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HomeMy WebLinkAboutSASSOON, MAUREEN, DR., MS, MPHINSURANCE ON FILE WORK MAY PROCEED UNTIL INSIUR�ANCE EXPIRES CLERKK CIF COUN DATE AUG 14 2019 ®� 'mot rAr+u�. AGREEMENT WITH MAUREEN SASSOON, MS. MPH TO PROVIDE OCCUPATIONAL AND ENVIRONMENTAL HEALTH V �w� AND SAFETY CONSULTING SERVICES THIS AGREEMENT is made and entered into this I' day of August, 2019 by and between Dr. Maureen Sassoon, MS, MPH ("Consultant'), 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 consultant having special skill and knowledge in the field of occupational and environmental health and safety consulting services. B. Consultant represents that it is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional in the same field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terns and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES Consultant shall perform those services relating to occupational and environmental health and safety consulting services including but not limited to those services set forth in Exhibit A, attached hereto and incorporated herein by reference. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit B. The total sum to be expended under this Agreement, shall not exceed $50,000 during the term of this Agreement. b. City acknowledges that agreement includes payment for services rendered between July I, 2019 through July 31, 2019. C. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 3. TERM This Agreement shall commence on the date first written above and terminate on June 30, 2021, unless terminated earlier pursuant to Section 12, below. The term of this Agreement may be extended upon a writing executed by the City Manager and the City Attorney for tip to one (])year. 45703vl N-2019-144 4. INDEPENDENT CONTRACTOR Consultant 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 Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to its employees and shall be responsible for all applicable withholding taxes. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance which shall include, but not be limited to protection against claims arising from bodily and personal injury, includingdeath,resulting therefrom and damage to property, resulting from any act or occurrence arising out of Consultant'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); and (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City. b. Worker's Compensation Insurance. In accordance with California State law, Consultant, if Consultant 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, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. c. Professional Liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim and $2,000,000 annual aggregate shall be maintained. d. The following requirements apply to the insurance to be provided by Consultant 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. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City. (ii) 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. #5703vl (iii) If the Consultant maintains broader coverage and/or higher limits than the minimums described above, the City requires and shall be entitled to the broader coverage and/or higher limits maintained by the Consultant. e. If Consultant 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 !it force and paid for, the City shall have the right, at the City`s election, to terminate this Agreement. Such termination shall not affect Consultant's right to be paid for its time and materials expended prior to notification of termination. Consultant 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 Consultant agrees to and shall indemnify; defend, and hold harmless the City, its officers, agents, employees, consultants, counsel, and representatives from liability for personal injury, damages, just compensation; restitution; judicial or equitable relief arising out of claims: (1) for personal injury, including death, and claims for property damage, arising from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on its behalf which relates to the services described in Section I of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution; judicial or equitable relief is due by reason of effects arising from this Agreement. 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. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for counsel to be selected by the City, regarding any action by a third party asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises 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. CONFIDENTIALITY If Consultant received from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use orldisclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information; but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant and disclosed without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without reference to information disclosed by the City. #5703vl 8. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interest and shall not Have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 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 facsimile or other telegraphic communication in the manner provided in this Section, to the following persons To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. BOX 1988 Santa Ana, California 92702-1988 Facsimile (714) 647-6956 Copies to: Executive Director of Human Resources City of Santa Ana 20 Civic -Center Plaza (M-24) P.O. Box 1988 Santa Ana, California 92702 Facsimile (714) 647-5311 To Consultant: Dr. Maureen Sassoon, MS, MPH P.O. Box 2028 Palos Verdes Peninsula, CA 90274 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 facsimile, 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 asset 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 Consultant 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 and will serve to fully supersede existing Agreement. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant. The parties agree that any terms or conditions of any #5703vl purchase order or other instrument that are inconsistent with, or in addition to, the terms or conditions hereof,shall not bind or obligate Consultant nor 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 are not embodied herein. 11. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant 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. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 12. TERMINATION This Agreement may be terminated by the City with thirty (30) days written notice of termination to the Consultant. a. As a condition of such payment, the City may require Consultant to deliver to the City al I the work product completed as of such date, and in such case such work product shall be the property Of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work that fails to meet the standard of performance specified in the Recitals of this Agreement. 13. NON DISCRIMINATION Consultant shall not discriminate because of race,, color, creed, relation, sex; marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities or any activities under this Agreement. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 14. 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. 15. PROFESSIONAL LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision ofthe services hereunder and required by the laws and regulations of the United Sates, the State of California, the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of #5703vl its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: DAISY GOMEZ Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: CkMN P 'k- f-, LAURA RPSSINI Senior Ass tans City FOR APIROdVAL: Executive DireLkor Human Resources Agency #5703v1 CITY OF SANTA ANA 1;i KRISTINE RIDGE �` City Manager CONSULTANT DR. MAUREEN SASSOON, MS, MPH ?02NX EXHIBIT A &D=—of Provided by Dr. Maureen Sassoon, CIH to the City of Santa Ana I. Conducting the City Safety Committee Meetings, pursuant to the City's Injury, Illness Prevention program (IIPP), approximately six times per year. 2, Employee Health & Safety Training (i.e., Cal -OSHA mandated training) for City employees covering such topics as respiratory protection, hearing conservation, emergency action/fire response, hazard communication, hazardous waste, confined space, lockout/block out, supervisor safety inspections and accident investigations and hands-on defensive driving on private property. 3. Inspection services as needed by a Certified Asbestos Consultant; per the State of California. 4, Inspection services as needed from a Lead -Certified California Department of Public Health Consultant, 3, A City -Wide Safety Inspection. 6, Advising the City and if necessary participating in representing the City's interests in issues involving Cal -OSHA, 7, Other third -party health and safety services on an as needed/required basis (i.e., employee work station er onamic P, Ar +' " ` nr t,• my g saa uau.5,indc�.�ra1'.y c,n•ve�G �nii"iiriice _.__ surveys) as requested by Risk Management and/or Human Resources, 8. Conduct an audit of the existing loss control programs with recommendations for changes, as deemed necessary. 