HomeMy WebLinkAboutState of Calif California National Guard Memorandum for Use of Training FacilitiesCity or
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REPORT TO THE CITU COUNCIL AGENDA ITEM NO. I G
COUNCILMEETING 613/10
xsvaov£o ex
June 3; 2010
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FROM: JERRY DYER, Chief of Police
Police Department
BY: TOM LASAND, Lieutenant
Training Bureau
SUBJECT: APPROVE TRE REVISED MEMORANDUM OF AGREEMENT BETWEEN THE CITY OF
FRESNO AND CALIFORNIA NATIONAL GUARD, FOR USE OF TRAINING FACILITIES
2ECOMMENDATIONS
t is recommended that Me City Council approve the Agreement between the City of Fresno antl the Curler
Nztional Guard, for use of training facilities.
E KECUTIVE SUMMARY
Me City of Fresno has entered into a Military Construction Cooperative Agreement as amended on May
Z0, 2010 (MCCA) with Me Nafional Guard Bureau (NGB). The NGB has agreed to provide 5560,000
towards construction costs of the Fresno Police Department Regional Training Center (FPDRTC). It 6
estimated Met no more than $20A00 of those funds will be required to provide upgrades to one of the
FPDRTC's plstol ranges so that it meets NGB standards. The balance of Me Funds will be available as the
NGB's contribution to Me construction of Me FPDRTC. Pursuant to the MCCA, the NGB funding is
contingent on this Memorandum of Agreement being executed between Me City of Fresno and the
Calfomla National Guard (CNG) before June 10, 2010, for long term usage of the upgraded FPDRTC
The CNG Is moulted to conduct weapons qualification and proficiency training for stalloned and deploying
personnel. At this dme, the CNG does not possess suitable facilities to conduct their qualifictions and
Veining. The construction funds provided for in the MCCA are contingent on a Memorandum of Agreement be
be negotiated and executed between the City of Fresno and the CNG before June 10, 2010, which will allow
Ne CNG to use the FPDRTC facilities for small arms weapons training for a period of 25 "am, During this
tern of Mis Memorandum of Agreement the CNG will utilize the FPDRTC Features at no cost The CNG
anticipates that approximately 250-300 of Meir personnel will qualify/train annually, primarily on weekends
when the FPDRTC ranges will normally not be in use by law enforcement.
On April 22, 2010, Council approved a Memorandum of Agreement between Me City of Fresno and the 14l
Fighter W ing. Pi to" Agreement being signed by the ower party the CNG's Judge Advocate determined
that the Agreement required limiting federal indemnity obligations In order to comply with federal requirements,
and to add the CNG as the correct signatory perry. This revised Memorandum of Agreement wind the CNG
ax fmuM[.lbtit) ille
suoanmmI"rl
Celifomla Nall Guard Memorandum of Agreement
June 3, 2010
Page 2
com9Gs gross issues and has received appropriate rehew and approval to form by the Judge Advocate's
Office and the Ciry Attorney's Office, and will supersede entirely, the version sorrowed! on Add 22, 2010.
FISCAL IMPACT
The NGB will fully fund the pistol range upgrades to NGB specifications. The remaining funds will be utilized
for operational start up costs, and debt seMco payments for the FPGRTC.
JPPtl
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Attachments: Revised! Memorandum of Agreement between City of Fresno and California National Guam
This Agreement made and entered into this t/_I day of June. 2010 by and between the CITY
OF FRESNO, a California municipal corporation (hereinafter refened to as "CITY-) and the
CALIFORNIA NATIONAL GUARD (Previously refereed to as the Fresno Air National Guard or
"FANGwhich shall hereinafter be correctly referred to as 'CNG').
RECITALS
WHEREAS, CITY owns and operates ordain Training Faatitles on its property in Ne
City of Fresno, State of Caldomia; and
WHEREAS, CNG is required to conduct weapons qualification and proficienq training
for stationed and deploying personnel and does not possess smalls facilities to conduct a
range of live -fire small arms and heavy weapons training to include use of the M9 (9mm).
