HomeMy WebLinkAboutSANTA ANA XTREME SOFTBALLCity of Santa Ana `n`R _
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AGREEMENT TERMINATION FORM
Please complete this form in its entirety when the attached agreement and all
amendments (if any) are no longer in effect.
Note: If your agreement is grant related, please ensure that all grant retention requirements
have been satisfied prior to signing the termination form.
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Return form to the Clerk of the Council Office (M-30). PAR 14'23u411:33
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The agreement with
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A-2019-133
No. was completed on
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Department: l--V
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Signature: c
Date: 11 0�
Revised: 10-18-16
A-2019-133
ouHANCE ON FILE
WORK MAY PROCEED
!NTIL IN URANCE EXPIRES
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CLERK 0 UNCIL CITY OF SANTA ANA
��aTe SEEP 1 0 2019 COMMUNITY BENEFIT AGREEMENT WITH
ID. cQA(lO SANTA ANA XTREME SOFTBALL
�1 ,L7 PARTIES AND DATE
This Community Benefit Agreement ("Agreement') is entered into on August 20, 2019, by
and between 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") and Santa Ana Xtreme Softball, a
California non-profit organization ("Recipient'). City and Recipient are sometimes individually
referred to as "Party" and collectively as "Parties" in this Agreement.
RECITALS
2.1 Community Benefit. The City wishes to provide Recipient with funding to assist
Recipient in operating a youth softball team that develops female athletes as future civic leaders
through self-discipline, hard -work and important life lessons ("Community Benefit'). The Parties
wish to enter into this Agreement to establish the terms and conditions under which the City will
provide funding for such program.
2.2 Public Purpose. The City believes there is a public purpose in supporting the
Community Benefit because it will assist City residents with providing a healthy activity and training
in an atmosphere of community participation. The foregoing is a general description of the public
purpose, and is not necessarily the only public purpose to be gained from the Community Benefit.
3. TERMS AND CONDITIONS
3.1 Use of Funds. The City has chosen to provide Recipient with Thirty -Thousand
Dollars ($30,000.00), as detailed in Exhibit B ("Program Budget') attached hereto and incorporated
herein by reference, because the City has determined that there is a public purpose to be served in
supporting the Community Benefit. Such funds shall be expended by Subrecipient on or before June
30, 2020. The funds shall be disbursed by City to Recipient on a quarterly basis subject to and upon
receipt and approval of a complete quarterly activity report from Recipient, with the final payment
subject to the satisfaction of the condition precedent of submittal of complete reporting information
due on or before July 15 of the applicable funding year, as hereinafter more fully set forth. Recipient
shall be obligated to perform such duties as would normally extend beyond the term, including, but
not limited to, obligations with respect to indemnification, audits, reporting, data retention/reporting,
and accounting. Failure to provide any of the required documentation and reporting will cause City
to withhold all or a portion of a request for reimbursement, or return the entire reimbursement
package to Recipient, until such documentation and reporting has been received and approved by
City. In executing this Agreement and receiving the funds, Recipient agrees to use the funds only for
the purpose described and subject to the terms and conditions provided for in this Agreement, and set
forth in greater detail in Exhibit A ("Scope of Services") attached hereto and incorporated herein by
reference. Should Recipient fail to use the funds for such purpose or otherwise comply fully with the
terms of this Agreement, City shall have the right to terminate this Agreement and demand the return
of the funds pursuant to Section 3.2 below.
3.2 Term; Termination of Agreement. This Agreement shall take effect on August 20,
2019 and remain in effect through June 30, 2020. The City has the right to terminate this Agreement
upon one day's notice, with or without cause. Should the City terminate this Agreement, it shall also
have the right to demand the immediate return of all funds provided to Recipient pursuant to this
Agreement, as well as interest at the rate of ten percent (10%) per amrum. Notwithstanding the
foregoing, the indemnification provisions of this Agreement shall survive any expiration or
termination of this Agreement.
3.3 Insurance. Prior to undertaking performance of work under this Agreement,
Recipient shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance
as described below:
a. Commercial General Liability Insurance. Recipient shall maintain commercial
general liability insurance naming the City, its officers, employees, agents, volunteers and
representatives as additional insured(s) and shall include, but not be limited to protection against
claims arising from bodily and personal injury, including death resulting therefrom and damage to
property, resulting from any act or occurrence arising out of Recipient's operations in the
performance of this Agreement, including, without limitation, acts involving vehicles. The amounts
of insurance shall be not less than the following: single limit coverage applying to bodily and
personal injury, including death resulting therefrom, and property damage, in the total amount of
$1,000,000 per occurrence, with $1,000,000 in the aggregate.
b. Business automobile liability insurance, or equivalent form, with a combined single
limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned,
hired and non -owned automobiles.
