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Home My WebLink AboutSOLOMON, STEPHEN (2)INSURANCE NOT ON FILE WORK MAY NO PROCEED CLERK OF COUNCIL E 2 2 2.521 1 DATE: MAYOR Vicente Sarmlento MAYOR PRO TEM ( David Penaloza COUNCILMEMBERS Phil Baca" Johnathan Ryan Hernandez Jessie Lopez Nelids Mendoza Thai Viet Phan RE CITY OF SANTA ANA PUBLIC WORKS AGENCY 20 Civic Center Plaza • P.O. Box 1988 Santa Ana, California 92702 �' �<t3�gessi(AMEnduta>(uiL(3 vmv.santa-ana.oro 7(77✓✓ ) 647-3320 February 11, 2021 Stephen H. Solomon 17853 Santiago Blvd. # 107-188 Villa Park, CA 92861 N-2019-049-01 CITY MANAGER Kristine Ridge CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Daisy Gomez Re: Extension of Agreement to Provide Administrative Hearing Services (#N-2019-049) Pursuant to Section 3 ("Term') of the above -referenced Agreement, entered into by Stephen H. Solomon and the City of Santa Ana, dated February 13, 2019, the time period of the Agreement is hereby extended for an additional one-year period, from February 13, 2021 through February 12, 2022. Any insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincerely, Minh Thai, Executive Director, Planning & Building Agency CITY OF SANTA ANA ATTEST Kriftine dge Daisy Gomez City Manager Clerk of 0te Council APPROVED AS TO FORM CONSULTANT Ryan Hgdge Stephen 11 Solomon Assisinnt City Attorney SANTA ANA CITY COUNCIL VMMo.iITWNti D.MPn . n VklMA Sam. binaNmR.' nw,m Wy rm T. Wn 2 wvar We 3 Wu 4 warns ne�W.6 om ww!.!ITM4.3P31^�ml dm�F A%M-t._n N_MnB"L.M M.yx!kA3e2.YlWayu_M Ch9iWlini.Ixl"9 Yls_nnav_nm,q�.�aw��av wa n're,^�m$=}ir k Digitally signed by Francine R. Francine R. Villareal Villareal AFRO® CERTIFICATE OF LIABILITY INSURANCE AM o2/oa/z1YTY 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(jes) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: COMPLETE EQUITY MARKETS INC AICNNo Ext: 847 541-0900 FAX, No: 847 541-0444 AD RIESS: 1190 Flex Court INSURER(S) AFFORDING COVERAGE NAIC# Lake Zurich, IL60047 INSURERA: Underwriters at Lloyd's London ohs Complete Equity Markets Insurance Agency, Inc. INSURED Stephen H. Solomon INSURER B INSURER C INSURER D: 18861 Ridgewood Lane INSURER E: Villa Park, CA 92861 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR R TYPE OF INSURANCE ADDL WVDSUBR POLICYNUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDI, YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 1XI OCCUR PFEN-rE REM SEE Ea occO nce 50 000 $ MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ EXCLUDED A X 1500312 02/05/21 02/05/22 GENU AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2000000 X POLICY PRO-JECT LOC PRODUCTS - COMP/OPAGG $ 1,000,000 $ OTHER'. AUTOMOBILE LIABILITY COMBI NED S INGLE LIMIT Ea accident $ BCD I LY INJURY (Per person) $ MY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON-OVirtdED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per ad. dent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION EMPLOYERS'LIABILITY YIN PERT STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E. L EACHACCIDENT $ OFFI CER/MEM BER EXCLUDED? ❑ NIA E. L. DISEASE - EA EMPLOYE $ (Mandatory in NH) f yes, describe under DESCRIPTION OF OPERATIONS below E. L. DISEASE -POLICY LIMIT $ Each Claim $1,000,000 A Professional Liability X 859995 06/01/20 06/01/21 A99regate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Subject to all policy terms, conditions, exclusions and endorsements of each respective policy. The City of Santa Ana, it's officers, employees, agents and representatives is an additional insured but only per the terms 8 conditions of the endorsement generated for each respective policy and subject to all policy terms, conditions, exclusions and endorsements. Primary/Non-Contributory, Waiver of Subrogation and 30 Day Notice of Cancellation applies to the General Liability policy. SURPLUS LINES NOTICE TO POLICYHOLDER - PLEASE SEE ATTACHED CERTIFICATE HOLDER CANCELLATION The City of Santa Ana Risk Management Division 20 Civic Center Plaza 4th Floor Santa Ana Ca 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD RiSle Mrsnaganad Division ram. rREmEWED &{APPRO�VVED By., olllli111.1� /-z' rb6HlM�e VaRRE/t¢bl. ® Risk Management Analyst 3 1. THE INSURANCE POLICY THAT YOU HAVE PURCHASED IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED "NONADMITTED" OR "SURPLUS LINE" INSURERS. 