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HomeMy WebLinkAboutCAZALES, RODOLFO DBA TOYAMA KARATE-DO ORGANIZATION 0 , a)> /c O % =— �� a) \ <co / O X § o - � \ 9 u - ll I ��� flL 3. ... _ - C / ■4 lit/ o ■ O ,. E _( \ C E / ) o D / E 0 § 3 a 0 E ` / / / a) p o k / 0 - \ ^ % \ a) \ § 2 * m o g 2 -0 ce _c « a) @ L c . t / \ 2 Z / k \ / \ . 0 � ■ E ■ 2 ' 7 \ \ \ / 0 / § : \ �� / / \ . . * 0 o IX c % g 0 a - 0 \ 2 CU , y \ y " CI @ _ c CO e a § • 2 NI 3 w ƒ / .\ k \ 45 0 0, 0, n Uo v- "E £ . 2 Ce / c / \ a \ 0 \ 0 lb c E 0 0 2 5 7 \ 2 » 7 c / � /c E u / \ 0 \ u E y = 2 4- A R % `, \ , e - a $ c # 9 a 2 \y. 0 o \ § ± 2 { / ' ƒ 0 / \ / ƒ U / Z } INSURANCE ON FILE WORK NAY PROCEED N-2018-125 UNTIL INSURANCEEXPIRES # � `OFCOUNCIL X311 RAW% RECREATION SERVICES AGREEMENT O:PRCSl/) Silvia Cuevas THIS AGREEMENT is made and entered into this 25" day of June, 2018 by and between Rodoifa Cazales dba Toyama Karate-Do:Organization ("Provider") and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). RECITALS A. The City desires to retain a recreation service provider having special skills, resources and knowledge to provide Toyama Karate -Do 'Martial Arts classes in its recreation class program. B. Provider represents that he is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that he is knowledgeable in their field and that any services performed by Provider under this Agreement will be performed in compliance with such standards as may reasonably be expected. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES Provider shall perform those services as set forth in Exhibit A to this Agreement. 2. COMPENSATION In consideration for the provision of the programs set forth in Exhibit A, City agrees to pay the Provider seventy percent (70%) of all gross revenue received from program participants. Total revenue to Provider shall not exceed° $25 000:00annually. Payment to Provider shall be made monthly within thirty (30) days following completion of the last class taught by Provider the prior month. City shall be responsible for collecting all fees ftom program participants. Provider shall not collect fees but will refer all interested participants to City for registration information. Provider agrees that City shall retain thirty percent ;(30%) of all gross revenue received from program participants as an administrative fee. 3. TERM This Agreement shall commence on September 1, 201$ and end on June 30, 2019 unless terminated earlier in accordance with Section 12 below. The term of this Agreement may be extended by a writing executed by the City Manager and the City Attorney. 4. INDEPENDENT CONTRACTOR Provider shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer-employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the manner in which Provider performs the services which are the subject matter of this Agreement; however, the services to be provided by Provider shall be provided in a manner consistent with all applicable standards and regulations governing such services. Provider shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. Provider is not an agent, representative or employee of City and Provider shall have no authority to act on behalf of the City. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Provider shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial -General Liability Insurance., Provider shall maintain commercial general liability insurance which shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Provider's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence and $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insured's provisions. b. Worker's Compensation. Insurance. In accordance with California State law, Provider, if Provider has "any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Provider agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. c. The following requirements apply to the insurance to be provided by Provider pursuant to this section: i. Consultant shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. ii. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved by the City. iii. Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. iv. Where the amounts or coverage provided by the certificates of insurance provides 2 coverage greater than those listed by this Agreement, the amounts provided by the certificates of insurance shall be incorporated by reference into the Agreement. V. Consultant shall supply City with a fully executed additional insured endorsement. d. If Provider fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to terminate this Agreement. Such termination shall not affect Provider's right to be paid for its time and materials expended prior to notification of termination. Provider waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 6. INDEMNIFICATION Provider agrees to and shall indemnify, defend and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Provider or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement, to the extent that the injury, damages, just compensation, restitution, judicial or equitable relief is caused by the negligence of the Provider. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. In no case will Provider be required to indemnify or hold harmless the City from injury, damages, just compensation, restitution, judicial or equitable relief caused by the negligence of the City. 7. CONFLICT OF INTEREST Provider covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 8. LIVE SCAN BACKGROUND CHECK Provider, and any employees, subcontractors or substitutes, in contact with minors under eighteen (18) years of age shall arrange for and submit to a Live Scan electronic background check for criminal history available through the California Department of Justice as a condition of this Agreement and provide proof of compliance prior to performing services hereunder. 9. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 With copy to: Santa Ana, CA 92702-1988 Fax (714) 647-6956 Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza (M-23) P.O. Box 1988 Santa Ana, California 92702 Fax (714) 571-4211 To Provider: Rodolfo Cazales 2525 N. Grand Avenue, Suite Z Santa Ana, CA 92705 Cell: (714) 474-4737 toyamausa@yahoo.com A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Provider regarding the subject matter herein, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Provider. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not 11 bind or obligate Provider or the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which is not embodied herein. It. ASSIGNMENT/SUBSTITUTES a. Assignment. The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to enter into this Agreement. Therefore, Provider may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. b. Substitutes. In the event Provider is not able to teach a class due to illness or some other cause beyond Provider's reasonable control, Provider must procure, at its sole expense, a qualified substitute instructor to teach the class at its regular time and place. Provider shall ensure that substitute instructors are at least twenty-one (21) years of age and comply with the City's insurance and live scan requirements contained herein. Evidence of compliance with City's insurance and live scan requirements shall be provided upon request. Provider must immediately notify the City of the substitute instructor's name, qualifications, address and phone number. If Provider cannot procure a qualified substitute and the City is unable to assist in this regard, then the class shall be canceled and a make-up class must be added to the session. Provider must notify participants as soon as possible of any class cancellation and make-up class. Provider must personally teach at least seventy-five percent (75%) of its offered classes. 12. TERMINATION a. This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of termination. b. Termination or cancellation of classes by the Provider outside of Section I l.b. must be given to the City at least thirty (30) days prior to termination/cancellation. Failure to provide adequate cancellation notice to the City may put future contracting of business with the City at risk and will result in the City's retention of ten (10%) percent of the final payment to Provider. Itt� 11DEV-01") Provider shall use attendance sheets generated and supplied by the City to record attendance in each class. Provider shall keep these and any other records in connection with the work to be performed under this Agreement and shall permit City, upon request, to review such records for a period of three (3) years from the date of final payment to Provider under this Agreement. 14. NON-DISCRIMINATION Provider shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by C applicable law, in the recruitment, selection, teaching, training, utilization, promotion, termination or other employment related activities or any services provided under this Agreement. Provider affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 15. JURISDICTION—VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 16. LICENSES Provider shalt, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. 17. SEVERABILITY In the event that one or more of the phrases, sentences, clauses, paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be interpreted to carry out the intent of the parties hereunder. 18. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 19. AUTHORITY The person(s) executing this Agreement on behalf of the parties hereto warrant that they are duly authorized to execute this Agreement on behalf of said parties and that by so executing this Agreement, the parties hereto are formally bound to the provisions of this Agreement. [signatures on next page] N-2018-125 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: Maria D. Huizar Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: (C t ti��Kvll Laura A. Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL: Jeannie Jurado Acting Executive Director of Parks, Recreation and Community Services Agency CITY OF SANTA ANA ✓G Raul Oodinez It City Manager Exhibit A SCOPE OF SERVICES A. Provider shall conduct Toyama Karate Do classes for ages -5yrs:old and up. B. Provider shall teach such or similar classes (1) at the times below at facilities to be designated by the City or (2) on a schedule agreed upon by the parties for each class session or term, including the location, specific days and hours when classes will be held, and holidays to be observed, in accordance with City's needs. TOYAMA KARATE DO Throughout a dynamic martial arts approach, students will have the opportunity to lean Karate -Do in a safe and structured environment. Our program will expose students to better their social skills, discipline, focus, and character. Students will also learn sport karate that will promote belt testing and competition. INSTRUCTOR: Toyama Karate -Do Staff LOCATION: Santa Anita Center, 300 S Figueroa St. Santa Ana, (714) 647-6552 Toyama Karate Do will consist of monthly sessions, held 2 days, per week, per 50 minutes.(5-13yrs) Toyama Karate Do will consist of monthly sessions, held 2 days, per week, per 50 minutes.(14yrs & Up) C. Provider shall provide all materials, supplies, equipment, records and personnel, Provider shall be responsible for clean-up of the facilities and materials and shall ensure the safety and effectiveness of instruction. CLASS SIZE A. Each class must have a minimum of 5 paid students and no more than 20 students. B. No registration will be accepted after the second meeting of classes. C. If the minimum registration has not been reached by the second class, the class shall be cancelled. Provider will be under no obligation to provide services for the cancelled classes, and the City will have no further obligations to pay Provider compensation for the remaining classes that were cancelled in that session. CLASS FEES A. Each participant shall pay class registration fees as established by City. B. Provider may not waive class participation/registration fees. C. Only registered participants may participate in class. D. Any refunds to participants will be made in accordance with City policy. E. Any materials fee shall be established by mutual agreement of City and Provider and shall be payable directly to Provider. Policy Number: Date Entered: 02/07/2018 � i% O CERTIFICATE OF LIABILITY INSURANCE DATE I/901YYYY) 2/7/2015 THIS 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. 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 endorsemen s . PRODUCER Reindeer Insurance Services 14037 Pioneer Blvd Norwalk CA 90650 N-2018-125 CONTACT NAME: .- PHONE . (562) 406-8838 FAX Net , (562) 406-8837 pooRless c sr@ Cruckbypass . com� INSURERS AFFORDING COVERAGE NAIC9 INSURERA:United States Fire Insurance Company AH-GA2692-004 INSURED Toyama Karate DO INSURER 8: _ INSURER C_: MED EXP (Any one Orson S5,000 Rodolfo CaSaleZ 1030 Moore Street INSURER D; Santa Ana, CA 92704 INSURER E; INSURER F: PERSONAL&ADV INJURY $1,000,000 CUVENAGCN GER'I'IFICATF NUTARFR• owmauirw Mlnm Co• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD Jum S POLICY NUMBER POLICY EFF MMIDOry V PO CY EXP M ID V LIMITS A COMMERCIAL GENERAL LIABILITY2,000,000 CLAIMS -MADE X OCCUR AH-GA2692-004 01/01/2018-01/01/2019.' - EACH OCCURRENCE $ PREASES Es occunenca $100,000 MED EXP (Any one Orson S5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- LOC GENERAL AGGR EGATE $4,000,000 PRODUCTS - COMPIOPAGG $ $ OTHER: AUTOMOBILE LIABILITY --.Ea..amnt ' COMILNEDSINGL LIMIT $ ANY AUTO _.- BODILY INJURY (Par person) $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY _ AUTOS ONLY "-'' {� v,� 6'e r� P.rM S,Jy BODILY INJURY (Per accident) S PROPERTY DAMAGE Par accident)$ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ ATE S EXCESS LIAR CLAWS -MADE DEC I I RETENTION $ $ A. WORKERS COMPENSATIONPER ANYPROPRIETORIPARTLIABILITY NEIVEXECUTIVE YIN OFFICERIMEMSER EXCLUDED? (Mandatory in NH),eGr HYes,descnI, under DE SGRIPTION OF OPERATIONS below NIA Y �a} - RCSE.L. �i� AG 1'"� 'r% y� gt,�L1 P Thi- STATUT ER E.L EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Sahedulo, may be attached it more space la.,wivo ) Karate School Additional Location:2320 N Grand Ave Santa Ana CA 92705 Certificate holder, its officers, agents, and employees are named as Additional Insured in regard to General Liability CITY OF SANTA ANA Att: PRCSA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 CIVIC CENTER PLAZA M-23 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 1986 ACCORDANCE WITH THE POLICY PROVISIONS. SANTA ANA CA 92702 AUTHORIZED REPRESENTATIVE i ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Produced usina Forms Boss Plus software. www.FornrsBoss.com', Imoresslve Publishina 800.208-1977 POLICY NO. AH-GA2692-009 COMMERCIAL GENERAL LIABILITY NAME INSURED:Toyama Karate Do THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of Santa Ana, its officers, agents and employees 20 Civic Center Plaza Santa Ana, CA 92701 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) Is amended to Include as an Insured the person or organization shown in the schedule, as an Insured but only with respected to liability arising out of your operations or premises owned by or rented to you. Reviewed by Carmen Ac sta PRCSAIRecreation CG 20261165 Copyright, ISO Properties, Inc., 2004 Page 