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Home My WebLink AboutPLACEWORKS (3)City of Santa Ana Clerk of the Council Cu )l 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TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect.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— No Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with MWAV ►' 6 No. l�V�� ` ✓tfr was completed on �I (List all amendments. Use space below if needed.) Department: /� yy��j I Phone/Ext.: Mi)Irn/r r V/r f t� • k- ' p DI Signature: A—�1'v'Q--,'— Date: i,lagreementsVormsVorm- agreement termination form_gol enr doc COTC Office Use Oni OF THE COUNCIL 6'21 Pm.23:5 and final payment has been made. fdaMAW � � bA INSURANCE ON FILE 4VORK MAY PROCEED UNTIL INSURANCE EXPIRES MAYOR 07 /O j 1 ZOZO MiguelA Pulido CLERK OF COUNCIL MAYOR PRO TEM DATE: Juan Villages COUNCILMEMBERS Phil Bacerra O, b / o) )PIS ire. tl'IQL1 tgOzy �t Cecilia Iglesias David Penaloza Vicente Sanniento Jose Solorio CITY OF SANTA ANA IAA 2 9 2020 PLANNING AND BUILDING AGENCY 20 Civic Center Plaza • P.0 Box 1988 Santa Ana, California 92702 wN sanla-ana.oro December 18. 2019 Place Works. Inc. Attn: Wendy Nowak_ Assoc. Principal 3 MacArthur Place. Ste. 1100 Santa Ana CA 92707 Re: Extension of Consultant Agreement No. A-2017-361 Dear Ms. Nowak: A-2017-361-01 CITY MANAGER Kristine Ridge CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Daisy Gomez Pursuant to Section 3 of Agreement No. A-2017-361, entered into by PlaceWorks. Inc.. and the City of Santa Ana, dated March 16. 2018. the term of the Agreement is hereby extended through .tune 30. 2020. The insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement, as amended. remain unchanged and in Full force and effect. Sincerely. Minh Thai Executive Director, Planning and Building Agency CITY OF SANTA ANA Kristine Ridge City Manager ATTEST Daisy Clerk of the CoJncil APPROVED AS TO FORM PLACEWORKS, INC. Lisa Storck y: JoAnn Hadfield Assistant Citv Attorney Title: Principal SANTA ANA CITY COUNCIL M, 1-1A Pd.nn 1':' v.'oa.I•r, d P,....rr:a i .., ..n l a gnrr..a MnvW IAa:r.r P ie•_ 1. .. :VV J \4n 1 _ Char :: Vla..; ". I, I - . ` ietrL.91n:1$:Y.G[x ._ Clavid nI d d. _'a'J Si"re i e_I'„'a W,II?. VnJ Cnal JidLa, dJ"3,G;j ",. 53' dd��_ti .�a �.. _ rtl_: a'_3 �® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 06128/2019 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. If SUBROGATION IS WAIVED, subject to the terms and conditions of the this certificate does not confer rights to the certificate holder in (feu of suc Marsh Risk & Insurance Services 17901 Von Karmen Avenue, Suite 1100 (949) 399-5800; License 00437153 Irvine, CA 92614 Attn: NewpodBeach.CedRequest@marshcom/F: 212-948.4323 CN 115158923-01-01-19.20 INSURED PlaceWorks, Inc Doe. The Planning Center Design Community & Enviomment 3 MacArthur Place, Suite 1100 Santa Ana, CA 92707 must nave muu1I IUnIHL nYoummu provisions or Be endorsed. certain policies may require an endorsement. A statement on COVERAGES CERTIFICATE NUMBER IOR-0ro212n46.21 DPlncanM MnnnamD• o 44520 25674 - - -- 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPEOFINSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/00 POLICY EXP-'-- MOLM21 YYY I LIMITS A X COMMERCIAL GENERAL LIABILITY !� CLAIMS -MADE 1E OCCUR X X EPK127413 0710112019 07N1/2020 EACHOCCURRENCE Is 5,000,000 DAMAGE TO RENTED PREMISES Ea accunence S 50,000 X 81 & PD Ded, $5.000 �d--___... _ _ MED EXP (Any one person) _ S 5,000 PERSONAL& AOVINJURY S 5,ODO,000 PER' GENL AGGREGATELIMB'. _ APPLIES r X_POLICY J PR T LOC GENERALAOGREGATE 5 5,000,000 PRODUCTS-COMP/OP AGO 5 5,000,000 OTHER i Contactors Pollution S 5,000,000 B AUTOMOBILE LIABILITY _1. ANY AUTO X X ! X BA1N9640fiA19CAG 0710112019 07/01/2020 COMBINED SINGLE LIMIT S 1,000,000 Ea accident BODILY INJURY (Per person) ,5 i OWNSAUTOONLY SCHEDULED OWNED SCHEDULED AUTOS -- � BODILY INJURY (Peraccident) S . HIRED - NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE g Peraccidomi CanplColl Deductibles 5 1.000 UMBRELLA UAS X�EXCESS LIAB X OCCUR CLAIMS -MADE