2. THE INSURER IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY TO CALIFORNIA LICENSED INSURERS. 3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED. 4. THE INSURER SHOULD BE LICENSED EITHER AS A FOREIGN INSURER IN ANOTHER STATE IN THE UNITED STATES OR AS A NON -UNITED STATES (ALIEN) INSURER. YOU SHOULD ASK QUESTIONS OF YOUR INSURANCE AGENT, BROKER, OR "SURPLUS LINE" BROKER OR CONTACT THE CALIFORNIA DEPARTMENT OF INSURANCE AT THE FOLLOWING TOLL -FREE TELEPHONE NUMBER: 1-800-927-4357 OR INTERNET WEB SITE V WW.INSURANCE.CA.GOV. ASK WHETHER OR NOT THE INSURER IS LICENSED AS A FOREIGN OR NON -UNITED STATES (ALIEN) INSURER AND FOR ADDITIONAL INFORMATION ABOUT THE INSURER. YOU MAY ALSO CONTACT THE NAIC'S INTERNET WEB SITE AT }WWWNAIC.ORG. 5. FOREIGN INSURERS SHOULD BE LICENSED BY A STATE IN THE UNITED STATES AND YOU MAY CONTACT THAT STATE'S DEPARTMENT OF INSURANCE TO OBTAIN MORE INFORMATION ABOUT THAT INSURER. 6. FOR NON -UNITED STATES (ALIEN) INSURERS, THE INSURER SHOULD BE LICENSED BY A COUNTRY OUTSIDE OF THE UNITED STATES AND SHOULD BE ON THE NAIC'S INTERNATIONAL INSURERS DEPARTMENT QID) LISTING OF APPROVED NONADMITTED NON -UNITED STATES INSURERS. ASK YOUR AGENT, BROKER OR "SURPLUS LINE" BROKER TO OBTAIN MORE INFORMATION ABOUT THAT IN RiskMwagxmentDMsian REVIEWED&APPROVED BY: � Risk Management Analyst binders'138 7. CALIFORNIA MAINTAINS A LIST OF APPROVED SURPLUS LINE INSURERS. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE: V'WW.INSURANCE.CA.GOV. 8.IF YOU, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN TWO BUSINESS DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO BUSINESS DAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU CANCEL COVERAGE, THE PREMIUM WILL BE PRORATED AND ANY BROKER'S FEE CHARGED FOR THIS INSURANCE WILL BE RETURNED TO YOU. LMA9098A 04 May 2017 D-2 (Effective January 1, 2017) Risk Mwagme tDMsian REVIEWED&APPROVEDBY: �� Risk Management Analyst binders'138 SOLOMON AND ASSOCIATES HEARING OFFICERS January 26, 2021 City of Santa Ana Risk Management Division 20 Civic Center Plaza, 4th Floor Santa Ana, CA 92702 Re: Auto Insurance Requirement Dear City of Santa Ana Risk Management Division: I, _Stephen Solomon . have entered into an agreement with the City of Santa Ana. Throughout the course of this agreement, I attest to the following: As an independent contractor, I will utilize my personal vehicle/non-company owned, borrowed, or rented/leased vehicle for transportation to and from work, and will carry my own automobile insurance. I, _Stephen Salomon , attest that I possess the legal authority to enter into an agreement with the City of Santa Ana as well as the legal authority to attest to the statements above. If at any time, it is found that I am not adhering to any/all statements in this document and have not provided the minimum Auto liability insurance coverage of $1 million per occurrence, the contract will be considered null and void and I will be held fully liable for any and all damages. Sincerely, M E Stephen Solomon Solomon and Associates Hearing Officers (714)345-9767 ssolomon408@gmail.com •iYort•M�: RIA Matt� DlAsiart D&{{A�P'PIRO MBV: a rrRiwlE r�hWi�M2 R• V �W Risk Management Analyst f d d6b Z6' l,Z CO 9ed 01/20/2021 x� a m C waF c s t: wuntan, rites , sae liked aul a n - nea auto Sine he t rid Owse cmee-au-s -a have any other st, s, ; as €et k¢ . Ca 92602 94VIS88-0204 Rime Management ElMsinn REVIEWED&APPROVED BY: '� Risk Management Analyst CITYOFSANTAANA RISK MANAGEMENT a &wa6ara 4 HUMAN RESOURCES " Managing R1s1(#mwAPosfflva ClIange WORKERS' COMPENSATION DECLARATION it 4tgEVZN P, hereby affirm under penalty of perjury, the (Name/Title) following declaration: I certify on behalf of H .solamoa✓ that during the term '' (Consultant/Company Name) of my contract for ' d � services with the City of Santa Ana, (Type fservi provided) I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately. Date: Print Name: 15�/��/ So.Cz,.y1o.