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Signed Contract_Rental Services, Inc for Criminal Background ChecksRental Services, Inc. 10050 Ralston Road, Suite #7 Arvada, CO 80004 (303) 420 -1212 (800) 628-6414 FAX (303) 420 -1477 FAX (800) 296 -9902 Basic Access Membership Application icI- Tat;, IUk9 �E Y cc CLERI Account Name Contact Name Title 7o laY c r. �rkr4(, ' t/dcf r,� A0. Address E -mail Address 4R)GaiC A. tzDit 5e' - qc/(tS Phone Number City State Zip �laky) q(3- ski -�Uq Billing Address true IA City State Fax Number Watt). Gig C 0 6 aQ Ore /J i1cQ Zip Company Web Address Is your company a: [] Corporation [] Limited Partnership [] Sole ProprietorshipkOther (describe)U`I(t) £I)1CCEL(O' Business location is: [] Residential Address How will credit information be used? 01/1 How long have you been in business? Number of employees? Authorized Users: Business Address !\1i A R R9 ate , .�� %�k I LYAD ECc. Would you like your results reported via: [] Fax [] Mail XWebsite 2 NOTE: A copy of your driver's license must accompany this application. Please list all rental properties owned or managed. (If contact information is different from the above please include contact name and phone number.) Rental Property Address City /State /Zip Number of Unit Rental Services, Inc. is in the business of assisting property owners, property managers, and licensed real estate brokers in the screening of potential residents for their rental properties. Credit reports are furnished to individuals or companies only for those purposes as stated in the Fair Credit Reporting Act. By law, you must have a permissible purpose to order a credit report, as stated in Section 604 of the Fair Credit Reporting Act. You may not run a credit report on yourself. I hereby certify that I own or manage the above properties. Credit reports obtained under this agreement are to be used for tenant screening purposes only. I understand that credit reports are regulated by state and federal law. I have read, understand, and will comply with all provisions of the Federal Fair Credit Reporting Act and the Access Security Requirements. I certify that I am the end user and will not resell or distribute credit reports obtained through Rental Services Inc. I also agree to obtain written consent from the applicant to run a credit report. Signature: 01 A, Date: 10050 Ralston Road, Suite #7 * Arvada, CO 80004 * (303) 420 -1212 * Fax (303) 420 -1477 www.erentalservicesinc.com 3 n A; EMPLOYEE MARILYN EDE 855 CENTRAL AVE. DUBUQUE, IOWA 52001 563 -589 -4410 EMPLOYEE MARY DERBY 855 CENTRAL AVE. DUBUQUE, IOWA 52001 563 -589 -4410 Federal Fair Credit Reporting Act And Access Security Requirements FCRA Information: Rental Services, Inc. strongly endorses the letter and spirit of the Federal Fair Credit Reporting Act. We believe that this law and similar state laws recognize and preserve the delicate balance between the rights of the consumer and the legitimate needs of commerce. We suggest that you and your employees become familiar with the following sections in particular: 604 Permissible Purposes of Reports 615 Requirements on users of consumer reports 616 Civil liability for willful noncompliance 617 Civil liability for negligent noncompliance 619 Obtaining information under false pretenses In addition to the Federal Fair Credit Reporting Act, other federal and state laws addressing such topics as computer crime and unauthorized access to protected databases have also been enacted. As a prospective user of consumer reports, we expect that you and your staff will comply with all relevant federal statutes and the statutes and regulations of the states in which you operate, and have on record at all times, a signed authorization from your applicant, to receive credit information. We support consumer reporting legislation that will assure fair and equitable treatment for all consumers and users of credit information. Access Security Requirements We must work together to protect the privacy and information of consumers. The following information security measures are designed to reduce unauthorized access to consumer information. It is your responsibility to implement these controls. If you do not understand these requirements or need assistance, it is your responsibility to employ an outside service provider to assist you. Capitalized terms used herein have the meaning given in the Glossary attached hereto. The credit reporting agency reserves the right to make changes to Access Security Requirements without notification. The information provided herewith provides minimum baselines for information security. In accessing the credit reporting agency's services, you agree to follow these security requirements: 1. Implement Strong Access Control Measures 4 1.1 Do not provide your credit reporting agency Subscriber Codes or passwords to anyone. No one from the credit reporting agency will ever contact you and request your Subscriber Code number or password. 1.2 Proprietary or third party system access software must have credit reporting agency Subscriber Codes and password(s) hidden or embedded. Account numbers and passwords should be known only by supervisory personnel. 1.3 You must request your Subscriber Code password be changed immediately when: • any system access software is replaced by system access software or is no longer used; • the hardware on which the software resides is upgraded, changed or disposed of 1.4 Protect credit reporting agency Subscriber Code(s) and password(s) so that only key personnel know this sensitive information. Unauthorized personnel should not have knowledge of your Subscriber Code(s) and password(s). 1.5 Create a separate, unique user ID for each user to enable individual authentication and accountability for access to the credit reporting agency's infrastructure. Each user of the system access software must also have a unique logon password. 1.6 Ensure that user IDs are not shared and that no Peer -to -Peer file sharing is enabled on those users' profiles. 1.7 Keep user passwords Confidential. 1.8 Develop strong passwords that are: • Not easily guessable (i.e. your name or company name, repeating numbers and letters or consecutive numbers and letters) • Contain a minimum of seven (7) alpha /numeric characters for standard user accounts 1.9 Implement password protected screensavers with a maximum fifteen (15) minute timeout to protect unattended workstations. 1.10 Active logins to credit information systems must be configured with a 30 minute inactive session, timeout. 1.11 Restrict the number of key personnel who have access to credit information. 1.12 Ensure that personnel who are authorized access to credit information have a business need to access such information and understand these requirements to access such information are only for the permissible purposes listed in the Permissible Purpose Information section of your membership application. 1.13 Ensure that you and your employees do not access your own credit reports or those reports of any family member(s) or friend(s) unless it is in connection with a credit transaction or for another permissible purpose. 1.14 Implement a process to terminate access rights immediately for users who access credit reporting agency credit information when those users are terminated or when they have a change in their job tasks and no longer require access to that credit information. 1.15 After normal business hours, turn off and lock all devices or systems used to obtain credit information. 1.16 Implement physical security controls to prevent unauthorized entry to your facility and access to systems used to obtain credit information. 2. Maintain a Vulnerability Management Program 2.1 Keep operating system(s), Firewalls, Routers, servers, personal computers (laptop and desktop) and all other systems current with appropriate system patches and updates. 2.2 Configure infrastructure such as Firewalls, Routers, personal computers, and similar components to industry best security practices, including disabling unnecessary services or features, removing or changing default passwords, IDs and sample files /programs, and enabling the most secure configuration features to avoid unnecessary risks. 2.3 Implement and follow current best security practices for Computer Virus detection scanning services and procedures: • Use, implement and maintain a current, commercially available Computer Virus detection/scanning product on all computers, systems and networks. • If you suspect an actual or potential virus, immediately cease accessing the system and do not resume the inquiry process until the virus has been eliminated. • On a weekly basis at a minimum, keep anti -virus software up -to -date by vigilantly checking or configuring auto updates and installing new virus definition files. 5 2.4 Implement and follow current best security practices for computer anti - Spyware scanning services and procedures: • Use, implement and maintain a current, commercially available computer anti - Spyware scanning product on all computers, systems and networks. • If you suspect actual or potential Spyware, immediately cease accessing the system and do not resume the inquiry process until the problem has been resolved and eliminated. • Run a secondary anti - Spyware scan upon completion of the first scan to ensure all Spyware has been removed from your computers. • Keep anti - Spyware software up -to -date by vigilantly checking or configuring auto updates and installing new anti - Spyware definition files weekly, at a minimum. If your company's computers have unfiltered or unblocked access to the Internet (which prevents access to some known problematic sites), then it is recommended that anti - Spyware scans be completed more frequently than weekly. 