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Home My WebLink AboutSMALL, PETER M. 2City of Santa Ana - y Clerk of the Council coTc office use only ------------- AGREEMENT TERMINATION FORM 12 Please complete this form in its entirety when the attached agreement and all ynlq Jl}! 19 P i amendments (if any) are no longer in effect. i NTA ANp Y 9 9 P 9 q CITE` OF OF COUNCIL Note: If our agreement is rant related, lease ensure that all rant retention requirements CLERK OF have been satisfied prior to signing the termination form. Is the agreement(s) a permanent record? Yes _ No Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. /J i The agreement with / �.� p/n No. N-2018-122 was completed on —7 I L7I V and final payment has been made. (List all amendments. Use space below if needed.) p ^ Department: TTt Phone/Ext.: S� Signature:QA}�cvCyC�JG� Date: (, Revised: 10-18-16 WC Declaration on file. INSURANCE NOT ON FILE ,!RK MAY N_ I PROCEED LERK OF COUNCIL ('*G/) DATE. Tom- 1 2015 0:PRCS(/) Silvia Cuevas May 31, 2018 Peter M. Small ("Speaker/Performer") ` P.O. Box 3452 Fullerton, California 92834 Re: SReaker/Performer Engagement Agreement N-2018-122 This letter represents your agreement with the City of Santa Ana ("City") as entered into on the above date for the engagement described below: Event Description: Historical Re-enactment Services, Character: George Washington 2. Date(s): Wednesday, July 4, 2018 3, Event Time('s): 5:00 p.m. to 8:00 p.m. 4. Location: Show will be presented at the Centennial Park, Santa Ana CA ("Property") Compensation: $250.00 (payable by check within 30 calendar days of event) provided agreement is fully executed; Speaker/Performer must provide IRS form W-9 before payment can be made. 6. Equipment provided by City: none 7. Equipment provided by SpeakerlPerformer: all supplies, costumes, and equipment, required for the performance S. City Contact Person (for coordinating purposes only): Sonia Batres (714) 571-4227 9. Independent Contractor: Speaker/Performer 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 professional manner in which Speaker/Performer performs the services that are the subject matter of this Agreement; however, the services to be provided by Speaker/Performer shall be provided in a manner consistent with all applicable standards and regulations. Speaker/Performer 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. 10. Indemnification: Speaker/Performer, his or her agents, or employees (if applicable) agrees to and shall indemnify, defend, and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from and against all loss, expenses, or liability (including costs and attorney's fees) arising from the negligence or willful misconduct of Speaker/Performer, his or her agents, or employees. 11. Release: Speaker/Performer accepts the Property and any City -provided equipment used in connection with the performance in their "as -is" condition, with all faults. Speaker/Performer Billy releases, waives and discharges forever any and all claims, demands, rights, and causes of action of any kind or nature against, and covenants not to sue, City, its elected officials, officers, employees, agents and volunteers, and all persons acting on behalf of, by, through or under each of them, under any present or future laws, statutes, or regulations for any claim or event relating to the condition of the .Property or City -provided equipment or Speaker/Performer's use thereof. Letter Agreement — Peter M. Small N-2018-122 Page 2 12, Commercial General Liability Insurance. Speaker/Performer shall maintain commercial general liability insurance naming the City, its officers, employees, agents, volunteers and representatives as additional insured(s) and 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 Speaker/Performer'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, with $2,000,000 in the aggregate. Such insurance shall: (1) name the City, its officers, employees, agents, volunteers, and representatives as additional insureds; (2) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (3) contain standard separation of insured provisions. 13. Worker's ,Compensation Insurance. In accordance with the California Labor Code, Speaker/Performer, if Speaker/Performer has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. 14. The City shall have the right and royalty -free license to simulcast or produce and show a tape -delayed broadcast of Speaker/Performer's presentation to the City community or general public, through webcast or any other means. This license shall be non-exclusive and the copyright shall remain with the Speaker/Performer. Copies of Speaker/Performer's presentation may be maintained by the City, and Speaker/Performer consents to use of such recordings. 15. Speaker/Performer shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, disability, or any other basis protected by applicable law in connection with any activities related to this Agreement. 16. This Agreement shall in all respects shall be interpreted, enforced, and governed exclusively by and under the laws of the state of California. Both parties 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. 