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HomeMy WebLinkAboutMULLEN, CHRISTINAINSURANCE ON FILE N-2019-191 WORK MAY PROCEED UNTIL INSURANCE EXPIRES nATEK t L IL Z(J1�TS AND HECITY OF SANTA ANA CULTURE GRANT AND CHRISTINA MULLEN BETWEEN c G A UD-) I-e. This Artist Grant Agreement ("Agreement") is made and entered this 20'" day of August, 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 Christina Mullen ("Grantee") for the purpose of providing grant funding pursuant to the Investing in the Artist Grant Program. City and Grantee may herein individually be referred to as a "Party" and collectively be referred to as the "Parties" to the Agreement. RECITALS: A. On July 18, 2019, the Arts and Culture Commission reviewed all applicants and recommended that Grantee be awarded an artist grant based on its Application for its artwork ("Project"). A true and correct copy of Grantee's Application is attached hereto as Exhibit A and incorporated herein by reference- B. In undertaking the performance pursuant to this Agreement, Grantee represents that it is skilled and knowledgeable in the arts and culture arena and that the Project created or performed hereunder will be created or performed in compliance with such standards as may reasonably be expected from an artist. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. Term. This Agreement shall be effective upon signature by both Parties and shall expire one year from the date first written above, unless terminated earlier in accordance with this Agreement. 2. Fundina. 2.1. Subject to Grantee's performance of all required actions under this Agreement, City shall provide funding, in two disbursements, as detailed below, of an amount not to exceed Five Thousand Dollars ($5,000) ("Grant Amount" or "Grant"). 2.2. Grantee will be paid in two (2) installments. First payment will be two-thirds of the funding amount provided above or $3,350.00 and will be provided within thirty (30) days of the full execution of the Agreement by the parties along with a complete invoice submitted by Grantee. The second and final payment will include the remaining amount of $1,650.00 and will be issued within thirty (30) days after the Grantee submits to the City all the proper receipts, invoices, and final report for the Project. 2.3. Appropriate performance of the Grantee will be determined by City in its sole discretion. City reserves the right to cease funding after the first disbursement detailed above, and to be reimbursed the initial payment, if Grantee's performance is determined to be insufficient or unacceptable in the City's sole discretion. 2.3. City represents that there is no correlation or connection between its selection of individuals for grant awards and an individual's business relationship or potential business relationship with City. 3. Grant Activities. Grantee agrees: 3.1. To perform the activities described in the Grant Application and Timeline submitted to City for consideration dated May 30, 2019, a copy of which is attached as Exhibit A and incorporated into this Agreement as if set out in full. 3.2. To submit all reports (each, a "Report"), which shall include, at a minimum, the items set forth as required by the Application. No personally identifiable information shall be included in any of the Reports, except where specifically requested. The Reports shall be in a format that is reasonably acceptable to City. City may request additional information as City, in its sole discretion, determines is necessary to monitor performance of this Agreement. City shall have the right to use any Reports submitted by Grantee, or any portion thereof, for any reason. 3.3. Grantee shall maintain all pertinent financial and accounting records pertaining to this Agreement in accordance with generally accepted accounting principles and other procedures reasonably specified by City. Upon termination or expiration of this Agreement or request by City, Grantee shall provide, at its expense, copies of all financial and accounting records produced by it arising out of this Agreement. 3.4. Grantee shall allow audits, compliance or special reviews and inspections, including on -site inspection, with or without prior notice, of Grantee's facilities by City or by third parties designated by City, or their authorized representatives. Grantee shall provide its full cooperation for any such audit, review or inspection, including providing timely access, for examination and copying of records (including computerized records) pertinent books, documents, papers, computer programs and records and reasonable access to its personnel. 