C. Worker's Compensation Insurance. In accordance with the provisions of Section
3700 of the Labor Code, Recipient, if Recipient 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, Recipient agrees to obtain and maintain any
employer's liability insurance with limits not less than $1,000,000 per accident.
d. If Recipient is or employs a licensed professional such as an architect or engineer:
Professional liability (errors and omissions) insurance, with a combined single limit of not less than
$1,000,000 per claim with $2,000,000 in the aggregate.
C. The following requirements apply to the insurance to be provided by Recipient
pursuant to this section:
(i) Recipient shall maintain all insurance required above in full force and effect
for the entire period covered by this Agreement.
(ii) Certificates of insurance shall be furnished to the City upon execution of this
Agreement and shall be approved by the City.
2
(iii) Certificates and policies shall state that the policies shall not be canceled or
reduced in coverage or changed in any other material aspect without thirty (30) days prior
written notice to the City.
f. If Recipient fails or refuses to produce or maintain the insurance required by this
section or fails or refuses to furnish the City with required proof that insurance has been procured
and is in force and paid for, the City shall have the right, at the City's election, to forthwith terminate
this Agreement. Such termination shall not affect Recipient's right to be paid for its time and
materials expended prior to notification of termination. Recipient waives the right to receive
compensation and agrees to indemnify the City for any work performed prior to approval of
insurance by the City.
3.4 No Oversight by City. Nothing in this Agreement shall be implied or interpreted as
City establishing or providing oversight, control or approval of the Community Benefit or any
activities conducted by the Recipient.
3.5 Indemnification. Recipient understands, acknowledges and agrees that Recipient
shall assume all risks associated with the Community Benefit, including, but not limited to, the
possibility of death or serious trauma or injury. To this end, therefore, Recipient shall defend,
indemnify and hold City and its officials, officers, employees, agents and volunteers free and
haraless from and against any and all claims, demands, causes of action, costs, expenses, liabilities,
losses, damages or injuries, in law or equity, to property or persons, including wrongful death, in any
rnannerarising out of or incident to any and all acts, omissions, willful misconduct or other activities
of the Recipient or its officials, officers, employees, agents, guests, participants attendees, and
contractors, including the performance of the Community Benefit or this Agreement, including
without limitation the payment of all consequential damages and attorneys fees and other related
costs and expenses. The only exception to the Recipient's obligations hereunder shall be for claims,
demands, causes of action, costs, expenses, liabilities, losses, damages or injuries caused by the sole
negligence, sole willful misconduct or sole active negligence of the City. Recipient shall defend, at
Recipient' own cost, expense and risk, any and all such aforesaid suits, actions or other legal
proceedings of every kind that may be brought or instituted against the City, its officials, officers,
employees, agents, or volunteers. Recipient shall pay and satisfy any judgment, award or decree that
may be rendered against the City or its officials, officers, employees, agents, or volunteers, in any
such suit, action or other legal proceeding. Recipient shall reimburse City and its officials, officers,
employees, agents, and/or volunteers, for any and all legal expenses and costs incurred by each of
them in connection therewith or in enforcing the indemnity herein provided. Recipient' obligation to
indemnify shall not be restricted or limited by insurance proceeds, if any, received by the City, its
officials, officers, employers, agents or volunteers. The indemnification provisions of this
Agreement shall survive any expiration or termination of this Agreement.
3.6 Records. Recipient shall keep records and invoices in connection with the work
to be performed under this Agreement. Recipient shall maintain complete and accurate records with
respect to the costs incurred under this Agreement and any services, expenditures, and disbursements
charged to the City for a minimum period of three (3) years, or for any longer period required by
law, from the date of final payment to Recipient under this Agreement. All such records and
invoices shall be clearly identifiable. Recipient shall allow a representative of the City to examine,
3
audit, and make transcripts or copies of such records and any other documents created pursuant to
this Agreement during regular business hours. Recipient shall allow inspection of all work, data,
documents, proceedings, and activities related to this Agreement for a period of three (3) years from
the date of final payment to Recipient under this Agreement.
3.7 Conflict Of Interest Clause. Recipient covenants that it presently has no interests
and shall not have interests, direct or indirect, which would conflict in any manner with performance
of services specified under this Agreement.
