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HomeMy WebLinkAboutKEENAN & ASSOCIATES (2)INSURANCE NOT REQUIRED WORK MAY PROCEED CLERK OF COUNCIL ATF. JUL 2 6 2018 13 X,� (2,(A) C (^,c a tit., BUSINESS ASSOCIATE AGREEMENT A-2017-074 'Ibis Business Associate Agreement (the Agreement) is entered into Jane 1, 2017 ("Effective 10ate") by and between City of Santa Ana, the sponsor ("Sponsor") of one or more health plans (collectively referred hereafter to as the "plan") and Keenan &Assoclates (Business Associate). WHEREAS, are Sponsor has independently contracted with Business Associates to provide services to, for or on behalf of the Plan, and WHEREAS, Plan wishes to allow the Business Associate to have access to'PI11 including but not limited to, EPE that is either provided to the Business Associate by the plan or received and created by the Business Associate on behalf of the flan in the course of providing its services to, for or on behalf of the plan, WHEREAS, the Plan is required to comply with 1-.UPAA (including, but not limited to, its Privacy Rule and SacuntyR.ttie), and other governmental regulations relating to the privacyand securityof individuals' persanallyieient:ifiable information. NOW, THEREFORE, ORE, for good and valuablc consideration, the receipt of which is hereby aclsatowledged, ;flan and Business Asso6ite agree as follows: D—rE NI'I 0—N§ Catch -ell d 1 Uig: 'Perms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in 45 C.PR. §§ 160.103 and 164,500 f'c d jC'a s: (a) gRg_As9Z.aatq "Business .Associate" shall generally have the same meaning as the term "business associate" at 45 CFR 160.103, and ut reference to this .Agreement, shall mean Keenan & Associates, (b) x,(11 shah have the same meaning as the term "breach" in 45 GFR § 164.402 (c) r yer�ecl Ent!U shall generally have the same meaning as the term "covered entity" at 45 CFR 160.103, and in reference to this Agreement shall mean the 'health and welfare benefits plans sponsored by the entitythat is signatoryto this Agreement. (d) lL,ldlxi4gd shall have. the same meaning as the terrra "individual" in 45 CrR § 164.501 and shall include a person. who qualifies as a personal represcntative .in accordan. ce with 45 a -R § 16.4.5020. (e)–Privacy ushall mean the Staudartis for Privacyof Individually Identifiable Health Information at 45 C14R Part 160 and Part 164, Subparts A and E. Keenan & Assucimas- License VO4.41271 Business ssocia(e Clamive( (Suauoiti1,Y) (&:v. 07/29111) Htge .t of 8 ll MI:+ ,ntt Exhibit 2 (1) Mte.=Laealk I,orI ,p�TI', . shall have generally the same nteaniag as the tenv "protected health information" in. 45 CTR § 164.501, acid for this Agreement shall be limited to the information created or received by Business Associate from or on behalf of the Covered Entity. (g) 51"g-,taaly shall mean the Secretary of the Department of Health and I Iumart Services or his designee. (h)r=d &tCg shall mean the Security Standards for the Protection of Electronic Hcalth. Infonn3ation at 45 C R Part 160 and Part 164, Subpart A and C. (a) 1 1 rlrpyuc P7TI �I -PITEl shall have the i eaning found in the Security Rule 45 CFE, Section 160,103. (j) Sec ,i:yjigid=t shallhave the same meaning as the term "security incident" in 45 CTR Parts 160 and 164, subparts A and C (lc) _ LMA— uke shall mean. the Privacy, Security,Breach Notification, and Enforcement Mules sit 45 CPR Part 160 and Part 164. (l) {esfmYl�c.t shall have the same meaning as the term. "designated record see" in 45 C`,R 164,501. (m)jLil) tgagtgi shall have the same meaning as the term "subcontrnrctor" in 45 CPR, 5160.103 (n) I)n.9�ui ecl,,Ia shall have the meaning given the term "unsecured protected health information in 45 CPR § 164.402. OTbLISx 7 ? r1 AQT LYJJfa F BUSINESS A5SQCIATE Business Associate agrees to: (a) Business Associate agrees to not request, use, or furtherdisclose PHI other Bran as permitted or required bythc Agreement or its permitted .or required bylaw, (b) Business .Associate agrees that it shall utilize appropriate physical, administrative and technical safeguards to ensure that the PI -II is not used or disclosed in any manner inconsistent with this Agreement. Such safeguards shall include, but not be limited to; (1) establishing policies and procedures to prohibit any e;,21oyee of Business Associate, who does not have a reasonable need forthe PHin order to accomplish an autnornred use or disclosure, from accessing such information and to infonn all employees of Business Associate Nvhose services may be used to fulfill obligations under this Agreement of the terms of this Agreement, and (2) disclosing to anyagent, Subcontractor or other third party, and requesting from Covered Entity, onlythe mi iimum,P! II necessaryto accomplish the intended purpose of the ttse, disclosure or request. ("Miaaimum necessary" shall be mtcnpreted in accordance with the I-l1PAA Rules.) Business .Associate shall provide Covered Erttitywith such information concerning the safeguards as Covered Entity may reasonably request from time to trine. Keenan & Asociate5 - Lic:mw B0451271 Business Assoclote Coanrnct (Sam'tciday) (Rev.07/29/13) Page 2 of s (c) Um appropriate safeguards, and comply with Sttbpatt C of 45 (TR Part 164 with respect to electronic PI TI, to prevent use or disclosure of PFR