HomeMy WebLinkAbout20011401.tiff RESOLUTION
RE: APPROVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARD FOR FAMILY
ADVOCATE PROGRAM AND AUTHORIZE CHAIR TO SIGN - CHILD ADVOCACY
RESOURCE AND EDUCATION
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Notification of Financial Assistance
Award for Family Advocate Program between the County of Weld, State of Colorado, by and
through the Board of County Commissioners of Weld County, on behalf of the Department of
Social Services, and Child Advocacy Resource and Education, commencing June 1, 2001, and
ending May 31, 2002, with further terms and conditions being as stated in said award, and
WHEREAS, after review, the Board deems it advisable to approve said award, a copy of
which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, ex-officio Board of Social Services, that the Notification of Financial
Assistance Award for Family Advocate Program between the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Social Services, and Child Advocacy Resource and Education, be, and hereby
is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said award.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 30th day of May, A.D., 2001.
BOARD OF COUNTY COMMISSIONERS
WELD COU TY, COLORADO
ATTEST: f •«
r186 ( �,,,,,� -� , M. J. ails, C it
Weld County Clerkto e : • ,4Me? �1/f
,., lenn Vaatr,l; em
BY: /.L. ,. �.,•, oL!�.gc^ ,'
Deputy Clerk to the Bob `'l ' i✓A.,'
William Jerke
APP D AS O ��RM: 4 (CJ ,,,/
vi E. Long N
Robert D. Masden
2001-1401
Pe
h 5S SS0028
DEPARTMENT OF SOCIAL SERVICES
PO BOX A
GREELEY,CO 80632
' WEBSITE:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933.C
COLORADO
MEMORANDUM
TO: M. J. Geile, Chair Date: May 23, 2001
Board of County Commissioners
FR: Judy Griego, Director Q
Weld County Departmen f S vial S ice
RE: PY 2001-2002 Notification of Financial Assistance Awards (NOFAA) under Core
Services Funds-C.A.R.E.
Enclosed for Board approval are the PY 2001-2002 Notifications of Financial Assistance
Awards(NOFAA) for Families, Youth, and Children Commission (FYC) Core Services
Funds, which are for the period of June 1, 2001,through May 31, 2002.
The Families, Youth and Children Commission (FYC) reviewed proposals under a
Request for Proposal process and are recommending approval of these bids.
Child Advocacy Resource and Education, Inc.
Lifeskills
1. Parent Advocate Program: This program is a very intensive home-based
intervention program. Each family would be provided with up to 55 hours per
month of life skills training. Approximately 165 clients in the 12-month program,
40-50 total family units, 35 families per month, three hours per week, average
stay is 20 weeks. Bicultural-bilingual and South County services available. Rate
is$54.98/hour.
2. Visitation Program: A maximum of 10-15 families per month, or an approximate
total of 25 clients per year. The average stay in the program is 1-128 hours. The
program has the capacity to be expanded when needed Rate is$45.84/hour.
If you have any questions, please telephone me at extension 6510.
Weld County Department of Social Services
Notification of Financial Assistance Award
for Families,Youth and Children Commission (Core) Funds
Type of Action Contract Award No.
X Initial Award FY01-PAC-6000
Revision (RFP-FYC-01005)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2001 and Child Advocacy
Ending 05/31/2007 Resource&Education
(C.A.R.E.)Family Advocate Program
3700 Golden Street
Evans,CO 80620
Computation of Awards Description
The issuance of the Notification of Financial Assistance
Unit of Service Award is based upon your Request for Proposal(RFP).
The program is a very intensive home-based The RFP specifies the scope of services and conditions
intervention program. Each family would be of award. Except where it is in conflict with this
provided up to 55 hours per month of Life Skills NOFAA in which case the NOFAA governs, the RFP
Training. Approximately 165 clients in the 12- upon which this award is based is an integral part of the
month program,40-50 total family units, 35 action.
families per month, 3 hours per week. The
average stay in the program is 20 weeks. Special conditions
Bicultural-bilingual services and South County 1) Reimbursement for the Unit of Services will be based
services are available. on an hourly rate per child or per family.