3.5. Grantee shall ensure that any areas utilized for the Project are maintained and restored to a well -maintained, safe, sanitary, and clean condition, and kept free of any hazardous waste at all times. All equipment associated with the installation of the artwork, trash and debris shall be removed and cleaned up on a daily basis. Grantee shall place a drop cloth or similar barrier on the ground below the artwork while installation is underway, which barrier shall be removed each day upon completion of an installation session. 3.6. The Project may not contain advertising, religious art, sexual content, negative or violent imagery, convey political partisanship or include any hidden, subliminal, or camouflaged messages or statements of any kind or nature. Appropriateness of the content of the Project will be determined by City in its sole discretion. 3.7. The Project may not include any breach of intellectual property, trademarks, brands, or images of illegal activity, and the Grantee must be the copyright holder for the Project. 4. Termination. 4.1. City may immediately terminate this Agreement upon one or more of the following: 4.1.1. Grantee's violation of any federal, state or local law or regulation. 4.1.2. Grantee's breach of any of the terms or conditions of this Agreement, including the Application and Timeline, or any unapproved deviation from said documents that has not been cured within 30 days of written notice of such breach. 4.2. In the event the Agreement is terminated under Section 4.1, City reserves the right to require Grantee to refund any or all grant funds awarded to Grantee under this Agreement, and Grantee agrees to refund to City any or all grant funds awarded under this Agreement. 5. Umitation_of Liabili 5.1. IN NO EVENT SHALL CITY BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES OR EXPENSES FOR ANY NEGLIGENCE, BREACH OF CONTRACT OR ANY OTHER ACT ARISING OUT OF OR RELATING TO THIS AGREEMENT OR THE ACTIVITIES COVERED HEREUNDER. 5.2. Section 5 and Section 6 do not limit grantee's rights, including its ability to seek recovery, against anyone other than City, its directors, officers, employees, agents, successors and assigns. 6. Indemnification 8.1. Grantee shall defend, indemnify, protect and hold harmless the City, and its elected and appointed officers, employees, members or agents from and against all claims for damages, liability, cost and expense (including without limitation attorney's fees) arising out of or alleged by third parties to be the result of the negligent acts, errors or omissions or the willful misconduct of the Grantee, and Grantee's employees, subcontractors or other persons, agencies or firms for whom Grantee is legally responsible in connection with the execution of the work covered by this Agreement. Grantee shall have no duty to indemnify or hold harmless the City if claims, damages, liability, costs, expenses (including without limitation, attorney's fees) arise from the sole negligence or sole willful misconduct of the City subsequent to declaration by the Grantee. Grantee's obligations shall survive the termination of this Agreement. 6.2. Grantee agrees to hereby fully release and forever discharge the City from any and all claims, demands, damages, losses, and liabilities (hereinafter collectively referred to as "claims"), which are or may related to or in any connected with the negligence or willful misconduct of its officers, officials employees, or agents in connection with the creation, painting, performance or installation of the Project hereunder. 6.3. Grantee further agrees that City may in good faith and on reasonable terms settle any such claims and that City's right to indemnification shall extend to any such settlement, provided City has given notice of such claim and its intent to settle. City's right to indemnification is to addition to, and may be exercised independently of, any remedy held by City under this Agreement, at law or in equity.. The indemnity provision set forth in this Agreement shall survive the termination or expiration of this Agreement indefinitely. 7. Insurance 7.1 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: Commercial General Liability Insurance. Consultant 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 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, with $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insureds provisions. b, Worker's Compensation Insurance. In accordance with the provisions of Section 3700 of the Labor Code, 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. 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. ii. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved by the City. 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. iv. Where the amounts or coverage provided by the certificates of insurance provides coverage greater than those listed by this Agreement, the amounts provided by the certificates of insurance shall be incorporated by reference into the Agreement. V. Consultant shall supply City with a fully executed additional insured endorsement. d. 