ether than as provided for by the agreement. (d) Business Associate agrees to mitigate, to the extent practicable, anyharmful effect that is known to Business Associate of a use or disclosure of PI -11 by Business Associate in violation of this Agreement. (e) Business Associate agrees to report to Covered .Entity, in writing, any use or disclosure by IBusiriess Associate of PER not permitted by this Agreement promptly after Business Associate's first awareness thereof, including but not limited to, any discovery of any inconsistent use or disclosure by Subcontractor of Business Associate. (f) Report to Covered Entity any use or disclosure of PFII not provided for by the Agreement of which it becomes aware, including breaches of Unsecured PHI information as required at 45 CPR 164.410 (without unreasonable delay, and, in no case later than 10 calendar days after discovery of a Breach), and any security incident of which it becomes aware, (g) BUSineSS A.ssaciate agrees to recluh'e that anySubcontractor, to whom itprovides PITT received from, or created or received byBusiness Associate on behalf of Covered Entity, execute a Business Associate Agreement acknowledging its compliance with the HTPAA Riles. (h) Business Associate agrees to provide access to P%1(, at the request of Covered Entity, and in the time and roamer reasonablydesignated by Covered Entity, to Covered Entity, or, as directed by Covered Entity, to an Individual in order to meet the requirements under 45 CPR 164.524 (within 30 clays after receipt of the request unless there is a 30 day extension.) (i) Business Associate agrees to make anyamendment(s) to PI -11 that the Covered Entity directs or agrees to pursuant to 45 C:PR 164.526, and in the time and manner reasonably designated by Covered Entity, i n a Designated Record Set, or take other measures as necessaryto satisfy Covered Entity s obligations under 45 a4R 164,526 no later than 60 clays afterthe receipt of the request. 0) Business Associate: agrees to make its internal practices, books and mcords relating to the use and disclosure of the PS ff available to the Secretaryorthe Secretary's designee for the purposes of determining Covered Entity's compliance with the I I PAA Rules. Business Associate shall fininediately notify Covered E ntity of its receipt of any Stich request for access, but in no case later than 60 days after the receipt of the request, (k) Business Associate agrees to document such disclosures of PH to the extent necessary for C overe,d E ntity to respond to a request by an Individual for an accounting of disclosures of PI -I1 in accordance with 45 CPR § 164,528 no later than 60 days after the receipt of the request. (1) Maintain and malT available the information required to provide an accounting of disclosures to either the Covered. Entity, or the Individual, as necessary to satisfy Covered Tntity°s obligations under 45 CTR 164.528 within 60 days after receipt of the request. (m) Business Associate agrees to provide Covered Entity, in the tinge and manner reasonably designates{ by Covered Entity, infornnation collected in accordance with Section (1) on page 3 of this Keenan CAswoWo, - Uegnse)l0451271 ft4,iness A550ciun: C0110no1(Sultovday) (Rev. 07097 U) raagq } of @ Agreement, to permit Covered Entity to respond to a request by an Indivichial for an accc)iuoting of disclosures of PFIX in accordance with 45 CCPR 164,528 no later than 60 days after the receipt of the .request. (n) Business Associate agrees to provide information arts{ documentation concerning Business Associate's compliance with dais Agreement to the extent reasotnablyrequestecl byavetvcl Entityas necessary to permit to respond to tlalyd laaaties' ingairics of and/or claims against Covered Entity relating to use and/or disclosure of PI -II and/or for Covered Entity to comply with laws) relating to its monitoring of compliance with this Agreement, Business Associate shall, upon C overed Entity's request, rertifyto Covered Entitytlaat it connplies with the terms of this Agreement (no later than 60 days after the receipt of the request, (a) Except as otherwise limited in this Agrecinent, Business Associate rmayobtain and/or use PH as necessary to perform its obligation to provide services to, for, or on behalf of the Plans, so long as such access and/or use is either permitted or required by law and, provided further, that Business Associate has met all legal requirements for such access and/or use. This specifically includes, but is not limited to, Business Associate's access and/or use of PI -3I as necessary to perform the services set forth in the service agreement between Business .Associate and Sponsor. (b) Business Associate .may not use or disclose PI -11 in a manner that would violate the I IIPAA Rules, If the Agreement ,perrrits the Business Associate to use or disclose PIT for its own management and administration and legal responsibilities, or for data aggregation services, then disclosure is permitted.for the specific uses and disclosures set forth below, i) Business Associate may use Pfll for proper management and administration of the Business Associate, or to canyout the legal responsibilities of the :Business Associate, u) Business associate may disclose PM for the proper management and administration of Business Associate or to carry out the 'legal responsibilities of the Business Associate, provided the disclosures are required by law, or Business. Associate obtains reasonable assurances fromthe person to wham the information is disclosed that the information will remain confidential and used, or farther disclosed, only as required by law or for the purposes for which it was disclosed to the person, and the person notifies Business Associate of any instances of which it is aw•rtre in which the confidentiality of the information has been breached. iii) Business Associate may provide data aggregation services relating to the health care operations of the Covered Entity, C7.