3. Protect Data 3.1 Develop and follow procedures to ensure that data is protected throughout its entire information lifecycle (from creation, transformation, use, storage and secure destruction) regardless of the media used to store the data (i.e., tape, disk, paper, etc.) 3.2 All credit reporting agency data is classified as Confidential and must be secured to this requirement at a minimum. 3.3 Procedures for transmission, disclosure, storage, destruction and any other information modalities or media should address all aspects of the lifecycle of the information. 3.4 Encrypt all credit reporting agency data and information when stored on any laptop computer and in the database using AES or 3DES with 128 -bit key encryption at a minimum. 3.5 Only open email attachments and links from trusted sources and after verifying legitimacy. 4. Maintain an Information Security Policy 4.1 Develop and follow a security plan to protect the Confidentiality and integrity of personal consumer information as required under the GLB Safeguard Rule. 4.2 Establish processes and procedures for responding to security violations, unusual or suspicious events and similar incidents to limit damage or unauthorized access to information assets and to permit identification and prosecution of violators. 4.3 The FACTA Disposal Rules requires that you implement appropriate measures to dispose of any sensitive information related to consumer credit reports and records that will protect against unauthorized access or use of that information. 4.4 Implement and maintain ongoing mandatory security training and awareness sessions for all staff to underscore the importance of security within your organization. 5. Build and Maintain a Secure Network 5.1 Protect Internet connections with dedicated, industry- recognized Firewalls that are configured and managed using industry best security practices. 5.2 Internal private Internet Protocol (IP) addresses must not be publicly accessible or natively routed to the Internet. Network address translation (NAT) technology should be used. 5.3 Administrative access to Firewalls and servers must be performed through a secure internal wired connection only. 5.4 Any stand alone computers that directly access the Internet must have a desktop Firewall deployed that is installed and configured to block unnecessary /unused ports, services and network traffic. 5.5 Encrypt Wireless access points with a minimum of WEP 128 bit encryption, WPA encryption where available. 5.6 Disable vendor default passwords, SSIDs and IP Addresses on Wireless access points and restrict authentication on the configuration of the access point. 6. Regularly Monitor and Test Networks 6.1 Perform regular tests on information systems (port scanning, virus scanning, vulnerability scanning). 6 6.2 Use current best practices to protect your telecommunications systems and any computer system or network device(s) you use to provide Services hereunder to access credit reporting agency systems and networks. These controls should be selected and implemented to reduce the risk of infiltration, hacking, access penetration or exposure to an unauthorized third party by: • protecting against intrusions; • securing the computer systems and network devices; • and protecting against intrusions of operating systems or software. Record Retention: The Federal Equal Opportunities Act states that a creditor must preserve all written or recorded information connected with an application for 25 months. In keeping with the ECOA, the credit reporting agency requires that you retain the credit application and, if applicable, a purchase agreement for a period of not less than 25 months. When conducting an investigation, particularly following a breach or a consumer complaint that your company impermissibly accessed their credit report, the credit reporting agency will contact you and will request a copy of the original application signed by the consumer or, if applicable, a copy of the sales contract. "Under Section 621 (a) (2) (A) of the FCRA, any person that violates any of the provisions of the FCRA may be liable for a civil penalty of not more than $2,500 per violation." I understand that if my system is used improperly by company personnel, or if my access codes are made available to any unauthorized personnel due to carelessness on the part of any employee of my company, I may be held responsible for financial losses, fees, or monetary charges that may be incurred and that my privilege may be terminated. I have read and understand the "FCRA Requirements" notice and Rental Services, Inc. "Access Security Requirements" and will take all reasonable measures to enforce them within my facility. I certify that I will use the Credit information for no other purpose other than what is stated in the Information Use section on the membership application. Signature: 10050 Ralston Road, Suite #7 * Arvada, CO 80004 * (303) 420 -1212 * Fax (303) 420 -1477 www.erentalservicesinc.com 7 AGREEMENT BETWEEN THE CITY OF DUBUQUE, IOWA AND RENTAL SERVICES, INC. This Agreement, dated for reference purposes the 1st day of July, 2012, is made and entered into by and between Rental Services, Inc. (herein "RSI "), and the City of Dubuque (herein "City "). Recitals Whereas, City licenses rental properties within the City of Dubuque; and Whereas, City requires that landlords and property managers ( "Rental License Holders ") perform criminal background checks on prospective tenants; and Whereas, City desires that RSI assist City by providing criminal background check information for the prospective tenants of rental license holders; and Whereas, RSI desires to act as City's agent for the sole purposes of obtaining criminal background checks on prospective tenants on the terms provided in this Agreement. Now, therefore, in consideration of the promises and covenants contained in this Agreement, and for other good and valuable consideration, RSI and City (the "Parties ") agree as follows: 1. The Services. Subject to the terms of this Agreement, RSI will provide to City the following services (the "Services "): (a) Criminal Background Check Reports. Using information provided to RSI by City ( "Prospective Tenant Information "), RSI will perform a criminal background check relating to each Prospective Tenant. For purposes of this agreement prospective tenant shall mean an individual who has applied to live in a rental dwelling owned or managed by a Rental License Holder. (b) Web Site Access. RSI will provide City with access to RSI's web site (the "RSI Site ") so that City may, by accessing the RSI Site, initiate criminal background checks. RSI will assign one or more passwords and user names to City for use in accessing the RSI Site. 2. Prospective Tenant Information from City. When requesting any criminal background check report, City agrees to provide to RSI such information relating to each Prospective Tenant as RSI may need to provide the Services, which information may include, but is not limited to, the Prospective Tenant's: • Full legal name • Any other names /aliases used • Current address, • Date of birth • Social Security Number /driver's license number /state identification number • Three prior addresses 3. Compensation. For each criminal background check report requested by City, City shall pay RSI $6.00, up to 5000 reports, and $5.00 for each report hereafter. City will also pay RSI and annual fee of $3,682.25. RSI may adjust the compensation of this Agreement by providing thirty (30) days written notice of such adjustments to City. 4. Relationship of Parties. The Parties agree that RSI shall be the agent of City for the sole purposes of obtaining criminal background check reports on Prospective Tenants and delivering the criminal background check reports to City, and neither RSI nor City shall be the agent or employee of the other for any other purpose nor does this Agreement create an employment, partnership or joint venture relationship between the Parties. Neither Party shall have the power or authority to bind, enter into agreements on behalf of, or otherwise incur obligations on behalf of the other Party. 5. Non - Exclusive Relationship. City understands and agrees that RSI may provide the Services to other property owners and managers. 