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 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 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. 8. general Provisions. 8.1. Grantee shall acquire prior written permission from City for any use of the City name or logo in association with its Project. 8.2. If any parts of this Agreement are held to be invalid or unenforceable, the remaining parts of the Agreement shall continue to be valid and enforceable. 8.3. Grantee shall comply with all governmental requirements that may now or in the future become applicable to its activities under this Agreement. 8.4. This Agreement, including Exhibit A, Application, and any amendments or schedules hereto, contain the full understanding and agreement of the Parties with respect to its subject matter, and no waiver, alteration or modification of any of the provisions to this Agreement shall be binding unless in writing and signed by an authorized officer of both Parties. 8.& No waiver by either Party or any breach, default, or series of breaches or defaults, and no failure, refusal, or neglect of either Party to exercise any right, power, or option given to it under this Agreement orto insist upon strict compliance with the terms of this Agreement shall constitute a waiver of these provisions with respect to any subsequent breach or waiver by either Party or its right at any time thereafter to require exact and strict compliance with provisions of this Agreement. 8.6. Any notice or other communication required or permitted to be made or given by either Party pursuant to this Agreement will be in writing and will be deemed to have been duly given: (1) five (6) business days after the date of mailing If sent by registered or certified U.S. mail, postage prepaid, with return receipt requested; (ii) when transmitted if sent by facsimile, provided a confirmation of transmission is produced by the sending machine; or (iii) when delivered if delivered personally or sent by express courier service. All notices to City shall include a reference to the Project title. All notices will be sent to the other Party at its address as set forth below or at such other address as such Party will have specified in a notice given in accordance with this section: Grantee: txhristina Mullen 27 Sage Grousrs fit. City: City of Santa Ana Clerk of the Council (M-30) 20 Civic Center Plaza P.O. Box 1988 Santa Ana, CA 92702 FAX (714) 647-6956 8.7. This Agreement is subject to all applicable local, State and Federal laws. 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. 8.8. Grantee agrees to comply with all applicable equal opportunity and affirmative action laws as appropriate, Grantee 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. Grantee affirms that it is an equal opportunity employer (if applicable) and shall comply with all applicable federal, state and local laws and regulations. 8.9. Any funds provided under this Agreement that are not expended, obligated or otherwise committed by the termination or expiration of this Agreement shall be immediately returned to City. 8.10. Grantee grants to City a non-exclusive, irrevocable, transferable, royalty free, worldwide license to use, reproduce, display, distribute, and prepare derivative works, in any form or media at the discretion of the City for the Project conceived, performed or created as a result of this Agreement. 8.11. Grantee and any of the Grantee's agents, employees or representatives are, for all purposes under this Agreement, an independent contractor and shall not be deemed to be an employee of the City, and none of them shall be entitled to any benefits to which City employees are entitled including but not limited to, overtime, retirement benefits, work's compensation benefits, injury leave or other leave benefits. 8.12. Neither Party shall assign any rights or obligations under this Agreement 8.13. Each Party 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. 8.14. Each Party warrants that they have executed this Agreement knowingly, freely and voluntarily and with full knowledge of its legal consequences. All parties involved warrant and represent that, prior to executing this Agreement, each Party has had the opportunity to review and consider this matter with legal counsel, and that the terms of this Agreement, and its consequences, are fully understood by each Party. 