,508.00 EX'CESS NON-FEDERAL -0- 4,062.00 -0- -0- -0- -0- -0- $171,264.00 30,677 .00 $12,933.00 40,824.00 $4,062.00 -0- $201,941.00 $53,757.00 $4,062.00 .. 0..0 o I\> 0 a n 0 '" ::r" I\> ... 1:1<..... ..... 0 1:1 o .... I\> 1:1 '" " 1:1 0 I\> "" " .. .. 0 ....,,'" .. 1\>"'< '" " 0 "I\> .... " '" ,0 ..... 1:1 '" 0 " I\> 1:1" " .. ""''' .. '" Ol ,,'" ......0: ';<~~ ......... Ol o a " .. .. I\> " 5.0: ..... 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"'n'<l ~ .. ~~ ~ ... ... ..,.~ ::TOO 0 ll> :! - ll> ...00 '" '" =' 0 ... .... <: :0: "''' ~ 0 "' - 0'<1 Z . " '" '" 0 . ... . ... > '" ... 2 . " 0 ... ;: '" <: - ....< '" =' ll> ... DO ... ll> "C .... .... ~ '" 0 ". :: ...." ~ ....'" '" C '" ::T .. 0 I :E: I .Q ;". 0' ::!! I~ z c:: cT '< > '< '" QI ~ = , " ... .... c..o a ~ s ~ i...... ~ cT (I) c:: 3 . . 0 ~ (I) QI ;:l 'g :; :i ;r , 2 ... Ul (I) :: ...~ 3 '..... :r. = _ '-0 .... cT W ::r = ~ = !~ c '< 0 3 A. 0' = - ~ A. : - = 0 ~ ~ ~ I I 6 I 1'-< ~ > ~ r:r-~ 3 ;l :::;. t:: e:n> r:g = 0 t'" 2l; S'"." 10 >3" ~=o -~.. I 00", ~ 21i~ 0 ;r " ~ > a l.;~ = ~" l'"l l'"l l:l:;O "1;01: ~A."C :JQ Q E: ~ = '" :m ,< :c ; ~ 01: "8 Ii ~ a= ... ClD San Bernardino Senior Companion Program Volunteer Stations 1. Adult Day Health Care Center - 6 2. Cas a Bernardine Retirement Home - 3 3. Department of Public Social Services (S.B. County) - 7 4. Family Services Agency - 3 5. Mental Health Association - 2 6. National In-Home Health Care - 3 7. Pacific Park Convalescent Hospital - 4 8. St. Bernardine's Medical Center Home Health Care - 1 9. S.B. County Hospital Social Services (New) - 1 10. S.B. County Housing Authority - 1 11. Senior Home and Health Care - 2 12. Senior Services Center Outreach Program - 7 13. Shea Convalescent Hospital - 4 14. Sierra Vista Sanitarium - 2 15. Veteran's Hospital Case Management Program - 4 16. Visiting Nurses Association, Pomona-West End - 5 17. Westside Drop-In Center - 6 ~ ~ M E M 0 RAN DUM 0 F U N D E R S TAN DIN G Between .CITY OF SAN BERNARDINO' SENIOR COMPANION PROGRAM SENIOR CITIZENS SERVICE CENTER 600 West Fifth Street San Bernardino, CA 92410 (714) 384-5100 AND NAME s:r ADDRESS 7 ~ () E. Q. 1- S' G; s Co.. Sv!; D ?if-- 38'1~7?S-t2_ 5'6" 7 -~ II( 1. The sponsor will: a. Recruit, interview, select and enroll volunteers in the project. b. Provide orientation to volunteer station staff prior to placement of volun- teers, and at other times as the needs arise. c. Refer volunteers to volunteer station for placement.. d. Designate a staff person to serve as liaison with volunteer station. e. Furnish adequate accident and liability insurance coverages as required by the program. f. Retain full responsibility for the management and fiscal control of the project. g. In cooperation with the program Advisory Council, arrange for a volunteer's appeals procedure to resolve problems arising between the volunteer, the sta- tion and/or the sponsor. h. Assign I Senior. Companions to serve ;:f adults between the hours of q.oo A t:l and "'00 PM' on the allowing dais of the week: Monday thru Fr,aay i. Specify activities to be performed by the volunteer under the direction of the program staff, in cooperation with the volunteer station. j. Approve individual written plans of care for each client. 