6. Rental Decisions. City and RSI acknowledge and agree that RSI provides only criminal background check reports and makes no recommendation as to actions concerning a Prospective Tenant. RSI shall have no liability to City for any rental, or the failure to rent, to any Prospective Tenant, or the terms of any such rental, regardless of whether or not a rental decision was based on information provided by RSI except for negligent acts by RSI. 7. Certification by City. City hereby certifies and covenants to RSI as provided in this Section 7. City provides each of these certifications as of the date of this Agreement and again as of the time City requests a criminal background check report. (a) City will request a background check report only for the purpose of assisting Rental License Holders in determining a Prospective Tenant's ability to, and likelihood of, meeting rental criteria set by the Rental License Holder (b) City will request criminal background check reports for Rental License Holders and will not request RSI to obtain or provide criminal background check reports on the officers, directors, members, partners, individual shareholders or other principals of a Rental License Holder. (c) City will request a criminal background check report only after receiving a signed waiver from the Prospective Tenant, except that City may rely on the faxed signature of a Prospective Tenant. Such waiver shall contain the necessary authorizations for RSI to obtain the required criminal background information. (d) Prior to requesting a criminal background check report City will verify the identity of each Prospective Tenant. 8. Representations and Warranties of City; Additional Obligations and Covenants of City. City represents, warrants, and covenants to RSI as follows: (a) All Prospective Tenant Information provided by City to RSI will be, to the best of City's knowledge, accurate, complete and shall not infringe upon the confidentiality or intellectual property rights of any third parties; (b) The individual executing this Agreement has the authority to execute this Agreement on behalf of the City and to bind City to the terms of this Agreement; (c) City will only use the Program Codes, codes provided by RSI to the City which will enable the City to submit and retrieve criminal background check requests and reports, assigned to City by RSI for the purpose of requesting criminal background check reports; (d) City will maintain the confidentiality of its Program Codes and share its Program Codes only with those employees of City who are authorized by City to initiate criminal background check report requests; (e) Prior to initiating a criminal background check report request, City will obtain the signature of each individual, as applicable, on the Tenant Consent form attached hereto as Exhibit A; (f) City will comply with all laws, rules and regulations governing the conduct of City's business, including but not limited to all applicable federal, state or local fair housing laws; by way of example and without limitation. City represents, warrants and covenants to RSI that City will not discriminate against any Prospective Tenant or Rental License Holder on any basis that is prohibited by any federal or state law, or any federal, state or local fair housing laws; and (g) City will retain copies of signed Tenant Consent forms, in City's files for a period of at least 60 months. 9. Confidentiality. Each Party agrees that it will, to the extent required by law and to the extent and in accordance with the policies used to protect its own information of similar importance, use its best efforts to refrain from and prevent the use of or disclosure of any Confidential Information (as defined below) of the other person, disclosed or obtained by such Party while performing its obligations under this Agreement, provided, however, that RSI may disclose any information reasonably necessary to be disclosed in order for RSI to provide the Services and perform its obligations under this Agreement. Notwithstanding anything to the contrary, neither Party shall use any Confidential Information in a manner which is detrimental to the other Party. The phrase "Confidential Information" includes, without limitation, all materials and information supplied by one Party to the other in the course of each Party's performance under this Agreement, including but not limited to each Party's business objectives and plans, marketing plans, City lists, and financial information. Confidential Information of RSI includes, in addition to the information described above, RSI's Recommendations, any forms or agreements provided by RSI to City, and any information available on the RSI Site. Neither Party will have an obligation of confidentiality with regard to any information insofar as such information: (1) was known to such Party prior to obtaining it from the other Party; (2) is at the time of disclosure publicly available or becomes publicly available other than as a result of a breach of this Agreement; or (3) is disclosed to such Party by a third party not under a duty not to disclose such information. In addition, the confidentiality obligations set forth above shall not apply to any Confidential Information which is disclosed pursuant to: (a) any law of the United States or any state thereof; or (b) the order, rules or regulations of any court or governmental agency. Prior to any disclosure required by law or order of any court or government agency, the disclosing Party agrees to notify the other Party of the required disclosure, so that the other Party may attempt to seek a protective order or other appropriate remedy and /or waive compliance with this provision. If, in the absence of a protective order or other remedy, or the receipt of a waiver, the disclosing Party concludes, after consultation with legal counsel, that it is nonetheless legally compelled to disclose Confidential Information, then the disclosing Party may, without liability hereunder, disclose only that portion of the Confidential Information which such counsel advises is legally required to be disclosed, provided that such Party agrees to exercise its reasonable best efforts to preserve the confidentiality of the Confidential Information, and reasonably cooperate with the other Party's efforts to obtain an appropriate protective order or other reliable assurance that confidential treatment will be accorded the Confidential Information. 10. Indemnification. (a) Indemnification by RSI. RSI shall indemnify, defend and hold harmless City and its officers, directors, employees, agents, successors and assignees, from any and all losses, liabilities, damages and claims, and all related costs and expenses (including reasonable legal fees and costs) ( "Losses "), arising from or in connection with a breach by RSI of any material term or condition of this Agreement and for any negligence of RSI. Notwithstanding the foregoing, RSI shall not be liable to City under this Section 10(a) if the alleged Losses were the result of the negligent acts or omissions of City or of an unrelated third -party who provided information or property to RSI and RSI in the exercise of its ordinary care had no reason to know that the use of such information or property would result in Losses to City. (b) Indemnification by City. City shall indemnify, defend and hold harmless RSI and RSI's officers, directors, employees, agents, successors, assignees, and third party suppliers from any and all Losses arising from a breach by City of any material term or condition of this Agreement, or any negligence by the City. 11. Insurance. RSI shall provide insurance during the term of this Agreement as set forth in the attached Insurance Schedule C. 12. Term; Termination of the Agreement. This Agreement shall have a term of two years, after which this Agreement will renew automatically for successive one -year periods (the "Renewal Terms "). (a) Termination by RSI. (1) RSI may terminate this Agreement by providing City written notice of termination of this Agreement at least 30 days prior to the end of the initial period or any Renewal Term. (2) RSI may terminate this Agreement immediately in the event that (i) City breaches this Agreement; or (ii) RSI reasonably believes that City is obtaining or using the criminal background check reports for other than permissible purposes as provided by this Agreement and applicable law, or otherwise is engaging in unlawful activity. (b) Termination by City. City may terminate this Agreement at any time, for any reason by providing fourteen (14) days written notice to RSI. (c) Obligations upon Termination. Upon termination of this Agreement for any reason, City shall cease to request or otherwise initiate criminal background check report requests, shall not access the RSI Site for any purpose, shall destroy all of City's Program Codes, and shall return all documentation or information provided by RSI to City ( "Program Materials "). Upon the termination of this Agreement, and at the request of RSI, City agrees that it will certify to RSI that it has not retained or reproduced the Program Materials. City's indemnification obligation to RSI under Section 10 of this Agreement, and City's obligation to preserve the confidentiality of RSI's Confidential Information under Section 9 hereto, shall survive termination of this Agreement. 