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HomeMy WebLinkAboutSHINE HWANG, DBA: SUNSHINE MUSICCity of Santa Ana t Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination form. / Is the agreement(s) a permanent record? Yes _ NoCMERK OF THE COUNCIL Return form to the Clerk of the Council Office (M-30). puc, 9.22 PYA:29 Call 647-1520 if you have any questions. The agreement with 71M.CM , ww ( "O� A\-j No. N-2019-201 was completed on (List all amendments. Use space below if needed.) Revised: 10-18-16 t ?�0 ,?-C and final payment has been made. Department: Tpc Phone/Ext.: GZ-Gl— Signature: `{ GV1tiLy Date: INSURANCE ON FILE VVORK MAY PROCEED UNTIL INSURANC�EbXPIRES \o \ ALL CLERK OF COUNCIL DATE' OCT 1 0 2019 RECREATION SERVICES AGREEMENT N-2019-201 �—(5N I THIS AGREEMENT is made and entered into on this Ist day October, 2019 by and C`^w between Shine Hwang dba SunShine Music ("Provider") 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 recreation service provider having special skills, resources and knowledge to provide music classes in its recreation class program. B. Provider represents that he is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that she is knowledgeable in their field and that any services performed by Provider under this Agreement will be performed in compliance with such standards as may reasonably be expected. 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: SCOPE OF SERVICES Provider shall perform those services as set forth in Exhibit A to this Agreement. 2. COMPENSATION In consideration for the provision of the programs set forth in Exhibit A, City agrees to pay the Provider seventy percent (70%) of all gross revenue received from program participants. Total revenue to Provider shall not exceed $25,000.00 annually. Payment to Provider shall be made monthly within thirty (30) days following completion of the last class taught by Provider the prior month. City shall be responsible for collecting all fees from program participants. Provider shall not collect fees but will refer all interested participants to City for registration information. Provider agrees that City shall retain thirty percent (30%) of all gross revenue received from program participants as an administrative fee. 3. TERM This Agreement shall commence on October 1, 2019 and end on September 30, 2020 unless terminated earlier in accordance with Section 12 below. The term of this Agreement may be extended by a writing executed by the City Manager and the City Attorney. 4. INDEPENDENT CONTRACTOR Provider 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 #8404v2 construed to create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the manner in which Provider performs the services which are the subject matter of this Agreement; however, the services to be provided by Provider shall be provided in a manner consistent with all applicable standards and regulations governing such services. Provider 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. Provider is not an agent, representative or employee of City and Provider shall have no authority to act on behalf of the City. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Provider shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Provider shall maintain commercial general liability insurance which 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 Provider'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); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (e) contain standard separation of insured's provisions. b. Worker's Compensation Insurance. In accordance with California State law, Provider, if Provider 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, Provider 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 Provider pursuant to this section: i. Consultant shall maintain all insurance required above in fill 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. #8404v2 d. If Provider 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 terminate this Agreement. Such termination shall not affect Provider's right to be paid for its time and materials expended prior to notification of termination. Provider 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 Provider agrees to and shall indemnify, defend and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Provider or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) 'from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement, to the extent that the injury, damages, just compensation, restitution, judicial or equitable relief is caused by the negligence of the Provider. This indemnity and bold 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 or by reason of the terms of, or effects, arising from this Agreement. City may snake all reasonable decisions with respect to its representation in any legal proceeding. In no case will Provider be required to indemnify or hold harmless the City from injury, damages, just compensation, restitution, judicial or equitable relief caused by the negligence of the City. CONFLICT OF INTEREST Provider 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. LIVE SCAN BACKGROUND CHECK Provider, and any employees, subcontractors or substitutes, shall arrange for and submit their fingerprints for a criminal background check through the Department of Justice through the City's Human Resources Department process. Consultant shall be responsible for all charges associated with fingerprinting. Consultant shall not perform any services pursuant to this Agreement until clearance is received and Consultant is notified by the City's Parks, Recreation and Community Services Department. 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 984042 first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 Fax (714) 647-6956 With copy to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza (M-23) P.O. Box 1988 Santa Ana, California 92702 Fax (714) 571-4211 To Provider: Shine Hwang dba SunShine Music 13337 South Street, #828 Cerritos, CA. 90703 Phone: 646-389-7157 or 631-512-2988 Email: shhie �&sunshuremns%cca.eom 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 fax, 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 as set 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 Provider 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. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Provider. 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 Provider 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 is not embodied herein. 984042 11. ASSIGNMENP/SUBSTITUTES a. Assignment. The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to enter into this Agreement. Therefore, Provider 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. b. Substitutes. In the event Provider is not able to teach a class due to illness or some other cause beyond Provider's reasonable control, Provider most procure, at its sole expense, a qualified substitute instructor to teach the class at its regular time and place. Provider shall ensure that substitute instructors are at least twenty-one (21) years of age and comply with the City's insurance and -live scan requirements contained herein. Evidence of compliance with City's - insurance and live scan requirements shall be provided upon request. Provider must immediately notify the City of the substitute instructor's name, qualifications, address and phone member. If Provider cannot procure a qualified substitute and the City is unable to assist in this regard, then the class shall be canceled and a make-up class must be added to the session. Provider must notify participants as soon as possible of any class cancellation and make-up class. Provider must personally teach at least seventy-five percent (75%) of its offered classes. 12. TERMINATION a. This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of termination. b. Termination or cancellation of classes by the Provider outside of Section 1 Lb. must be given to the City at least thirty (30) days prior to tennination/cancellation. Failure to provide adequate cancellation notice to the City may put future contracting of business with the City at risk and will result in the City's retention of ten (10%) percent of the final payment to Provider. 13. RECORDS Provider shall use attendance sheets generated and supplied by the City to record attendance in each class. Provider shall keep these and any other records in connection with the work to be performed under this Agreement and shall permit City, upon request, to review such records for a period of three (3) years from the date of final payment to Provider under this Agreement. 14. NON-DISCRIMINATION Provider 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, teaching, training, utilization, promotion, termination #8404v2 or other employment related activities or any services provided under this Agreement. Provider affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 15. 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. 16. LICENSES Provider 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. 17. SEVERABILITY In the event that one or more of the phrases, sentences, clauses, paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be interpreted to carry out the intent of the parties hereunder. 18. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 19. AUTHORITY The person(s) executing this Agreement on behalf of the parties hereto warrant that they are duly authorized to execute this Agreement on behalf of said parties and that by so executing this Agreement, the parties hereto are formally bound to the provisions of this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: ME CITY OF SANTA ANA D Gomez Kristine Ridge Clerk of the Council City Manager [Signatures continue on the next page] #8404v2 APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: Laura Rossini Senior Assistant City Attorney RECOMMENDED #84042 AL: Director of Parks, . and Community Services Agency PROVIDER: Shine Hwang dba Sunshine Music Exhibit A SCOPE Of SERVICES A. Provider shall teach Music Makers for ages 1-5 years old. B. Provider shall teach such or similar classes (1) at the times below at facilities to be designated by the City or (2) on a schedule agreed upon by the parties for each class session or tern, including the location, specific days and hours when classes will be held, and holidays to be observed, in accordance with City°s needs. Music Makers Exploring Musicianship through singing, playing, creating and moving to music in a game -like learning environment. Storytelling and acting are also included to help your child to learn the foundation of music and develop social, language, motor and cognitive skills. Adults are required to participate in class for 1-3 years old. Adult participation is optional for ages 3-5. INSTRUCTOR: Sunshine Hwang LOCATION: El Salvador Center, 1825 W Civic Center Dr, Santa Ana, (714) 647-6558 • Music Makers classes will consist of monthly sessions, held 1 day per week, 30 minutes per day. Ages 1-3 years old. • Music Makers classes will consist of monthly sessions, held 1 day per week, 30 minutes per day. Ages 3-5 years old. C. Provider shall provide all materials, supplies, equipment, records and personnel. Provider shall be responsible for clean-up of the facilities and materials and shall ensure the safety and effectiveness of instruction. CLASS SIZE A. Each class must have a minimum of 3 paid students and no more than 10 students. B. No registration will be accepted after the second meeting of classes. C. If the minimum registration has not been reached by the second class, the class shall be canceled. Provider will be under no obligation to provide services for the cancelled classes, and the City will have no further obligations to pay Provider compensation for the remaining classes that were cancelled in that session. CLASS FEES A. Each participant shall pay class registration fees as established by City. B, Provider may not waive class participation/registration fees. C. Only registered participants may participate in class. D. Any refunds to participants will be made in accordance with City policy. E. Any materials fee shall be established by mutual agreement of City and Provider and shall be payable directly to Provider. #8404v2 A CERTIFICATE OF LIABILITY INSURANCE DAT9%M�(Zo 9 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 policy(Ies) must 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 rights to the certificate holder in lieu of such endorsements . PRODUCER MERRIWETHER & WILLIAMS INSURANCE SERVICES 550 MONTGOMERY ST STE 550 SAN FRANCISCO, CA 94111-6507 4159863999 CONTACT NAME: _ PHCNN ExL; 4159863999 qM, Nu: 4159884421 EMAIL ADDRESS, _ INSURERS) AFFORDING COVERAGE MID INSURER A: United States Fire Insurance 21113 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP)AND ITS PARTICIPATING MEMBERS: INSURER B: INSURERC: Sunshine Music 5244 Oliva Avenue INSURER D INSURER E: Lakewood, CA 90712 INSURER I: CUVCHAUES CERTIFICATE NHMRFRr imP3n5897 DOWICInu M.M..... 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. LTR TYPE OF INSURANCE NSRL WVDR POLICYNUMBER wyopwFF M DOIYYYY POMDYE%P MMIODIYYYY LIMITS A GENERALLIABILITY X cOMMERCAL GENERAL LIABILITY CLAIMS -MADE nXOCCUR X SRPGAPML-101-0719 AM 112:01AM torov AM 12:01 AM GENERAL AGGREGATE $1,000000.00 PRODUCTS -COMPMP AGG $1,000,000.00 PERSONAL &ADV INJURY $1,000,000.00 OCCURRENCE EACH OCCU2:01 $1,000,000.00 FIRE DAMAGE (Any Dne pro) $300,000,00 DEN% AGGREGATE LIMIT APPLIES PER: PRO- X POLICY LOC JECT MED E%P (Anyoro pareon) $0,00 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SOLIEGULED AUTOS AUTOS HIREDAUTO NON OWNED AUTOS cOMemEDSNGLELMR $ BODILY INJURY (Per Penton) $ BODILY INJURY(P., Gcddanl) $ PROPERTY DAMAGE P.a $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAMS MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION 5 EACH OCCURRENCE $0,00 GENERAL AGGREGATE $0.00 EACH OCCURENCE $ GENERAL AGGREGATE $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It mare apace is regelred) Music Lessons for kids The Certificate Holder is added as an additional insured but only with respect to liability arising out of the named Insured during the policy period. Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage L.cnI irP .mI D City of Santa Ana By RISk MANAGEMENT DIVISION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 20 Civic Center Plaza BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana, CA 927D1 �7 Q WO 4 2019 L .l AUTHORIZED REPRESENTATIVE FRANCINE R. VILLAREAL Merriwether & Williams Insurance Services ACORD 25 (2010105) V141120.001 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A CERTIFICATE OF LIABILITY INSURANCE °AT911 20 9rr' 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 policy(les) must 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 rights to the certificate holder in lieu of such endorsements). PRODUCER MERRIWETHER & WILLIAMS INSURANCE SERVICES CONTACT NAME: SAN FRANCISCO, CA 94111-6507 SA FRANCI CO, ST411 -65 4159863999 PHONE Af Np J: 4159863999 FAX N.I. 4159864421 EMAIL ADOREss: INSURERS) AFFORDING COVERAGE NAICp INSURERA: United States Fire Insurance 21113 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION(PURCHASINGGROUP) AND ITS PARTICIPATING MEMBERS: INSURERS: INSURERC: Sunshine Music 5244 Oliva Avenue INSURERO: _ INSURERS: Lakewood, CA 90712 NSURERF: 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, INS LT0. TYPE OF INSURANCE ADOLBVefl INBR NAro POLICY NUMBER POLICY FIT MMIODMYY POLICY EXP DDmrr LIMITS GENERAL LIABILITY GENERAL AGGREGATE $t,000,oao.00 X COMMERCYLGENERRLMLIrY PRODUCTS -COMPIOP AGO $1,000,000.00 PERSONAL S ADV INJURY $1,000,Oo0.0O A cIVAB DE � SCCUa SRPGAPML-101-0719 12:01 019 12:01 AM 112:01 M 12:01 AM EACHOCCURRENCE $1,000,000.00 FIRE DAMAGE (My one fret $300,000.00 GENT AGGREGATE UNIT APPLIESPER: NED EXP(Myone perrerl $0.00 X POLICY JER LOL AUTOMOBILE LIABILITY COMBDSmcLE Lunn $ BODILY INJURY (Per pereon) $ ARYAVTO ALL OWNED SCNEDUI£0 A. AUTOS BODILY INJURY (Per acddenl) $ HIRE. AUTO AUi CEO PROPERTY DAMAGE Pa avNeN $ UMBRELLA UAS accuR EACH OCCURRENCE EXCESS LIAR CINYS�MADE AGGREGATE $ OED RETENTION f EACHOCCURRENCE $0.00 GENERAL AGGREGATE $0.00 EACH OCCURENCE I $ GENERAL AGGREGATE $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addifl.n.I Remark. Schedule, If more apace le required) Music Lessons for kids Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage HOLDER SunShine Music REVIEWED &APPROVED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 5244 Oliva Avenue BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lakewood, CA 90712 By Risk MANAgCMENT DIVISION ACCORDANCE WITH THE POLICY PROVISIONS. S24 2 1g AUTHORIZED REPRESENTATIVE Merriwether & Williams Insurance Services ACORD 25 (2010/05) v141120.001 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CRU M & FORSTER` NAMED INSURED MEMBER CERTIFICATE OF COVERAGE CERTIFICATE#: USP305627 MASTER POLICY #: SRPGAPML-101-0719 Policyholder: Named Insured Member: Sports and Recreation Providers Association Purchasing Group Sunshine Music 1776 South Naperville Road, Bldg-B 5244 Oliva Avenue Wheaton, IL 60187 Lakewood, CA 90712 Certificate Coverage Period: 10/01/2019 12:01 AM to 10/01/2020 12:01 AM at 12:01 A.M. at the mailing address of the Named Insured Member shown above. Master Policy Issued By: United States Fire Insurance Company Certificate of Coverage Issued By: Francis L. Dean & Associates, Inc. 1776 South Naperville Road, Bldg-B P,O. Box 4200 Wheaton, IL 60189 Telephone: (630) 665-7011 Location / Description of Operations: Music Lessons for kids See Endorsement Schedule below for any exclusions or limitations COVERAGEISI Insurance is provided only for those coverages for which a limit or the word "Included" Is shown below. General Liability Limits of Insurance $1,000,000.00 General Aggregate Limit (Other Than Products —Completed Operations) $1,000,000.00 Products —Completed Operations Aggregate Limit $1,000,000.00 Personal And Advertising Injury Limit $1.000,000.00 Each Occurrence Limit $300,000.00 Damage To Premises Rented To You Limit $0.00 Medical Expense Limit Limits of Insurance — Optional Coverages Excluded Abuse & Molestation Coverage — Each Occurrence Limit Excluded Abuse & Molestation Coverage — Aggregate Limit Included Bodily Injury To Athletic Or Sports Participants $1.000,000.00 Each Sports, Health, Fitness And Wellness Services Incident Limit $1,000,000.00 Sports, Health, Fitness And Wellness Services Aggregate Limit Premium $406.00 Total Estimated Commercial General Liability Premium Due From Member Hired / Non -Owned Automobile Liability Limits of Insurance Excluded Covered Autos Liability Limit Premium $0.00 Total Estimated Hired / Non -Owned Automobile Liability Premium Due From Member L guor Liability Limits of Insurance (the applicable statutory limit or the limit as shown below, whichever is less) Excluded Each Common Cause Excluded Aggregate Limit Premium $0.00 Total Estimated Liquor Liability Premium Due From Member MG 05 009 07 17 REVIEWED & APPROVED By RISk MANACIr.M[NT DIVISION S ? 