�S�,i['r,,�,",()ty5 dlr GOy a itELl EN"i'I'I"Y (a) Covered Entity shall provide Business Associate with the notice of privacy practices that Covered Entity produces inaccordance with 45 CFR S 1.64.520, as well as any changes to such notice, Kien & Asawdarns — tAcense 00451271 Business Assucimc Conunct (Somurday) (ricv, 07/29/3) page a of 8 K mi, (b) Neither Sponsor nor Covered Entityshall request Business Associate to use or disclose PHI in any rnanner that would not be permitted or required by law if done by covered Entity, (c) Covered 'Entity shall notify Business Associate in writing of any restriction to the use or disclosure of PI -11 that Covered Entityhas agreed to in accordance with e15 CTR § 164.522. rND-F'MNjfI AjjQ-N. (ti) Business Associate agrees to indemnify, defend, and hold harmless the covered Esutity, its trustees, officers, directors, employees, agents, or representatives, from anyclaim or penaltyarising out of any improper use and/or disclosure of PI -H r"rt violation of the PrivacyRegulation, to the extent that such improper use and/or disclosure resulted from Business Associate's negligence or failure to comply with the teams of this Agreement or the Privacy Regulation. (b) The Sponsor and Covered Entity agree to indemnify, defend and hold harmless Business Associate and/or all of Business Associate's officers, directors, employees, agents, or representatives, from any claim or penalty from any improper use anti/or disclosure of PPII, to the extent that such improper use and/or disclosure resulted from the Sponsor's or Covered Emityrs negligence, failure to comply with the terms of this Agreement or the Privacy Regulation, or was based upon the Sponsor's or Covered Entity's written direction to use and/or disclose PI -11 in the manner challenged. SLIORM Business Associate agrees to; a) Implement safeguards that reasonably and appropriately protect the confidentiality; integrity, and availability of the electronic PHI that it creates, receives, maintains, or transnuts on behalf of the Covered Entity; u) Ensure that any Subcontractor, to whom it provides this infornlation agrees to implement reasonable and appropriate safeguards; iii) Report on a quarterly basis to the Covered Entity, in writing, any Security Incident involving Covered Entity's data. If, however, a Security Incident results in the unauthorized disclosure of Unsecured PHI, Business Associate shall notify Covered Entity in accordance with the Breach notification provisions below. iv) Notify Covered Entity no latter than ten (10) days after discovery of a Breach of Unsecured PER,' v) Performthe four factor riskassessrnent of anyMaeh that is discovered in accordance wth the HIPAA Rules to determine if notification is required, and advise Covered Entityof its findings. Covered Entity has 60 flays from the discovery date of s. reportable Breach to report said Breach to tine Individual and 1-I1-1.8 (ifl3reach involves 500 or more Individuals.) I<.unnwi & Assaniaw - tireme 40,151271 business Assoeli , Commut (Scatti nday) (Rev.07/29/13j Page 5 of S vi) Make its policies and procedures, and documentation required by this subpart relating to such safeguards, available to the Secretary for purposes of determining the Covered Entity's compliance with 45 CFR Pam, 162 and 164 and; vi) Authorize termination of the contract by the Covered Entity if the Covered Entity' determines that the Business Associate has violated a material terns of the contract, 7nutiio, (a) The Term of this Agreement shall be effective as of the effective date herein and shall terminate when all of the PER provided by Covered Entity to Business Associate, or created or received by Business Associate on behalf of Covered Entity, is destroyed or retamted to Covered Entity, or, if it is infeasible to return or destroy PEE, protections are extended to such, information, in accordance with the tenmination provisions in this Section or on the date Covered Entity terminates for cause as authorized in paragraph (b) of this Section, whichever is sooner. (b) Upon Covered Entity's knowledge of a material Breach by Business Associate, Covered Entity s all provide an opportunity for Business Associate to cure the breach or end the violation and terminate this Agreem(nt. If the Business Associate does not cure the breach or end the violation within the time specified by Covered Entit); Covered. Entity shall have the right to immediately terminate this Agreement, Such termination shall. not abrogate any rights which Covered. Entity has against Business Associate for violation of this Agreement. (c) T.tTron termination of