EX6J3287561943 0710112019 0710112020 EACH OCCURRENCE 5 4,000,000 5 _ 4,000,000 S AGGREGATE LIED RETENTIONS B WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANYPROPRIETORIPARTNEWEXECUTIVE OPFICERIMEMBEREXCLUDEOi N� (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA UB7K7286761943G 1 1 07/01/2020 1 X PER D7H- STATUTE ER__ E.L. EACH ACCIDENT is 1,000,000 E.L. DISEASE -EA EMPLOYEd 5 1,000,000 E.L. DISEASE -POLICY LIMIT I 5 1,000,000 A Errors & Omissions -Claims Made EPK127413 0710112019 07101/2020 Each ClaiMAggregate 5,000,000 Rehm Dates: See 2nd Page DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD101,Addlllonal RemarksSchedule,maybeaUaehodifmoraapece lerequlred) Re: Operations performed by the named insured for the certificate holder City of Santa Ana, its officers, agents, employees, and volunteers are induced as additional insured where required by written contract with respect to General and Auto Liability. This insurence is primary and non- contributory war any existing insurance and limited to liability arising out of the operations of the named insured and where required by written contact with respect to General Liability. Waiver of subrogation is applicable where required by wriaen contract with respect to General and Auto Liability. CERTIFICATE HOLDER ULVIEWEU & APPROVED CANCELLATION Cityof Santa Ana Risk Management Division 20 Civic Center Plaza, 41h Floor Y IS MANAGEMENTDIVISION 0 2019 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana, CA 92701 •r & FRANCINER.VIL REAL AUTHORIZED REPRESENTATIVE of Marsh Risk &InsumnceService. Rosslynda Martinez B"sa s6 o L,a4�%J�ffi01�� @ 1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD EA1N96406A19CAG Effective 07/01/2019 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, 13USINE s s AUTO EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GENERAL DESCRIPTION OF COVERAGE —This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions or this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what Is and is not covered. A. BROAD FORM NAMED INSURED B. BLANKET ADDITIONAL INSURED C. EMPLOYEE HIRED AUTO D. EMPLOYEES AS INSURED E. SUPPLEMENTARY PAYMENTS — INCREASED LIMITS F. HIRED AUTO — LIMITED WORLDWIDE COV- ERAGE— INDEMNITY BASIS G. WAIVER OF DEDUCTIBLE —GLASS PROVISIONS A. BROAD FORM NAMED INSURED The following is added to Paragraph A.1., Who Is An insured, of SECTION 11— COVERED AUTOS LIABILITY COVERAGE: Any organization you newly acquire or form dur- ing the policy period over which you maintain 50% or more ownership interest and that is not separately insured for Business Auto Coverage. Coverage under this provision is afforded only un- til the 180th day after you acquire or form the or- ganization or the end of the policy period, which- ever is earlier. B. BLANKET ADDITIONAL INSURED The following Is added to Paragraph c. in AA., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF USE — INCREASED LIMIT I. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES — INCREASED LIMIT J. PERSONAL PROPERTY K. AIRBAGS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS M. BLANKET WAIVER OF SUBROGATION N. UNINTENTIONAL ERRORS OR OMISSIONS this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section It. C. EMPLOYEE HIRED AUTO 1. The following is added to Paragraph A.1., Who Is An Insured, of SECTION II — COV- ERED AUTOS LIABILITY COVERAGE: An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in an "employee's" name, with your permission, while performing duties related to the conduct of your busi- ness. 2. The following replaces Paragraph b, in B.S., Other Insurance, of SECTION IV — BUSI- NESS AUTO CONDITIONS: Any person or organization who Is required under b. For Hired Auto Physical Damage Cover - a written contract or agreement between you and age, the following are deemed to be cov- that person or organization, that is signed and ered °autos" you own: executed by you before the "bodily Injury" or (1) Any covered "auto" you lease, hire, "properly damage" occurs and that Is In effect rent or borrow; and during the policy period, to be named as an add[- (2) Any covered "auto" hired or rented by tional insured is an "insured" for Covered Aut VIEWED & APPRITIVEIRmployee" under a contract in Liability Coverage, but only for damages to whI Risk MANAGEMENT DiWisilemployee's" name, with your CA T3 53 02 15 ra2015 The Travelers Ind empl r C p� .21 12019served Page 1 of 4 Includes copyrighted material of Ins ur n is In itl "s p iission. 