M4IM16 series (.223), M249 ( 223), Ml (]62) and Barratt Sniper Rifle (50 cap', and
WHEREAS, this Agreement safeties the requirement in the Milken Construction
Cooperative Agreement No. W9121A-10-2-2104 EMCCA"), dated February 11, 2010, as
mended, between CITY and the National Guard Bureau ENCEE) which in exchange for
contribution of funs by NGB to CITY far correpucton of Me Training Fadlities, CNG and CITY
would enter into this Agreement for Me noncxclusWe use by CNG of sill Training Facilities for
small arms qualification and other weapons training fm a period of 25 years at no coat (other
Man reimbursement for non -no oral wear and tear); and
WHEREAS, CITY is agreeable to said use of its Training Facilities and hereby grants
permission for said use upon Me terms and conditions herein and CNG agrees to the shame and
conditions herein.
/S9a3zl,'J 41
NOW, THEREFORE, in consideration for the use of the Training Erroll it is mutually agreed
as follows:
t. Description of Prooedv. The property subject to this Agreement is Mat property
located at 6375 W. Central Ave., and adjacent land and structures commonly known as follows:
Fresno Police Department Regional Training Center ('Training Facilfties"), which consists of
Shod Classrooms, Mat Room. Six Tactical Petal Ranges. 200 Yard Rifle Range and Sniper
Page 1 M e
CITY OF FRESNO POLICE DEPARTMENT
REGIONAL TRAINING CENTER
is
6375 W. Central Ave.
e n
Fresno, CA 93706
Phone: 559-621-2157 Fax: 559-621-2175
-_
MEMORANDUM OF AGREEMENT
FOR USE OF TRAINING FACILITIES
This Agreement made and entered into this t/_I day of June. 2010 by and between the CITY
OF FRESNO, a California municipal corporation (hereinafter refened to as "CITY-) and the
CALIFORNIA NATIONAL GUARD (Previously refereed to as the Fresno Air National Guard or
"FANGwhich shall hereinafter be correctly referred to as 'CNG').
RECITALS
WHEREAS, CITY owns and operates ordain Training Faatitles on its property in Ne
City of Fresno, State of Caldomia; and
WHEREAS, CNG is required to conduct weapons qualification and proficienq training
for stationed and deploying personnel and does not possess smalls facilities to conduct a
range of live -fire small arms and heavy weapons training to include use of the M9 (9mm).
M4IM16 series (.223), M249 ( 223), Ml (]62) and Barratt Sniper Rifle (50 cap', and
WHEREAS, this Agreement safeties the requirement in the Milken Construction
Cooperative Agreement No. W9121A-10-2-2104 EMCCA"), dated February 11, 2010, as
mended, between CITY and the National Guard Bureau ENCEE) which in exchange for
contribution of funs by NGB to CITY far correpucton of Me Training Fadlities, CNG and CITY
would enter into this Agreement for Me noncxclusWe use by CNG of sill Training Facilities for
small arms qualification and other weapons training fm a period of 25 years at no coat (other
Man reimbursement for non -no oral wear and tear); and
WHEREAS, CITY is agreeable to said use of its Training Facilities and hereby grants
permission for said use upon Me terms and conditions herein and CNG agrees to the shame and
conditions herein.
/S9a3zl,'J 41
NOW, THEREFORE, in consideration for the use of the Training Erroll it is mutually agreed
as follows:
t. Description of Prooedv. The property subject to this Agreement is Mat property
located at 6375 W. Central Ave., and adjacent land and structures commonly known as follows:
Fresno Police Department Regional Training Center ('Training Facilfties"), which consists of
Shod Classrooms, Mat Room. Six Tactical Petal Ranges. 200 Yard Rifle Range and Sniper
Page 1 M e
Tower. Tactical Training House, K-9 Field and an Emergency Vehicle Operations Course
(EVOC) with Pit, Skid Pad and Pursuit Course.