this .Agreement for anyreason, Business Associate, with respect to PH receivedfrom.C,overed Entity, or created, maintained, orreceived byBusiness Associate on behalf of Covered Entity, shall. Retain only that PI -11 which is necessary for Business Associate to continue its proper management and administration or to carryout its legal responsibilities; it) Return to Covered Entity (or, if agreed to by Covered Entity, destroy) the .remaining PI -11 that the Business Associate still maintains in anyfortm; iii) Continue to use appropriate safeguards and comply with the HUPAA Rules regarding the use and disclosure of the PT -11, for as long as Business Associate retains the PH; iv) Not use ordisclose the PFTs retained byBusiness Associate otherthan for the purposes for which such PER was retained and subject to the same conditions which applied prior to tertnination; and v) Return to Covered Entity (or, if agreed to byCovered Entity, destroy) the PINT retained by Busnress Associate when it is no longer needed by Business Associate for its proper m anagenrent and administration or to carry out its legal responsibilities, Nliscellan us (a) A reference in this .Agreement to a section m the Privacy Rule means the section as in effect or as amended, and forwhich compliance is required, Kdenhn &•. Aesoainlev— Licanen N(h15127 t Boiiaeas Asaocinru CQOUiiVr (Su,n¢aid8Y1 (Rea, 07/29/ 0) Pete 6 of 8 Cf mus (b) No modification, amendment, or waiver of any provision of this Agreement will be effective unless in writing and signed by the party to be charged. 7.1to Parties agree to take such action as is necessary to amend this Agreement front time to time as is necessary for Business Associate and Covered Entity to coinply with the requirements of the 11PA.A'Rules. (c) Any ambiguity in this Agreement shall be resolved in favor of a meaning that pernxits both parties to cornply with the F IPAA Roles and/or other applicable law, (d) Notices; (r) All reports or notices to Covered Entity (7ttrsuant to this Agreement shall be sent to the names and addresses listed on the signature page, or to such other individuals and/or addresses as a patty may later designate in writing. Unless expressly prohibited under the I IIPAA Ru(es, Such notices and reports may also be sent via email. (u) All such reports or notices shall be sent byPirst Class Mail or express courier service, and shall be deemed effective when delivered, or if refused, when delivery is attempted, (e) Nothing expressed or implied in this Agreement is intended to confer, nor shall anything herein confer, upon any person other than the Sponsor, Covered Entity, Business Associate, and their respective successors or assigns, any rights, remedies, obligations or liabilities whatsoever. (1) 71tis Agreement constitutes the complete agreement of the parties relating to the access, use, disclosure and sectuityof Pi -i and, except as otherwise provided herein, supersedes all prior representations or agreements, whether ornl or written, with respect to the confidentiality and, security of MR. (g) 'Ibe parties hereby agree and affirm that the Subject matter of this Agreement is unique, and that it maybe impossible to measure the damages which would result to Covered Entity from violations by Business Associate of the agreements set; forth herein. Accordingly, in addition to any other remedies which Covered Entity may have at law or in equity, the parties hereby agree that either party Shall have the right to have all obligations and other provisions of this Agreement specifically performed by the other party, as applicable, and that either party shall have the right to seek preliminary and permanent injunctive relief to secure specific performance, and to prevent a breach or contemplated breach, of this Agreement, without, in any case, proof of actual damages, (h) Disputes arising out of or relating to this Agreement which cannot be resolved by negotiation between the parties shall be submitted to non-binding mediation, if the dispute is not resolved through mediation, it shall l c resol ved by final atarl binding arbitt anon adanuris terecl byJAMS dispute resolution service pursuant to its Streamlined. Arbitration Rules and Procedures, or such other arbitration procedures as agreed to in writing by the Parties. Negotiation, mediation, and arbitration shall be the exclusive means of dispute resolution between the patties and their respective agents, employees and officers. The site of the arbitration shall be in Orange County, California. A judgment of anycourt having jurisdiction may be entered upon the award. IN WITNESS WHEREOF, the patties hereto hereby set their hands as of the date first above written. Keeotw & Assisdwn q - License 1:0.151371 13a9i1ess Assoaiatc Cuntracl (Scnrrertrnyl (Ib;v, 07/29/13) Page 7 of 8 Kmow S Associates - t.roense HU451271 Business Associate Cootrna (ScatteMay) (Rev, 07/29/13) Page 8 of 8 It Ott:, Keenan 8e A,ssociates City of Santa .Ana, as Sponsor and Representative of the Pisixx(s) Signature: Signature: By: _ See Attached 8igrnatnce� By: John Scattertlay Page Senior "Vice Nresident AcicYress: 20 Livia Ceretec 1'Yaray Address: 2355 Crenshaw Blvd., 5tc, M-24 200 Post Office Box 1988 FTelephone: 714 647.5340 Telephone! 