13. Miscellaneous. (a) Governing Law. This Agreement shall be construed and governed by the laws of the State of Iowa, without reference to the choice of law principles thereof. (b) Notices. All communications or notices required or permitted by this Agreement shall be sufficiently given for all purposes hereunder if given in writing and delivered (i) purposely, (ii) by United States first class mail, (iii) by reputable overnight delivery service, (iv) by electronic mail, or (v) by facsimile. All notices delivered in accordance with this Section shall be sent to the appropriate address or number, as set forth below. (c) Severability. Whenever possible, each provision of this Agreement will be interpreted in such manner as to be effective and valid under applicable law, but if any provision of this Agreement is held to be prohibited by or invalid under applicable law, such provision will be ineffective only to the extent of such prohibition or invalidity, without invalidating the remainder of this Agreement. (d) Amendments. This Agreement may be amended only by a writing executed by the Parties. IN WITNESS WHEREOF, the Parties have caused this Agreement to be executed in their names as of the date first above written. RENTAL SERVICES, INC. CITY OF DUBUQUE Signature: Name: Title: 10050 Ralston Road, Suite 7 Arvada, CO 80004 Phone: 303 - 420 -1212 Fax: 303 - 303 - 420 -1477 Date: Signature: Michael C. Van Milligen City Manager 50 W. 13th Street Dubuque, IA 52001 Phone: 563 - 589 -4110 Fax: 563 - 589 -4149 Date: f�° Dubuque 'VP 2007 THE CITY OF DUB Masterpiece on the Mississippi City of Dubuque Prospective Tenant Background Check Consent Form Last Name First Name Middle Name Any Other Names Used Date of Birth Sex Current Address: Three (3) Prior Addresses (Include City, State, Zip) 1. 2. 3. • Additional household members eighteen (18) ye `Hider: (■ . Je, Date of Birth) 1. Social `lrity NW r 2. Number of household members under ek, \leal Have you been convicted of a' �. or a serious "4.. , of age: 'ggravateu misdemeanor in the past five (5) years? I hereby consent to the use of D. ibove ► -ion to search my criminal history records. I am of legal age, sign this as my or PI act and uno_ .sand what it means and what I am agreeing to by signing. Date Signature ■ Additional household members ei gf (18)years or older must also complete a Prospective Tenant Background Check Consent Form DISCLAIMER: This information iii .omided at the request of Landlord, and in accordance with the written instructions of the individual to whom it relates, and Landlord agrees that, .decision to rent is Landlord's SOLE decision. The city of Dubuque is not an agent of Landlord nor does it guarantee or warrant the character or suitability of tenant. The city is simply providing information requested. To be Completed by Landlord Property Agent Name of Property Property Address (Include Apt. #) Number of Bedrooms in Unit Fax # Phone # Date For Internal Use by City Only Form Received by: Date: Check Completed by: Date: INSURANCE SCHEDULE C INSURANCE REQUIREMENTS FOR PROFESSIONAL SERVICES TO THE CITY OF DUBUQUE 1. All policies of insurance required hereunder shall be with an insurer authorized to do business in Iowa. All insurers shall have a rating of A better in the current A.M. Best Rating Guide. 2. All Certificates of Insurance required hereunder shall provide a thirty (30) day notice of cancellation to the City of Dubuque, except for a ten (10) day notice for non- payment, if cancellation is prior to the expiration date. 3. shall furnish a signed Certificate of Insurance to the City of Dubuque, Iowa for the coverage required in Paragraph 6 below. Such Certificates shall include copies of the following endorsements: a) Commercial General Liability policy is primary and non - contributing. b) Commercial General Liability additional insured endorsement. c) Governmental Immunities Endorsement. , shall upon request, provide Certificates of Insurance for all subcontractors and sub -sub contractors who perform work or services pursuant to the provisions of this contract. Said certificates shall meet the insurance requirements as required of 4. Each certificate shall be submitted to the contracting department of the City of Dubuque. 5. Failure to provide minimum coverage shall not be deemed a waiver of these requirements by the City of Dubuque. Failure to obtain or maintain the required insurance shall be considered a material breach of this agreement. 6. Contractor shall be required to carry the following minimum coverage /limits or greater if required by law or other legal agreement: a) COMMERCIAL GENERAL LIABILITY General Aggregate Limit Products - Completed Operations Aggregate Limit Personal and Advertising Injury Limit Each Occurrence Limit Fire Damage limit (any one occurrence) Medical Payments $2,000,000 $1,000,000 $1,000,000 $1,000,000 $ 50,000 $ 5,000 1 of 2 January 2008 INSURANCE SCHEDULE C (Continued) INSURANCE REQUIREMENTS FOR PROFESSIONAL SERVICES TO THE CITY OF DUBUQUE This coverage shall be written on an occurrence form, not claims made form. All deviations or exclusions from the standard ISO commercial general liability form CG 0001 or Business owners BP 0002 shall be clearly identified. Form CG 25 04 03 97 'Designated Location (s) General Aggregate Limit' shall be included, Governmental Immunity endorsement identical or equivalent to form attached. Additional Insured Requirement: The City of Dubuque, including all its elected and appointed officials, all its employees and volunteers, all its boards, commissions and /or authorities and their board members, employees and volunteers shall be named as an additional insured on General Liability including "ongoing operations" coverage equivalent to ISO CG 20100704. b) Automobile $1,000,000 combined single limit. c) WORKERS COMPENSATION & EMPLOYERS LIABILITY Statutory for Coverage A Employers Liability: Each Accident Each Employee Disease Policy Limit Disease d) PROFESSIONAL LIABILITY e) UMBRELLA /EXCESS LIABILITY * *Coverage and /or limit of liability to be determined on a case -by -case basis by Finance Director. $ 100,000 $ 100,000 $ 500,000 $1,000,000 Completion Checklist n Certificate of Liability Insurance (2 pages) n Designated Location(s) General Aggregate Limit CG 25 04 03 97 (2 pages) Li Additional Insured CG 20 10 07 04 ❑ Governmental Immunities Endorsement 2 of 2 January 2008 ACORDTM, CER TIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 12/7/2007 PRODUCER (563) 123 -4567 Insurance Agency Street Address City FAX (563) 987 -6543 ST Zip Code 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 POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Company Street City St Zip Code INSURER A: Insurance Company INSURER B INSURER C INSURER D. INSURER E COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM /DDIYY) POLICY EXPIRATION DATE (MMIDD/YY) LIMITS A X GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X PREMISES ERENTED nce) $ 50 , 000 CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L GENERAL AGGREGATE $ 2,000,000 AGGREGATE LIMIT APPLIES PER: POLICY X rsref OC PRODUCTS - COMP /OP AGG $ 1 , 000 , 000 A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY ANY AUTO , ' AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY. AGG $ A EXCESS/UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ 0 1e /.I EACH OCCURRENCE $ 1,000,000 X AGGREGATE $ 1,000,000 X $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below Cc ®�e .� ® • j X TORY LAMBS OTH- ER E EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E L. DISEASE - POLICY LIMIT $ 500 , 000 A OTHER Professional Liability $1,000,000 DESCRIPTION OF OPERATIONS/ L OCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS The City of Dubuque is an additional insured on general liability policies including ongoing & completed operations coverage equivalent to ISO CG 2010 0704 & CG 2037 0704. General Liability policy is primary & non - contributing. Form CG 2504 0397 "Designated Locations" general liability aggregate limit is included. Governmental immunities endorsement is included. CERTIFICATE HOLDER CANCELLATION City of Dubuque 50 West 13th Street Dubuque, IA 52001 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) INS025 (0108).06 AMS VMP Mortgage Solutions, Inc (800)327 -0545 ©ACORD CORPORATION 1988 Page 1 of 2 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) 1NS025 (owe).os AMS Page 2 of 2 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 25 04 03 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED LOCATION(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Location(s): ANY AND ALL COVERED LOCATIONS (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. For all sums which the insured becomes legally obligated to pay as damages caused by "occur- rences" under COVERAGE A (SECTION I), and for all medical expenses caused by accidents under COVERAGE C (SECTION I), which can be attributed only to operations at a single desig- nated "location" shown in the Schedule above: 1. A separate Designated Location General Aggregate Limit applies to each designated "location ", and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Location General Aggregate Limit is the most we will pay for the sum of all damages under COVERAGE A, except dam- ages because of "bodily injury" or "property damage" included in the "products- completed operations hazard ", and for medical expenses under COVERAGE C regardless of the num- ber of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits ". 3. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the Designated Loca- tion General Aggregate Limit for that desig- nated "location ". Such payments shall not re- duce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Location General Aggre- gate Limit for any other designated "location" shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Ex- pense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Location General Aggregate Limit. B. For all sums which the insured becomes legally obligated to pay as damages caused by "occur- rences" under COVERAGE A (SECTION 1), and for all medical expenses caused by accidents under COVERAGE C (SECTION I), which can- not be attributed only to operations at a single designated `location" shown in the Schedule above: 1. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products - Completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Location general Aggregate Limit. CG 25 04 03 97 Page 1 of 2 CG 25 04 03 97 C. When coverage for liability arising out of the "products- completed operations hazard" is pro- vided, any payments for damages because of "bodily injury" or "property damage" included in the "products- completed operations hazard" will reduce the Products - Completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate Limit nor the Designated Location Gen- eral Aggregate Limit. D. For the purposes of this endorsement, the Defi- nitions Section is amended by the addition of the following definition: "Location" means premises involving the same or connecting Tots, or premises whose connection is interrupted only by a street, roadway, waterway or right -of -way of a railroad. E. The provisions of Limits Of Insurance (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. Copyright, Insurance Services Office, Inc., 1996 Page2of2 CG25040397 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): The City of Dubuque, including all its elected and appointed officials, all its employees and volunteers, all its boards, commissions and /or authorities and their board members, employees and volunteers. Location(s) Of Covered Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. fhe acts or omissions of those acting on your behalf; CG 20 10 07 04 in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "pi JNci ty d0 of ye° occurring after: Page 1 of 2 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or Page 2 of 2 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. All terms and conditions of this policy apply unless modified by this endorsement. © ISO Properties, Inc., 2004 CG 20 10 07 04 CITY OF DUBUQUE, IOWA GOVERNMENTAL IMMUNITIES ENDORSEMENT 1. Nonwaiver of Governmental Immunity. The insurance carrier expressly agrees and states that the purchase of this policy and the including of the City of Dubuque, Iowa as an Additional Insured does not waive any of the defenses of governmental immunity available to the City of Dubuque, Iowa under Code of Iowa Section 670.4 as it is now exists and as it may be amended from time to time. 2. Claims Coverage. The insurance carrier further agrees that this policy of insurance shall cover only those claims not subject to the defense of governmental immunity under the Code of Iowa Section 670.4 as it now exists and as it may be amended from time to time. Those claims not subject to Code of Iowa Section 670.4 shall be covered by the terms and conditions of this insurance policy. 3. Assertion of Government Immunity. The City of Dubuque, Iowa shall be responsible for asserting any defense of governmental immunity, and may do so at any time and shall do so upon the timely written request of the insurance carrier. 4. Non - Denial of Coverage. The insurance carrier shall not deny coverage under this policy and the insurance carrier shall not deny any of the rights and benefits accruing to the City of Dubuque, Iowa under this policy for reasons of governmental immunity unless and until a court of competent jurisdiction has ruled in favor of the defense(s) of governmental immunity asserted by the City of Dubuque, Iowa. No Other Change in Policy. The above preservation of governmental immunities shall not otherwise change or alter the coverage available under the policy. SPECIMEN 1 of 1 January 2008 NOV 09 2010 1:34PM RENTAL SERVICES PIN I COL ASSURANCE - ITEM 1. INSURED: RENTAL SERVICES INC 10050 RALSTON ROAD STE 7 ARVADA CO 80004 ITEM 2. POLICY PERIOD: ITEM 3. A. 303 420 1477 7501 E Lowry' Blvd Denver, CO 80230-7006 Phone: (303) 361-4000 / (800) 873-7242 Fax (303) 361-5000 / (888) 329-2251 www.pinnacol.com POLICY INFORMATION PAGE Policy #: 4040725 : Policy Type: ADVANCE • ‘r4 AGENT: p COLORADO WORKEkSI COMPENSATION NETW 6635 SOUTH DAYTON, SUITE 240 GREENWOOD VILLAGE, CO 80111 (303) 770-2800 RE / 8.00 • FROM 03/01/2010 TO 03/01/2011 12;01 AM, MOUNTAIN STANDARD TIME of Workers' Compensation Insurance: Part One of the policy applies to the workers' cornpensatIon taw ot the states listed here: COLORADO B. Employers.Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3 A. The limits of our liability under part two are: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 . EACH EMPLOYEE BODILY INJURY BY DISEASE . . $500,000 POLICY LIMIT c. . , • • . . , Other States Insurance: Part Three of the policy applies to.the states ,. if any, listed here: • .• : NONE . • • ' . . . . .. . (Please contact Pinnacol AseuranCe forinforrnation on coverage outside the state of Colorado) . . . Thli policy includes the attached c:ridorsernents and schedules: - • • 511 . Other State Endorsement '' . .. . CATO9 Catastrophe (Other than Certified Acts of Terrorism) TER09 Terrc•rism Risk Insurance Program Reauthorization Act • ITEM 4. We will determine the premium for this policy by our manuals of rules, classifications, rates and rating plans, All information required below is subject to verification and change by audit. The statements of estimated advanced premium are also a part of this policy. Pinnacol As,1 urance' 7501 E Lowry Blvd Denver, CO 802301 Page 2 ef U0408 - 03/01/2010 18:42:20 404072.5 P4ALL • NOV 09 2010 1:34PM RENTAL SERVICES RAVELERS J 303 420 1477 P.3 One Tower Square, Hartford, Connecticut 06183 BUSINESSOWNERS COVERAGE PART DECLARATIONS OFFICE PAC NO.: I- 680 -0031 CS60- PHX -'1 0 ISSUE DATE: 06 -16 -10 . • - INSURING COMPANY: • HE PHOENIX INSURANCE COMPANY POLICY PERIOD: • Fran• 08 -10 -10 to 08- 10 -1°1 .12 :0i A.M. Standard Time a.t- your mailing address . FORM OF BUSINESS: CORPORATION COVERAGES AND LIMITS OF INSURANCE: Insurance applies only .to an item for whi oh' a "limit" or the word "included" is shown. COMMERCIAL GENERAL LIABILITY COVERAGE 'OCCURRENCE FORM LIMITS OF INSURANCE General Aggregate (except' Products- Completed Operations Limit) $ 2,000,000 Products - Completed Operations.ACgregate Limit $ 2,000,000 Personal and .Advert i si ng i nj ur•y Limit $ , 1 000 , 000 Each Occurrence .Limit $- 1,000,000 Damage to Premises Rented, to You $ '300,000 Medical Payments Limit (any. one person) 5,000 BUSII-iESSOWNERS PROPERTY COVERAGE =.DEDUCTIBLE AMOUNT: Busi.nessoWnwrs:Property Coverage: $ 500 per occurrence. Building Glass: ` $ 500. per'occurrence. USINESS INCOME /EXTRA EXPENSE LIMIT: Actual loss for 12 consecutive months eriod of Restoration -Ti me Peri od: Immediately' `ADDITIONAL COVERAGE: ,..r Fine Arts: $ 25,000' . Ither additional coverages apply and may be changed by an endorsement. Please read the policy. gCIAL PROVISIONS: COMMERCIAL GENERAL LIABILITY COVERAGE IS SUBJECT TO A GENERAL AGGREGATE LIMIT MP 10 01 02 05 (Page 1 of 02) To be Placed on the Insured / Applicant's Letterhead To Underwriter: Re: Warranty Statement for Proposed Coverage After inquiry, no person to be insured has had any claims or knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim. It is understood and agreed that if such knowledge or information exists any claim or action arising there from is excluded from this proposed coverage. This warranty statement duly completed, together with any supplementary information, must be signed in ink by the person indicated. I agree that this warranty statement and all other information which is provided are incorporated into and form the basis of any contract of insurance. I HEREBY DECLARE that the above statements and particulars are true and I have not suppressed or misstated any material fact and that I agree that this warranty statement shall be the basis of the contract with you, the Underwriters. Signature: Date: (mm /dd /yy) The signature must be of a person authorized to execute on behalf of the applicant. A copy of this should be retained for your records. May 24, 2011 Adco General Corporation PO Box 40007 801 Kalamath Street Denver, CO 80204 303.893.5770 phone 303.893.3301 fax unvw.adcogen.com To: Sally Magill Carver & Associates From: Jackie Kniss RE: Rental Services, Inc. Professional Liability Coverage commission: 10% Premium: $3,250. Co fee: 75. Adco fee: 250. Tax: 107.25 Total: $3,682.25 When coverage is placed in a surplus lines market, the producer is responsible for documentation of the Diligent Search in the admitted market and compliance with the corresponding State surplus lines law for which this coverage is procured. In accordance with your request for a proposal, and based upon the information submitted, I am pleased to offer the following indication subject to receipt, review and acceptance of: 1. Newly signed and dated Main Form Application if not bound by 01/20/11. Limit of Liability (Each Claim, including Damages, Claim Expenses and Supplementary Payments) $ 1,000,000 Limit of Liability (in the aggregate for all Claims, including Damages, Claim Expenses and Supplementary Payments) $ 1,000,000 Deductible (Each Claim, including Damages and Claim Expenses, but not Supplementary Payments) $ 2,500 Premium $ 3,250.00 Administrative Fee $ 75.00 The above indication is subject to our standard certificate (policy) form and is inclusive of the following: 1. One (1) year policy period; 2. Prior acts coverage to inception date of coverage; 3. 