2. The volunteer station will: a. Designate firM; M_J_1k.qr to serve as liaison with the sponsor. ~ b. Integrate Senior Companions into individual written care plans that address the social and health needs of each client. c. Where appropriate, assure adequate health and safety provisions for the pro- tection of volunteers. d. Collect and validate appropriate volunteer reports for submission to the sponsor. - ~ e. In consultation with the sponsor, make investigations and reports regarding accidents and injuries involving volunteers. The volunteer, station is not liable for accidents involving the volunteers. f. Assist the program staff in the coordination of volunteer assignments, orien- tation, in-service training and other pre-gram related activities. g. Select and provide -=3 adults tc be served by the volunteers. h. Designate service space for use by volunteers in their activities. (This depends on the nature of the volunteer station.) i. Provide the following meal arrangements for volunteers chargeable to non- federal support at $2.00 each day. (This depends on the nature of the volun- teer station.) rvA- j. Provide the following transportation arra',~ements for volunteers chargeable to non-federal support at $2AOO a day. (This depends on the nature of the volunteer station.) rv-- k. Obtain a written agreement from person(s) to be served or from persons legally responsible for the adult to be served by the volunteer in a private home. (The document authorizes volunteer service in the home, and requests specified volunteer activities.) THJS MEMORANDUM MAY BE AMENDED AT ANY TJME BY THE PARTIES JNVOLVED. SJGNATURE FOR VOLUNTEER STATION (~ dMo.~, ~gW TITLE . ~CJQ.C ~ DATE ilJP-~?ft. / SIGNATURE FOR SENJOR COMPANION PROGRAfo!C-,h~-d=-J, f~,...... .~. ~~ ~ / TITlE -J L-Jt--{_~dLC-1- tl~l~ATE &/; a../l)'J MEMORANDUM UPDATED SJGNATURE FOR VOLUNTEER STATJON TITLE DATE SJGNATURE FOR SENJOR COMPANION PROGRAM TITLE DATE f~".,f.1 CrkTIFlCtTf Jt.i. j I l!t:i 1 J;-n q. JQ~'I ""AU[ "NO A.ODr..E.~~ 0' AGE NC'\' 703 7,:\0-<'3('1 INSuR/..NU C.OM~'AN' THE CP'A cn"lfAtllFS 1 t~ C CIGNA CC RPOUT 10"1 ?It> S PEYTr~i STRrET P 0 !\['X 14 ALE X VI- 2<314 AGENCY CODE CGLlIMbIA /'in 1 04~ -0014 109343 NAME AND MAILING ADDRESS OF INSUF=lED POLICY NUMBER POLICy TYPE SEt,IGR (['''If At Ir N p~ QC GllP04056 DAV P lUSt-51 ) POLICY PERIOD /INCEPTION) (EXPIRATIONI bOO ~; 5TH 5T July 1, 1088 TO July 1, 10PO SMI BF~"IA~D n:o CA 92410 1. OAVP P!: fSO"lAL LIAPILITY ------------------------------------------------------------------------------- VOLtHHE Cf S !r:)U~I-'KE SEQvICE peLlCY . DECLARt-TIor,s , ---------------------------------------~-------------------------------------- This PC I icy, sUbject to a II its terms, conditions, and I imi tat Ions. I s contlnueo In force for a further Pf r lod of Twelve 112) months and sha I' expire . - on July 1, 1080, 12.01 a.m., Standard TI~e at t~e place or places ceslgneted In said polley. PEPSONAL LIAeILITY - LI~IT OF LIABILITY Personal Injury Liability or Property 'Ja1ll2ge L1a!:llllty or 51,000.000 each occurrence 53,000,000 annual aQcreQate ~. (I t ~ C 0:-'" ~ I r, !:! ;' PRE~IUM ca~PUTATION ESTIMATED NUMBER OF VOLUNTEFRS PEP YEAR RATE PER VOLUNTEER PER YEAR OR PART THEREOF ADVANCE PREMIUM 54 As per the records of the insured organization .40 s 45.00 M IN IrU~ PRE'1lU~: S 45.00 513 BAL TI"'(i~E, "1[' CCi'1M 151. SICE30Q/MHC=C LD 4787 E GL-181b CASA51-3 SC2 N< -- /---~> <........