4 2019 FRAWINE R. VILLAREAL Page 1 of 2 CRUM&FORSTER' NAMED INSURED MEMBER CERTIFICATE OF COVERAGE This Certificate of Coverage evidences your coverage as a Named Insured Member under the Master Policy described herein. United States Fire Insurance Company certifies that the Named Insured Member as shown herein is insured under the Sports & Recreation Providers Association Purchasing Group Master Policy. The Limits of Insurance, Premium and Effective Date of coverage applicable to the Named Insured Member are as specified above. This Certificate of Coverage, together with the Common Policy Conditions, Coverage Part(s), Coverage Form(s) and Endorsements attached to the Master Policy, complete the above numbered insurance contract. The Master Policy, containing the terms and conditions of coverage, has been furnished to the Policyholder and a copy of that policy accompanies this Certificate of Coverage. All claims are paid according to the terms and conditions of the Master Policy. Schedule of Additional Insureds The entities shown below are added as Additional Insureds, but only In respect to liability caused by operations of the Named Insured Member during the certificate policy period. Form Number Description FSPG 101.0.0007 Name Of Additional Insured Person(s) Or Organization(; Designated Person/Org FSPG 101.0.0008 Name Of Additional Insured Governmental Entity(ies) Designated Person/Org (CA Govt) FSPG 101.0,0009 Name of Additional Insured State Or Governmental Agency Or Subdivision or State/Govt Agency/ Subdivision Political Subdivision: FSPG 101.0,0010 Name Of Additional insured Person(§) Or Organization(s): Vendors_ FSPG 101.0.0011 Name Of Additional Insured Person( ) Or Omanization(s): Managers or Lessors of Premises FSPG 101.0.0012 Name Of Additional Insured Person(s) Or Organization(s); Lessor of Leased Equipment Endorsement Schedule Form Number Description CG 2144 Premises: Limitation To Designated Protect Or Operation: Premises, Projects, Operations CG 21 53 Description of Dosignated Ongoing Opera i : In addition, scheduled activities Exclusion — Designated exclusion endorsement applies: Inflatable Amusement Devices, Carnival Rides, Ongoing Operations Knockerball/Bubble Soccer, Bungee Devices, Fireworks, Mechanical Bucking Devices: including Multi Ride Attachments, Permanent & Mobile Rock Wall Structures, Security Services Other Than Contracted Law Enforcement Officers, Trampolines, and Zip Lines. Specified Location (if Ap Ip i99b—li Crum & Forster is part of Fairfax Financial Holdings Limited. C&F and Crum & Forster are registered trademarks of United States Fire Insurance Company. REVIEWED & APPROVED By Risk MANAGEMENT DlvisiON MG 05 009 07 17 , 0t9 Page 2 of 2 FRANCINE R. VILLAREAL UNITED STATES FIRE INSURANCE COMPANY Administrative Offices: 5 Christopher Way • 3" Floor • Eatontown, NJ 07724 BLANKET BENEFITS FOR ACCIDENTS ONLY CERTIFICATE OF COVERAGE This Certificate contains the terms under which the United States Fire Insurance Company agrees to insure certain persons and pay benefits. This Certificate is a part of, and is governed by, a Group Policy that has been issued in the state of ILLINOIS and shall be governed by its laws. Coverage under this Certificate is provided in consideration of payment of the initial premium, continued payment of premiums when due, and completion of an Application. This Certificate is a part of, and is governed by, a Group Policy. The Group Policy has been issued to, and is the contract between, the Group Policyholder and The United States Fire Insurance Company. The Group Policy is held by the Group Policyholder and may be inspected upon request at any reasonable time. The name of the Group Policyholder is shown in the Schedule. This Certificate has been issued to you, the Certificateholder, as a Participant under the Group Policy, in accordance with the terms, conditions, and limitations of the Group Policy. 10 DAY RIGHT TO RETURN THIS CERTIFICATE If for any reason, you are not satisfied with this Certificate, you may return it to us within 10-days after receiving it. Upon its return, we will refund any premium paid and this Certificate will be deemed void, just as though it had never been issued. THIS IS ACCIDENT ONLY COVERAGE. READ IT CAREFULLY. BENEFITS ARE NOT PAYABLE FOR LOSS DUE TO SICKNESS. THIS CERTIFICATE PAYS BENEFITS FOR SPECIFIC LOSSES FROM ACCIDENTS ONLY. THIS CERTIFICATE IS NOT RENEWABLE. Signed for The United States Fire Insurance Company By: Signature Signature M Douglas M. Libby James Kraus Chairman and CEO Secretary GAC26932 ByRJkA&mP OVED SMr4AceeD 24209 �- FRANONE R. VILLAREAL TABLE OF CONTENTS The following provisions appear within this Certificate in the following order: Schedule of Benefits Definitions Scope of Coverage Description of Hazards Description of Benefits Exclusions Additional Exclusions Limitations Premium Provisions General Provisions Claim Provisions GAC26932 REVIEWED & APPROVED By Risk MANAGcMENT DIVISION SEPWVILREAL F ANCIN SCHEDULE OF BENEFITS COVERAGE IS PROVIDED UNDER GROUP POLICY NUMBER: AH-GA26932-002 ISSUED TO GROUP POLICYHOLDER: The Group and Blanket Accident & Health Insurance Trust CERTIFICATEHOLDER: Sunshine Music CERTIFICATE NUMBER: US1298016 CERTIFICATE EFFECTIVE DATE: 10/01/2019 12:01 AM CERTIFICATE EXPIRATION DATE: 10/01/202012:01 AM Benefits are payable for 12 months from the date of an Injury, The Injury must occur after the Effective Date and prior to the Expiration Date and care must be Medically Necessary. PREMIUM: $150.00 DEDUCTIBLE AMOUNT: $100.00 COINSURANCE PERCENTAGE: 1GO% of Usual, Reasonable & Customary Charges, URC MAXIMUM BENEFIT AMOUNT: $10,000.00 ELIGIBLE PERSONS: All Participants & Staff of the Policyholder's Programs SPECIFIED ACTIVITY: Music Lessons for kids MEDICAL EXPENSE BENEFIT Hospital Room & Board Daily Maximum Benefit Amount: URC Intensive Care Room & Board Daily Maximum Benefit: URC Hospital Miscellaneous Maximum Benefit Amount: URC Outpatient Pre -Admission Testing Benefit Amount: URC Outpatient Hospital Emergency Room Treatment Maximum Benefit Amount: URC Surgical Benefits Primary Surgeons Maximum Benefit Amount: URC Assistant Surgeon, Second Surgical Opinion, Consultation Maximum Benefit: URC Anesthesia Maximum Benefit: URC Surgical Facility Maximum Benefit per Operating Session: URC Doctor's Visits In -Hospital Maximum Benefit: URC Office Visits Maximum Benefit: URC Maximum for All In -Hospital and Office Doctor's Visits: URC X-ray and Laboratory Maximum Benefit Amount: URC Nursing Maximum Benefit Amount: URC Physiotherapy Benefit Maximum Benefit Amount (Hospital Inpatient): URC Maximum Benefit Amount (Outpatient): URC Maximum for All Physiotherapy Combined (Inpatient & Outpatient): URC Ambulance Maximum Benefit Amount: URC GAC26932 Medical Equipment Rental Charges Maximum Benefit Amount: URC Medical Services and Supplies Maximum Benefit Amount (Blood, Blood Transfusions, Oxygen): URC Dental Treatment For Injury Only Maximum Benefit Amount: URC OUT -PATIENT PRESCRIPTION DRUG BENEFIT Maximum Benefit Amount: URC ACCIDENTAL DEATH, DISMEMBERMENT, LOSS OF SIGHT, SPEECH, OR HEARING Principal Sum: $2,500.00 GAC26932 DEFINITIONS The terms shown below shall have the meaning given in this section whenever they appear in this Certificate. Additional terms may be defined within the provision to which they apply. "Accident" means a sudden, unforeseeable external event which: (1) Causes Injury to one or more Covered Persons; and (2) Occurs while coverage is in effect for the Covered Person. "Benefit Period" means the period of time from the date of Injury, as shown in the Schedule of Benefits. "Covered Person" means a person eligible for coverage as identified in the Application for whom proper premium payment has been made, and who is therefore insured under this Certificate. "Deductible" means the amount of Eligible Expenses which must be paid by the Covered Person before benefits are payable under this Certificate. It applies separately to each Covered Person. "Doctor" means a licensed practitioner of the healing arts acting within the scope of his license. Doctor does not include: (1) The Covered Person; (2) The Covered Person's spouse, child, parent, brother, or sister; or (3) A person living with a Covered Person. "Eligible Expenses" means the Usual, Reasonable and Customary charges for services or supplies which are incurred by the Covered Person for the Medically Necessary treatment of an Injury. Eligible Expenses must be incurred while this Certificate is in force. "He", "his" and "him" includes "she", "her" and "hers." "Health Care Plan" means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under: (1) Group or blanket insurance, whether on an insured or self -funded basis; (2) Hospital or medical service organizations on a group basis; (3) Health Maintenance Organizations on a group basis. (4) Group labor management plans; (5) Employee benefit organization plan; (6) Professional association plans on a group basis; or (7) Any other group employee welfare benefit plan as defined in the Employee Retirement Income Security Act of 1974 as amended. "Hospital" means an institution which: (1) Is operated pursuant to law; (2) is primarily and continuously engaged in providing medical care and treatment to sick and injured persons on an inpatient basis; (3) Is under the supervision of a staff of doctors; (4) Provides 24-hour nursing service by or under the supervision of a graduate registered nurse, (R.N.); (5) Has medical, diagnostic and treatment facilities, with major surgical facilities; (a) On its premises; or (b) Available to it on a prearranged basis; and (6) Charges for its services. "Hospital" does not include: (1) A