12 month discovery period @ 75.00 % NP; 4. 100% Lloyds syndicate paper which is rated A by A.M. Best. Financial Size Category is Class XV; 5. Attached endorsements apply: (1) E2.1, (2) E65.1, (3) E240.5, (4) E9990.2, (5) E135.1, (6) E999.1 THIS POLICY IS A CLAIMS -MADE POLICY WHICH PROVIDES LIABILITY COVERAGE ONLY IF A CLAIM IS MADE DURING THE POLICY PERIOD OR ANY APPLICABLE EXTENDED REPORTING PERIOD. "THIS CONTRACT IS DELIVERED AS SURPLUS LINE INSURANCE UNDER THE NONADMITTED INSURANCE ACT. THE INSURER ISSUING THIS CONTRACT IS NOT LICENSED IN COLORADO BUT IS AN APPROVED NONADMITTED INSURER. THERE IS NO PROTECTION UNDER THE PROVISIONS OF THE COLORADO INSURANCE GUARANTY ASSOCIATION ACT." Richard R. Thomas (Page 1) 6. Hiscox Professional Liability Policy Includes: Third Party Discrimination 60 Day Post - Policy Reporting Personal Injury Independent Contractor Coverage Punitive Damages up to $250,000 (where insurable by law) Choice of Defense Counsel (subject to approval) Spousal Liability Bilateral Tail Joint Venture Coverage The Named Insured's profession under Item 3 of the Declarations will read: Solely in the performance of providing tenant and /or employee screeing services, for others for a fee. (Page 2) JUN 28 2011 2:56AM RENTAL SERVICES INC AWR 303 420 147'7 p.2 CERTIFICATE OF LIABILITY INSURANCE OP ID:. SPA 0ATe (ME DOAYYYY) 06121/11 TI-IIS 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 INSURERS ), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED. the policy(ies) must be endorsed. N SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on thls certificate does not confer rights to the Certificate holder in lieu of such endorsement(s). PRODUCER 303-420-1637 NAMEA T Jeff Malone Carver and Associates PNONE FAX 303 -431 -9237 7710 Ralston Road CA0 . No, Eotl: (NC, No): Arvada, CO 80002 A DRESS: Don W Carver INSURED Retail Service, Inc. 10050 Ralston Rd Suite 7 Arvada, CO 80004 • PRODUc =gym ERID0: RENTA -1 INSURER S AFFORDING COVERAGE WIC a INSURER A: Continental Western Group 10804 INNSURERe :Lloyds Of London - Hiscox INSURER C: INSURER D: INSURER E: INSURER F: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VWIICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIFS DESCRIBED HEREIN I5 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILNTR TYPE OF INSURANCE •f •,• -1 • 1 -. POLICY NUMBER (MWDD/YWY) (MNIDCDI FYI LASTS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY X J OCCUR BINDER #0701011'• . - - _ '07/01117 07/01/12 EACH OCCURRENCE $ 1,000,00 OAM ISEET E R oci au ee S 300,00' ■ CLAIMS MADE , MED EXP (Any one . _ son $ 10,001'' ■ ■ GEN'L PERSONAL &ADVINJURY $ see bet' GENERAL AGGREGATE S 2,000,001- AGGREGATE LIMIT APPLIES PER POLICY X PRO- • LOC PRODUCTS - COMP/OP AGO $ 2,000,001' $ AUTOMOBILE ■ LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE OMIT (Ea accident) S BODILY INJURY (Per Parton) $ BODILY INJURY (Per accident) S PROPERTY DAMAGE (Per accident) S S ■ ■ ■ ■ UMBRELLA LIAR EXCESS LL413 ■ ■ OCCUR CLAIMS -MADE ... . ,.. .:. ,. .. EACH OCCURRENCE $ AGGREGATE 8 DEDUCTIBLE RETENTION $ $ $ -■ S WORKERS COMPENSATION _.... AND EMPLOYERS' UABLIITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y N OFFICERMEMBEREXCLUDED7 (Mandatory In NH) Byes, describe irides DESCRIPTION OF OPERATIONS below NIA ` ■ J " 1, ■ -,j EL EACH ACCIDENT E.L DISEASE - EA EMPLOYE 8 E.L DISEASE • POLICY UNIT $ B B Professional Llabl Personal Injury LI MPL1188978.11 MPL1188978.11 07/01/11 07/01/11 07/01/12 07/01/12 each Clai 1'000,00' aggregate 1,000,00' DESCRIPTION City primary 0required OF OPERATIONS I LOCATIONS / VEIECLES (Attach ACORD 101, Additional Remarks Schedule If more space is required) of Dubuque, Iowa is additional per CLCG 00130706 attached, insurance is ' and non - contributory and per project aggregate Is providedif by written contract. Iowa Governmental Liability Endorsement 338) is attached. CERTIFICATE HOLDER CANCELLATION DUBUQ -1 City of Dubuque, row 50 W. 13th Street Dubuque, IA 52001 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITN THE POLICY PROVISIONS. © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORD 26 (2009/09) JUN 2€3 2011 2: 56FIM RENTAL SERVICES INC 303 420 1477 P= 3 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. IOWA GOVERNMENTAL LIABILITY AMENDATORY ENDORSEMENT This endorsement modifies insurance under the following: FIRE/EMS-PAK COMMERCIAL GENERAL LIABILITY COVERAGE FORM FIRE/EMS -PAK BUSINESS AUTO COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM BUSINESS AUTO COVERAGE FORM PUBLIC OFFICIALS LIABILITY COVERAGE FORM A. It is both your and our understanding that you wish to fully Invoke and take = . nt: of all Immunities you and/or any other insured has or has been granted against I® , ire t, "� , without Implied limitation, Immunities which would be waived by the purchase of ins nest - B. This Insurance does not include coverage for any liability or suit for amage 5 Is barred by the doctrines of sovereign Immunity or govemmental Immunity, as sewn Iowa Cods, Chapter 070 ets y €r • C. This policy is not intended to act as, nor is it,a waiver, 01 lj, efe`n f.IImitation of damages, which is available to an Insured by statute or at common law.Osef h inlava Code, Chapter 670.07. D. For any suit or claim for damages within the 'Scapa of Idigiftog.e Chapter 670 et seq, the amount of coverage under this poficy Includes liability onteitir arri40,as set forth in that Statute, but in no case will our liability exceed the Limits of Liab]t as shown on the Declarations page of this policy. E. For any suit or claim for damages not within theteopaeof Iowa Code, Chapter 670 et seq, the Limits of Liability apply as shown on the Deck ns pagrcf this policy. 1 9 Sr CW33300700 Page 1 of 1 JUN 28 2011 2:56AN RENTAL SERVICES INC 303 420 1477 p.4 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT Ct'. ='EFULLY. GENERAL LIABILITY ENHANCEMENT ENDORSEMENT This endorsement modifies Insurance provided under -the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. MEDICAL PAYMENTS If SECTION I - COVERAGE C MEDICAL PAY- MENTS is not otherwise excluded from this Coverage Part: 1. The Medical Expense Limit provided by this policy, subject to the terms of SECTION III - LIMITS OF INSURANCE, shall be the, greater of: a. $10,000; or b. The Medical Expense Limit shown in the Declarations of this Coverage Part, B. FIRE, LIGHTNING, EXPLOSION, SMOKE AO.' SPRINKLER LEAKAGE DAMAGE TO PREM- ISES YOU RENT If damage to premises rented to you under C ave ' erage A. is not otherwise excluded from this pol- icy, the following applies: t The last paragraph of SECTION I - CO\t '.. ERAGE A.2. Exclusions is deleted and fee.: (b) That is Fire, LightningExptoslon or Sprinkler Leakage inOranbe for prem- ises rented to you $- tempprarily occu- pied by you with pereplesiogeof the owner; 4. Paragraph 9.a..4. CTIO`Iti}_;,Y ere EFIN1- TIONS is dead and replaclfify the fol- lowing: 4 a. A ppntradth for a lease of premises. H" r, tfilatportiorefoI the contract for a IeaseV prestisfiliat indemnifies any „person ;,organization for damage by Ilise'rliiiighti4lryg, explosion or sprinkler ` aakage to promises while rented to you - dire;temporarily occupied by you with perttts§eon of the owner is not an "in- Ii . cured bntract•; WoN -Owl: ED WATERCRAFT graph g.(2) of SECTION I - COVER- , E A.2. Exclusions is deleted and re- placed by the following: A watercraft you do not own that is: ,; (a) Less than 51 feet long; and (b) Not used to carry persons or property for a charge. Di SUPPLEMENTARY PAYMENTS SECTION I -S UPPLEMENTARY PAYMENTS - COVERAGES A AND B is amended as fol- lows: • placed by the following: Exclusions c. through n. do not apply to damage by fire, lightning, expios(diii'or sprir - kler leakage to premises while rented to your or temporarily occupiedf _cz CO' ission of the owner. . aepartte limit f.;,- insurance applies to tuts" coverage es df " scribed in SECTION!1l - LIMITS "` SURANCE. ;'.:.. 2. Paragraph 6. o €._SECT�A III - LIMITS OF ;Wdp tNSURANCEleted arid, replaced by the following: f,,;;;' 6. Subjetit.to S.ioverthe greater of a. $30000; or kll. `;tfie Da *To Premises Rented ,To You LEittit shown In the Declare:" -4g7 the most we will pay under COVER- AGE ,A for damages because of "prop - ert I:Samage" to any one premise:►; Mite rented to you, or temporarily ,oc- . cupied by you with the permission of the owner ansing Out of any one fire, light= ring, explosion or sprinkler leakage..in cidant. 3. Paragraph 4.b.