310 T12-0363^ .Attention: Di'reetor of Pe:csonaxel V Attention: Privacy Officer Services Kmow S Associates - t.roense HU451271 Business Associate Cootrna (ScatteMay) (Rev, 07/29/13) Page 8 of 8 It Ott:, ATIUS7'. CYTY OF SrANI'eA AICA C: MARIA IIUIZAR Raul Godin Clerk of the Council City Manager APPROVED AS 1'0 FORM: SOMA R. CARVALHO City Attorney By: _.. _ pv I.,nura A,. Rossi�ai Senior Assistant City Attorney Executive Director of Human Resources MAYOR Miguel A. Pulido MAYOR PRG TEM Michele Martinez COUNCILMEMBERS P. David Benavides Vicente Sarmiento Jose Solorio Sal TlnaJero Juan Villages CITY OF SANTA ANA FINANCE AND MANAGEMENT SERVICES AGENCY Purchasing Division 20 Civic Center Plaza Santa Ana, California 92701 Phone: 714-647-6941 Fax: 714-647-6944 ACTING CITY MANAGER Gerardo Mouet CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Maria D. Huizer The Tax Equity & Fiscal Responsibility Act of 1982 and Backup withholding Regulations of 1983 require us to have a Social Security or Federal Tax Identification Number (TIN) on file for all vendors subject to form 1099 reportable payments. Please print, sign and return this form, along with your completed and signed W-9 (attached). Business Name I Lee G)(i B) rt kSD( DBA (if applicable) Purchase -Prom Address I,,,, r^� _VJ boa) Remit -To Address p ', C�Oc is w4_S PhAA'V ,tai_`, Phone - ...-__ �.,. ._ Fax ._ ffPmymrm Terms _ CQcL.f� .. . _ Its o Email Web Address tov), k e C in a YJ C o ytn Slpru Here Title r (P ax)C (4 Form " Request for Taxpayer L orm tome (Rev, December 2014) Identification Number and Certification ter. Do not oepanment of the Treasury o the 10 nternal Revenue Service k. 1 Nam��nhuwn on ourtncomu tax return). Name is required on this I lie do not leave this lino bank ( Y ) I 2 Oualnass narne/dleregarded entity name, If d4f trent from above m........,______.._.___.._.. _.... ro p' 3 Chuck appropriate box for federal tax classification; shock only one of the following cover, hones: 4 Eoth for ora (codes apply only to C oestrin ammo&, net irkfividaihq see o )� Indlwdlanl7sole proprietor or � C Corporation ❑ S Corporation ❑ Panner hip �� 7msVe ,tale Instruotione on page 3): wp o alis In member LLC Exempt Payee code (if any) F 0 (] lure eted Mobility company. Enter the tam classification (C=C corporation, S=S corporation, P=partnorshlp)------- o Exemption from FATCA reporting p lieke. For s ahlgle roof Has LLC oral Is number o nrded, do not cheek LLC', check the appropriate box in the Ilne above for Ilte 7nx classification of IIFe single Inamber tiwllcr. g code (If any) ,is 7d 5 Ci state, and pnn.x io .— c 1_ --- —d ,._ ......,,- � 8 Address nwltlber, street,and 1111 Or cotta no — � Requester's rlamd and address (optional) C Jj biz Enter your "FIN in the appropriate box. The 71N provided must match the name given on lino Ito avoid (somal samuny norm backup withholding. For individuals, this is generally your sci security number (SSN). However, for a resident allen, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it Is your employer Identification number (LIN). If you do not have a number, see How to get a 111 TIN on page 3. or Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for Employer iduntifioat guidelines on whose number to enter. Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to fie); and 2. I am not Subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that i am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified trio that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S, person (defined below); and 4. The FATCA couple) entered on this form (if any) Indicating that I am exempt from FATCA reporting Is correct. Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments ether than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions on pagro 3. _.. ..... Sign Signature of t ,%N HereU.S. personb "j General Instructions Section refm'ences safe the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release It) is at www.lrsgov/iw9, Purpose of Form All Individual or anhty(Fckm NI 9 lophr tll9l f who Is rebuked In file an 1niformdtfon rNb.imwith the lRt must cousin, yom t•odeet taxpayer khattfirrohon nurnbar.(TIN) which may be your social security upnni BIS", Individual taxpaynr rentlrorann number (111N) adoption Laxp lyaor WmAlllostiorl onrn0pr ATIN), or employer Iocirtilcnllol rumba, (E IN), to upon, on ail In9ornatfon rob.ini If is innounl paid to you, or other amount reportable on an information return, Exampbs of information returns include, but are not limited to, the following, • Form 1099 -INT (interest earned or paid) • Form 1099 -DIV (dividends, Including those from stocks or mutual funds) • Form 1099-MISC (various types of Income, prized, awards, or gross proceeds) • Form 1090-0 (stock or mutual fund sales and certain other transactions by brokers) = Form 1009-3 (proceeds from real estate transactions) • Farm 1099-K (merchant card slid third party network transactions) bates • Form 1096 (home mortgage Interest), 1096-E (student loan instant), 1099-T (tuition) a Form 1099-0 (canceled debt) • From 1099-A (acquisition or abandonment of seared properly) Use Form W-9 only if you are a U.S. person (including a resident al air), to provide your correct TIN. I( you do net return Form W 9 to the requester with a TIN, you might be subject to baclvp wirhltotding, See What 