clinic or facility for: (a) Convalescent, custodial, educational or nursing care; (b) The aged, drug addicts or alcoholics; or (c) Rehabilitation; or (2) A military or veterans hospital or a hospital contracted for or operated by a national government or its agency unless: GAC26932 (a) The services are rendered on an emergency basis; and (b) A legal liability exists for the charges made to the individual for the services given in the absence of Insurance. "Hospital Stay" means a Medically Necessary overnight confinement in a Hospital when room and board and general nursing care are provided for which a per diem charge Is made by the Hospital. "Injury" means bodily harm which results, directly and independently of disease or bodily infirmity, from an Accident. All injuries to the same Covered Person sustained in one accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury. "Medically Necessary" or "Medical Necessity" means the service or supply is: (1) Prescribed by a Doctor for the treatment of the Injury; and (2) Appropriate, according to conventional medical practice for the Injury in the locality in which the service or supply is given. "Nurse" means either a professional, licensed, graduate registered nurse (R.N.) or a professional, licensed practical nurse (L.P.N.). "School" means the participating School or School -District where the Covered Person is enrolled -or employed. The School must be a duly accredited (state certified or accredited) primary, elementary, secondary, or collegiate School. "Sickness" means Illness or disease which begins or for which an expense was first incurred while coverage is in force under this Certificate for the Covered Person. Sickness includes complications of pregnancy. All related conditions and recurring symptoms of sickness to the same person will be considered one sickness. "Student Infirmary" means an on campus facility which: (1) Provides medical care and treatment to sick and injured students and faculty; (2) Is under the supervision of a Doctor; (3) Provides nursing services; and (4) Charges for its services. "Student Infirmary" does not include: (1) Medical, diagnostic or treatment facilities with major surgical facilities: (a) On its premises; or (b) Available to it on a prearranged basis; or (2)ln-patient care. (No benefits are payable forservices, supplies, or treatment in a Student infirmary. This definition is applicable only to its reference in the provision titled Additional Exclusions.) "Supervised or Sponsored Activity" means a Certificateholder or School authorized function: (1) In which the Covered Person participates; (2) Which is organized by or under its auspices; which is within the scope of customary activities for such entity and is shown on the Schedule of Benefits, "Usual, Reasonable and Customary means: (1) With respect to fees or charges, fees for medical services or supplies which are; (a) Usually charged by the provider for the service or supply given; and (b) The average charged for the service or supply in the locality In which the service or supply is received; or (2) With respect to treatment or medical services, treatment which is reasonable in relationship to the service or supply given and the severity of the condition. SCOPE OF COVERAGE We will provide the benefits described in this Certificate to all Covered Persons who suffer a covered loss which: (1) Is within the scope of the DESCRIPTION OF BENEFITS PROVISIONS and results, directly and Independently of disease or bodily infirmity, from an Injury which is suffered in an Accident; (2) Occurs while the person is a Covered Person under this Certificate; and GAC26932 (3) Is within the scope of the risks set forth in the DESCRIPTION OF HAZARDS provisions. Full Excess Medical Expense: If an Injury to the Covered Person results in his incurring Eligible Expenses for any of the services in the SCHEDULE OF BENEFITS, we will pay the Eligible Expenses incurred, subject to the Deductible Amount and Coinsurance Percentage (if any), that are in excess of Expenses payable by any other Health Care Plan, regardless of any Coordination of Benefits provision contained in such Health Care Plan. The Covered Person must be under the care of a Doctor when the Eligible Expenses are incurred. The Expense must be incurred solely for the treatment of a covered Injury: (1) While the person is insured under this Certificate; or (2) During the Benefit Period stated on the SCHEDULE OF BENEFITS. The first Expense must be incurred within the time frame shown on the SCHEDULE OF BENEFITS. The total of all medical benefits payable under this Certificate Is shown on the SCHEDULE OF BENEFITS; and (1) Subject to the specific maximums shown on the SCHEDULE OF BENEFITS; and (2) Subject to compliance with the requirement, set forth in the Limitations section of this Certificate, Non -Duplication of Benefits Provision: This provision applies if a Covered Person: (1) Is covered by any other blanket or group health care plan; and (2) Would, as a result, receive total medical expense or service benefits in excess of the expenses actually incurred. In this case, the medical expense benefits we will pay under this Certificate will be reduced by such excess. This provision does not apply if we would be primary under any coordination of benefit guidelines contained in the other health care plans. PROVISIONS CONCERNING COVERED PERSONS Eligibility: Persons eligible to be insured under this Certificate are those persons described as an ELIGIBLE CLASS on the Application who have completed any applicable Service Waiting Period. This includes anyone who may become eligible while this Certificate is in force. Effective Dates: A Covered Person will become an insured under this Certificate, provided proper premium payment is made, on the latest of: (1) The Effective Date of this Certificate; or (2) The day he becomes eligible according to the referenced date shown in the Application. Termination: Insurance for a Covered Person will end on the earliest of: (1) The date he is no longer in an Eligible Class. (2) The date he reports for active duty in any Armed Forces, according to the referenced date shown in the Application. We will refund, upon receipt of proof of service, any premium paid, calculated from the date active duty begins until the earlier of: (a) The date the premium is fully earned; or (b) The Expiration Date of this Certificate. This does not include Reserve or National Guard duty for training; (3) The and of the period for which the last premium contribution is made; or (4) The date the Group Policy is terminated. GAC26932 DESCRIPTION OF HAZARDS HAZARD: CERTIFICATE HOLDER FUNCTIONS Subject to all other provisions of this Certificate, coverage is provided for a Covered Person while he is: (1) Attending or participating in a Supervised or Sponsored Activity; or (2) Attending a Certificate holder function. The Covered Person must be: (1) On the premises of the Certificate holder: (a) During its normal hours; (b) During scheduled functions; or (c) During other periods if he is attending or participating in a Supervised or Sponsored Activity; (2) Not on Certificate holder premises and attending or participating in a Supervised or Sponsored Activity; (3) Traveling directly, without interruption: (a) Between his home and the Certificate holder's premises for participation in a Supervised or Sponsored Activity; (b) Between the site of the Supervised or Sponsored Activity and his home or the Certificate holder's premises. (c) In a vehicle which is: (1) Designated or furnished by the Certificate holder; (it) Operated by a properly licensed adult driver; and (iii) Under the direct supervision of the Certificate holder; or (d) In a vehicle other than that described in (3)(c) when operated by a properly licensed driver. Travel time includes the time: (i) To or from home, the Certificate holder's address and the Supervised or Sponsored Activity; (ii) Before the appointed time; and (iii) After the Supervised or Sponsored Activity Is completed. Unless otherwise stated, we will pay benefits for a covered loss, only once, even if coverage was provided under more than one Description of Hazards. DESCRIPTION OF BENEFITS BENEFIT A; BENEFITS FOR ACCIDENTAL DEATH, DISMEMBERMENT, LOSS OF SIGHT, OR SPEECH AND HEARING If, within 1-year from the date of an Accident covered by this Certificate, Injury from such Accident, results in Loss listed below, we will pay the percentage of the Principal Sum set opposite the loss in the table below. If the Covered Person sustains more than one such Loss as the result of one Accident, we will pay only one amount, the largest to which he is entitled. This amount will not exceed the Principal Sum which applies for the Covered Person, Loss Loss of Life Loss of Both Hands Loss of Both Feet Loss of Entire Sight of Both Eyes Loss of One Hand and One Foot Loss of One Hand and Entire Sight of One Eye Loss of One Foot and Entire Sight of One Eye Loss of Speech and Hearing (both ears) Loss of One Hand Loss of One Foot OAC26932 Percentasla of Principal Sum 100% 100% 100% 100% 100% 100% 100% 100% 50% 50% Loss of Entire Sight of One Eye Loss of Speech Loss of Hearing (both ears) Loss of Thumb and Index Finger of the Same Hand 50% 50% 50% 25% Loss of a hand or foot means complete Severance through or above the wrist or ankle joint. Loss of sight means the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means. Loss of speech means total, permanent and irrecoverable loss of audible communication. Loss of hearing means total and permanent loss of hearing in both