002090 FRANCINE R. VILLAREAL SA7E37616719CAG Effective 07/01/2019 COMMERCIAL AUTO permission, while performing duties related to the conduct of your busi- ness. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". D. EMPLOYEES AS INSURED The following Is added to Paragraph A.1„ Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: Any "employee" of yours Is an "Insured" while us- ing a covered "auto" you don't own, hire or borrow in your business or your personal affairs. E. SUPPLEMENTARY PAYMENTS —INCREASED LIMITS 1. The following replaces Paragraph A.2.a.(2), of SECTION II — COVERED AUTOS LIABIL- ITY COVERAGE: (2) Up to $3,000 for cost of bail bonds (in- cluding bonds for related traffic law vlola- tions) required because of an "accident" we cover. We do not have to furnish these bonds. 2. The following replaces Paragraph A.2.a.(4), of SECTION II — COVERED AUTOS LIABIL- ITY COVERAGE: (a) With respect to any claim made or "suit" brought outside the United States of America, the territories and possessions of the United States of America, Puerto Rico and Canada: (1) You must arrange to defend the "in- sured" against, and investigate or set- tle any such claim or "suit" and keep us advised of all proceedings and ac- tions. (ii) Neither you nor any other involved "insured" will make any settlement without our consent. (iii) We may, at our discretion, participate in defending the "insured" against, or in the settlement of, any claim or "suit". (iv) We will reimburse the "insured" for sums that the "insured" legally must pay as damages because of "bodily injury" or "property damage" to which this insurance applies, that the "in- sured" pays with our consent, but only up to the limit described In Para. graph C., Limits Of Insurance, of SECTION II — COVERED AUTOS LIABILITY COVERAGE. (4) All reasonable expenses incurred by the (v) We will reimburse the "insured" for "insured" at our request, Including actual the reasonable expenses incurred loss of earnings up to $500 a day be- with our consent for your investiga- cause of time off from work. tion of such claims and your defense F. HIRED AUTO — LIMITED WORLDWIDE COV- or the "insured" against any such "suit", but only up to and included ERAGE — INDEMNITY BASIS within the limit described in Para - The following replaces Subparagraph (5) in Para- graph C., Limits Of Insurance, of graph 0.7., Policy Period, Coverage Territory, SECTION II — COVERED AUTOS of SECTION IV — BUSINESS AUTO CONDI. LIABILITY COVERAGE, and not in TIONS: addition to such limit. Our duty to (5) Anywhere in the world, except any country or make such payments ends when we jurisdiction while any trade sanction, em- have used up the applicable limit of bargo, or similar regulation imposed by the insurance in payments for damages, United States of America applies to and pro- settlements or defense expenses, hlbtts the transaction of business with or (b) This Insurance is excess over any valid within such country or jurisdiction, for Cov- and collectible other insurance available ered Autos Liability Coverage for any covered to the "Insured" whether primary, excess, "auto" that you lease, hire, rent or borrow contingent or on any other basis. Without a driver for a period of 30 days or less (c) This insurance is not a substitute for re - and that Is not an "auto" you lease, hire, rent or compulsory insurance in any or borrow from any of your "employees", count country outside the United States, its ter - (if you are a partnership), m WED & APPR & W� and possessions, Puerto Rico and (if you (if you are a limited liability comp k MANAGEMENT Dar' members of their households. 