6a backup withholding? on page 2. By signing the filled -out form, you: I CmzMy-triial it,(, PIN-youNraytiving is woman (or you am- writing fma-rwanber _._.. to be issued), 2. Certgy that you are not sub(ect to backup withholding, or 3. Claim exemption from backup withholding if you are a U,S. exempt payee. It applicable, you are also certifying that as a U.S. person, your allocable share of any partnership Income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA shape) entered on this form (if any) Indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information. Cal. No. 10231 X Form W-9 (Rev. 12-2014) Electronic Fulgtis j ansferjEF"Trac AC 1IEJ-09Q—r9 Guldellri for Participants These guidelines apply to payees who elect to participate In the Electronic Funds Transfer (EFT or ACH) program offered by the City of Santa Ana. If you elect to participate In the City of Santa Ana's Electronic Funds Transfer program, payments formerly made by check will be made by electronic funds transfer through the Automated Clearing House (ACM) network. Use of Electronic Funds Transfer as a form of payment means funds will be available in your account within two buslness days from the date of payment. Identifying Your Bank Account • You must complete the Electronic Payment (ACH) Enrollment Form and on your organization's letterhead. • The Payee/Company Information section must be signed and dated by an authorized Individual in your organization. • The Bank/Financial Institution Information section must be signed by an authorized officer of the banklfinanclal institution. Setting Up Electronic Payments • Upon City of Santa Ana's receipt of the Electronic Payment (ACH) Enrollment Form, please allow up to two weeks for completion of enrollment process. Changing Electronic Payments • If the account designated for electronic payments hes changed, please submit a new Electronic Payment (ACH) Enrollment Form as soon as possible, using the some procedure, • If an electronic payment (ACH) Is returned to the City of Santa Ana due to unreported change of bank or bank account, the payment will be re -issued once the updated/correct bank information has been received and processed. Withdrawing from the Program • If you choose to cancel your electronic payment (ACM) enrollment, the City of Santa Ana muot be notified, In writing, on your organization's letterhead. • After rocel t of your withdrawal notification, it may take up to one week to process the request, All questions relating to the City of Santa Ana's Electronic Payments program should be directed to: Purchasing_AP(a>santa-ane, org. ACTINO CITY MANAGER MAYOR Gerardo Mouel Miguel A, Pullen MAYOR PRO TEM i arvk X�,z RNEY CSon Carve Mlohele Martinez COUNCILMEMBERa l pe �? e R. ho CLERK OF THE COUNCIL Marla D. Htdzei P. David Denavldes 0 vloonle sermlanto Jose solaria Sal Tlnalero Juanvlilegas CITY OF SANTA APIA FINANCE AND MANAGEMENT SERVICES AGENCY Purchasing Division 20 Civic Center Plaza Santa Ana. Calllornla 82701 Electronic Fulgtis j ansferjEF"Trac AC 1IEJ-09Q—r9 Guldellri for Participants These guidelines apply to payees who elect to participate In the Electronic Funds Transfer (EFT or ACH) program offered by the City of Santa Ana. If you elect to participate In the City of Santa Ana's Electronic Funds Transfer program, payments formerly made by check will be made by electronic funds transfer through the Automated Clearing House (ACM) network. Use of Electronic Funds Transfer as a form of payment means funds will be available in your account within two buslness days from the date of payment. Identifying Your Bank Account • You must complete the Electronic Payment (ACH) Enrollment Form and on your organization's letterhead. • The Payee/Company Information section must be signed and dated by an authorized Individual in your organization. • The Bank/Financial Institution Information section must be signed by an authorized officer of the banklfinanclal institution. Setting Up Electronic Payments • Upon City of Santa Ana's receipt of the Electronic Payment (ACH) Enrollment Form, please allow up to two weeks for completion of enrollment process. Changing Electronic Payments • If the account designated for electronic payments hes changed, please submit a new Electronic Payment (ACH) Enrollment Form as soon as possible, using the some procedure, • If an electronic payment (ACH) Is returned to the City of Santa Ana due to unreported change of bank or bank account, the payment will be re -issued once the updated/correct bank information has been received and processed. Withdrawing from the Program • If you choose to cancel your electronic payment (ACM) enrollment, the City of Santa Ana muot be notified, In writing, on your organization's letterhead. • After rocel t of your withdrawal notification, it may take up to one week to process the request, All questions relating to the City of Santa Ana's Electronic Payments program should be directed to: Purchasing_AP(a>santa-ane, org. Electronic Payment (ACH) Enrollment Form The City of Santa Ana must be notified of any bank account changes, Failure to notify the City Of such changes may result in your payment being delayed, Keeran lin16n fbayAl -of Add on JIM* Amount: vdHa C, cox 6, n m t o 6 SaiL — tSt,I HOftWcY PO4- 7urn -' 4— M E Ell E01 K Z�] E