2) The hourly rate will be paid for only direct face to face
Cost Per Unit of Service contact with the child and/or family or as specified in
the unit of cost computation.
Hourly Rate Per $ 54.98 3) Unit of service costs cannot exceed the hourly and
Unit of Service Based on Approved Plan yearly cost per child and/or family.
4) Payment will only be remitted on cases open with, and
Enclosures:, referrals made by the County Department of Social
_X Signed RFP:Exhibit A Services.
Supplemental Narrative to RFP: Exhibit B 5) Requests for payment must be an original form and
Recommendation(s) submitted to the Weld County Department of Social
Services by the end of the 25th calendar day following
Conditions of Approval
the end of the month of service. The provider must
submit requests for payment on forms approved by
Weld County Department of Social Services.
Approvals: Program Official:
BY BY �J 1
M. J. ile, Chair Judy Gri o, Di ctor
Board of Weld County Commissioners Weld ounty Department of Social Services
Date: Q 5/3O/07-po I Date:_5#3/O(
(
2001-1401
Signed RFP: Exhibit A
Child Advocacy Resource Education (C.A.R.E.)
RFP: 01005-Lifeskills-Parent Advocate Program
INVITATION TO BID
RFP-FYC 01005
DATE:February 28, 2001 BID NO: RFP-FYC-01005
RETURN BID TO: Pat Persichino, Director of General Services
915 10th Street, P.O. Box 758, Greeley, CO 80632
SUMMARY
Request for Proposal (RFP-FYC-01005) for:Family Preservation Program--Life Skills Program Family
Issue's Cash Fund or Family Preservation Program
Funds
Deadline: March 23, 2001, Friday, 10:00 a.m.
The Families, Youth and Children Commission, an advisory commission to the Weld County Department of
Social Services, announces that applications will be accepted for approved vendors pursuant to the Board of
Weld County Commissioners' authority under the Statewide Family Preservation Program (C.R.S. 26-5.5-
101) and Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement
(C.R.S. 26-5.3-101). The Families, Youth and Children Commission wishes to approve services targeted to
run from June 1,2001, through May 31, 2002, at specific rates for different types of service, the county will
authorize approved vendors and rates for services only. The Life Skills Program must provide services that
focus on teaching life skills which are designed to improve household management competency,parental
competency, family conflict management and effectively accessing community resources. This program
announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work
Delivery Date >c rce....
(After receipt of order) BID MUST BE SIGNED IN INK
Gwen sc}1OO /e /
u ^ //pp TYPED OR PRINTED SIGNATURE
VENDOR cll (CA /" o Co.c /(- °Ike-Ctc �( I / •dl & n /
(Name) °^�— ' + t"r-C • J Handwritten SignatureleeeJJJBy Authorized
( c.a mc , Officer or Agent of Vender
ADDRESS 32 °6 (r o/6(-{4.- £4 TITLE Il.)CGurck c)f tb1,C4
Euo.-.,.r , Co $ aC 1,9 DATE fl2crc' 22 27O
PHONE # ( `I'7( 9'79) 314 - t i r/
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 32
RFP-FYC-01005 Attached A
LIFE SKILLS PROGRAM BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING
FAMILY PRESERVATION PROGRAM
2001/2002 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2001-2002
BID #RFP-FYC-01005 n I
•
NAME OF AGENCY: �i �tX.- AlUo caCt� ✓L-cr ov,rCc c- -L c-ett-cot m Tp L . (cmx0
_ADDRESS: 37O0 Go /of-Le,- Sf , E`uck_nt • co rob -a
PHONE: 01 7o ) 3 T L b s X 2 6
CONTACT PERSON: Kest- TITLE/fon, Qas-tiro-rtn,4 €1. Coord,w cr
DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Life Skills Program Category must
provide services that focus on teaching life skills designed to facilitate implementation of the case plan by improving
household management competency.parental competency.family conflict management and effectively accessing
community resources
12-Month approximate Project Dates: _ 12-month contract with actual time lines of:
Start June 2001 Start June 1 zoo/
End May 31. 2002 End YYl a y 3/, a2 0 c a.
TITLE OFPROJECT:Por^ r p eo-.5t ! b rte+ CI c0.y' °1'"
AMOUNT REQUESTED: Ir 54- 72 per h r.