ears which cannot be corrected by any means, Loss of a thumb and Index finger means complete Severance through or above the metacarpophalangeal joints (the joints between the fingers and the hand), In California, loss of a thumb and index finger means loss by complete Severance of at least one whole phalanx of -each In South Carolina, the complete severance of four whole fingers from one hand equals the loss of one hand. "Severance" means the complete separation and dismemberment of the part from the body, BENEFIT - MEDICAL EXPENSE We will pay, Eligible Expenses for a Covered Person's Injury, subject to the Deductible Amount and Coinsurance Percentage, if any, shown in the Schedule of Benefits. Eligible Expenses are those incurred for: (1) Hospital Room and Board — charges for the most common semi -private daily room rate for each day of the Hospital Stay, up to the Maximum Daily Benefit Amount shown in the Schedule of Benefits for Hospital Room and Board. (2) Intensive Care Room and Board - charges for each day of Intensive Care Unit confinement, up to the Daily Maximum Benefit Amount shown in the Schedule of Benefits for the Intensive Care Room and Board benefit. This payment is in lieu of payment for the Hospital Room and Board charges for those days. (3) Hospital Miscellaneous - charges during a Hospital Stay, up to the Maximum Daily Benefit Amount shown in the Schedule of Benefits for the Hospital Miscellaneous benefit. Miscellaneous charges do not include charges for telephone, radio or television, extra beds or cots, meals for guests, take home items, or other convenience items. (4) Outpatient Hospital Expenses - charges by a Hospital for: (a) Pre -admission testing (confinement must occur within 7 days of the testing); or (b) Emergency room treatment, up to the Maximum Benefit Amount per emergency shown in the Schedule of Benefits for the Outpatient Emergency Room Treatment benefit. (5) Surgical Benefits - charges for: (a) A Doctor, for primary performance of a surgical procedure, up to the Maximum Benefit Amount shown in the Schedule of Benefits per procedure. Two or more surgical procedures through the same incision will be considered as one procedure. However, we will pay up to 50% of the surgical procedure charge when more than one surgical procedure through different operating fields are performed during the same surgical session. (b) A Doctor, for: (1) assistant surgeon duties; (ii) a second surgical opinion; or (iii) consultation, up to the Maximum Benefit shown in the Schedule of Benefits for an Assistant Surgeon, Second Surgical Opinion, and Consultation. GAC26932 (c) Anesthesia and its administration, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Anesthesia benefit. (d) Use of surgical facilities, up to the Maximum Benefit Amount per operating session, as shown in the Schedule of Benefits for the Surgical Facility benefit. (6) Doctor's Visits - charges by a Doctor for other than pre- or post -operative care: (a) For in -Hospital visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Doctor's Visit — In -Hospital. (b) For office visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Doctor's Office Visits. Total visits per Injury will not exceed the combined Maximum shown in the Schedule of Benefits for All In - Hospital and Office Doctor's Visits. (7) X-Ray and Laboratory - charges for X-ray and laboratory tests, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the X-ray & Laboratory benefit. (8) Nursing Services - Charges for nursing services (other than routine Hospital care) by or under the supervision of a licensed graduate registered nurse, up to the Maximum Benefit Amount shown on the Schedule of Benefits for the Nursing benefit. (9) Physiotherapy - Charges for physiotherapy: (a) While Hospital confined, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Hospital Inpatient Physiotherapy benefit; (b) As an outpatient, up to the Maximum Benefit Amount shown on the Schedule of Benefits for the Outpatient Physiotherapy benefit. Physiotherapy includes: (a) Heat treatment; (b) Diathermy; (c) Microtherm; (d) Ultrasonic; (e) Adjustment; (f) Manipulation; (g) Massage therapy and (h) Acupuncture. Total treatment per Injury will not exceed the Maximum Benefit Amounts for Physiotherapy shown in the Schedule of Benefits. (10) Ambulance - from the place where the Injury occurred to the Hospital, up to the Maximum Benefit Amount shown In the Schedule of Benefits for the Ambulance benefit. (11) Medical Equipment Rental - charges for medical equipment for; (a) A wheelchair; (b) An iron lung; or (c) Other medical equipment for which prior approval by us has been given; up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Medical Equipment Rental benefit. (12) Medical Services and Supplies - Charges for medical services and supplies for: (a) Oxygen and its administration; (b) Blood and blood transfusions; up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Medical Service & Supply benefit. (13) Dental Treatment - Charges for dental treatment for Injury to a tooth which was sound and natural at the time of Injury, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Dental Treatment benefit. GAC26932 The amounts payable under this Medical Expense benefit could be greatly reduced if the Covered Person does not comply with the requirements In the Limitations section of this Certificate. BENEFIT - OUT -PATIENT PRESCRIPTION DRUG BENEFIT We will pay the Eligible Expenses, subject to the Deductible Amount and Coinsurance Percentage shown in the Schedule of Benefits, if any; for a Prescription Drug or medication when prescribed by a Doctor on an outpatient basis. Prescription Drug means a drug which: (1) Under Federal law may only be dispensed by written prescription; and (2) Is utilized for the specific purpose approved for general use by the Food and Drug Administration The Prescription Drug must be dispensed for the out-patlent use by the Covered Person: (1) On or after the Covered Person's Effective Date; and (2) By a licensed pharmacy provider. Benefits are payable up to the Maximum Benefit Amount shown on the Schedule of Benefits. The amount payable under this benefit could be greatly reduced if the Covered Person does not comply with the requirements in the Limitations section of this Certificate. EXCLUSIONS Benefits will not be paid for a Covered Person's loss which: (1) Is caused by or results from the Covered Person's own: (a) Intentionally self -Inflicted Injury, suicide or any attempt thereat. (In Missouri this applies only while sane.); (b) Voluntary self -administration of any drug or chemical substance not prescribed by, and taken according to the directions of, a doctor (Accidental ingestion of a poisonous substance Is not excluded.); (c) Commission or attempt to commit a felony; (d) Participation in a riot or insurrection; (a) Driving under the Influence of a controlled substance unless administered on the advice of a doctor; or (f) Driving while Intoxicated. "Intoxicated" will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs; (2) Is caused by or results from: (a) Declared or undeclared war or act of war; (b) An Accident which occurs while the Covered Person is on active duty service in any Armed Forces. (Reserve or National Guard active duty for training is not excluded unless it extends beyond 31 days.); (c) Aviation, except as specifically provided in this Certificate; (d) Sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, bacterial or viral infection, regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning. (a) Nuclear reaction or the release of nuclear energy. However, this exclusion will not apply if the loss is sustained within 180 days of the initial incident and: (i) The loss was caused by fire, heat, explosion or other physical trauma which was a result of the release of nuclear energy; and (ii) The Covered Person was within a 25-mile radius of the site of the release either: 1) At the time of the release; or 2) Within 24 hours of the start of the release. ADDITIONAL EXCLUSIONS Benefits will not be paid for: 1. Normal health checkups; GAG26932 2. Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury resulting from an Accident while the Covered Person is covered under this Certificate, and rendered within 6 months of the Accident; 3. Services or treatment rendered by a doctor, nurse or any other person who is: (a) Employed or retained by the Certificateholder; or (b) Who is the Covered Person or a member of his immediate family; 4. Charges which: (a) The Covered Person would not have to pay if he did not have insurance; or (b) Are in excess of Usual, Reasonable and Customary charges. 