1 of 1 _ ADDITIONAL. INSURED ENDORSE fvfENT Insurance Company United States Fire Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # AH-GA2692.004 relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers, employees, agents and representative are named as additional insureds ("additional insureds") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective 01/01/2018 Policy # AH-GA2692-004 Issued to Toyama Karate Do Name Insured Countersigned by this endorsement form as part*V►eWed by N-2018-125 WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury, the (Name! He) following declaration I certify on behalf of T*,44hat during the tern (Consu ant/Company Name) contract for Recreation Classes services with the City of Santa Aria; not employ any person in any manner so as to become subject to the workers' ' compensation laws of California, and agree that if I should become subject to th workers' compensation provisions of Section 3700 of the Labor Code, I shall foi comply with those provisions and provide proof of workers' compensation cove DATE:/201 Eoi b' By: 6 K Name:�G0�r. Title: D� irw Telephone: WARNING: FAILURE TO SECURE WORKER', UNLAWFUL, AND SHALL SUBJECT AN EMP: AND CIVIL FINES UP TO ONE HUNDRED TH ® Policy Number: Date Entered: 01/02/2019 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1/2/2019 THIS 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. 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). PRODUCER Reindeer Insurance Services CONTACT NAME, 14037 Pioneer Blvd Norwalk CA 90650 PHONE .(562)406-8838 FaArc Me:(562) 406-8837 ADDRESS; car@truckbypass. com .— INSURERS AFFDRDING COVERA-E NAICN _. WsURED Toyama Karate DO INSURERA:United States Fire Insurance conglany Rodolfo C8Lalex N!ao{r_ 1030 Moore Street P WSURER e: __ INSURERC: - -- INSURER D: — Santa Ana, CA 92704 INSURER 9: $1,000,000 INSURER F : - COVERAGES reoT¢Irwrrv. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE KCYIWUN NUMUGR: INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED WITH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. HEREIN IS SUBJECT TO ALL THE TERMS, INSR AD DL SUER EFF ANDY EtP L TYPE OF NNSURMICE POLICY NUMBER MPMNDY A COMMERCUM-GENE1 A 11ASIUTY OMn3 EACH OCCURRENCE $1,000,000 CtAIMS#MOE Fx OCCUR USP262607 ;01/01/2019 01/01/2020 A D PRE ISE. Eatlaurrmm S 300, 000 MED EXP(ArN 0.lanwn) $5,000 PERSONAL INJURY 31.000,000 GEN'LAGGREGATE LIMITAPPLIES PER: POLICY E] PRO- O - F GENERALAGGREGATE $2,000,000 LOC PRODUCTS-COMPIOPAGG $2,000,000 OTHER E AUTOMOBILE LIABILITY COMBINED IN ELI ANYAUTO Eaa ibni)__ $ BODILY INJURY(Pwpemon) $ OWNED SCHEDULED BODILY INJURY (Par ardtlant) $ AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE E E UMBRELLA UAe OCCUR a y ,�\ EACH OCCURRENCE $ EXCESS UAe CLAIM"'OE V V /// AGGREGATE t PER OTH- $ DEO RETENTION $ WORKERS COMPENSATION ANDEMPLOYERSLIABl1TY - YIN MY OFFICEIUMEMBER EXCLUDED? �ECUi1VE ❑,NIA '(�- v� ,! STA ER El, EACH ACCIDENT $ (Mandaory In NH) �- E.L. DISEASE - EA EMPLOYEE $ ttyyea.tlescribeumler DESCRIPTpN OF OPERATIONS bebw \ E.L. DISEASE -POLICY LIMIT $ Q� DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, ADEIHOn.l Remarks ScOetlule, may a aaacnetl I rtgre aWce IN,pulmtl) Karate School Location:2320 N Grand Ave Santa Ana CA 92705 Certificate holder, its officers, agents, and employees are named as Additional Insured in regard to General Liability CFRTIFireiF U MOD CITY OF SANTA ANA Att:PRCSA 20 CIVIC CENTER PLAZA M-23 PO BOX 1988 SANTA ANA CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ' V ©1988-2015 „o -. w. u „n,,,e art" tug0 are reglsrereO marKS DT ACORD Produced using Forms Boss Plus software. w .FormsBoss.com: Imoressive Publishina 800.208-1977 reserved. ADDITIONAL INSURED ENDORSEMENT Insurance Company: This endorsement modifies such insurance as in afforded by the provisions of Policy # OSP%6 2+60 7 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701, officers, employees, agents and representatives are named as additional insured with regard to liability and defense of suits arising from the operations and uses performed by on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insured. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or orgatuzation as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect to the additional insured, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty -30 days written notn *s ve to the Citv of Santa Ana, 20 Civic Center Plaza, Santa Ana, California? ��2 (Completion of the following, including countersignature, is required to make this end effective). <e CI Effective 20/ JG this endorser o art of Q` Policy # LL PZ 6060 7 Issued to "ce Name Insured Countersigned by 13 lil WORKERS' COMPENSATION DECLARATION 1� +76 1; hereby affirm under penalty of perjury, the (Nam tle) following declaration 1 certify on behalf of --7e-9 A, &.z�hat during the term of my (Consulwt/Company Name) contract for Recreation Classes services with the City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: By:: /90 Ci v �GL44 Name: y— X, le? 14i�'%� -, /) a Title: C/G✓/l/�� Telephone:; WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.