,St - 3/.1.210/
Name and Signature of Person Preparing ocument Date/,( /
��-�,-ifre./ `3/2 4
Name and Signature Chief A ministrat ve Officer Applicant Agency Date
MANDATORY PROPOSAL REQUIREMENTS
For both new bids and renewal bids, please initial to indicate that the following required sections are included in this
Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund
Year 2000-2001 to Program Fund year 2001-2002.
Indicate No Change from FY 2000-2001 to 2001-2002
Project Description
Target/Eligibility Populations ,� ,r L(Mtx, 0
Types of services Provided ,(iW atna-�K9-
Measurable Outcomes �/
Service Objectives ^G a 1 C
Workload Standards
Staff Qualifications
Unit of Service Rate Computation
Program Capacity per Month
Certificate of Insurance
Page 26 of 32
RFP-FYC-01005 Attached A
Date of Meeting(s)with Social Services Division Supervisor: 5/2 74 /
Comments}by SSD Supervisor: / 1{ c �� �� �X�f \--6,1c10
"t1.a-4._://-�T Gl � ,tom-,-� LYIi°W,. a717t � • fit,
v
ck R6-116 -,91f )1 /
Name and Signature of SSD Supervisor Date
Page 27 of 32
I. Project Description
Home-Based Parent Education was developed with the primary purpose of strengthening
and preserving families while protecting children from (re) abuse or neglect; thereby,
preventing out-of-home placement or expediting the return to the home from children
living in foster care.
Home-Based Parent Education
Each family that meets the Family Preservation criteria that is referred into the program
would be provided up to 55 hours of Parenting and Life Skills Training which would
enhance and strengthen the parents' ability to create and maintain stable and nurturing
home environments. Services are designed to promote healthy child development, assist
children and families to resolve crisis, connect with appropriate and necessary services,
and remain safely together in their homes, avoiding unnecessary out-of-home placement
of children and helping children already in out-of-home care to be returned to and
maintained with their families.
The Family Advocate Program will also offer this service to families that are in need of
supervised visitation. While supervising a family visit for safety and parental
appropriateness, the Family Advocate will continue to use that time for parenting and life
skills education. The visits can occur either at the family home, careHouse, (The Family
Visitation Center in Evans) or at another agreed upon location. C.a.r.e. is prepared to
make appropriate arrangements as needed to provide supervised visits at other locations
in Weld County, particularly the South Weld County area.
II. Target / Eligibility Populations
A. Total number of clients to be served:
This depends on the amount of referrals into the program; however, as stated below, the
program has the capacity to serve approximately 35 families per month, or an
approximate total of 165 clients per year.
B. Total individual clients and the children's ages:
As stated above, there is a total capacity of 165 clients; this includes parents, plus
children aged birth through teens. Families eligible for this program can vary in age from
pregnant/parenting teens through grandparents or other specific caregivers.
C. Total family units: 40-50 total family units per year.
C. Sub-total of individuals who will receive bicultural/bilingual services:
5-6 families per year. This can change due to referrals.
D. Sub-total of individuals who will receive services in South Weld County:
10-12 families per year.
F. The monthly average capacity: 35-40 families
G. The monthly average capacity: 35 families
H. Average stay in the program: 20 weeks
I. Average hours per week in the program: 3 hours per week.
The figures above are approximate. Each family in the program has an individual
service plan depending on the needs of the family and recommendation of the
caseworker. Therefore, not every family utilizes the program for a uniform amount of
hours. The program has the capacity to expand as needed.
III. Type of Service to Be Provided
Each of the following services could be provided to any family enrolled in the program;
however all families do not need all services. Services provided would be determined by
the program coordinator, parent educator and caseworker.
A. Teaching, modeling, demonstrating and coaching as an interactive process with
the clients:
Home-Based parenting and life skills education by a trained parent educator including
role modeling, homework, teaching and coaching of appropriate interactions with the
family.
B. Training in household management, including budgeting,cleaning, maintenance,
purchasing, menu planning, food preparation, etc.
Intensive home-based training in household management, especially as it pertains to safe
and nurturing child rearing. The goal is to help parents establish appropriate household
environments.
