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Home My WebLink AboutSTORM, GAYCity of Santa Ana - Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements 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. The agreement with N-2018-121 No. was completed on (List all amendments. Use space below if needed.) COTC Office Use 7iiq .RI!. 19 PM 3: 12 CITY OF SP1MJA ANA CLERK CF COUNCIL % It and final payment has been made. Department: TOI)QAqr Phone/Exf.: Signature: ASKJICti U'Ne cLo Date:i�l� Revised: 10-18-16 INSURANCE Nff ON FILE WC Declaration on file. WORK MAY NOT PROCEED Cb CLERK OF COUNCIL (Need &J) DATE: rill 7 2018 o: PRCS (/ ) Silvia Cuevas_" May 30, 2018 Gay Storm C'Speaker/Performer") 15241 Cascade Lane Huntington Beach, California 92647 Re: Sneaker/Performer Engagement Agreement This letter represents your agreement with the City of Santa Ana C City'*) as entered into on the above date for the engagement described below: Event description: Historical Re-enactment Services, Character: Statue of Liberty to share historical information with attendees and provide visual aids during presentation referenced in Scope of Services attached as Exhibit A. 2. date(s): Wednesday, July 4, 2018 3. Event Time(s): 4:00 p.m. to 8:00 p.m. 4. Location: Show will be presented at the Centennial Park, Santa Ana CA ("Property") 5. Compensation: $300 (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: Stage, microphone and sound equipment 7. Equipment provided by Speaker/Performer: all supplies, costumes, and equipment, required for the performance 8. 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-empioyce 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. to. Indemnification: Speaker/Performer, his or her agents, or employees (i f 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 fully 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. i Letter Agreement — Gay Stoll" Page =' 12. Commercial General Li, insurance naming the Ciil and shall include, but ni including death resulting Speaker/Performer's opei involving vehicles. The a to bodily and personal inj $1,000,000 per occurrene officers, employees, ages ^ .,trihutnry with resnect t ACTING EXECUTIVE DIRECTOR N-2018-121 Exhibit A 714.309.1646 http:tlha tboxwtlltravel.com May 14, 2018 Thank you so much for your continued interest in Hatbox Will Travel I This is to confirm the following: Gay Storm, artist, will perform as Lady Liberty AKA The Statue of Liberty, At the City of Santa Ana Annual Fourth of July Celebration to be held at Centennial Regional Park, 3000 West Edinger Avenue in Santa Ana On Wednesday, July4, 2018. It is understood that the festivities will be from 4:00 pm to 8:00 pm. She will perform on stage at a time to be determined for no more than twenty minutes (microphone to be provided for her) and will also interact with people from a booth to be supplied by others. Gay Storm will provide costuming and props for her show. As last year, compensation will be $300.00. Contact person for event is Sonia Batres: (714) 571-4227 sbatres@santa-ana.org Gay Storwv 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. 0. Box 6450 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: City of Santa Ana TYPE: 4th 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 Of Insurance: Medical Payments (Any One Person) 5,000 MEGL643 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,000/$3,000,000 ❑ $2,000,000/52,000,000 Damage To Property (If purchased) The limits of insurance apply separately to each event insured by this policy as if a separate policv 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 provisions. -/�C7 _.�- AUTHORIZED REPRESENTATIVE: DATE ISSUED: a& �0 &�ilJ:unt 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 Invoice At 869837 Page 1 of ACCOUNT NUMBER _ DATE SANTANA-OS 6/28/2018 BALANCE DUE ON _ L AGENCY CODE ) 7/28/2018 - 200 [AMOUNT PAID AMOUNTDUE '- Special Events Program $1,395.00 Client: City of Santa Ana Policy: Special Event Liability Policy Number: SEP41026 Insurance Carrier: Evanston Insurance Company Effective: 1/1/2018 to 1/1/2019 Item # Trans Eff Date Due Date Trans Description Amount 3279214 1/1/2018 7/28/2018 ENDT Premium 4th of July Celebration $1,298.61 3279215 1/1/2018 7/28/2018 SURT Surplus Lines Taxes $38.96 3279216 1/1/2018 7/28/2018 SURF Surplus Lines Stamping Fees $2.60 3279217 1/1/2018 7/28/2018 OFEE Other Fees & Services $12.98 3279218 1/1/2018 7/28/2018 BNKF Bank Fee $41.85 Total Invoice Balance: $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 WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury, the �. amaTi e) following declaration I certify on behalf of f fSt rnkLA)11L-DQt1.lg that during the term of my (consdY .) contract for P54J�fTt�/JlA 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 provi ions and provide proof of workers' compensation coverage. DATE: By. Name: �! Title: "—O Telephone: / WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRM41NAL 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. eaay� L7I� R0m`�`. P�GSP