(1)(b) Other Insurance •df SECTION IV - COMMERCIAL GENERAL LIAfatL!TY CONDITIONS is deleted and re- placed by the following: 1. The limit of insurance In paragraph 1.b. is increased from $250 to $2,500; and 2. The limit of insurance in paragraph i.d. is increased from $250 to $500. E. AUTOMATIC ADDITIONAL INSURED - SPECIFIED RELATIONSHIPS The following is added to Paragraph 2. of SEC - TION II • WHO IS AN INSURED: e. Any person or organization described in paragraph 2.f. below, whom you and such person or organization have agreed In writ- ing in a contract or agreement that such per- son or organization be added as an addi- tional insured an your policy. Such person or organization is an insured provided: CL CG DO 13 07 06 Includes copyrighted material of Insurance Services Page 1 of 4 Offiva; Inc., with its permission JUN 28 2011 2:57RM RENTAL SERVICES INC (1) The written or oral contract or agree- ment Is: (a) Currently in effect or becomes effec- tive during the policy period; and (b) Executed prior to an 'occurrence" or offense to which this insurance_ would apply. (2) They are not specifically named as; an additional insured under any other pro= vision of, or endorsement added to, this policy. r Only the following persons or organizations are additional insureds under this endorse- ment, and coverage provided to such addi- tional insureds is limited as provided herein: • (1) The manager or lessor of a premise . leased to you, but only -with respect; to liability arising from the ownershjp, maintenance or use of that part of the premises leased to you and subject to the following additional exclusioni:: • This insurance does not apply to: (a) Any "occurrence" which takes'plade after you cease to be a tenant of- that premises. (b) Structural alterations, new construe= tion or demolition operations pers u ' formed by or on behalf of the mark agerorlessor. (2) Any person or organization frorrawli'oi you lease equipment, but or* ith re- spect to liability for "bodily Wry", "prop - arty damage" or "personeli and actSterti;se, ing injury" caused, in vkie a'r 1r>$rt,,by ,. your maintenance, Oe'G. tion br,.use equipment leased :to you by shah pe r son(s) or organizatfon(s) r However, this tlisr`rantve does not•apply to any "occu,rrence" 'which takes place after i£ie,ae)a.iipment leases;ex�ilres. (3) Any „person - organizetibn referred to beloil'tes vefY_ or, but only with respect to "bodily injury" or "'property damage" „ariewg cut =of "pair products" which are ciistnputed di ;,as Jd In the regular cerise. of tl4 vendq0 business, subject to the • foil ! kviarg - additional exclusions: 1:4.) The insurance afforded the vendor dyes not apply to: ' • .:i. t) "Bodily injury" or "property darn, - age" fir which the vendor o is - ligated to pay damages by rase son of the assumption of liability in a contract or agreement, This exclusion does not apply to ,li- ability for damages that the ven- dor would have in the absence of the contract or agreement; • .. 303 420 1477 P.5 (il) Any express warranty unauthor ized by you; (ill) Any physical or chemical change in the product made in- tentionally by the vendor; (iv) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, d,,then repack- aged in the origifieffeontainer; (v) Any faiiur Seto mace such in- spectional1justenetti'ts, tests or serviglri, as ° >tke vender has agreed • 'maker, no t et lIy un- dertakes to maka'jprhe usual course of businaa_'in connec- tidti with the distrltutlon or sale of else products'; (vi) ei;pemogstr*t tin, installation, servicing or repair operations, e0,?t such operations per- ' ffr1ieti at the vendor's premises in connection with the sale of :the product; (vtt'y Products which, after distribu- te tion or sale by you have been labeled or relabeled or used es a container, part or Ingredient of any rather thing or substance by or for the vendor; or (viii) "Bodily injury" or "'property dam- age" arising out of the sole neg- ligence of the vendor for its own acts or omissions or those of its employees or anyone else act- ing on its behalf. However, this exclusion does not apply to: i. The exceptions contained in Sub- paragraphs (iv) or (vi); or ti. Such inspections, adjust- ments, tests or servicing as the vendor has agreed to make or normally under- takes to make in the usual course of business, in con- nection with the distribution or sale of the products. (b) This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompa- nying or containing such products. (4) Any state or political subdivision, subject to the following additional provision: CLCG00130706 inc'udes copyrighted material of Insurance Services Office, Inc., with its permission Page 2 of 4 JUN 20 2011 2 :50AM RENTAL SERVICES INC This insurance applies only with respect to the following hazards for which •tne state or political subdivision has issued a permit in connection with premises you own, rent, or control and to Which this insurance applies: (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, cano- pies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners, or decora- tions and similar exposures; or (b) The corisfruction, erection, or-re- moval of elevators; or The ownership, maintenance, or use of any elevators covered by this insurance. F. BROADENED NAMED INSURED Paragraph 3. of SECTION fl - WHO iS AN I14- SURED is deleted and replaced by the follow- ing: Any organization, other than a joint venture, over which you maintain ownership or majority inter- est of more than 50% will be a Named Insured1f there is no other similar insurance available -to that organization. However: a. Coverage under this provision is affordeck ohly anti; the 180th day after you a quiver r form the organization or the end of theepbta. icy period, whichever is earlier, ., b. COVERAGE A does riot apply to !'bodily in- jury" or "property dareaoe" that- ctrrnad he- - fore you acquired or formefi o'tite °Vetiza tion. c. COVERAGES does ni 3apjily to "p rsonaj and advertising inju,!j; JUN 28 2011 2a58AM RENTAL SERVICES INC However, our rights may only be waived prior to the °occurrence giving rise to the injury or danl- age for which we make payment under this G¢v- erage Part. The insured must do nothing after a loss to impair our rights. At our request, the sured will bring °suit' or transfer those r hts to us and help us enforce those rights. 303 420 1477 p,7 L. OTHER INSURANCE If this policy includes a Coverage Form or an Endorsement which provides coverage for loss or damage covered by one or more of the Ex- tensions of this endorsement, the limit and the coverage provided by this endorsement are de- leted and replaced by the limit and coverage provided by that Coverage Form or Endorse- ment. CL CG 00 13 07 06 Includes copyrighted maierlal of Insurance Services Page 4 of 4 Office, Inc„ with its permission NO ONE CHECKS. THEM Rental Services, Inc. (303) 420 -1212 (800) 628 -6414 FAX (303) 420 -1477 FAX (800) 296 -9902 Banking Reference Customer Name % 2:)uh,(COL--- Address T Name of BankIME I1 I C 1) T F �upoaS Address E (c MA IA) Rr. atALl(I�GE-; IA Bank Phone Number (s t _ ?) 3?-Pi " cmi Business/Personal Checking Account Information: Name of Account Gel ) ��Ptl1 . MI Lit) ( Account Number Sy I give Rental Services, Inc. permission to request business checking account information on the above account as part of their membership due diligence pros -ss O _ Signature Date 6p(7,/ BANK USE ONLY Bank Verification Information: Date Account Opened Customer's nature of business Time Verified by Date 10050 Ralston Road, Suite #7 * Arvada, CO 80004 * (303) 420 -1212 * Fax (303) 420 -1477 www.erentalservicesinc.com 15 Masterpiece on the Mississippi CREDIT REFERENCE AND GENERAL INFORMATION GENERAL INFORMATION Name: City of Dubuque Address: 50 West 13th Street City, State, Zip: Dubuque, IA 52001 -4805 Type of Business: Governmental Agency Federal Identification Number: 42- 6004596 BILLING ADDRESS: Dubuque Police Department 770 Iowa Street Dubuque, IA 52001 KEY CONTACTS: Dawn Young Accounts Payable — Police Department 770 Iowa Street Dubuque, IA 52001 563 -589 -4461 dyoung@cityofdubuque.org Kenneth J. TeKippe, Finance Director 50 West 13`h Street Dubuque, IA 52001 -4805 (563) 589 -4133 Kathy Sturm, Purchasing Coordinator 50 West 13th Street Dubuque, IA 52001 -4805 (563) 589-4131 BANK INFORMATI ©N: Name: Address: City, State, Zip: Contact: Phone: Account Number: Name: Address: City, State, Zip: Contact: Phone: Account Number: CREDIT REFERENCES: Name: Address: City, State, Zip: Phone: Name: Address: City, State, Zip: Phone: Name: Address: City, State, Zip: Phone: American Trust & Savings Bank 895 Main Street Dubuque, IA 52001 Gene Hayertz, Vice President (563) 589 -0806 702005 (General Account) Dubuque Bank & Trust 1398 Central Avenue Dubuque, IA 52001 Doug Stillings, Vice President - Business Development (563) 589 -1976 132 (General Account) Tschiggfrie Excavating 425 Julien Dubuque Drive Dubuque, IA 52003 (563) 557-7450 Mike Finnin Ford 3600 Dodge Street Dubuque, IA 52003 -5251 (563) 556 -1010 Weber Paper Company 4300 Chavenelle Drive Dubuque, IA 52002 (563) 588-4611 The City of Dubuque Finance Department authorizes the banks and credit references listed above to provide information to establish an account with a vendor. 04� Finfatice Department/ epresentative . �i'itle Date Masterpiece on the Mississippi DIRECT BILLING INFORMATION City certifies that the individual whose name appears below is authorized to apply for credit on behalf of the City. City certifies that the information provided relating to this credit application is true and complete. City hereby grants Rental Services, Inc. permission to verify the credit information provided herein. BILLING CONTACT Dawn Young Accounts Payable (563) 589 -4461 770 Iowa Street Dubuque, IA 52001 dyoung(cr� cityofdubuque. org ADDITIONAL BILLING INFORMATION Require a P.O. Number on Invoice: NO Sales Tax Exempt: YES Tax ID# 42- 6004596 //f 6 ;2 /((p(//// Signature Date Rental Services, Inc. (303) 420 -1212 (800) 628 -6414 FAX (303) 420 -1477 FAX (800) 296 -9902 FICO End User Agreement I understand and agree to the following terms and conditions regarding the use of credit scores and reason codes obtained through Rental Services, Inc. and Experian. 