5. An Injury that is caused by flight In: (a) An aircraft, except as a fare -paying passenger; (b) A space craft or any craft designed for navigation above or beyond the earth's atmosphere; or (c) An ultra light, hang-gliding, parachuting or bungi-cord jumping; 6. Travel in or upon: (a) A snowmobile; (b) Any two or three wheeled motor vehicle; (c) Any off -road motorized vehicle not requiring licensing as a motor vehicle; 7. Any Accident where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator's license; 8. That part of medical expense payable by any automobile Insurance policy without regard -to fault. (Does not apply in any state where prohibited); 9. Injury that is: (a) The result of the Covered Person being Intoxicated. ("Intoxicated" will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs); or (b) Caused by any narcotic, drug, poison, gas or fumes voluntarily taken, administered, absorbed or Inhaled, unless prescribed by a doctor; 10, Any Sickness, except infection which occurs directly from an Accidental cut or wound or diagnostic tests or treatment, or ingestion of contaminated food, 11. Expenses to the extent that they are paid or payable under other valid and collectible group insurance or medical prepayment plan; 12. Blood or Blood plasma, except for charges by a Hospital for the processing or administration of blood; 13, Elective treatment or surgery, health treatment, or examination where no Injury is involved; 14. Injury sustained while in the service of the armed forces of any country. When the Covered Person enters the armed forces of any country, we will refund the unearned pro rate premium upon request; 15. Eyeglasses, contact lenses, hearing aids, braces, appliances, or examinations or prescriptions therefore; 16. Treatment in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay; 17, Treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy; 18. Cosmetic surgery, except for reconstructive surgery on a diseased or injured part of the body; 19. Any loss which is covered by state or federal worker's compensation, employers liability, occupational disease law, or similar laws; 20. The repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices; 21. Rest cures or custodial care; 22, The repair or replacement of existing dentures, partial dentures, braces or fixed or removable bridges; 23. Expenses incurred for an Accident or Sickness after the Benefit Period shown in the Schedule of Benefits; 24. Orthopedic appliances which are used mainly to protect an Injury so that a covered student can take part in Interscholastic or intercollegiate sports; 25. Services and supplies furnished by the Policyholder's infirmary, Its employees, or doctors who work for the Policyholder's; 26, Hernia of any kind; or any bacterial infection that was not caused by an Accidental cut or wound; 27. Prescription medicines unless specifically provided for under this Certificate. LIMITATIONS Any benefits payable under this Certificate will be limited to the following: (1) The medical benefits otherwise payable under this Certificate will be reduced by 50% if: ,,jq\ GAC26932 (a) Excess insurance is provided under this Certificate; and (b) The Covered Person has coverage under another plan providing medical expense benefits; and (c) The other plan is an HMO, PPO or similar arrangement ("PPO-Preferred Provider Organization" means an Organization offering health care services through designated health care providers who agree to perform these services at rates lower than nonpreferred providers.); and (d) The Covered Person does not use the facilities or services of the HMO, PPO or similar arrangement for the provision of benefits. 'The Covered Person's limitation does not apply to emergency treatment required within 24 hours after an Accident which occurred outside the geographic area serviced by the HMO, PPO or similar arrangement. (2) Costs that exceed the Usual, Reasonable and Customary charges in the area where the services are furnished or supplies provided. Services, supplies and equipment must be: a) Medically necessary for the care or treatment of a covered Injury; b) Received while coverage is in force under this Certificate; and c) Rendered and/or prescribed by a licensed Doctor other than the Covered Person (or a member of his household or immediate family) in accordance with current medical standards and practices. (3) The application of the Coordination of Benefits or Non -Duplication of Benefits provision. (4) If the Covered Person is admitted into the Hospital on a Friday or a Saturday on a non -emergency basis and the procedure for which he is admitted is not performed on the day of or the day after admission, we will not pay the Hospital charges for room and board or miscellaneous Hospital charges for the initial Friday or Saturday preceding the procedure. PREMIUM PROVISIONS GRACE PERIOD: A grace period of 31-days is granted for each premium due after the first premium due date. Coverage will stay in force during this period unless notice has been sent, in accordance with the POLICY TERMINATION provision, of the intent to terminate coverage under this Certificate. Coverage will end if the premium is not paid by the and of the grace period. PREMIUMS: Premium due dates are the first of every month. Premium payment made in advance or for more than a one month period will not affect any provisions of this Certificate with regard to change. Failure by the Certificateholder to pay premiums when due or within the grace period shall be deemed notice to us to terminate coverage at the end of the period for which premium was paid. CHANGES IN RATES: We have the right to change the premium rates on any premium due date: (1) After the first 12 months Insurance is in effect; (2) Coinciding with a change in the coverage provided or classes eligible; or (3) Coinciding with a change in the risks we have assumed. We will give 31 days written notice of any change under (1) above. Notice will be sent to the Certificateholder's most recent address in our records. GENERAL PROVISIONS ENTIRE CONTRACT; CHANGES: GAC26932 This Certificate, the application of the Certificateholder (if any, a copy of which is attached), endorsements, riders and attached papers constitute the entire contract between the parties. If an application of a Covered Person is required, the application of any Insured, at our option, may also be made a part of this contract. All statements made by the Certificateholder or by a Covered Person are deemed representations and not warranties. No such statement will cause us to deny or reduce benefits or be used as a defense to a claim unless a copy of the instrument containing the statement is or has been furnished to such person; or, in the event of his death or incapacity, his beneficiary or representative. After 2-years from the Covered Person's effective date of coverage, no such statement, except in the case of fraud or with respect to eligibility for coverage, will cause such coverage to be contested. No change in this Certificate will be valid until approved by one of our executive officers. This approval must be endorsed on or attached to this Certificate. No agent may change this Certificate or waive any of its provisions. WORKERS' COMPENSATION INSURANCE: This Certificate is not in lieu of and does not affect any requirement for coverage under any Workers' Compensation Insurance. CERTIFICATES OF INSURANCE: A -certificate of insurance will be delivered to the Certifiicateholder for delivery to a Covered Person, Each certificate will list the benefits, conditions and limits of the Certificate. It will state to whom the benefits will be paid. CONFORMITY WITH STATE STATUTES: Any provision of this Certificate in conflict, on the Effective Date of this Certificate, with the laws of the state where It is delivered, is amended to conform to the minimum requirements of such laws. CLAIM PROVISIONS NOTICE OF CLAIM: Written notice must be given to us within 30 days after a covered loss occurs or begins or as soon as reasonably possible. Notice can be given at our administrative office as shown on the cover page or to our agent. Notice should include the Certificateholder's name and number and a Covered Person's name and address, CLAIM FORMS: When we receive the notice of claim, we will send forms for filing proof of loss. If claim forms are not sent within 15 days after notice is given, the proof requirements will be met by submitting, within the time required under PROOF OF LOSS, written proof of the nature and extent of the loss. PROOF OF LOSS: Written proof of loss must be furnished to us in the case of a claim for loss for which this Certificate provides periodic payment contingent upon continuing loss within 90 days after the end of the period for which we are liable. Written proof that the loss continues must be furnished to us at intervals required by us. In case of claim for any other loss, proof must be furnished within 90 days after the date of such loss. If that is not reasonably possible, we will not deny or reduce any claim if proof is furnished as soon as reasonably possible. Proof must, in any case, be furnished not more than a year later, except for lack of legal capacity. TIME OF PAYMENT OF CLAIMS: Benefits due under this Certificate for a loss, other than a loss for which this Certificate provides installments, will be paid immediately upon receipt of due written proof of such loss. Subject to written proof of loss, all accrued benefits for loss for which this Certificate provides installments will be paid Monthly; any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of a written proof of loss, unless otherwise stated in the Description of Benefits. PAYMENT OF CLAIMS: GAC26932 Benefits for a Covered Person's loss of life will be paid to the beneficiary named in our records, if any, at the time of payment. The benefits can be paid in one sum or, at a Covered Person's written request, In accordance with one of our settlement plans. If a Covered Person has not requested any settlement plan, the beneficiary can do so in writing after a Covered Person's death. If there is no named beneficiary or surviving beneficiary, a Covered Person's loss of life benefits will be paid in one sum to the first surviving class of following in the order shown below: (1) The beneficiary named to receive a Covered Person's proceeds; (2) Spouse; (3) Child or children; (4) Mother or father; (5) Sisters or brothers; or (6) The estate of a Covered Person. If we are to pay