3.8 Independent Contractor. Recipient shall, during the entire tern 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 Recipient performs the services which are the subject matter of this Agreement;
however, the services to be provided by Recipient shall be provided in a manner consistent with all
applicable standards and regulations governing such services. Recipient shall pay all salaries and
wages, employer's social security taxes, unemployment insurance and similar taxes relating to
employees and shall be responsible for all applicable withholding taxes.
3.9 Assignment. Inasmuch as this Agreement is intended to secure the specialized
services of Recipient, Recipient 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 Recipients retained by City.
3.10 Exclusivity and Amendment. This Agreement represents the complete and exclusive
statement between the City and Recipient, and supersedes any and all other agreements, oral or
written, between the parties. In the event of a conflict between the tenns of this Agreement and any
attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified
except by written instrument signed by the City and by an authorized representative of Recipient.
The parties agree that any terms or conditions of any purchase order or other instrument that are
inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate
Recipient or the City. Each party to this Agreement acknowledges that no representations,
inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone
acting on behalf of any party, which are not embodied herein.
3.11 Discrimination. Recipient shall not discriminate because of race, color, creed,
religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined
and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion,
termination or other employment related activities. Recipient affirms that it is an equal opportunity
employer and shall comply with all applicable federal, state and local laws and regulations.
3.12 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
4
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.
3.13 Professional Licenses. Recipient shall, throughout the term of this Agreement,
maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the
provision of the services hereunder and required by the laws and regulations of the United States, the
State of California, the City of Santa Ana and all other governmental agencies. Recipient shall notify
the City immediately and in writing of its inability to obtain or maintain such permits, licenses,
approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement.
3.14 Entire Contract/Modification. This Agreement contains the entire agreement of the
Parties with respect to the subject matter hereof, and supersedes all prior negotiations,
understandings or agreements. The terms and conditions of this Agreement may be altered, modified
or amended only by written agreement signed by both Parties.
3.15 Authority to Enter Agreement. The person executing below on behalf of Recipient
represents and warrants that the Recipient has all requisite power and authority to conduct its
business and to execute, deliver and perform this Agreement. Each Party warrants that the
individuals who have signed this Agreement have the legal power, right and authority to make this
Agreement bind each respective Party.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first
above written.
'
�/. Gomez
Cleik of the Council
APPROVED AS TO FORM:
SONIA R. CARVALHO
City
10
RECOMMENDED FOR APPROVAL
Steven A. Mendoza
Executive Director
Community Development Agency
CITY OF SANTA ANA
Kri6tinc Ridge
City Manager
"RECIPIENT"
Santa Ana Xtreme
'- N•�'�`De La
Title: Executive Director
City of Santa Ana Scope of Work
Program Year 2019-20 (July 1, 2019 - June 30, 2020)
Name of Organization Santa Ana Xtreme Softball
Name of Funded Program Santa Ana Xtreme Fastpitch
Annual Accomplishment Goal
Unduplicated Participants anticipated to be served during the 12-month contract period.
45 TOTAL 45 Santa Ana Participants 1 100%1 1 451 Low Income Participants 100%
Schedule of Performance
Unduplicated
(estimated)
Quarter 1: JUL 1 - SEP 30
Quarter 2: OCT 1 - DEC 31
Quarter 3: JAN 1 - MAR 31
Quarter 4: APR 1 - JUN 30
11
Estimated
Invoicing
$ 7,500.00
$
7,500.00
$
7,500.00
$
7,500.00
$
30,000.00
We provide a safe structured environment that teaches young female athletes how to play the
game of softball at an elite level in preparation for High School and College participation as a
student athlete. This is done be providing group and one-on-one lessons for each players various
needs. In addition, to providing homework assistance, time management skills, preparation for
various college entry requirements (SAT, ACT,
etc.), financial aid applications, college entry applications, early college acceptance and finding
colleges that will provide financial scholarships to each players unique financial situation. If
additional finances can be secured for our program, we would provide tutoring, test taking
preparation skills, screen for test anxiety and additional college entry test preparation. One of the
organizations primary goals is to help these female youths develop their interpersonal and
communication skills along with self-discipline and teamwork. In hopes they will one day become
future civil leaders that will give back to their community. The organization also takes these female
athletes to college
recruiting events throughout the United States to college recruiting events and functions to help
increase their chances of being accepted to a college of their choice. The frequency of our
programs services are 3-4 times weekly. Our target population is female youths in the city of Sant;
Ana. It is primarily done in a group setting, but various times throughout the year it will be done on
a one-on-one basis when extra help is needed or if that will be the most productive for the
individual in need of additional help.