E T.p';—dtWIAccount ft-be,X21 Ca;;�06 Tjpt of Account: 0 Savings 11%6 I confirm the identity of the above-named payee(fl) and the account number and title, As repreventadve of the above-natned Aolancial in4uhlika), A, corUry-Qua. the aarcesAo receive and ctoposit 1ho paynnoro-IftnLiTIOd uIRIVO with 3IMParta 240, 209, and 210, Date; quMV: I Noun or: I p] 4y DATE (MM ID OIYYYY) CERTIFICATE OF LIABILITY INSURANCE Il/I/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS N-6 -RI _GHTS UPONTHE CERTIFICATE HOLDER. TIilS 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(8), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate Holder Is an ADDITIONAL INSURED, the policy(les) mustbe 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 AssuredPartners Northeast, LLC 123 Main Street 14th Floor White Plaine NY 10601 ___ RED ._- _ _ INSU Keenan & Associates C/O AssuredPartners, Inc. 200 Colonial Center Parkway T.aka Mery FL 32746 Jeanne Vezina (914)761-9000_. _(9141761 444 3749 a® JVeZinskeg.com _ IN$URER(S-fAFFORpING COVERAGE.. _, NA Charteroak Fire ,-,.___ 2_561 Travelers Indeaa?1ty Co. ,2565 Travelers Prop Casualty 'Co. of Am., 2567 ,Federal Insurance Co, _. _ 2028 10VERAGES CERTIFICATE NUMBER CL179_2895998 HL-VISIUN NUMuetc: THIS IS TO CERTIFY THAT 'rHE 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. I�tt TYPE OF INSURANCE ADD X COMMERCIAL GENERAL LIABILITY A 7 , CLAIMS -MADE ` X. OCCUR III x GEN L AGGREGATE LAMP APPLIES PGI2'. X POLICY F� J1 -Cr L 1 IOC 4 AUTOMOBILE LIABILITY B x ANY AUTO ALL AUTOS OWNED 3 `HIREDAUTOS I_ X I UMSRMA A LIAR I X OCCUR C F.xCE58 LIAfl CLAIMS C D 1 Raployas Theft 6301C226996 HA330p0750 ..n,- CUP9J434350 IA VB304e1072-17 -_.J-.__-_.._.. 10225-9951 10/1/20171 10/1/281.9 PERSONALdADV INJURY I 10/1/2019 10/1/2019 BODILY INJURY(P0raccdsnt) $ PROPEIH[Y RAMAUE $ a 10/1/2017 10/1/2018 EL FACIIACCID 10/1/2017 10/1/2018 E,1_01 SEAS E -E EL DISEASE - P' 10/1/2017 10/1/2010 1 $10,000,0001-imlt 11000,000 11000,000 10,000 1,000,000 7.,000,000 2,000,000 1,000,000 25,000 $100,000 Ded. '_-0— ___ _.... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AGGRO IDt, Additional Ramarks Schedule, may bo mtNehetl If more specs Is reyulredl The City of Santa .Ana, its officers, employees, agents, and representatives included as additional insured with respects to General Liability per endorsement kCG D2 47 08 05 (Copy Attached). Coverage is primary non-contributory. 30 Day Notice of Cancellation Applies. City of Santa Ana 20 Civic Center Plaza Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TNF POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ©1988-2014 AC( ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD 11,18025(C11401) PROD17CT5 COMPIOP AJ)i BODILY INJURY(Por e,1 10/1/2019 10/1/2019 BODILY INJURY(P0raccdsnt) $ PROPEIH[Y RAMAUE $ a 10/1/2017 10/1/2018 EL FACIIACCID 10/1/2017 10/1/2018 E,1_01 SEAS E -E EL DISEASE - P' 10/1/2017 10/1/2010 1 $10,000,0001-imlt 11000,000 11000,000 10,000 1,000,000 7.,000,000 2,000,000 1,000,000 25,000 $100,000 Ded. '_-0— ___ _.... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AGGRO IDt, Additional Ramarks Schedule, may bo mtNehetl If more specs Is reyulredl The City of Santa .Ana, its officers, employees, agents, and representatives included as additional insured with respects to General Liability per endorsement kCG D2 47 08 05 (Copy Attached). Coverage is primary non-contributory. 30 Day Notice of Cancellation Applies. City of Santa Ana 20 Civic Center Plaza Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TNF POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ©1988-2014 AC( ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD 11,18025(C11401) POLICY NUMBER:6301C226998 COMMERCIAL GENERAL LIABILITY ISSUE DATE: 10-01-2017 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE NAME OF PERSON(S) OR ORGANIZATION(S): The City of Santa Ana, its officers, employees, agents, and representatives PROJECTILOCATION OF COVERED OPERATIONS; 20 Civic Center Plaza Santa Ana, CA 92701 1. WHO IS AN INSURED - (Section II) is amended to include the person or organization shown in the Schedule above, but: a) Only with respect to liability for "bodily injury", "property damage" or "personal injury; and b) If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor In the performance of "your work" on of for the project, or at the location, shown in the Schedule. The person or organization does not qualify as an addi- tional insured with respect to the independent acts or omissions of such person or organiza- tion. 2, The insurance provided to the additional insured by this endorsement is limited as follows: a) In the event that the Limits of Insurance of this Coverage Part shown in the Declarations exceed the limits of liability required by a "written contract requiring insurance" for that - - additional insured, the insurance provided to the additional insured shall be limited to the limits of liability required by that "written con- tract requiring Insurance". This endorsement shall not increase the limits of insurance de- scribed in Section III - Limits Of Insurance. b) The insurance provided to the additional In- sured does not apply to "bodily injury", "prop- erty damage" or "personal injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or sur- veying