C. Teaching Child rearing and discipline, parenting:
Provide home-based parent education utilizing ongoing support and encouragement
including but not limited to developmentally based behavior management, problem
solving, conflict resolution, protection and appropriate supervision of children, anger
management and stress management.
D. Teaching how to establish community linkages/advocacy/and making use of
services.
Provide information, training and role modeling in accessing community resources, as
well as follow through in using resources.
E. Demonstrating nurturing/esteem role modeling:
The parent educator will model and teach a nurturing parent role with a focus on parent/
child self esteem. The goal is to increase positive family relationships.
The supervised visitation service provided through this program includes all of the above
activities when appropriate to the goals for the family. This program has the ability to
meet with the family separately from the supervised visit time to address concerns and
work on issues that will aid them during future visit times. This will include parental
support and guidance, help with the use of community resources and ongoing
communication and feedback about parenting progress and goals.
Quantitative Measures: Each service can be offered to each family enrolled in the
program, depending on need. Therefore,there is a potential for up to 50 families per
year. These figures are estimates, based on the previous year. The program can be
expanded when needed, depending on the number of referrals.
The Family Advocate Program is the only home-based program of its' kind in Weld
County, working with this population of families that are at risk of children's placement.
We do not provide mental health services, substance abuse treatment or other
professional services that are funded by another source.
IV. Measurable Outcomes
All families in the program will be evaluated using the following measures. In some
instances, availability and ability of the clients might affect the program's success in
obtaining outcomes. The average number of families available for measurement of
outcomes is 50.
A. Improvement of household management competency as measured by pre and
posttest instruments.
This is measured by staff report and observation.
B. Improvement of Parental Competency as measured by pre and post assessment
instruments.
This will be measured by advocate report and observation, and pre and posttest
scores on the Ongoing Planning and Assessment Form for Home-based Programs.
C. Parents can independently work with other sources in the community and within
the local, state, and federal governments.
This will be measured by advocate report and observation of the family's
progress, and pre and post test scores on the Ongoing Planning and Assessment Form for
Home-based Programs.
D. Families receiving Life Skills services will remain intact six months after
discharge of the services.
Parents will sign a consent to allow c.a.r.e. to do a follow-up contact with
WCDSS six months after completion of the program.
E. Families/Participants who complete the Life Skills Services will have improved
competency level or reduced risk on standardized assessment, such as the Risk
Assessment Tool.
Utilizing the Ongoing Planning and Assessment Form for Home-based Programs.
pre and post test, there will be documentation of improved competency and/or reduced
risk. This will also be measured ongoing by advocate report and observation.
V. Service Objectives
A. Improve Household Management Competency:
Intensive home-based household management techniques taught by trained family
advocates to improve the capacity of parents to provide a safe, nurturing environment.
This will include but not be limited to cleaning, budgeting, purchasing, safety, and
maintenance.
This will be measured partly through the Ongoing Planning and Assessment Form
for Home-based Programs as well as advocate report and observation.
B. Improve Parental Competency:
The program will provide home-based parent education including coaching,
instructing,problem-solving, role modeling, and supervision that will help improve the
parent's ability to provide sound relationships within the family. This will include but
not be limited to nutrition, hygiene, discipline and protection.
This will be measured by advocate record and observation;as well as pre and post
scores on the Nurturing Quiz which tests knowledge of parenting, and the Ongoing
Planning and Assessment Form for Home-based Programs which documents changes for
families.
C. Improve Ability to Access Resources
Advocate will provide information,training, and follow-through to families to
enable them to effectively learn to access appropriate community resources, including
those on the local, state, and federal level.
Outcomes will be measured by advocate record and observation as well as
improved scores on the Ongoing Planning and Assessment Form for Home-based
Programs.
VI. Workload Standards
A. Number of hours per day, week, or month.
Up to 55 hours for each family unit for length of stay in the program. This number
changes depending upon DSS request, contracted hours with the family and any periodic
changes due to the progress and needs of the family.
B. Number of individuals providing services:
12-15 part-time Parent Educators, I Full-time Coordinator, 1 half-time
Coordinator, and 1 Agency Director, working with up to 50 families per year.