EXHIBIT A
FISCAL YEAR 2019-2020
PROGRAM BUDGET
Organization Name Santa Ana Xtreme Softball
Program Name Santa Ana Xtreme
EXPENDITURES
Enter budget categories and oroiected expenditures for the oronosed Droeram: Slaries nn hanafltc
Category
Expenditures
Funded By
Santa Ana
City Funds
Expenditures
Funded By
Other Sources
Program
Budget
Total
Organization
Budget
Administrative Staff Salaries
$8,273
$ 6,000
$14,273
$ 15,000
Program Staff Salaries & Benefits
$15,000
$ 10,000
$25,000
$ 25,000
Contractual/Professional Services
$1,000
$ 400
$1,400
$ 1,400
Field Fees
$2,000
$ 2,000
$4,000
$ 6,000
Travel (4 coachs)
$0
$0
Equipment
$0
$0
Tournament & Friendly Games
$0
$0
Business License, Insurance
$1,000
$1,000
Office Supplies
$0
$0
Uniforms
$0
$0
TOTAL Direct Costs
$27,273
$18,400
$45,673
$47,400
Indirect Costs 10%
$2,727
$2,727
TOTAL BUDGET
$30,000
$18,400
$48,400
$47,400
* Indirect cost rate: 10% Non -Federal entity without federaly recognized negotiated indirect
cost rate, will charge a de minimis rate of 10% of modified total direct
costs.
PROGRAM RESOURCES
LISTALL OTHER PROGRAM RESOURCES FOR 2019-2020
Funding Source Total must equal Program Budget Total listed above.
FUNDING SOURCE AMOUNT
Santa Ana City Funds
TOTAL $
EXHIBIT B
2019-2020 CITY FUNDS BUDGET LINE ITEMS
ADMINISTRATIVE STAFF
Position Title
Annual Salary
& Benefits
City Funds
Requested
Description
President
$ 3,000
$ 4,500
Oversee organization & hold quarterly meetings
Vice President/Treasurer
$ 3,000
$ 4,500
Assist President with duties & maintain organization
finances.
PROGRAM STAFF
Position Title
Annual Salary
& Benefits
City Funds
Requested
Description
Events Coordinator
$ 1,300
$ 2,000
Coach the team on fundamentals of softball
Operations Administrator
$ 2,000
$ 3,000
Field and Site Supervisor
$ 1,300
$ 2,000
Pitching Instructor/Coach
$ 1,600
$ 2,500
Hitting/Strength & Conditioning
Instructor
$ 750
$ 1,000
Hitting & DefensiveInstructor
$ 2,300
$ 3,500
Pitching/Hitting & Defensive Inst $ 750 $ 1,000
CONTRACTUAL/PROFESSIONAL SERVICES
Type of Service
Contract
Amount
CDBG Funds
I Requested
Description
Defensive Instructor
$ 700
$ 700
Instructor to provide clinic on fielding in softball
Conditioning Instructor
$ 700
$ 700
Instructor to provide clinic on conditioning
OTHER LINE ITEMS
Line Item
Program
Amount
CDBG Funds
Requested
Description
Field Fees
$ 6,000
$ 2,273
Fields used to hold practice and play games
Travel (4 coachs)
$ 2,000
Out of area travel (mileage or airfare, hotel)
Equipment
$ 2,000
Bases for field, softballs, equipment to upkeep fields
Tournament & Friendly Games
$ 18,000
Competitive Games played
Business License, Insurance
$ -
$ 1,000
Operate in the City & provide Insurance to all players
Office Supplies
$ 500.00
Paper, copier ink, Postage, envelopes, etc
Uniforms
$ 10,000
Practice & tournament uniforms to play in games
EXHIBIT B-1
CERTIFICATE OF LIABILITY INSURANCE �-- 1{1I� DATE IMMIDONyyyI
THIS CER IFICATE IS ISSUED AS A MATTER CERTIFICATE DOES NOT AFFIRMATIVELY OR OF INFgRMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4HOLDER .ITHIS
NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 13ETWEEN THE ISSUING INSURCR(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: If the oertiftaata holder isan AppITIONALiNSUREQ, the poticy(ies) must have AppiTIONAL INSURED previsions orlre endorsed,
if SUBROGATION IS WAIVED, sub)eck to kha terms and caodltfon8 of the Policy' 00"0ln po0oles may require an Endorsomant: A statement on
this aertifiOatE does not Oonfor rights ka Rhe certlflCata holder In Ileu of such Endarsemant(s
'RoOUCER T
Gaollaudl Insurance Services, Inc 'NONE
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1315 Walnat SL Suite 1761 .MAif_ _ .S,N.a1;,.,,___.• 14-8199
INSURED
AmericanFasi pitch Association`
Banta Ana)(trame .