8.15. This Agreement represents the entire agreement and understanding between the parties, and supersedes any and all prior agreements and understandings between the parties, whether oral or written, 8.16. Each undersigned represents and warrants that its signature herein below has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. {Signatures on following page} J 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 OF SANTA ANA KRISTINE RID E City Manager GRANTEE: By: (RYAN 0. HODGE Name: CHRISTINA MULLEN Assist nt City Attorney Title: ARTIST RECOMMENDED FOR APPROVAL: ems_ ST VEN ENDO Executi erector Communi y Development Agency EXHIBIT A INVESTING IN THE ARTS GRANT PROGRAM APPLICATION Line Item Budget "Input your information directly onto this form (2 pages) and upload onto Submittable.com. PERSONNEL Description of Personnel (artist fees, consultants, administrative fees, etc.) Total Compensation Grant Funds Requested Lead Artist 15/hr x 400 hours $4,500.00 $1125.00 Mural Assistant / Interns 15/hrx 200hours $3,000.00 $1300.00 Cons ultant/Admin 30hr x 20hr $600.00 $300.00 EQUIPMENT, MATERIALS, AND SUPPLIES Item (equipment, materials, supplies) Quan- tity Unit Cost Total Cost Grant Funds Requested Documentation Supplies-Film/Printing 50 $6.00 $300.00 $300.00 Hospitality -Workshops and Mural Unvieling ApproxrrBD Food/Water $800.00 $400,00 Workshop Design Supplies -Paper, Pencils, Erasers 40 $10.00 $400.00 $200.00 Protective Mural Shield/Gloss Medium Varnish 9 $80.00 $720.00 $320.00 New Wood Panels 9 $450.00 $450.00 $200.00 Preparation Sanding/Gesso 20 $10.00 $200.00 $115.00 Buckets, Sand Paper, Drop Clothes 20 $10.00 $200.00 $100.00 Painl/Brushes 40 $25.00 $1000,00 $600.00 ADDITIONAL EXPENSES Description (permits, fees, facility rental for project) Total Cost Grant Funds Requested No Permits Are Required For This Project $0.00 $0.00 Travel Expenses/Mileage/Airline Expense $1000.00 (in -kind) $0.00 Final Awards/Certificates $300,00 ($160.00 in kind)$140.00 City of Santa Ana, Community Development Agency 20 Civic Center Plaza, M-25, Santa Ana, CA 92701 (714) 647-5360 Line Item Budget — Page 2 Enter budget categories and projected expenditures for the proposed program: Category Expenditures Funded By Santa Ana Grant Expenditures Funded By Other Sources (Including in -kind) Total Project Budget Personnel Total $2,725.00 $5,375.00 $8100,00 Equipment Total 0.00 0.00 0.00 Supplies Total Paint, Brushes, Paper, Pencils, Mural Shield, Print $1,735.00 $1,435.00 $3170,00 Materials Total - Hospitality Morkshop Refreshments $400.00 $400.00 $800.00 Additional Expense Total certlfmtes/Mlleage $140.00 $1160m $1300.00 TOTAL $5,000.00 $8,370.00 $13,370 PROJECT REVENUE LIST ALL OTHER PROJECT RESOURCES "Funding Source" total must equal "Total Project Budget" listed above. FUNDING SOURCE AMOUNT Santa Ana Artist Grant $5,000.00 In -Kind Donations/Artist Donations/Private Sponsors $8,370,00 TOTAL PROGRAM BUDGET $13,370.00 City of Santa Ana, Community Development Agency 20 Civic Center Plaza, M-25, Santa Ana, CA 92701 (714) 647-5360 Honoring The Past Restoration Mural Project Timellne August -September 2019: -Start Organizing Student/Volunteer Crews, Meet with Community Partnership Organizations -Creating Handbook for Mural Process Workshops, Art as a Form of Wellness -Timelines, Start purchasing materials/Outreach, Press Releases -Start Website Documenting Process September -October 2019: -Meet with Seniors and students at partner organizations to work on design elements/sketches -Record stories, take photos of seniors for mural, meet with student volunteers and interns on design elements/sketches workshops October -November 2019: -Send out updates to team, follow up with student interns and volunteers --Meet with Seniors and students at partner organizations to work on design elements/sketches -Record stories, take photos of seniors for mural, meet with student volunteers and interns on design elements/sketches November -December 2019: -Meet with Partner Organizations/Follow Up, Complete Interim Report with Evaluations --Meet with Seniors and students at partner organizations to work on design elements -Work on wellness mural handbook for students and children's mural coloring books December -January 2020: --Meet with Senior Centers, Santa Ana College and Schools -Purchase awards/certificates, Print free coloring books for children -Meet with Seniors and students at partner organizations to work on colorations of final design --Record stories, take photos of seniors for mural January -February 2020: -Implement final coloration scheme on mural with seniors/volunteers/students/interns --Meet with Seniors at partner organizations to work on colorations --Record stories, take photos of seniors for mural -Meet with student volunteers and interns on colorations February -March 2020: --Meet with Seniors and students at partner organizations to work on painting -Documentation, Outreach, Press Releases-Website Updates March -April 2020: -Meet with Senior Centers, Santa Ana College and Schools