C. Maximum caseload per worker:
Each part-time Parent Educator could work with from 1-4 families, depending
upon skill level, amount of contracted hours per family, and personal work preference.
D. Modality of treatment:
Home-based instruction and/or supervision, coaching, role modeling, practicing,
and support.
E. Total number of hours per day/week/month:
From 1-50 hours per month, depending upon needs of the family. On the average,
each family works directly with a parent educator for up to 12 hours per month in the
program.
F. Total number of individuals providing this service:
12-15 part-time Parent Educators, 1 FT Program Coordinator, 1/2 time Program
Assistant, 1 Agency Director(.05 time weekly).
G. The maximum caseload per supervisor:
25-30 families per month.
H. Insurance:
Child Advocacy Resource and Education, Inc. carries a commercial general
liability policy with Non-Profit Mutual Risk Retention Group, Inc.
VII. Staff Qualifications:
A. Yes, the staff that is providing direct services will have the minimum qualifications in
education and experience. The majority of the staff has bachelor's degrees in related
areas.
The 12-15 Parent Educators will meet the minimum qualifications of a Case
Services Aide II, which includes graduation from High School or GED equivalent and six
months full-time public contact experience. In addition, ad advocate will have had
experiences with parenting and/or working with children and families in environments
such as a day care or preschool. Currently, one staff member has a master's degree,two
have high school degrees, and eight have bachelor's degrees in related fields.
The Coordinator of the Home Based Parent Education Program holds a
Bachelor's Degree in General Studies with an emphasis in Early Childhood Education.
She has 22 years of experience in the human services field as both a teacher and
supervisor.
The half/time Program Assistant, has a Bachelor's degree and appropriate
experience.
The Executive Director has a Master's in Agency Counseling with an emphasis in
Marriage and Family Therapy. She has seven years experience as a Family Advocate and
four years experience as a Program Coordinator.
B. Total number of staff available for the project:
14-18.
RFP-FYC-00005 Attached A
VIII. COMPUTATION OF DIRECT SERVICE RATE
This form is to be used to provide detailed explanation of the hourly rate your
organization will charge the Core Services Program for the services offered in
this Request for Proposal. This rate may only be used to bill the Weld County
Department of Social Services for direct, face-to-face services provided to
clients referred for these services by the Department. Requests for payment based
on units of service such as telephone calls, no shows, travel time, mileage
reimbursement, preparation, documentation, and other costs not involving direct
face-to-face services will not be honored. Likewise, billings must be for hours
of direct service to the client, regardless of the number of staff involved in
providing those services. Therefore, it is imperative that this rate be
sufficient to cover all costs associated with this client, regardless of the
number of staff involved in providing these services.
(Explanations for these Lines are Provided on the Following Page)
Total Hours of Direct Service per Client 56. Hours [A]
Total Clients to be Served 5O Clients [B]
Total Hours of Direct Service for Year a 15-O Hours [C]
(Line [Al Multiplied by Line [B]
Cost per Hour of Direct Services cso. 8
$ Per Hour [D]
Total Direct Service Costs $ 131 S I 0 [E]
(Line [C] Multiplied by Line [D] )
Administration Costs Allocable to Program $ (o D�'f0 O [F]
Overhead Costs Allocable to Program $ /Cc, 91,
[G]
Total Cost, Direct and Allocated, of Program$ 15 /1 /77 [H]
Line [E] Plus Line [F] Plus Line [c] )
Anticipated Profits Contributed by this Program $ —' C [I]
Total Costs and Profits to be Covered q
by this Program(Line [H] Plus Line [I] ) $ /5 I/ / S / 1•11
Total Hours of Direct Service for Year a $O
[K]
Page 31 of 33
RFP-FYC-00005 Attached A
(Must Equal Line [C] )
Rate per Hour of Direct, Face-to-Face Service
•
to be Charged to Weld County Department of
Social Services $ 5 }. 98 (L]
Day Treatment Programs Only:
Direct Service House Per Client Per.Month (M]
Monthly Direct Service Rate $ (M]
[A] This is an estimate of the total hours of direct, face-to-face service each
client will receive from the time he or she enters the program until completing
the program.