2926 Calls I mmera
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CLAIMS -MADE Fxi� OCCUR
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DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORO IDi, Adrlitlobsl Ramark3Schr
City of Santa Ana, officers, agents, employees, and. volunteers are named as
Memorandum of ❑nderstanding- Such insurance as f ,,�kvvIs policy,.
nonoontn'autory. Cartifioste of Insurance shall prove % �50Y GLrrfdr u4
INJURY IF.,
9 1 01/01/2020
01/01=19 01101/20201 AD&O ( $10,000
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V Insured on this policy. pursuant to written contract,. agreement, or
nary, and any insurance darted by City shall be Excess and
lcellation. All policy terms and conditions apply;.
V I ' - v V VIJU ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Santa Ana- Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS,
20 CIVIC Center Plaza
AUTHO En REP SENTATIVE
Santa Ana CIA 92701 ' 4F ACORQ 25 (2016103) The ACORD name and logo are registered marks of ACOROOR OR TION,.AII rights reserve,
POLICY NUMBER: GSL2019060001
COMMERCIAL GENERAL LIABILITY
CG 20 01 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
City of Santa Ana, its officers, employees, agents and volaatears
Risk H'ianaomeat Division
20 Civic Center Plaza
Santa Ana, CA 92701
The following Is added to the Other Insurance
condition and supersedes any provision to the
Contrary;
Primary and Noncontributory Insurance
This insurance is primary to and will not seek
contribution from any other insurance available to
an additional insured under your policy provided
that:
(1) The additional insured is a Named Insured
under such insurance; and
(2) You have agreed in writing in a contract or
agreement that this insurance would be pri-
mary and not seek contribution from any other
Insurance available to the additional Insured.
CG 20 01 04 13 p ISO Properties, Inc., 2004
Page 1 of 1
POLICY NUMBER: GSL2019060001
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
"PIPIAMM . r
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
City of Santa Ana, its officers, employees, agents and volunteers
Risk Rianagernent Division
20 Civle Center Plaza
Santa Ana, CA 92701.
Section 11 Who is An Insured Is amended to In-
clude as an additional insured the person(s) or organ.
Ization(s) shown In the Schedule, but only with re-
spect to liability for "bodily injury", "property damage"
or `'personal and advertising injury" caused, in whole
or in pail, by your acts or omissions or the acts or
omissions of those acting on your behalf:
A. In the performance of your ongoing operations; or
B, In connection with your premises owned by or
rented to you.
CG 20 26 07 04
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Page i of 1 171
CERTHOL DER COPY
SP
P,O, BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 09-06-2019
CITY,OF SANTA ANA
RISK,MANAGEMENT DIVISION;-
20 CIVIC CENTER PLZ
SANTA ANA CA 82701-4058
SP
GROUP;
POLICY NUMBER;. 92599t91-2019
CERTIFICATE ID-. 1
CERTIFICATE EXPIRES: 08-30-2020_
<08-30-2019y08-30-2620
This Is to certify that we have Issued a valid Workers' Compensation insurance. policy in e form approved by the
California Insurance Commissioner to the employer named below for the -policy period indicated.
This policy i9 not subject to cancellation by the Fund except upon SO days advance written notice to the employer.
Wa will also tdeVe :.you 30da" 1011111 notice should this Policy be carrceliad;pdor to its nor
mal expiration.
This certificate of :insurance is not an Insurance policy and does not amend, extend ar :altar the coverage afforded
by the Policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued Or to wrilltih it may partaiin, the insurance
afforded by the
'3Pollii�cTyydescribbeed herein Is subject to ail the terms, oxciusions, and conditions, of such policy.
Authorized Reprasontative % President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS:' $J,DOO,OOQ dPfR OCCURRENCE
ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2019-09-06 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:
CITY OF SANTA ANA
ENDORSEMENT H2O65 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 09-06-2019 IS
ATTACHED To AND FORMS A PART OF THIS POLICY,
& APPROVED
ICtEMENT DIVisiON
EMPLOYER A 13 2aig
SANTA AAA AVE'SDFT9ALL Sp ZIAM�/
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28f&. W AI:TON HA M. LAMBERT
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SANTA ANA CA..92704
(SITY,CN)
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