2. Purpose. CNG is hereby given a nonexclusive license to use the Training
Facilites for meeting and training purposes only. This license also includes (i) non-exclusive
access to classroom and restroom space, a phone and one internet-corrected computer at the
Training Families; and ()i) exclusive access to space designated by CITY on the premises M at
least TdYi,20' where CNG may place its CONI type storage container, or similar, for storage
a CNG's equipment such as targets antl other nursing aids t. e., non -ammo and nen-arsenal.
CNG'a anticipated use is estimated at about 250-300 shooters per year primarily on weekends.
However, large scale deployment of weapons or change in Army or Air Force Guidance on
frequency of qualification may increase estimated shouters to 800-1000 per year. This license
is personal to CNG and shall not be assigned. Any attempt to assign the license shall
automatically terminate t. No legal title or leasehold interest in the Training Facilities or
premises Is created or vested In CNG by the grant of this license.
3 Tenn of Annulment. The tam of this emAprreemerent shall be for 25 YEARS
ng on fl \..n t, 2010 add shall continue until l 11�n 1, 2035 or until xlMed by
either party upon 120 calndar days' written notice to the other party's designated
representative set fold herein. Minor modifications to the Agreement to facilitate changes in
conditions and/or operational requirements as Spread to by the ladies will be incorporated by
amendment as provided herein.
4. Reservations for Fac Ikons. CNG will notify CITY In advance of scheduled Unit
Training Assembly ("UTA') periods for the fisc»I year (October through September) not later
than August 15n of each year. CNG shall request in writing Sidi clays and specific times for
non -UTA use N the Training Fair as far In advance as possible and, in any event, at least
10 calendar days prior to the date of the requested use except In case of emergency. The
notification and the requests shall be submitted to the Fresno Police Department Training
Facility, 8375 W. Combat Avenue. Fresno. California 937M which will then dispatch a written
confirmation of the reservation. It Is understood that other contracting paries with the CITY may
have a similar use of the Training Facilities, and Ieasonahle accommodation of all such paries
is the desired objective. However, one range constructed in accordance with Air National Guard
standards pursuant to the MCCA ("Range W) will be designated as primary for use by CNG,
and CNG will have pngdty use of this rerge during pro-ecreduled UTA Fences, and other
periodic non -UTA periods as reasonably scheduled In advance in accordance with this
provision. CNG's use of other timelines of the Training coolies will be subject to availability,
and CNG acknowledges Nat criminal justice agencies will be given priority use of same.
Page 2 of 8
REQUEST FOR FACILITY USAGE SHALL BE SUBMITTED TO'.
FRESNO POLICE DEPARTMENT
REGIONAL TRAINING CENTER
6375 W. Central Ave.
Fresno, California 93706
Phone' 559-621-2157 FAX 559-621-2175
5. Limitations.
(a) The use ct the Training Facilites Is subject to the understanding that the
faciity taken be reserved only if not in use by the CITY or other similar
contracting parties with Me CITY.
(b) CNG's use of Me Training Facilities is subject to the completion of
construction of Me Training FacilPoes by C" and payment of $590,000
by CNG to CITY in accordance with Ms MCCA. In the event the MCCA is
terminated prior to IIs expiration, the Agreement shall automatically
terminate and n either parry hereunder will be obligated to the other.
(c) Except for Range kfi, CITY reserves the right to use the Training Facilities
at all times, and may terminale scheduled use M Me Training Fadldies by
notice to CNG'a designated representative:
Sidi James Lane 5323 E. McKinley Ave
(559) 6511-52611 Fresno, Ca 937V
Fax:(559) 11511.5370
Jamea.lavnescafraa anp of mil
This shall to CNG's designated representative for all coordination
beteeen CITY and CNG, or such other representative as CNG may from
fime to fime designate in a written nice to CITY.
(d) CITY reserves the right to close Me Training Facilities during bines of
emergency, wren needed by the Fresno Police Department for its
activities, and for repair and maintenance.
(a) The use of the Training Facilities Is subject to Me understanding Mat all of
the Training Facilities are made avallabk on an 'as is' condition.