[B] This is an estimate of the number of clients who will be served during the period
from June 1, 2000, through May 31, 2001.
[D] This represents the average hourly salary and benefits that your organization
pays its direct service providers plus any costs which are directly attributable
to the face-to-face session with the client.
[F] This represents the salary and benefits of direct service, supervisory, and
clerical personnel which are not incurred in providing direct, face-to-face
service to the client, but can be allocated to this program for time spent on the
program for activities such as travel, phone conversations, "no-shows,"
discussions with involved parties, meeting preparation, and report completion.
[G] This represents the Agency Overhead costs, such as Rent, Utilities, Supplies,
Postage, Travel Reimbursement, Telephone Charges, Equipment, and Data Processing
which are not incurred in providing direct, face-to-face service to the client,
but can be allocated to this program for time spent on the program for activities
such as travel, phone conversations, "no-shows, " discussions with involved
parties, meeting preparation, and report completion.
[H] This represents the Grand Total Costs directly attributable or allocable to this
program. It should be a reasonable assumption that if you decided to discontinue
this program, your agency would realize a reduction in costs approximately equal
to this amount.
[I] This represents the total amount of profit your firm expects to realize as a
result of operating this program. Any difference between Lines [H] and [J] must
be substantiated by an amount indicated on this line.
(L] This is the actual direct, face-to-face hourly service rate at which you will be
requesting payment for the services provided under the conditions of this Request
Page 32 of 33
NORTH AMERICAN Policy Number: From To
SPECIALTY INSURANCE COMPANY
650 Elm Street AFC 0000549-03 06/01/00 06/01/01
Manchester, NH 03101-2524
WOO) 542-9200 1201 A.M.Stand.rd Tine at N.
ma... of the Insured.ulyn.d h.,.
Transaction: $ENEWALof AFC 0000648.02;:
Named Insured and Mailing Address Agent •
•
CHILD ADVOCACY RESOURCE&EDUCATION, INC. Agency Code: 30003-01
DBA: .A.R.E. TALBOT/BOULDER INSURANCE ASSOCIATES, INC.
814 9TH STREET 1601 28TH STREET
GREELEY, CO. 80632 BOULDER, CO. 80301
Business Description: Type of Business Audit Period:
NON-PROFIT ORGANIZATION NON-PROFIT NONE
COMMON POLICY DECLARATIONS
In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this
policy. This policy consists of the following coverage parts for which a premium is indicated. This premium may be subject to adjustment,
• •Form No. Coverage!Part Description
NAS-CP-DEC COMMERCIAL PROPERTY S 409.00
NAS-IM-DEC COMMERCIAL INLAND MARINE $ NOT COVERED
NAS-CR-DEC COMMERCIAL CRIME $ 100.00
NAS-GL-DEC COMMERCIAL GENERAL LIABILITY S 1,892.00
NAS-CA-DEC1 COMMERCIAL AUTOMOBILE S 210.00
$ ;PoiicyP;emlum s 2,611.00
5E�r�£ :44,"*"
� ¢• Y om¢ $ $ 4{�Mz9'0„ •ts.yT.b 3 $
� 'AiilAC .98�'s M,..,.•a,Y� a �., f $ b ' q>F d. ' .se ,`°°E
aotelhmep0ss fg1flEtrrtf f .• ;•., S 2,611.00
❑ FACULTATIVE
❑ AUDITABLE
Premium shown is payable: (If applicable) 2,611.00
At Inception 1st Anniversary 2nd Anniversary
. ....................... ...
Forms and Endorsementsaippllcabo to all Coverage Parts I
NAS-POL-OO1 (7-96) NAS-COM-DEC IL OO17 (11-98) IL OOO3 IL 0021 14.98)
IL O169 (4-98) IL O228 (4-98)
THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.
Countersigned at: This Day of By: ,e71r-.c. ,k
(Authorized Signature)
Issuing Office: PUC Issued Date
NAS-COM-DEC (05/98)
Includes copyrighted material of ISO Commercial Risk Services,Inc.. with its permission. Copyright,ISO Commercial Risk Services. Inc.. 1983, 1984
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