+1 Print Title: S70 L f lJW A/Ar— /2 S�G'6�e Signature: Telephone: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. kjRisk Mgmtklnsurance Requirements�WC Declaration 08152019 Risk MwaganattDMsian pr`REMEWED&{AP'�R PIRIOeVVEDBY. R. VNMK �� Risk Management Analyst Digitally signed by Francine R. Francine R. Villareal Villareal AFRO® CERTIFICATE OF LIABILITY INSURANCE AM o2/oa/z1YTY 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(jes) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: COMPLETE EQUITY MARKETS INC AICNNo Ext: 847 541-0900 FAX, No: 847 541-0444 AD RIESS: 1190 Flex Court INSURER(S) AFFORDING COVERAGE NAIC# Lake Zurich, IL60047 INSURERA: Underwriters at Lloyd's London ohs Complete Equity Markets Insurance Agency, Inc. INSURED Stephen H. Solomon INSURER B INSURER C INSURER D: 18861 Ridgewood Lane INSURER E: Villa Park, CA 92861 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR R TYPE OF INSURANCE ADDL WVDSUBR POLICYNUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDI, YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 1XI OCCUR PFEN-rE REM SEE Ea occO nce 50 000 $ MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ EXCLUDED A X 1500312 02/05/21 02/05/22 GENU AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2000000 X POLICY PRO-JECT LOC PRODUCTS - COMP/OPAGG $ 1,000,000 $ OTHER'. AUTOMOBILE LIABILITY COMBI NED S INGLE LIMIT Ea accident $ BCD I LY INJURY (Per person) $ MY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON-OVirtdED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per ad. dent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION EMPLOYERS'LIABILITY YIN PERT STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E. L EACHACCIDENT $ OFFI CER/MEM BER EXCLUDED? ❑ NIA E. L. DISEASE - EA EMPLOYE $ (Mandatory in NH) f yes, describe under DESCRIPTION OF OPERATIONS below E. L. DISEASE -POLICY LIMIT $ Each Claim $1,000,000 A Professional Liability X 859995 06/01/20 06/01/21 A99regate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Subject to all policy terms, conditions, exclusions and endorsements of each respective policy. The City of Santa Ana, it's officers, employees, agents and representatives is an additional insured but only per the terms 8 conditions of the endorsement generated for each respective policy and subject to all policy terms, conditions, exclusions and endorsements. Primary/Non-Contributory, Waiver of Subrogation and 30 Day Notice of Cancellation applies to the General Liability policy. SURPLUS LINES NOTICE TO POLICYHOLDER - PLEASE SEE ATTACHED CERTIFICATE HOLDER CANCELLATION The City of Santa Ana Risk Management Division 20 Civic Center Plaza 4th Floor Santa Ana Ca 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD RiSle Mrsnaganad Division ram. rREmEWED &{APPRO�VVED By., olllli111.1� /-z' rb6HlM�e VaRRE/t¢bl. ® Risk Management Analyst 3 1. THE INSURANCE POLICY THAT YOU HAVE PURCHASED IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED "NONADMITTED" OR "SURPLUS LINE" INSURERS. 2. THE INSURER IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY TO CALIFORNIA LICENSED INSURERS. 