services, including: I. The preparing, approving, or failing to prepare or approve, maps, shop draw- ings, opinions, reports, surveys, field or- ders or change orders, or the preparing, approving, or failing to prepare or ap- prove, drawings and specifications; and ii. Supervisory, Inspection, architectural or engineering activities. c) The insurance provided to the additional in- sured does not apply to "bodily injury' or "property damage" caused by "your work" and included in the "products -completed op- erations hazard" unless a "written contract requiring insurance" specifically requires you to provide such coverage for that ddditionaJ__ insured, and then the insurance provided to the additional Insured applies only to such "bodily injury" or "property damage" that oc- curs before the end of the period of time for which the "written contract requiring insur- ance" requires you to provide such coverage CG D2 47 08 05 Q 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2 COMMERCIAL GENERAL LIABILITY A 4. or the end of the policy period, whichever is earlier. The Insurance provided to the additional insured by this endorsement is excess over any valid and collectible 'other insurance", whether primary, excess, contingent or on any other basis, that is available to the additional Insured for a loss we cover under this endorsement. However, if a "written contract requiring insurance" for that ad- ditional insured specifically requires that this in- surance apply on a primary basis or a primary and non-contributory basis, this insurance is pri- mary to 'other insurance" available to the addi- tional insured which covers that person or organi- zation as a named insured for such loss, and we will not share with that 'other insurance". But the insurance provided to the additional insured by this endorsement still is excess over any valid and collectible 'other insurance", whether pri- mary, excess, contingent or on any other basis, that is available to the additional insured when that person or organization is an additional in- sured under such other insurance". As a condition of coverage provided to the additional insured by this endorsement: a) The additional insured must give us written notice as soon as practicable of an "occur- rence" or an offense which may result in a claim. To the extent possible, such notice should include: I. How, when and where the 'occurrence" or offense took place; it. The names and addresses of any injured persons and witnesses; and iii. The nature and location of any injury or damage arising out of the "occurrence" or offense. b) If a claim is made or "suit' is brought against the additional insured, the additional Insured must: I. Immediately record the specifics of the claim or "suit" and the date received; and ii. Notify us as soon as practicable. The additional Insured must see to It that we receive written notice of the claim or "suit' as soon as practicable. c) The additional insured must immediately send us copies of all legal papers received In connection with the claim or "suit', cooperate with us in the investigation or settlement of the claim or defense against the "suit", and otherwise comply with all policy conditions. d) The additional insured must tender the de- fense and indemnity of any claim or "suit' to any provider of "other Insurance" which would cover the additional insured for a loss we cover under this endorsement. However, this condition does not affect whether the insur- ance provided to the additional insured by this endorsement is primary to 'other insur- ance" available to the additional insured which covers that person or organization as a named insured as described in paragraph 3. above. 5. The following definition is added to SECTION V. — DEFINITIONS: "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or organization as an additional In- sured on this Coverage Part, provided that the "bodily Injury" and 'property damage" oc- curs and the "personal injury" is caused by an offense committed: a. After the signing and execution of the contract or agreement by you; b. While that part of the contract or agreement Is in effect; and c. Before the end of the policy period Page 2 of 2 0 2005 The St. Paul Travelers Companies, Inc. CG D2 47 08 05 POLICY NUMBER 63010226998 ISSUE DATE: 10/1/2017 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, DESIGNATED ENTITY -NOTICE OF CANCELLATION PROVIDED BY US This endorsement modifies Insurance provided under the following: .i ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCfiP.t2U1,F. I�I I CANCELLATION: Number of bays Notice of Cancellation: 30 PERSON OR ORGANIZATION: The City of Santa Ana, its orfI :ers, employees, agents, and representatives 1 ADDRESS: 20 Civic Center Plaza Santa Ana, CA 92701 PROVISIONS: If we cancel this policy for any statutorily permitted above. We will mall such notice to the address shown reason other than nonpayment of premium, and a In the schedula above at least the number of days number of days is shown for canoollatlon In the shown for cancellation In the schedule above before sehed0s above, we will mall notice of cancellation to the effective date of cancellation, the person or organization shown In the sohedule IL T4 06 03 11 v vii'rhe Travelers Indemnity ownpuny. All rights m5erved, Pegg 1 of 1