(fl CNG acknowledges that 4 has inspected! the Training Fadlities prlor to
e. CNG recognizes and accepts that CITY is making no representation
Mat the Training Facilities are suited for training or qualification of any kind
and CNG accepts the Training Facilities win all defects, latent or patent.
other Man those identified at the time of inspection.
(g) No pinata use of the Training Facilities is pevolged, except as expressly
provided for in Me than cement Fresno Police Department Regional
Page 3 of 8
Training Center Operations Manual ("Manual") as the Fresno Police
Department may amend from time -to -time, prescribing procedures and
condfiions In utilizing the Training Faclfities, a copy of which Is attached
and incorporated into this Agreement (including any fusure amendments)
as it fully set form herein. Guests and non -CNG members or persons not
expressly included with LNG's prescribed use of the Training Facilities,
are not allowed to enter the Training Facilites without the prior express
written consent of the Fresno Police Department Regional Training Center
Supervisor who may in usher sole discretion require the person to
complete a City of Fresno release form (depending upon the nature and
purpose of the entry, the form may or may not or the form attached in
Exhibit A). In any event, all such guests and not members or
persons shall be the sole responsibility of CNG and subject to all Fresno
Police Department Training Center rules, regulations and directions of its
staff.
(h) CNG will maintain the Training Facilities in a safe operative condition while
In use by the CNG and will conduct adequate periodic inspections prior to
and at the conclusion of each use to that end
(i) All range fil will be under direct supervision of competent
Rangemasters who have completed a government approved
firearmslrargemaster instructor course (el POST). Cll use of the
Sung ranges must be conducted in compliance with the men current
Manual. A copy of all Rangemaster certifications must be on file with me
CITY prior to the use of the firing ranges.
j) Wished (water electricity, phone and Intemet) mat are available without
akeration or modification by CITY will he supplied without charge and the
repair and maintenance of the Training Facility will be the responsibility of
CITY.
(k) CNG will contact the Fresno Police Department Duty Office at (559) 621-
2375 whenever a unit enters the Training Facilities for a reserved period of
use that is during nen-0usiness hours as set forth in the than cument
Manual. CNG shall be responsible for ensuring that the enhance remains
locked! and secure at all times with alarm activated
(I) Any improvements installed a provided by CNG shall be submitted to
CITY in writing and are subject to the written approval by CITY prior to the
installation period Approval by CITY is in CITY's sole and absolute
discretion, and may be withheld for any reason. Fixtures shall remain
following termination or expiration a this Agreement.
(m) CITY, or its duly authorized representatives or agents, may enter upon
said premises at any and all reasonable fines during the term of this
Agreement for the purpose of determining whether the CNG is complying
wish the terms and conditions hereof, or for any other purpose incidental k
the rights of CITY.
Page 4 of 8
(n) CNG shall supply be personnel with all equipment necessary to use the
Training FacilNes (e.g., targets, ammunilion, weapons and other
equipment necessary for any use of the Hing range). If available, CNG
may use CITY -owned 'tactical tnuning" gear for use in the Tal
Training Hai
(o) After each use of the Trashing Facilities, CNG's personnel shall leave the
Training Facilibes in Me same condition it was in before use including, but
not limited to. removal of shell casings and all other debris when using the
firing range. If the Training Facilities are not adequately restored to the
same condition it was in before use. the CITY reserves the right to charge
CNG for the costs Ne CITY incurs In restoring the Training Facilities to
Meir prior contlition.
(p) CNG shall not interfere wM Ne use of the Training Facilities by oOer
users.
(q) CNG may Install on the one Internet -connected computer to which it has
access, alWmpriete drivers t0 allow for a smart card reader to be used t0
enter data Into government databases.
(r) CNG may use 0s smoke grenades and tear gas in training areas
designated by CITY for this purpose, subject to procedural restrictions
contained in the Nen current Manual.
(s) CNG may conduct night firing, subject to scheduling In advance with CITY
for Nis express activity and subject to procedural restrictions wntained in
Ne then current Manual.
(t) CNGa security force point of contacts shall use necessary access
credentials provided by CITY to gain access to the Training Faci@ies
during scheduled usage periods.