_--:-,~.. ..--........,/ \.... ~"."' .or ....../" I .. .r' ---------~------------------------ IA.uthorlreo Signature) HARRY F CUSTIS AlA) SIGNATURE Of AUTHORIZED REPRESENTATIVE ~~!r~.-!;L (;~r""JrJ~t."T1 .i,~ Il Jr n ~), ):~, '- ""AMI. AND AD[)~[S$ OF AG[NC~ 71 :' 7, '-- C, , r 1 IN~tJ~Afl,j(:l (.('MI'I"~" t ~ THE elf A sp~rA~Irs I~S <'1/ S F'~YTr', STQ[::~ ALEX 'JI 27'14 AGENCY CODE CJG~.A cr- QPOF AT Jr,', P ') Rf'X 14 CGLUM~I& rD2104~ -OGI4 t [-;._ NAME AND MAilING ADDRESS OF INS, URf D , S;.t;I[!~ CL'~r'.t lr', " ICtS,',I) bao ~. ~H' S~ SP: HP'JA~r. It') CA Ie ~24? 'F JG POLICY NUMBE.R 'UY23~('CJ POLICY T 'fPE. r AVP 92410 POLICY PERIOD IINCEPTION) July 1, 1 <:;(H: TO IEXPIRA1IONl Julv I, 19f1Q 1. ')&vr ~s ~~Tr lltQILITY ------------------------------------------------------------------------------- Excess ~PTr~rPILr LIA"ILITY ----------------------------------------------------------------------------- In cons Ideratlon of payment of the total Dr emlurn Inoicated, the policy designated herein Is rene~ed by the Company for the periOd stated, SUbject to all the terms thereof, and endorsements thereto and additional Drovlslon of t~e reverse hereof. Number of Volunteers ~ate Per Volunteer $ Renewal Premium $ 41 2.75 112.75 ~I'JI'U" PRErIUM: $ 55.00 ----------------------------------------------------------------------------- 513 ~AL TI'-iC~f, ~r con 6670 100 HTF c')!""1 1~1. CASA51-4 SC2 J ~ ; .-, j -( ~---~0/ /V \..../:/..J - ---------~---------------------- (Authorized Slgraturel HARRY F CUSTIS .IA) SIGNA1URf Of AUTHORIZED REPRESENlATIVE . ~~ /~=~[J;~ c i~'.::' Cl~.~f\ c()r~;)ANIL.5. l:\Ie ,;;,/. I.~;~ , C~:;e>-:=""7t INSU~"''''Ct lol.........U['.[..... .""C. J;.!,( ::CN":'PCl.. S(~VIC(S.INC. ,...$",:_....<:( IlAC~CQ,. ....0 '"Gl""$ .,s... .......o.c.c...c... !c.....'C[!o Ilt..[~,' ..~... :.:..!o""~ '''''''50 .....:" "C"""'!.''''''~C~ MEMORANDU."1 DATE: January, 1989 TC: Project DIrectors FRO!": Laurie S. Coleman, NatIonal Accounts Manasei RE: Olde. A~erlcan Volunteer lnsurance Renewal we are pleased to enclose ycur July I, 1988 to July I, 1989 Volunteer Insurance Renewal Certificates. Please remember that the Accident coverage Is continuous untl I can c e " e d ; the ref 0 r e you w I I I no t r e c e I v ear e new a I certificate for this coverage. Ycur Invoice wI I I serve as evidence that this coverage has been renewed. I would like to take thIs o~portunlty to once again thank you for your continued participation In the Volunteer Insurance Se.vlce Pr09ra~. LSC/pm ~'. SC'..;TH ;t,!:YTO"" ST_[CT ...l..O'-'NC...... ."litGl""A 2Z.;J'_""" T[L['...C....[ '70')' ')":tOO ~...JIt,TO.;J' ":)-..0741 TC..(,1l 9O.3C13