17. This Agreement represents the complete and exclusive statement between the City and Speaker/Performer regarding the subject matter herein and supersedes any and all other agreements, oral or written, between the parties. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Speaker/Performer, Please execute this letter to reflect your agreement to the terms an CITY OF SANTA ANA RAUL GODINE II City Manager ATT 4 �MARIA D. HUIZAR '6 . Clerk of the Council RECOMMENDED FOR APPROVAL JEANNIE JURADO APP OVED AS TO FAAO l By: 10eA,_a.1�C��p�. h�y�jlJF1.�.- LAURA ROSSINI Senior Assistant City Attorney Parks, Recreation, and Community Services Agency ACTING EXECUTIVE DIRECTOR SCOPE OF SERVICES - Exhibit A P.O. BOX 3452, FULLERTON, CA 92834 TELEPHONE: 949-631-2703, cell: 760-717-9666E-MAIL: historyalive5@hotmaii.com, WEBSITE: www.history-alive.com INVOI Submitted to City of Santa Ana for services performed on and at: Date: Wednesday, July 4, 2018 Time: 5:00-8:00 P.M. Place: Independence Day Event Program: George Washington Performer: Peter M. Small Paid to the order of: Peter M. Small Amount to be paid: $250.00 Address: P,O, Box 3452, Fullerton, CA 92834 (Residence: 2117 Elden Avenue, #9, Costa Mesa, CA 92627) May 30, 2018 N-2018-122 WORKERS' COMPENSATION DECLARATION I / �•a' ( hereby affirm under penalty of perjury, the (Name/Title) following declaration: I certify on behalf of Iv . Ce: (`- that during the term of my —,WonaultantlCompany Name) contract for 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 I 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: - J uo e- (2, ao l e M Name: Title:e— Telephone: aVgg E,31 3 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. Q�G EVANSTON INSURANCE COMPANY CERTIFICATE NO.: CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with Apex Insurance Services P. O. Box 6450 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: City of Santa Ana TYPE: 41h of July Celebration P O Box 1988 DATE(S): July 4, 2018 Santa Ana, CA 92702 LOCATION: Centennial Park *Liquor Liability Yes ❑ No "Liquor Liability after 12 am ends before 2 am ❑ This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41026 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2018 EXPIRATION: JANUARY 1, 2019 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products & Completed Operations 1,000,000 SPECIAL CONDITIONS: Personal & Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) 100,000 Certificate Oflnsurance: Medical Payments (Any One Person) 5,000 MEGL643 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,00053,000,000 ❑ $2,000,000/$2,000,000 Damage To Property (If purchased) The limits of insurance apply separately to each event insured by this policy as its separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS Robert Broski AWRS-7 El Toro Lady Marines Peter Small Deborah McIntosh Go On Wheels/Ernesto Rivas Gay Storm CANCELLATION. Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy revisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: Aifiant Alliant Insurance Services, Inc. Newport Beach - Alliant Insurance Services, Inc. 1301 Dove Street, Ste. 200 Newport Beach CA 92660-2436 Phone: (949) 756-0271 City of Santa Ana PO Box 1988 Santa Ana, CA 92702 Client: City of Santa Ana Policy Number: SEP41026 Insurance Carrier: Evanston Insurance Company Item # Trans Eff Data 3279214 1/1/2018 3279215 1/1/2018 3279216 1/1/2018 3279217 1/1/2018 3279218 1/1/2018 Invoice # 869837 Page 1 of 1 ACCOUNTNUMBER --- 1 DATE ..J SANTANA-08 _ 6/28/2018 aAL NCE DUE ON ___T AGENCYCODE 7/28/2018 200 AMOUNTPAID AMOUNT DUE $1, 395.00 Special Events Program Policy: Special Event Liability Effective: 1/1/2018 to 1/1/2019 Due Data Trans Description 7/28/2018 ENDT - Premium 4th of July Celebration 7/28/2018 SURT Surplus Lines Taxes 7/28/2018 SURF Surplus Lines Stamping Fees 7/28/2018 OFEE Other Fees & Services 7/28/2018 BNKF Bank Fee Total Invoice Balance: Amount $1,298.61 $38.96 $2.60 $12.98 $41.85 $1,395.00 IMPORTANT NOTICE: The Nonadmitted & Reinsurance reform act (NRRA) went into effect July 21, 2011. Accordingly, surplus lines tax rates and regulations are subject to change which could result in an increase or decrease of the total surplus lines taxes and/or fees owed on this placement. If a change is required, we will promptly notify you. Any additional taxes and/or fees owed must be promptly remitted to Alliant Insurance Services, Inc. IMPORTANT NOTICE: The Foreign Account Tax Compliance Act (FATCA) requires the notification of certain financial accounts to the United States Internal Revenue Service. Alliant does not provide tax advice. Please contact your tax consultant for your obligations regarding FATCA. Alliant embraces a policy of transparency with respect to its compensation from insurance transactions. Details on our compensation policy, including the types of income Alliant may earn on a placement, are available at www.alliant.com. For a copy of our policy or for inquiries regarding compensation issues pertaining to your account contact: Alliant Insurance Services, Inc., Attn: General Counsel, 701 B St., 6th Floor, San Diego, CA 92101