benefits to the estate or to a person who is incapable of giving a valid release, we may pay up to $1,000 to a relative by blood or marriage whom we believe is equitably entitled. This good faith payment satisfies our legal duty to the extent of that payment. Any other accrued benefits which are unpaid at a Covered Person's death may, at our option, be paid either to his beneficiary or to his estate. All other benefits, unless specifically stated otherwise, will be paid to a Covered Person. PAYMENT OF CLAIMS: OTHER BENEFITS: All other benefits will be paid to the Covered Person, if he is living, If not, we will pay his beneficiary or his estate, CHANGE OF BENEFICIARY: (Applicable only if an Accidental Death or Dismemberment benefit is provided) The Insured can change the beneficiary at any time by giving us written notice. The beneficiary's consent is not required for this or any other change which a Covered Person may make unless the designation of beneficiary is irrevocable or otherwise required by law. CONDITIONAL CLAIM PAYMENT: If a Covered Person incurs expenses for Injuries received in a covered Accident, and in our opinion a third party may be liable, we will pay benefits if: (1) The Covered Person first agrees in writing to refund the lesser of: (a) The amount we actually paid for such expenses; or (b) The amount actually received from the third party for such expenses; and (2) The third party's liability is determined and satisfied whether by settlement, judgment, arbitration or otherwise. However, prior to our payment of benefits under this Certificate, if the third party's liability is satisfied in an amount less than the benefits payable under this Certificate, we will pay the difference. PHYSICAL EXAMINATION AND AUTOPSY: We will pay the cost and have the right to have the Covered Person examined as often as reasonably necessary while the claim is pending. We can have an autopsy made at our expense unless prohibited by law. (Autopsies are not permitted to be required in Massachusetts, Mississippi and South Carolina.) RECOVERY OF BENEFITS: We reserve the right to recover from a Covered Person any benefits we have paid to him for injuries: (1) Received in a covered Accident; and (2) Which are covered under: (a) workers' compensation or similar statutory remedies available under law; or b) Any employer's liability Insurance. It will be assumed that the Covered Person is in receipt of such benefits unless he gives us proof such benefits have been denied to him. SUBROGATION: 4 GAC26932 Y✓ If we have paid benefits to a Covered Person for Injuries received in a covered Accident, and in our opinion a third party may be liable, we will be subrogated to the extent of such payment and to all of the rights of the Covered Person regarding the recovery of benefits paid or to any settlement or judgment which results from the exercise of these rights. The Covered Person agrees to sign papers and do whatever else is necessary to transfer his rights to us. We will exercise such rights on his behalf. He further agrees to furnish us with all relevant information and documents. LEGAL ACTIONS: No action at law or in equity shall be brought to recover benefits under this Certificate less then BO days after written proof of loss has been furnished as required by this Certificate. No such action shall be brought more than 3 years after the time written proof of loss is required to be furnished. GAC26932 t 0\ \r)0I When used throughout this document "The Company", "Our", "We", or "Us" means: ❑ United States Fire Insurance Company 1-71 PRIVACY POLICY AND PRACTICES The Company values your business and your trust. In order to administer Insurance policies and provide you with effective customer service, we must collect certain information about our customers. We want you to know that we are committed to protecting your private information and we will comply with all federal and state privacy laws. Below is a Privacy Notice describing our policy regarding the collection and disclosure of personal Information. Please review this Notice and keep a copy of it with your records. Your Privacy is Our Concern When you apply to The Company for insurance or make a claim against a policy written by The Company, you disclose information about yourself to us. There are legal requirements governing the collection, use, and disclosure of such Information. The Company maintains physical, electronic, and procedural safeguards that comply with state and federal regulations to guard your personal information. We also limit employee access to personally identifiable information to those with a business reason for knowing such Information. The Company Instructs our employees as to the importance of the confidentiality of personal information, and takes measures to enforce employee privacy responsibilities. What kind of information do we collect about you and from whom? We obtain most of our information from you. The application or claim form you complete, as well as any additional information you provide, generally gives us most of the information we need to know. Sometimes we may contact you by phone or mail to obtain additional information. We may use information about you from other transactions with us, our affiliates, or others. Depending on the nature of your insurance transaction, we may need additional information about you or other individuals proposed for coverage. We may obtain the additional information we need from third parties, such as other insurance companies or agents, government agencies, medical personnel, the state motor vehicle department, information clearinghouses, credit reporting agencies, courts, or public records. A report from a consumer reporting agency may contain information as to creditworthiness, credit standing, credit capacity, character, general reputation, hobbies, occupation, personal characteristics, or mode of living. What do we do with the Information collected about you? If coverage is declined or the charge for coverage is increased because of information contained in a consumer report we obtained, we will inform you, as required by state law or the federal Fair Credit Reporting Act. We will also give you the name and address of the consumer reporting agency making the report. We may retain information about our former customers and may disclose that information to affiliates and non -affiliates only as described in this notice. To whom do we disclose information about you? We may disclose all the information that we collect about you, as described above. We may disclose such information about you to our affiliated companies, such as: • Insurance companies; • Insurance agencies; • Third party administrators; • Medical bill review companies; and • Reinsurance companies. We may also disclose nonpublic personal information about you to affiliated and nonaffiliated third parties as permitted by law. You have a right to access and correct the persona] information we collect, maintain, and disclose about you, How to contact Us GAC26932 You may obtain a more detailed description of the information practices prescribed by law by contacting us at the address below. Remember to include your name, address, policy number, and daytime phone number. Privacy Policy Coordinator Fairmont Speciality 5 Christopher Way, 3,d Floor Eatontown, New Jersey 07724 GAC26932 When used throughout this document "Company", "Our", "We", or "Us" means: 0 United States Fire Insurance Company GRIEVANCE PROCEDURES When you submit a claim and that claim is denied, we will provide a written statement containing the reasons for the Adverse Determination. You have the right to request a review of any Company decision or action pertaining to our contractual relationship and to appeal any adverse claim determination we've made by filing a Grievance. These procedures have been developed to ensure a full investigation of a Grievance through a formal process. DEFINITIONS A "Grievance" is a written complaint requesting a change to a previous claim decision, claims payment, the handling or reimbursement of health care services, or other matters pertaining to your coverage and our contractual relationship. An "Adverse Determination" is a determination by the Company or its designated utilization review organization that (i) a service, treatment, drug, or device, is experimental, investigational, specifically limited or excluded by your coverage; or (ii) a facility admission; the availability of care, continued stay -or other health care services proposed or furnished have been reviewed and, based upon the information provided, does not meet the contractual requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness and therefore, the benefit coverage is denied, reduced or terminated in whole or in part. INFORMAL GRIEVANCE PROCEDURE You, your authorized representative, or a provider acting on your behalf may submit an oral complaint to us within 60-days after an event that causes a dispute. Telephoning allows you to discuss your complaint or concerns and gives us the opportunity to immediately resolve the problem. If we don't have all the information necessary to review your complaint, we will request any additional information within 6 business days of receiving your complaint. After we receive all the necessary information, we will provide you, your authorized representative, or a provider acting on your behalf with our written decision within 30-days after receiving the complaint and all necessary information. If the problem cannot be resolved in this manner, you still have the right to