3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED. 4. THE INSURER SHOULD BE LICENSED EITHER AS A FOREIGN INSURER IN ANOTHER STATE IN THE UNITED STATES OR AS A NON -UNITED STATES (ALIEN) INSURER. YOU SHOULD ASK QUESTIONS OF YOUR INSURANCE AGENT, BROKER, OR "SURPLUS LINE" BROKER OR CONTACT THE CALIFORNIA DEPARTMENT OF INSURANCE AT THE FOLLOWING TOLL -FREE TELEPHONE NUMBER: 1-800-927-4357 OR INTERNET WEB SITE V WW.INSURANCE.CA.GOV. ASK WHETHER OR NOT THE INSURER IS LICENSED AS A FOREIGN OR NON -UNITED STATES (ALIEN) INSURER AND FOR ADDITIONAL INFORMATION ABOUT THE INSURER. YOU MAY ALSO CONTACT THE NAIC'S INTERNET WEB SITE AT }WWWNAIC.ORG. 5. FOREIGN INSURERS SHOULD BE LICENSED BY A STATE IN THE UNITED STATES AND YOU MAY CONTACT THAT STATE'S DEPARTMENT OF INSURANCE TO OBTAIN MORE INFORMATION ABOUT THAT INSURER. 6. FOR NON -UNITED STATES (ALIEN) INSURERS, THE INSURER SHOULD BE LICENSED BY A COUNTRY OUTSIDE OF THE UNITED STATES AND SHOULD BE ON THE NAIC'S INTERNATIONAL INSURERS DEPARTMENT QID) LISTING OF APPROVED NONADMITTED NON -UNITED STATES INSURERS. ASK YOUR AGENT, BROKER OR "SURPLUS LINE" BROKER TO OBTAIN MORE INFORMATION ABOUT THAT IN RiskMwagxmentDMsian REVIEWED&APPROVED BY: � Risk Management Analyst binders'138 7. CALIFORNIA MAINTAINS A LIST OF APPROVED SURPLUS LINE INSURERS. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE: V'WW.INSURANCE.CA.GOV. 8.IF YOU, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN TWO BUSINESS DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO BUSINESS DAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU CANCEL COVERAGE, THE PREMIUM WILL BE PRORATED AND ANY BROKER'S FEE CHARGED FOR THIS INSURANCE WILL BE RETURNED TO YOU. LMA9098A 04 May 2017 D-2 (Effective January 1, 2017) Risk Mwagme tDMsian REVIEWED&APPROVEDBY: �� Risk Management Analyst binders'138 SOLOMON AND ASSOCIATES HEARING OFFICERS January 26, 2021 City of Santa Ana Risk Management Division 20 Civic Center Plaza, 4th Floor Santa Ana, CA 92702 Re: Auto Insurance Requirement Dear City of Santa Ana Risk Management Division: I, _Stephen Solomon . have entered into an agreement with the City of Santa Ana. Throughout the course of this agreement, I attest to the following: As an independent contractor, I will utilize my personal vehicle/non-company owned, borrowed, or rented/leased vehicle for transportation to and from work, and will carry my own automobile insurance. I, _Stephen Salomon , attest that I possess the legal authority to enter into an agreement with the City of Santa Ana as well as the legal authority to attest to the statements above. If at any time, it is found that I am not adhering to any/all statements in this document and have not provided the minimum Auto liability insurance coverage of $1 million per occurrence, the contract will be considered null and void and I will be held fully liable for any and all damages. Sincerely, M E Stephen Solomon Solomon and Associates Hearing Officers (714)345-9767 ssolomon408@gmail.com •iYort•M�: RIA Matt� DlAsiart D&{{A�P'PIRO MBV: a rrRiwlE r�hWi�M2 R• V �W Risk Management Analyst f d d6b Z6' l,Z CO 9ed 01/20/2021 x� a m C waF c s t: wuntan, rites , sae liked aul a n - nea auto Sine he t rid Owse cmee-au-s -a have any other st, s, ; as €et k¢ . Ca 92602 94VIS88-0204 Rime Management ElMsinn REVIEWED&APPROVED BY: '� Risk Management Analyst CITYOFSANTAANA RISK MANAGEMENT a &wa6ara 4 HUMAN RESOURCES " Managing R1s1(#mwAPosfflva ClIange WORKERS' COMPENSATION DECLARATION it 4tgEVZN P, hereby affirm under penalty of perjury, the (Name/Title) following declaration: I certify on behalf of H .solamoa✓ that during the term '' (Consultant/Company Name) of my contract for ' d � services with the City of Santa Ana, (Type fservi provided) I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately. Date: Print Name: 15�/��/ So.Cz,.y1o.+1 Print Title: S70 L f lJW A/Ar— /2 S�G'6�e Signature: Telephone: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. kjRisk Mgmtklnsurance Requirements�WC Declaration 08152019 Risk MwaganattDMsian pr`REMEWED&{AP'�R PIRIOeVVEDBY. R. VNMK �� Risk Management Analyst