(u) CNG shi review any CITY -proposed amendments to the Manual, and
provide to CITY comments for CITYs consideration, addressing issues
unique to CNG.
8. Liability/Claims
(a) All claims against CNG ansing out of the activities encompassed within
this agreement are subject to the Federal Tart Claims Ad.
(b) All claims for damages caused by the CNG to CITY property, seducing
normal wear and tear, shall be initiated by submission of a Standard Form
95 (Fxblblt C) to:
Claims
Office of The Staff Judge Advocate -Box 14
California National GuaN State Headquarters
9800 Goethe Rd.
Sacramento CA 95828
Page 5 of 8
(918) 9543505
(c) CNG shall not use CITY premises, property (including equipment,
Instruments and supplies) or personnel for any purpose other than in the
performance of hisOer obligal under this Agreement
(d) CNG adtnowledgas that the Training Facilities and adivilles involving
firearms, physical agility and concept, K-9 training, and law enforcement
specialized driver training have inherent dangers that no amount of carer
caution, instruction or expertise can eliminate.
(e) This Section 8 shall survive expiation or termination of this Agreement.
Z. Self-insurance. CNG is self-insured as evidenced by the Certificate of Sed -
Insurance (Exhibit B). CNG'a Candidate of Self -Insurance shall at all Mmes during the life of
this agreement be deemed suff¢ient In satisfaction of all insurance requirement.
8.. ConirnmM with Law and Safety. CNG shall observe and comply all and shall
ensure that its personnel utilizing the Training Facilities observes and opuniMes with, all
applicable requirements contained in the then current Manual and with all applicable lam,
ordinances, codes and regulations of all governmental agencies, including federal, state,
municipal and local governing bodies having jurisdiction over aspect of this Agreement The
use of the Training Facilities by CNG shall be in accordance with the then current Manual and
these laws, Ordinances, codes and regulations.
9. Accident. If a death, serious personal Injury or substardiai property damage
occurs in conneNon with the performance of this Agreement, CNG shall immediately notify the
Fresno Police Department Regional Training Canter Administrator, Duty Once, in person or by
telephone. CNG shall promptly submit to CRY and the Fresno Police Department Regional
Training Center a will report, In such forth as may be required by CITY, of all accidents
which occur in connection with this Agreement. This report must include the following
information'. (1) name and work a ldrass of the Injured or deceased consorts); (2) a detailed
description Of accident and whether any of CITYs equipment, tools, materiel Or staff were
involved
10. Dao -Free Wmkolace. CNG and CNG§ servicemembers shall comply with the
CITY's policy of maintaining a drug-free workplace. Neither CNG nor CNG's employees shall
unlawfully manufacture, distribute , dispense, poseess or use conimlled substances, as defined
in 21 U.S. Code Section 812. including marijuana, heroin, cocaine and amphetamines, at the
CITY facility, Including the Training Facilities. If CNG or any employee of CNG is convicted or
pleads nolo contends to a criminal drug statute violation occurring at a CITY facility or work
site, the CNG within 5 days thereafter shall notify the Fresno Police Department Regional
Training Center. Violation Of this provision shall consfitute a material breach of this Agreement.
11. Non -d'scr)m nation. CNG will comply with all applicable federal requirements
pertaining to non-discrimination to Include the relevant Federal law, Department of Defense
Instructions, Army Regulations, and Air Force Instructions.
12. Bindinn. Subject to Section 13 below, once this Agreement Is signed by all
parties, it shall W binding upon, and shall inure to the benefit a, all parties, and each parties'
Page 6 of 8
respective heirs, successors, assigns, transferees, agents, servants, employees, and
representatives.
13. Assignment of Agreement. Nothing contained in this Agreement shall be
commued to permit assignment or Venter by CNG of any rights under this Agreement and such
assignment or transfer is expressly prohibited and void.
14. governing Law and Venue. This Agreement shell lbs govemed by, and
construed and enforced in accordance with, the lawsof the State of California, excluding,
however, any cortlict of laws rule which would apply the law of another jurisdiction. Venue for
purposes of the !ling of any action regarding the enforcement or interpretation of this
Agreement and any rights and duties hereunder shall be Fresno County. California.