9,0ther tasks as requested by the Executive Director of Human Resources or her designee. Exhibit B FEE AGREEMENT FOR OCCUPATIONAL & ENVIRONMENTAL HEALTH & SAFETY CONSULTING SERVICES DR. MAUREEN SASSOON, MS, MPH Certified Industrial Hygiene Fees: 3101544-2912 I. General industrial hygiene services (excluding legal cases) are charged at a rate of $175/hour, portal-to-portal, with a 4-hour minimum. Additional charges, such as but not limited to: equipment and laboratory fees, printing and duplicating fees, data base fees (i.e., such as are associated with Phase I research), and travel related fees (i.e., airfare, hotel, car rental) are charged to the client per associated incurred cost, if the client pays them direct or up front, otherwise there is a 10% mark-up. Invoices are submitted monthly, for services rendered, and are expected to be paid in -full, within 30 days of the invoice date. Account balances not paid within 30 days are subject to a 1.5% monthly service charge, on the remaining balance. 2. General office work, report writing and research are charged at $175/hour. 3. Legal Cases, including preparation, document review, research, industrial hygiene surveys and all other related work including Court time (with or without testimony) and Depositions are charged at a rate of $450/hour, with a 4-hour minimum, plus expenses if outside the greater Los Angeles area. 4. Deposition and Court fees are due at the beginning of each day. If you agree to these by US PS to Dr. Mau Company: JCY1 V . �t (Print Name) (Effective: December 2014) s and conditions, please sign and date at the bottom and reply Sassoon at PO Box 2028, PVP, CA 90274. Date Title CXFcui-lVL trtcfw of AAMavu 0 __ ACORD 25 (2016103) DRMAU-1 CERTIFICATE OF LIABILITY INSURANCE I DA^'(MWDDIYYYY) 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 pollcy(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 darts to the certificate holder in lieu of such endorsement(s). Brokers INSURED Dr. Maureen Sassoon P O Box 2028 Palos Verdes Peninsula, CA 90274 INC. .g u: 310.524-1357 �vc ,Nv1,949-313-3323 CAoMSS, carole.ml�hell@sig.us INSUNER(S) AFFORDING COVERAGE._. NAICB INSURER A: Westchester Surplus Lines Ins_ _ ,10172 INSURER e : INSURER C : INSURER 0: E rout --Donee reor.nrArc Unseneo. 1 ncv(mnM un uDr_n. 2 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, MBR TYPE OF INSURANCE ISSRDDL,'UPOLICY NUMBER POLICY EFF POLICY UP LIMITS A X COMMERCML GENERAL UARRITY EACH OCCURRENCE IS 1,000.000 . CLMMS-MAOE ix, 1 OCCUR y Y G24270427008 OT/0112019 07/01/2020 DAMAGE TO RENT°i S 50,000 MED EXP(Any one pamml ;S 5,000 X Prof 8, P011ut-CLM 1,000,000 PFRSONAL A ADV INAIRY S (it: NL AGGHIrGATF LIMIT APPI. IESPERI GFNFRALAGGREGATE S 2,000,000 X POLICY jCa LOC PRODUCTS -COMPIOP AGO IS 2,000.000 _ -IS I (nlFl AUTOMOOILELIABWTY COMBINED SINGLE LIMIT ISFA Err.Mem1_ S.. ANY AUTO BOmLY INJVRY (Pe[pgSPP) 5 OWNED SCHEDULED AUTOS ONLY AUTO.pSSWWqq BODILY INJURY(P., amMMl) S ,.. .. AUM0.50N OY AUTOB P40FER Y DAMAGE ONLY . UMBRELLA LIAR IOCCUR EACH OCCURRENCE 5 EXCESS LVIB ICWMS-MADE ArngcgATF $ RETENTIONS A _ _DED J WORKERS CONVERSATION ANDEMPLOYERS' LIABILTY ", _ PI'It OTH- "rARHI" :FR YIN ANY "EXECUTIVE 'NIA F I. EACH ACCIDENT S ICEgqO,dPM,RITETO�RpENGWUEOi ImmMlory IA NH)---' F I. nISFASE - EA EMPLOYEE S II Vee, dssetlW pnMr __..... pFSC91PT10 OF OP RATIONR trhN FI. _DISFASE- LILY LIMIT S 'A Professional Llab 024270427008 07/01I2019 07I01/2020 Prof,Liab 1,000,000 A IContractore Poll 07/0112019 07/01/2020 Pollution 1,000,000 DESCRIPTION OP OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Addlllprwl Remarks Schetlulp, mry be slbchptl II mpro specs b unnlmdL Policy Provides 30 days 10 days for nonpayment REVIEWED & APPROVED notice of cancellation oxcept Endorsements Attached are Applicable where required by Written B RiSk MANAGEMENT DNIsION Contract.Cit, of Santa Ana, officers agents, employees and volunteers are named as additionally insured on I(As policy pursuant to written contract y agreement or memorandum of understanding. Such Insurance as is (NOTL) IN 20191Q RTIFI(:ATE HOLDER CSANTAA City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 1AUTHORQ-ED REPRESENTATIVE 91988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ....., I --.-..— SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MOWER CODE CSANTAA DRMAU-1 NOTEPAD: i„SUREDa„AMe Dr. Maureen Sassoon OP ID: C6 afforded by this policy shall be primary, and any insurance Carried by the City shall be excess and noncontributory. PAGE 2 D•t^ 0711712019 By Risk M N &EAPPROVED1 JUL 17 2019 FRANCINE R. VILLAREAL Named Insured Endorsement Number Dr. Maureen Sassoon Poky Symbol Polley Numbor policy poriod Effective Date of Endorsement ECP G24270427 008 07/01/2019 to 07/01/2020 07/01/2019 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company mean me panty number. The nemelnder of the Imormetion is to be completed only when this endonemeol Is Issued subsequent to the preperallan of me policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Nome of Person or Omanizoliorr Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement wit be shown in the Declarations as applicable to this ouwreenieut./ The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or your work done under a contract with that person or organization and included in the products -completed operations hazard. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain the same. REVIEWED & APPROVED By Risk MANAGEMENT DIVISION U 17 2019 FRANCINE R. VILLAREAL ENV-3143 (03A5) Includes copyrighted material of Insurance Services Office, Inc. with Its permission Page 1 of 1 Named Insured Endonemant Number Dr. Maureen Bassoon PolicySymbol Policy Number e URM of Endorsement ECP G24270427008 07/01/2019to 07/01/2020 07/01/2019 Issued By (Name of Insurance company) Westchester Surplus Lines Insurance Company Inert the porey municer. The remalMarof Me Informa Ion Is to be completed only when We endorsennnt Is law" subsequent b Use prepandon of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT OWNERS, LESSEES OR CONTRACTORS —SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Oroanization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) A. SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to bodily Injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. REVIEWED & APPROVED By Risk MANAGEMENT DIVISION JUL 17 2019 �1t10 O.nf� ti��_ FRANCINE R. VILLAREAL ENV-3100 (08-04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 Named Insured Endorsement Number Dr. Maureen Sassoon Policy symbol Policy Number Peter Period Effective Date of Endorsement ECP G24270427008 07/01/2019to 07/01/2020 07/01/2019 slued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company lnserlthapollcynumber. The romeh,der ofths fnrormetion is to ba completed only amen leis endorsamenl Is Issued wbse ent to de pmpamllon of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT - OWNERS, LESSEES OR CONTRACTORS (PRIMARY AND NON-CONTRIBUTORY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as appucabte to this endorsement.) SECTION II - WHO IS AN INSURED Is amended to include: A. SECTION 11 - WHO IS AN INSURED is amended to include as an Insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion Is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after. (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional Insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the Injury or damage arises has been put to Its intended use by any person or organization other than another contractor or subcontractor engaged in perforating operations for a principal as a part of the same project. C. The coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. REVIEWED & APPROVED By Risk MANAGEMENT DIVISION JYUJ 17 2019 FIR NCINE R. VILLAREAL ENV-3101 (08-04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 ALL KNOWN OR REPORTED INCIDENTS EXCLUSION Named Insured _ Endoreamont Number Dr. Maureen Sassoon Policy Symbol Policy Number Policy Pedatl Effect" Dataof Endorsement ECP G24270427008 07/01/2019to 07/01/2020 07/01/2019 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY CONTRACTORS POLLUTION LIABILITY PROFESSIONAL LIABILITY This Insurance does not apply to bodily Injury, property damage, personal and advertising Injury, or pollution conditions from any incident, claim, suit, act, error, omission or accident: 1) of which the insured is aware, or reasonably should have been aware; or 2) committed by the insured or alleged to have been committed by the insured which is known or reported to the insured, his agent, broker or insurance company prior to the inception date of this policy are excluded from coverage under this policy. All other terms and conditions remain the same. REVIEWED & APPROVED By Risk NIANACEMEN7 EIMSION f pp 17 "'o �1- �RANCINE R. VIL.LAREAI. ENV-3103 (12/10) ®Chubb. 2010. All fights reserved. Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT— PRODUCTS -COMPLETED OPERATIONS HAZARD Nam e nsumd Endorsement Number Dr. Maureen Sassoon Potlry symbol Polley Number Poley Perbd LMMO Date of Endorsement ECP G24270427008 07l01l2019to 07/01/2020 07/01/2019 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request Is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section 11— Who Is An Insured is amended to include as an additional insured the person(s) or organizations) shown in the Schedule, but only with respect to liability for bodily injury or property damage caused, in whole or in part, by your work performed for that additional insured and included in the products -completed operations hazard. All other terms and conditions remain the same. REVIEWED & APPROVED By Risk MANAGEMENT DMSION JU , 17 2019 =ERANCINE R. VILLAREAL ENV-3225 (10-08) Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT— PRODUCTS -COMPLETED OPERATIONS HAZARD PRIMARY & NON-CONTRIBUTORY Named Insured Erulon:emenl Number Dr. Maureen Sassoon Policy symbol Policy Number Policy Period - EHeclive Date of Endoreement ECP G24270427008 07/01/2019to 07/01/2020 07/01/2019 ISSaed By(Name of insurance company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section It —Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily Injury or property damage caused, in whole or In part, by your work performed for that additional insured and included in the products -completed operations hazard. Furthermore, the coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. All other terms and conditions remain the same. REVIEWED & APPROVED By RISk MANAGEMENT DIVISION ^_ JUL 17 2019 (I f 0 .ytl � n �. n FRANCINE R. VILLAREAL ENV-3226 (10-08) Page 1 of 1 WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury, the (Nemernee) following declaration: I certify on behalf of I tAtjgftsA that during the term of my 11n... ham/Company Name) contract for SU LTi n) (-� 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: O t — By: Name�j( (MC�.u�{Ey\ Title: Telephone: \o 'S4,�} &.C112k. 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 ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. RE RIEIWM D & MPPRENTpO s oD DRMAU-1 OP 10. CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rohts to the certiOcatR hold. I. liou „ f m„-H nnAnaemm�n Hel PRODUCER Brakke Schafnitz Ins. Brokers License #OK07568 , 12th Floor ,90401 INSURED Dr. Maureen Sassoon V P O Box 2028 Palos Verdes Peninsula, CA 90274 WSURERF- COVERAGES CFRTIFICATF NI IMRFR- 1 D V, O 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WBR TYPE OF INSURANCE LBU POLICY NUMBER POUCYEFF POUCYEXP LWn9 A X COMMERLULL GENERAL LIABILITYV CWMS.MADE �X OCCUR Y Y G24270427009 07/01/20)R 07/01/20 EACH OCCuRRENCE 1,DO0.000 MADE TO RENTED 50,000 5,000 M D UP pn w anon X Prof & Poflut-CL119 PERSONAL fl ADV INJURY - 1,000,000 INL AGORE AT�EpPURnMpIIT ES PER X PDLICY IuIJECT II Lac GENERA -AGGREGATE 2,000,000 PRODu7TS-COA4PQPAO0 I 2,000.G00 O AUTOMOBILE UASILRY COMBINED SINGLE LIMIT ANYrr11AUTO OPUTOSEDOM.Yq�O OILED �� �pµpWl.�oBO ONLY BO I V INJURY x VRRITT U PerAUTOSONLYAUTOS ��'tlmt AMFGE UL®RELLA LMa OCCUR EACH OCCURRENCE S EXCESS LAS CLAIM&MODE AGORE-rATE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' DABIU1Y ANY PROPRIETORIPARTNER/E%ECUTNE OFFICEEMBER EXCLUDED? 1IMM�e �I�n AN'�R)) Ilya;R"1F ON 1"O DESC ONOF OPERATONS law NIA I PER OTH• I STATUTE 91. H ACCIDENT 015 - EA EMPLOYEE E L DISEASE- POLO I A Professional Llab 024270427009 07/01/2020 07/01/2021 Prof.Liab 1,00000 A Contractors Poll 07/0112021 07JO112021 Pollution 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, AMMOnal Wmar SchadW.. may be ahzcheU If — v.. Ic Policy Provides 30 days notice of cancellation except 10 days for nonpayment ✓ Y K1skMANAQEMENTDiViSiON Endorsements Attached are Applicable where required by Written f Contract.C! of Santa Ana, officers, agents, employees and volunteers are �',Il'y�r� named as additionally insured on this policy pursuant to written contract, J�({j�/ y 9 2020 agreement or memorandum Of understanding. Such Insurance as is (NOTE) ANCIiE ACEVEEIO CSANTAA City of Santa Ana Risk Management Division 20 Civic Center Plaza 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. AUMORIZEDR,EPRREE�SENTATNE AGUKU 2012u1 emJ) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered mauls of ACORD W NOTEPAD. XOLOERCWE CSANTAA DRMAU-1 PAGE2 INSDaED'S NAME Dr. Maureen Sassoon _ OP ID: C6 Dno 06/0412020 afforded by this policy City shall becyshall be primary, and any insurance carried by the excess and noncontributory. REVIEWED & APPROVED By Risk MANAGEMENT DIVISION J p 9 2020 ANGIE ACEVEdO Westchester A Chubb Company ADDITIONAL INSURED ENDORSEMENT — ONGOING WORK OR OPERATIONS Dr. Maureen Sassoon ECP I G24270427 009 1 07/01/2020 to 07/01/2021 Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE: Name of Person(s) or Organization(e): As required by written contract, prior to a loss to which this insurance applies (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) A. SECTION II - WHO IS AN INSURED is amended to include as an additional insured the persons or organizations shown in the Schedule, but only with respect to liability for injury or damage, to which this insurance applies, caused, in whole or in part, by: I. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insureds. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: Exclusions This insurance does not apply to injury or damage occurring after: a. All work or operations, including materials, parts or equipment furnished in connection with such work or operations, on the project (other than service, maintenance or repairs) to be performed by you or on your behalf at the site of the covered operations has been completed; or b. That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or pp�� gng�g performing operations for the additional insured as a part of the same p U Ot PANED ENV-3250(12/18) Includes copyrighted material of insurance Services office, Inc. with its pennisci y Risk MANAGPOPIDRLiSiON (221012.1) JU 9 2020 ANGiE ACEVE& Westchester A Chubb Company C. With respect to the insurance afforded to these additional insureds, the following is added to SECTION III — LIAIM OF INSURANCE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. All other terms and conditions of this policy remain unchanged. REVIEWED & APPROVED BY Risk MANAGEMENT MWON JU�_9 2020 —A—NGiiEE A'CCEVEdo ENV-3250 (12/18) Includes copyrighted material of Insurance services Office, Inc. with its permission Page 2 of 2 (221012.1) Westchester A Chubb Company ADDITIONAL INSURED ENDORSEMENT — PRODUCTS -COMPLETED OPERATIONS HAZARD Named hu tred Endorsement Number Dr. Maureen Sassoon Policy Symbol Policy Number Policy Period Effective Date of Pndotsemenl ECP G24270427 009 07/01/2020 to 07/01/2021 07/01/2020 Issued oy(Name of hu mane Company) Westchester Surplus Lines Insurance Company Iruertthe policy number. The remainder of the information is to be completed only when this andomniont is Issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: As required by written contract, prior to a loss to which this insurance applies (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for injury or damage, to which this insurance applies, caused by or resulting from your work performed for that additional insured and included in the products -completed operations hazard, and only to the extent that such injury or damage is caused, in whole or in part, by your negligence or the negligence of those acting on your behalf. However: 1. The insurance afforded to such additional insured only applies to the extent permitted bylaw; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to SECTION III - LIMITS OF INSURANCE: If coverage provided to the additional insured is required by a contract or agreement, the Iy�q�t.we will ay on behalf of the additional insured is the amount of insurance: KtV�E�/E(��1 APPROVED 1. Required by the contract or agreement; or By Rlsk MANACWMEW DivisiON 2. Available under the applicable Limits of Insurance shown in the Declarations; JUN 2,A 2020 whichever is less. ---�_ This endorsement shall not increase the applicable Limits of Insurance shown in the DeclarationsANG1E ACEVEdO All other terms and conditions of this policy remain unchanged. ENV-3251 (12/18) Includes copyrighted material of Insurance services Office, Inc. with itspermission Page 1 of 1 (221012.2) Westchester A Chubb Company PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION Named Insured Endorsement Number Dr. Maureen Sassoon Pot-Symhol Policy Number Polity Period Efhstive Date of Endorsement ECP G2427o42y 009 0�/01/2o2o to 07/01/2021 07/01/2020 Issued By @lame of Imurance Company) Westchester Surplus Lines Insurance Company Wert the policy number. The remainder of the information is to be camDleted Doty when [his endorsement ri issued subsequent to the preparation of the polity. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary and Noncontributory Insurance This policy is primary to, and will not seek contribution from, any other insurance available to an additional insured under this policy, provided that: a. The additional insured is a named insured under such other insurance; and b. You have agreed in a written contract or agreement that this insurance would: (1) act as primary insurance; and (2) would not seek contribution from any other insurance available to the additional insured. All other terms and conditions of this policy remain unchanged. REVIEWED & APPROVED By RISk MANAGEMENT DIVISION JUN 1020 ANgiE ACEVEdO ENV-3252 (12-18) Includescopy6ghted material of Insurance Services Office, Inc. with its permission Page 1 of 1 (266562.1) Named Insured Endorsement Number Dr. Maureen Sassoon Policy Symbol Policy Number Policy Period Effective Data of Endorsement ECP G24270427 009 07/01/2020 to 07/01/2021 07/01/2020 Issued By (Name of Insurance company) Westchester Surplus Lines Insurance Company insen me polcy numoer. I ne rsnNlnder of the Information is to be completed only when this endorsement is issued subsequent to the Praparstlun of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Omanizafion� As required by written contract, prior to a loss to which this insurance applies - - •-•1-r•r W,. 1"u j� t... Ulllfilum ens enuulsernent win oe snown in the ueclarations as applicable to this endorsement) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or your work done under a contract with that person or organization and included in the products -completed operations hazard. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain the same. REVIEWED & APPROVED By Risk MANaGEMENT Division JU 2020 ANC1iE ACEVEdO ENV-3143 (03-05) Includes copyrighted material of Insurance Services Office, Inc. with Its permission Page 1 of 1 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s Location And Description Of Completed O erations As required by written contract, prior to a loss to which this insurance applies N/A Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for 'bodily injury" or "Property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the 'products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and B. VVith respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement, or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the 2. If coverage provided to the additional insured Declarations. is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 0413 © Insurance Services Office, Inc., 2012 REVIEWED & APPROVED By Risk MANAGEMENT DivtSiON JU 2020 ANGIE ACEVEdO Page 1 of 1 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Locations Of Covered O rations Or Organization(s) () Pe As required by written contract, prior to a loss to NIA which this insurance applies will be A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury', "property damage" or "personal and advertising This insurance does not apply to "bodily injury" or "property injury" caused, in whole or in part, by: damage" occurring after. 1. Your acts or omissions; or 1. All work, including materials, parts or 2. The acts or omissions of those acting on your equipment furnished in connection with such work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations on behalf of the additional insured(s) at the for the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the 1. The insurance afforded to such additional injury or damage arises has been put to its intended use by any person or organization insured only applies to the extent permitted by law; and other than another contractor or subcontractor engaged in performing 2. If coverage provided to the additional insured operations for a principal as a part of the is required by a contract or agreement, the insurance afforded to such insured same project. &APPROVED additional will not be broader than that which you are REVIEWED By RISK MANAgEMENT DIVISION required by the contract or agreement to provide for such additional insured. J U!N 2020 ANC{IE AcEvEdO CG 20 10 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. REVIEWED & APPROVED By Risk MANAgEMENT DiviSiON JUN 9 2020 ANCIE ACEVEdo Page 2 of 2 ® Insurance Services Office, Inc., 2012 CG 20 10 04 13 CITY OF SANTA ANA RISK MANAGEMENT a Liaret x 4 HUMAN RESOURCES Managing Risk emw9n Posktve Change WORKERS' COMPENSATION DECLARATION hereby affirm under penalty of perjury, the (Name/Title) following declaration: certify on behalf of 't ,;, , W\t}21��;_i that during the term (Consultant/Company Name) of my contract for LZ1'`�''� u ��, hca_ services with the City of Santa Ana, (Type of service provide ) 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 the provisions and provide proof of workers' compensation coverage immediately. Date: D�/251 Z020 Print Name: Print Title: Signature_ 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. REVIEWED & APPROVED By Risk MANAGEMENT DIVISION J2020 ANgiE'IACEVEdo 1. t Risk Mgmt1insurance Requirements) WC Declaration 08152019