9(�j T 2ppa !rtTl� Page 2 of 4 02015 The Travelers n y hts re red. CA T3 53 02 15 Includes copyrighted material Ic s e its permission, FRANCINE R. VILLAREAL BA7E37616719CAG Effective 07/01/2019 You agree to maintain all required or compulsory insurance in any such coun- try up to the minimum limits required by local law. Your failure to comply with compulsory insurance requirements will not invalidate the coverage afforded by this policy, but we will only be liable to the same extent we would have been liable had you complied with the compulsory in- surance requirements. (d) It is understood that we are not an admit- ted or authorized Insurer outside the United Stales of America, its territories and possessions, Puerto Rico and Can- ada, We assume no responsibility for the furnishing of certificates of insurance, or for compliance in any way with the laws of other countries relating to insurance. G. WAIVER OF DEDUCTIBLE —GLASS The following is added to Paragraph D., Deducti- ble, of SECTION III — PHYSICAL DAMAGE COVERAGE: No deductible for a covered "auto" will apply to glass damage if the glass is repaired rather than replaced. H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF USE — INCREASED LIMIT The following replaces the last sentence of Pare - graph AA.b., Loss Of Use Expenses, of SEC-TION III — PHYSICAL DAMAGE COVERAGE; However, the most we will pay for any expenses for loss of use is $65 per day, to a maximum of $750 for any one "accident". ° I. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES — INCREASED LIMIT The following replaces the first sentence in Para- graph A.4.a., Transportation Expenses, of SECTION Ili — PHYSICAL DAMAGE COVER- AGE: We will pay up to $50 per day to a maximum of $1,5D0 for temporary transportation expense in- curred by you because of the total theft of a cov- ered "auto" of the private passenger type. J. PERSONAL PROPERTY The following Is added to Paragraph A.4., Cover- age Extensions, of SECTION III — PHYSICAL DAMAGE COVERAGE; Personal Property We will pay up to $400 for"loss" to wearing ap- parel and other personal property which is: (1) Owned by an "insured"; and OF-VII COMMERCIAL AUTO (2) In or on your covered "auto". This coverage applies only in the event of a total theft of your covered "auto". No deductibles apply to this Personal Property coverage. K. AIRBAGS The following is added to Paragraph B.3., Exclu- sions, of SECTION tit — PHYSICAL DAMAGE COVERAGE: Exclusion 3.a. does not apply to "loss" to one or more airbags in a covered "auto" you own that In- flate due to a cause other than a cause of"loss" set forth in Paragraphs A.f.b, and A.1.c., but only: a. if that "auto" is a covered "auto" for Compre- hensive Coverage under this policy; b, The airbags are not covered under any war- ranty; and c. The airbags were not intentionally inflated. We will pay up to a maximum of $1,000 for any one "loss". L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS The following is added to Paragraph A.2.a., of SECTION IV — BUSINESS AUTO CONDITIONS: Your duty to give us or our authorized representa- tive prompt notice of the "accident' or "loss" ap- plies only when the "accident" or "loss" is known to: (a) You (if you are an Individual): (b) A partner (f you are a partnership); (c) A member (if you are a limited liability Com- pany); (d) An executive officer, director or insurance manager (if you are a corporation or other or- ganization); or (a) Any "employee" authorized by you to give no- tice of the "accident" or "loss". M. BLANKET WAIVER OF SUBROGATION The following replaces Paragraph A.6., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — BUSINESS AUTO CONDI- TIONS: 5. Transfer Of Rights Of Recovery Against Others To Us We waive any right of recovery we may have against any person or organization to the ex- tent required of you by a written contract signed and executed prior to any "accident' or "loss", provided that the "accident" or "loss" & AofPRsOVout ED f operations contemplated by CO20e7 CA T3 53 02 15 �D2015 The Travelers li olernndy Includes copyrighted malerlal of Insurance reserved. Page 3 