15. Headfirst The section headings in this Agreement are for convenience and
reference only and shall not be construed or held in any way to explain, modify or add to the
Interpretation or meaning of the provisions of this Agreement.
18, Eimemability. The provisions of this Agreement are severable. The Invalidity, or
un inforceadlity of any one provision in this Agreement shall not affect the other provisions.
17. Interpretation. The pates acknowledge that this Agreement in its final farm is
the result of the combined efforts M the parties and Nat, should any provision of this Agreement
be found to be ambiguous In any way, such ambiguity shall not be resolved by construing this
Agreement In favor of or against either pant, but rather by construing the terms In accordance
with their generally accepted meaning.
18 Exhibits. Each exhibit and attachment referenced in Nie Agreement is, by the
reference, incorporated into and made a part of this Agreement.
19. P eced of Documents. In the event of any conflict between the body of this
Agreement and any Exhibit or Attachment hands, the terns and condhions of the body of this
Agreement shall control and take precedence over the teals and conditions expressed within
the Exhibit or Adachment. Furthermore, any tame or conditions contained wthin any Exhibit or
Attachment hereto which purport to modify the allocation of risk betvreen Ne pates, provided
for within the body of this Agreement, shall be null and void.
20, Cumulative Remedies. No remedy or election hereunder shall be deemed
exclusive but shall, wherever possible be cumulative with all oflrer remedies at law or in equity.
21. No Third Party Benef sanies. The rights, interests, duties and obligations darned
within this Agreement are intended for the specific parties hereto as Identified in the preamble of
this Agreement. Notwithstanding anything slated to the contrary in this Agreement, it is not
Intended that any rights or interests in this Agreement benefit or flow to the interest of any third
parties.
22. Extent of Agreement. Each party acknowledges that they have reed and fully
understand the contents of this Agreement. This Agreement represents the entire and
integrated agreement between the parties with respect to the subject matter hereof and
supersedes all prior negotiations, representations or agreements, either written or orel,
Page 7 of 8
23. Modification of Agreement. This Agreement may W supplemented, amarxied or
modified only by mutual agreement of the parties, No supplement, amendment or modification
of this Agreement shall be binding unless it is In writing and signed by authorized
representatives of bath parties.
24. Authority to Contract. By signing on the signature page below, the CNG's
signatory warrants and represents that shelhe executed this Agreement in hismer authorized
capacity and by herlhis signature on this Agreement, shelhe or the amity upon behalf shalhe
acted, executed this Agreement.
IN WITNESS WHEREOF, the parties have executed this Agreement the day and year
wntten below, and CIN has hereunto caused IN corporate name to he signed by its Chief of the
Fresno Police Department who hereunto is duly authored the day and year written below:
CALIFORNIA NATIONAL GUARD: CITY OF FRESNO:
By By 14�le
Charles E. Bourbeeu ,zj . Jerry -Dyer, Chad of Police
Colonel, National Guard Bureau, Fresno Police Dapadment
United Slates Property 8 Fiscal
Officer for California
DATE' d 12 L
ATTEST
Rebecca E.Klisch
City Clark
By: iron
(Deputy)
Dade: 10/3//0
DATE: 6 /7! / 0
APPROVED AS TO FORM:
James Sanchez
City AVomey
By.
(Deputy �y <
Date: L -19-10
Attachments:
Exhibit A— INTENTIONALLY OMITTED
Exhibit B — Certificate of Self4nsutance
Exhibit C — Standard Form 95 (Claim for Damage. Injury)
Page 6 of 8
EXHIBITA
INTENTIONALLY OMITTED
EXHIBIT B
CERTIFICATE OF SELF-INSURANCE
CERTIFICATE OF SELF INSURANCE
'Phis cedifcate is issued as a matter of inf rmration only and confers no rights upon the m-ificate
holder
Ibis is to ccm1v that the Stam of Cali fomlwCelilbmnia National Guard (CNG) is self-insured far
all liability coverage and pemtissively self-insured for worker's compensation coverage.