submit a written request for the complaint to be reviewed through the Formal Grievance Procedure, as outlined below. FORMAL GRIEVANCE PROCEDURE A formal Grievance may be submitted by you, your authorized representative, or in the event of an Adverse Determination, by a provider acting on your behalf. If you file a formal Grievance, you will have the opportunity to submit written comments, documents, records and other information you feel are relevant to the Grievance, regardless of whether those materials were considered in the initial Adverse Determination. First Level Review Within 3 working business days after receiving the Grievance, we must acknowledge the Grievance and provide you, your authorized representative or a provider with the name, address, and telephone number of the coordinator handling the Grievance and information on how to submit written material. The person(s) who reviews the Grievance will not be the same person(s) who made the initial Adverse Determination. During the review, all information, documents, and other materials submitted relating to the claim will be considered, regardless of whether they were considered in making the previous claim decision. The Insured will not be allowed to attend, or have a representative attend, a First Level Review, The Insured may, however, submit written material for consideration by the reviewer(s). Grievance When the Grievance is based in whole or in part on a medical judgment, the review will be conducted by, or in consultation with, a medical doctor with appropriate training and expertise to evaluate the matter. Following our review of your Grievance, we must Issue a written decision to you and, if applicable, to your representative or provider, within 20-days after receiving the Grievance. The written decision must include: (1) The name(s), title(s) and professional qualifications of any person(s) participating in the First Level Review process. (2) A statement of the reviewer's understanding of the Grievance. (3) The specific reason(s) for the reviewer's decision in clear terms and the contractual basis or medical rationale used as the basis for the decision in sufficient detail for the Insured to respond further to our position. (4) A reference to the evidence or documentation used as the basis for the decision. (5) If the claim denial is based on medical necessity, experimental treatment or similar exclusion, instructions for requesting an explanation of the scientific or clinical rationale used to make the determination. (6) A statement advising you of your right to request a Second Level Review, if applicable, and a description of the procedure and timeframes for requesting a Second Level Review, Second Level Review The -Second Level Review process is available if you are not satisfied with the outcome of the First level Review for an Adverse Determination. Within ten business days after receiving a request for a Second Level Review, we will advise you of the following: (1) the name, address, and telephone number of a person designated to coordinate the Grievance review for the Company; (2) a statement of your rights, including the right to: • attend the Second Level Review • present his/her case to the review panel; • submit supporting materials before and at the review meeting; ask questions of any member of the review panel; • be assisted or represented by a person of his/her choice, including a provider, family member, employer representative, or attorney. • request and receive from us free of charge, copies of all relevant documents, records and other information that is not confidential or privileged that were considered in making the Adverse Determination. We must convene a review panel and hold a review meeting within 45-days after receiving a request for a Second Level Review. We will notify you in writing of the meeting date at least 15-days prior to the date. The review meeting will be held during regular business hours at a location reasonable accessible to you. In cases where a face-to-face meeting is not practical for geographic reasons, we will offer you the opportunity to communicate with the review panel at our expense by conference call or other appropriate technology. Your right to a full review may not be conditioned on whether or not you appear at the meeting. If you choose to be represented by an attorney, we may also be represented by an attorney. If we choose to have an attorney present to represent our interests, we will notify you at least 15 working days in advance of the review that an attorney will be present and that you may wish to obtain legal representation of your own. The panel must be comprised of persons who: (1) were not previously involved In any matter giving rise to the Second Level Review; (2) are not employees of the Company or Utilization Review Organization; and (3) do not have a financial interest in the outcome of the review. A person previously involved in the Grievance may appear before the panel to present information or answer questions. All persons reviewing a Second Level Grievance involving a Utilization Review non -certification or a clinical issue will be providers who have appropriate expertise, including at least one clinical peer. If we use a clinical peer on an appeal of a Utilization Review non -certification or on a First Level Review, we may use one of our employees on the Second Level Review panel if the panel is comprised of 3 or more persons. Grievance r� We must issue a written decision to you and, if applicable, to your representative or provider, within 10 business days after completing the review meeting. The decision must include: (1) the name(s), title(s) and qualifying credentials of the members of the review panel; (2) a statement of the review panel's understanding of the nature of the Grievance and all pertinent facts; (3) the review panel's recommendation to the Company and the rationale behind the recommendation; (4) a description of, or reference to, the evidence or documentation considered by the review panel in making the recommendation; (5) In the review of a Utilization Review non -certification or other clinical matter, a written statement of the clinical rationale, including the clinical review criteria, that was used by the review panel to make the determination; (6) the rationale for the Company's decision if it differs from the review panel's recommendation; (7) a statement that the decision is the Company's final determination in the matter; (8) notice of the availability of the Commissioner's office for assistance, including the telephone number and address of the Commissioner's office. EXPEDITED REVIEW Youareeligible for an expedited review -when the timeframes for an Informal, formal First Level review or Second Level review would reasonably appear to seriously jeopardize your life or health, or your ability to regain maximum function. An expedited review is also available for all Grievances concerning an admission, availability of care, continued stay or health care service for a person who has received emergency services, but who has not been discharged from a facility. A request for an expedited review may be submitted orally or in writing. An expedited review must be evaluated by an appropriate clinical peer in the same or similar specialty as would typically manage the case being reviewed. If we don't have the information necessary to decide an appeal, we will send you notification of precisely what is required within 24-hours of our receipt of your Grievance. All necessary information, including our decision, will be transmitted by telephone, facsimile, or the most expeditious method available. Provided we have enough information to make a decision, you, your authorized representative, or a provider acting on your behalf will be notified of the determination as expeditiously as the medical condition requires, but in no event more than 72-hours after the review. has commenced. Written confirmation of our decision will be provided within 2 working business days of the decision and will contain the same items described in the written decision requirements for First Level reviews. If the expedited review does not resolve the situation, you, your representative or a provider acting on your behalf may submit a written Grievance. We will not provide an expedited review for retrospective reviews of Adverse Determinations Grievance Shine Hwang 5244 Oliva Avenue 414 Lakewood, CA. 90712 8/14/2019 City of Santa Ana Risk Management Division 20 Civic Center Plaza, Santa Ana, CA 92702 Re; Auto Insurance Requirement Release of Liability. Dear City of Santa Ana Risk Management Division: I, Shine Hwang, Recreation Instructor hereby release the City of Automobile Liability. I do not use/drive any vehicle during the course and scope of my course/instruction class. During the term Oct 1, 2019 through Oct 31, 20201 will be teaching music at El Salvador center located at: 1825 W Civic Center Dr. Santa Ana, CA. 92703 Sincerely, Shine Hwang Recreation Instructor REVIEWED & APPROVED By RISK MANAtiEMENr DIVISION U4219 FRANCINE R. VILLAREAL WORKERS' C OMPENSATION DECLARATION 1 5kht _ {wry q hereby affirm under penalty of peljuty, the (Name Ii following declaration: I certify on behalf of 5a4 t f 3iZ that [luring the term of my rConsnliarn'Campiny Ngmcl contract for Recreation Classes _ 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: 81G it By: Name: Title: _ Telephone: _ (G 3-- 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 AT'hORNEY'S FEES. REVIEWED &APPROV APPROVED y ry D SEP 24 201 FRANC R. VILLAREAL