1. Notwithstanding any contrary provision of this End User Agreement, End User may disclose the Scores provided to End User under this End User Agreement to credit applicants, when accompanied by the corresponding reason codes, in the context of bona fide lending transactions and decision only. 2. Client agrees to comply with all applicable laws and regulations using the scores and reason codes purchased from Broker and certifies that it has permissible purpose under the Fair Credit Reporting Act to obtain said score information. Client agrees to limit its use of the scores and reason codes to its own business and will not sell, transfer, license or distribute said scores to third parties. Client agrees to maintain security procedures to minimize the risk of disclosure of said scores to employees without the need to know. 3. Client and its employees, agents or subcontractors will not use any of the trademarks, service marks, logos, names, or any other proprietary designations, whether registered or unregistered, of Experian information Solutions, Inc. or Fair Isaac and Company or the affiliates of either of them, or of any other party involved in the provision of the Experian/Fair Isaac Model without such entity's prior written consent. 4. Client will not in any manner, directly or indirectly, to discover or reverse engineer any confidential and proprietary criteria developed or used by Experian/Fair Isaac in performing the Experian/fair Isaac Model. 5. Client agrees that in the event of any payment that may be awarded to client for incidental, indirect, special or consequential damages is limited to lesser of the fees paid by Rental Services, Inc. to Experian or the fees paid by client to Rental Services, Inc for the Fair Isaac scores for the preceding 6 months of service. 6. Warranty- Experian/Fair Issac warrants that the Experian/Fair Isaac Model is empirically derived and demonstrably and statistically sound and that to the extent the population to which the Experian/Fair Isaac Model is applied is similar to the population sample on which Experian/Fair Isaac Model was developed, the Experian/Fair Isaac Model score may be relied upon Broker and/or end Users to rank consumers in the order of risk of unsatisfactory payment such consumers might present to End Users. Experian/ Fair Isaac further warrants that so long as it provides the Experian/ Fair Isaac Model, it will comply with regulations promulgated from time pursuant to the Equal Credit Opportunity Act, 15 USC Section 1691 et.seq. The forgoing warranties are the only warranties Experian/Fair Isaac have given Broker and/or End Users with respect to the Experian/Fair Isaac Model and such warranties are in lieu of all other warranties, express or implied, Experian/Fair Isaac might have given Broker and or end Users with respect thereto, including, for example, warranties of merchantability and fitness for a particular purpose. Broker and each respective End User's rights under the foregoing Warranty are expressly conditioned upon each respective End User's periodic revalidation of the Experian/Fair Issac Model in compliance with the requirements of Regulation B as it may be amended from time to time (12 CFR section 202 et seq.). Signature: CIA Date: 10050 Ralston Road, Suite #7 * Arvada, CO 80004 * (303) 420 -1212 * Fax (303) 420 -1477 www.erentalservicesinc.com 16 Rental Services, Inc. (303) 420 -1212 (800) 628 -6414 FAX (303) 420 -1477 FAX (800) 296 -9902 Account Fee and Quick Application Registration To setup a Full Access account with Rental Services a one time inspection fee of $85.00 is required for a commercial address and annually for a residential address. A $10.00 cancelation fee is charged if the inspection is ordered and then cancelled. Limited Access or Basic Access accounts will be required to pay a one time setup fee of $35.00 [] Full Access Account Basic or Limited Access Account The RSI Quick Application is a new and exciting tool that can be used in place of a standard rental application. Quick Application allows your prospective renters to apply online! Once your account is established, you can login to the RSI website and email out the Quick Application to your applicant. They complete the application online and the information is sent to RSI for processing. Once the application is completed, an email is sent to you and the results can be viewed from the RSI website. If you want to use the RSI Quick Application process, a one time $15.00 setup fee will be charged to your account. [] Yes, I would like to use the RSI Quick Application. VNo, I do not want to use the RSI Quick Application at this time. The RSI Single Family Lease is an automated document available online. Once your account is established, you can login to the RSI website and after you have screened and approved your applicant, you can print a lease. Choose the rent amount, fees and addendums that apply. Print as many leases as you need. A sample is available on the RSI website. If you want to use the RSI Single Family Lease process, a one time $30.00 setup fee will be charged to your account. [] Yes, I would like to use the RSI Single Family Lease. No, I do not want to use theSingle Family Lease at this time. Signature: Date: 10050 Ralston Road, Suite #7 * Arvada, CO 80004 * (303) 420 -1212 * Fax (303) 420 -1477 www.erentalservicesinc.com 17 Rental Services, Inc. (303) 420 -1212 (800) 628 -6414 FAX (303) 420 -1477 FAX (800) 296 -9902 Additional Documentation Proof of property ownership or management must also be provided with this application. Please include one of the following forms of documentation from each line listed below based on the number of units or type of business. Documentation: Small Landlord (2 -100 units) [] Copy of tax statement or closing document for each property [] Copy of property insurance statement or copy of property deed for each property [] If your phone number is unlisted or a cell phone we will also need a copy of your phone bill [] Copy of 3 signed rental applications and/or 1 from each property (either existing or new tenants) Large Landlord (101 and ut units) [] Copy of business license or tax identification number [] Copy of closing documentation or tax documentation for each property [1 If your phone number is unlisted or a cell phone we will also need a copy of your phone bill. [] Copy of 3 signed rental applications (either existing or new tenants) Management Company [] Copy of Property List on company letterhead [] Copy of business license [] Copy of 3 signed rental applications (either existing or new tenants) Personal Documentation: [1 Copy of driver's license (Only need for small or large landlords) Physical Inspection: The credit bureaus require any business that would like to access credit information must submit to a physical inspection of their business premises. The purpose of the inspection is to make sure there is a business located at the given address, a way to secure credit information and a way to destroy credit information. Businesses or landlords that operate from a residential address will need to have the physical inspection conduct annually. If you have less then ten units RSI recommends that you setup a limited access account. This type of account will analyze the credit information and give you a recommendation in place of the actual credit report. 10050 Ralston Road, Suite #7 * Arvada, CO 80004 * (303) 420 -1212 * Fax (303) 420 -1477 www.erentalservicesinc.com 18 Rental Services, Inc. (303) 420 -1212 (800) 628 -6414 FAX (303) 420 -1477 FAX (800) 296 -9902 Electronic Payments Rental Services, Inc. offers automated payments online and by phone for invoices, services and products. This service is offered as an added benefit to our clients. For invoices, a convenience fee of 2.50% will be charged based on the total transaction amount each time the service is used. For all other services, RSI assesses a flat rate fee of $2.00 per transaction. We will continue to provide Rental Services, Inc. customers with the ability to make payments in person or by mail without any fee. Paying a convenience fee is a choice made only by those who choose to use our phone or online services. We will always continue to accept payments by mail or in person. Customers may continue to pay their bills by mail or in person without any additional charge. Payments to Rental Services, Inc. can be made between the hours of 9:00 a.m. to 5:30 p.m., Monday through Friday (except holidays) to the accounts receivable department at the following location: • 10050 Ralston Road, Suite 7, Arvada, Colorado 80004 Automatic Payments Pay by Credit Card (optional) Complete the following if you prefer to have your monthly charges applied to a card. Card Type: [] Visa [] MasterCard [] American Express Card Number: Expiration Date: Security Code: Name on Card: Signature: By signing above I hereby authorize Rental Services, Inc. to charge my credit card account for any products, services or balance due. I agree that I understand and am bound by Rental Services, Inc. Service Agreement. In the event of any dispute arising from or charge back from my credit card, I shall be fully and solely responsible for the settlement of payment. Rental Services, Inc. shall not be held liable in any manner. This authorization also serves as a waiver and release of claims against Rental Services, Inc. from any liability and indemnification. 10050 Ralston Road, Suite #7 * Arvada, CO 80004 * (303) 420 -1212 * Fax (303) 420 -1477 www.erentalservicesinc.com 19