I unds are available for damages caused by negligent acts by military pe unnel acting within the
scope of their duties. Claims for damages may he submitted as follows:
.Against Jre Stem of California: State Board of Control
926 J Street. Suite 300
Sacramento, CA 95814
Against Ne National Guam: Slag Judge Advocate (Changes Once)
(Fated States) Office of the Adjoined General
9800 Gamble Road
Pool Once Bax 269101
Sacramento, CA Ml
4 9101
Notwithstanding soy requirement, term, or condition ofany common ar other document with
respect or which this cenificrbe may be issom, there may be restrictions by law as le who may
he paid by the Slate of Cali Pontis or the federal govemmrm.
Subject matterufthtarenifredip 'fhc CNGMcmomndmnol'Agmemcntfur Uscof Training
Facilities with Ne City of Fresno. Speci0ea0y. all CNG aativitics at Finano Police Department
Regional I'mining Center, 6375 V Conoid Ave. Fresno, CA 937M
Date issued: 10 May 2010
Rraedta: City of Fresno
Issued try: Joint Headquarters, California National Game, 990 Gredw Road,
Post Office Box 269101, Sacramento. CA 95926-9101
David L. Re
utTman
LTC, JA, CA ARNG
Acting State Staff Judge Advocate
EXHIBIT C
STADARD FORM 85
CLAIM FOR DAMAGE, INJURY OR DEATH
CLAIM FOR DAMAGE
HBTMIrnONs: FNem.eea wmeIM NOew
mapwOVF➢
Um wPoanel MeeJalu
Div.
INLIM" ONOEATNffl�llw
I. SuNMr Tu A,~1Ee Fermi Apmv.
If Whnem eN tlNnamY OMaW AMA"Itlnlire.xom
LEFF btr k lmmwye V . V,er, ertv, Slats np L C"*R
S. TYPE OF EMPLOYMEN
a.OpiE OF &Pits
6. MPMTFL Sip}
6. DATE ANDDAY OF ACCIDENT
]. i1ME O.M. w Phil
El MULLAH, El
B. Be of CM, 0S 11 '"FWAY m, 1pury O M, ION,/rryXpparsma a+O Y"Y'ly
u�rMN. eY,d o/oa'aunem'e Y0 wwwe rXm A N» e0mmwl mpea It ""MA;
0. Nwwm DAMpa
ME AND ADDRESS OF OW]IER. I P OTHER THAN CUIMANT IkorMtD nmx. any, ENNA 1gC d
DESELME THE PROPERTY. NATURE AND EXTENT OF DAMAGE AND THE LOCATION WHERE PROPERTY MAY DEQNSPECTEU. ISM
loWNRY/NR06RF DEATH
STATE NATURE AND EXTENT OF EACH INJURY OR FALSE OFDEATH. MANOR FOPMSTHE 6ASNOFTHE CLAWIF OTHER THAN CLPIMMT,
STATE MAME OF INJURED PERSON OF OECEDNJi.
11. MYNIQUESES
OOF£SS IWXAr FVast dly. S/ma aM C00aJ
3. ISm lvrrur'ImammvurM AMOUNT
OF CIAM 0, dMN
12, NIOPEFn DAMAGE
136. FULSOME INJM
1k. WRONGFUL OGTI
IId TOTAL XnAau m vdlY my aw
MmAm a Fdn A;mml
I CEIRRIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMEAYS AND IXMIBE CAUSED IT THE ACCIDENT ABOVE AND AGIFE TO ACCFT
MEN) A14OUNT IN FULL SATHIRACTION DUALFMBIT OF INS ELAIM.
EONANRE OFCUIMAM (Sea FvµDlkmmrtvwre Mcl
I m, NAM �urW al ab�Mlory
O4TE OF CUIM
ChA PNllLIY FOR PRFRENTMD
CNrtNL PENALTY me MNSEN:M FNIIMILBI!
OAIM
C15M M MY(MO JULY STATE g
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M of umma Mn 810.000 or II yoamM1w n Wn6"m
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