of 4 with Its permission. En A klf`I AICn 1n1i AnrA1 BA7B37616719CAG Effective 07/01./2019 COMMERCIAL AUTO such contract. The waiver applies only to the The unintentional omission of, or unintentional person or organization designated in such error In, any Information given by you shall not contract. prejudice your rights under this insurance. How- N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right to col - The following is added to Paragraph 8,2., Con- lect additional premium or exercise our right of cealment, Misrepresentation, Or Fraud, of cancellation or non -renewal. SECTION IV — BUSINESS AUTO CONDITIONS: REVIEWED & APPROVED By Risk MANAGEMENT DiviSION C 4109 FRANCINE R. VILLAREAL Page 4 of 4 @ 2015 The Travelers Indemnlly Company. All rights reserved. CA T3 53 02 15 Includes copyrighted matedial of Insurance Services Office, Inc. with its permission. EPK127413 Effective 07/01/2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE. READ IT CAREFULLY, affirkh 1Lip I ki This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART ERRORS AND OMISSIONS LIABILITY COVERAGE PART THIRD PARTY POLLUTION LIABILITY COVERAGE PART SCHEDULE 'Name Of Additional Insured Person(s) or Organization(s) here Required By Written Contract. A. SECTION III — WHO IS AN INSURED within the Common Provisions Is amended to include as an additional insured the person(s) or organization(s) indicated in the Schedule shown above, but solely with respect to "claims" caused in whole or in part, by "your work" for that person or organization performed by you, or by those acting on your behalf. This insurance shall be primary and non-contributory, but only in the event of a named insured's sole negligence. 8 We waive any right of recovery we may have against the person(s) or organization(s) indicated in the Schedule shown above because of payments we make for "damages" arising out of "your work" performed under a designated project or contract with that person(s) or organization(s), C. This Endorsement does not reinstate or increase the Limits of Insurance applicable to any "claim" to which the coverage afforded by this Endorsement applies. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. REVIEWED & APPROVED By RISK MANAGEMENT DIVISION 0 4209 FRANCINE R. VILLAREAL EN0118-0211 Page 1 of 1 FPK127413 Effective 07/01/2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. , ,LaEATIONAL. INSURED ® OWNERS, LESSEES OR CONTRACTORS — COMPLET'ED OPERATIONS This endorsement modes Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Person(s) or Organization Is): Location And Description Of Completed Operations Where Required By Written Contract. Where Required By Written Contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section III — Who Is An Insured within the Common Provisions is amended to include as an Insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work' at the location designated and described in the schedule of this endorsement performed for that additional Insured and Included In the "products -completed operations hazard". REVIEWED & APPROVED By RU MANAGEMENT DIVISION OC1242.019 FRAN INE R. VILLAREAL EN0320-0211 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION - CERTIFICATE HOLDER(S) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART ERRORS AND OMISSIONS LIABILITY COVERAGE PART THIRD PARTY POLLUTION LIABILITY COVERAGE PART ONSITE CLEANUP COVERAGE PART SCHEDULE Certificate Holder(s) - - --- , -- itofficers employees, agents and representatives The City of Santa Anas _—? 20 Civic Center Santa Ana Ca 92701 Under the Common Provisions, SECTION VI — COMMON CONDITIONS, item 2. Cancellation And Nonrenewal is amended by the addition of the following: If we cancel this Policy before the expiration date thereof, we will mail a 30 days written notice (ten (10) days for non-payment of premium) to the Certificate Holder(s) indicated In the Schedule shown above. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. REVIEWED & APPROVEL, By RISk MANAGEMENT f!lVISION ®4 _4 F CINEWINEE 11 �� ILLAREAL EN0136-0211 Page 1 of 1