for Organizing Paint Days --Meet with Seniors and students at partner organizations to work on painting process April -May 2020: --Meet with Seniors at partner organizations to work on colorations -Dissemination of Children Mural Coloring Books -Meet with student volunteers and interns on colorations -Transfer final design images with seniors and student painters May -June 2020: --Public Paint Day at 41h Street Market Workshops -Summer Internships and Student Paint Days at Santa Ana College Workshops -Meet with Seniors and students at partner organizations to work on colorations -Interns work on certificates/honors/awards --Documentation, Press Releases-Website Updates June -July 2020: -Public Paint Day at 4th Street Market Workshops --Summer Internships and Student Paint Days at Santa Ana College Workshops -Final Mural Shield Painting Day/Final Preservation Coating -Final Photo Shoot with Community Paint Team, Public Ceremony for Completion of Mural -Set up Food, Refreshments/DJ/Microphone Final Celebration Ceremony -Student and Senior Recognition Awards --Press Releases-Website Updates July -August 2020: -Print sample mural workshop handout for future workshops -Document final painting rendering and process of completed mural for report -Timeline for ongoing workshops for organizations to continue their own art wellness projects -Compile Data and Information Pertaining to the # of participant and feedback/Final Report Due x+ A.!J4 VAw VY a+ iUtE; 4F INSURANCE DOES NOT CONSTITUTE A CONTRACT LAIFND OR SETW EN THTHE E 5SUING NGS SU�r�{$j, CER. ANFS'r41R r^.FrFT,FN^a Tti uh� nee niuwtxu provisions orbs endorsed, j f SUOROGA"aON IS WAIVED, subject to the temta and condldoria of the policy, certain POhaias may require an. endorsement A statement an I this aarOHncate does not eroNar HnhM m ...e.ux„a,. u,.w _ ` Auto insurance Specialists 17785 Center Court Drive Suite 000 Christina Mullen 27 Sage Orcuse, Court Sacramento CA 05834 THIS IS TO CERTIFY THAT THE POLICIES INDICATED, ttCVIWON NUMWFK: OF INSURANCE USTED BELOW HAVE SEEN ISSUER TO THE INSURED NAMED'AROVE FOR THE POLICY PERIOD NOMITHSTANOW0 ANY REQUIREMENT„ CERTIFICATE MAY Be ISSUED OR MAY TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH. RESPECT PERTAIN ME WSURANCE AFFORDED BY THE POUOIES DESCRIBED TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH HEREW IS eUBJECT TO POUCH.. LIMITS KNOWN Mtf! 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DATE MEREOP, NOUCS VALL BE OaUvermo IN 20 Civic Center Plaza, 45h Floor N"(� jA (yj, LAMBEi ACCOROANRA VtN THE Santa Aria, CA 02701 �- AUTHOREEDRAPRE35NTAT`Nj yy w 1uu$14Q14 ACORO CORPORATION. AS rights reserved. ACORD 2$ t20103i The ACORD name and logo are registered Pierce of ACORD Produces ushp Farm saw Woe 5oftware.wwy,fem,eaoae,ranr{RI RfgrensSe PuEsaatnp @Etl.Z16.S9i1 CITYOF,SSANTA ANA RISK MANAGEMENT. w 4 HUMAN RESOURCES ' riat NJ* positive Char1ge J WORKERS' COMPENSATION DECLARATION hereby affirm under penalty of perjury, the (Namg1T1tfe) following declaration: I certify on behalf of 5 &Comp;ony that during the term (ConsuttNName) of my contract for Tnie$� Vn ;� services with the City of Santa Ana, (TYPe,v;ce grovided) 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 previsions and provide proof of workers' compensation coverage, Date: 11 t Print Name: r ! _ rizo i YA trl i Print Title: i �1 [rVIV VA l i Signature: Telephone d ' Li s 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 ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. kiffisk Mgmt1insurance Requirements}WC 08152019 0 Natlonwlde7 Is on your side AUTO POLICY NUMBER: PPNCO076074489 NAMED INSURED & MAILING ADDRESS Christina Mullen 11624 Sandy Bar CT Rancho Cordova CA 96670 Nationwide Insurance company Of America AUTO MEMORANDUM OF INSURANCE POLICY EFFECTIVE DATE 10/31/2018 POLICY EXPIRATION DATE 10731/2019 ADDITIONAL INTEREST LIENHOLDE.R Capita: One Auto Finance PO Box 60511 City Of Industry CA 91716 LOAN# 1 **"*TO REPORT CLAIMS, CALL 1.8e0.421.3M5 ADDITIONAL INTEREST LEASEHOLDER wrs r nev ! rvw 1 tLG d Interests This mem0 Memorandum of lhaurance orandum dum does not amend, provides extend lor otherwise change the terms, exclusions onstand conditions oftany Insuranced byyour e Provided, A2Declar titions Page supersodmg this memorandum will be mailed, which Will provide WInpiete Updated cave,=ages and pramtum details, VEHICLE: ' VEHICLE IDENTIFICATION NUMBER COMPREHENSIVE DEDUCTIBLE COLLISION DEDUCTIBLE BODILY INJURY LIABILITY LIMIT PROPERTY DAMAGE LIABILITY LIMIT 2011 VOLV XC90 YV4952GY3B1602176 $500 $500 $5001000 / $600,000 $50,000 Satanoe, It any, will. be bitted by the company, Checks and drafts are received subject to collection only, AGENT NAME Nss Insurance Services SCAOI1 MU (2-10) AGENT NO, PHONE NO, 62194 1.800-421-1444