HomeMy WebLinkAboutLUIS RAUL MARTINEZ (3)INSURANCE ON FILE
WORK MAY PROCEED
UNTJL,lNSU` dNC!;,JPIRES
CLERK OF COUNCIL 11
DATE:
P 0 Cl) ()(AvviA.Q C OWA r-4) f-P' AGREEMENT WITH LUIS RAUL MARTINEZ
TO PROVIDE COUNSELING SERVICES
THIS AGREEMENT, made and entered into this 1ST day of July, 2021,
N Luis Raul Martinez (hereinafter "Consultant"), and the City of Santa Ana, a
04 municipal corporation organized and existing under the Constitution and laws
® California (hereinafter "City").
M-
LU
Cn RECITALS
N-2021-169
by and between
charter city and
of the State of
A. The City desires to retain a consultant having special skill and knowledge in the field
of counseling and/or instructional services encompassing the fields of anger
management, stress reduction, conflict management/resolution, domestic violence
avoidance, chemical dependency, life skills/family issues and community resources to
the inmates housed at the Santa Ana City Jail.
B. Consultant represents that he is able and willing to provide such services to the City.
C. In undertaking the performance of this Agreement, Consultant represents that he is
knowledgeable in his field, and that any services performed by Consultant under this
Agreement will be performed in compliance with such standards as may reasonably be
expected from a professional consulting firm in the field.
NOW THEREFORE, in consideration of the mutual and respective promises, and subject to
the terms and conditions hereinafter set forth, the parties agree as follows:
1. SCOPE OF SERVICES
Consultant and City shall perform those services as set forth in Exhibit A to this Agreement
which include counseling and/or instructional services to inmates in the areas of anger agreement,
stress reduction, conflict management/resolution, domestic violence avoidance, chemical
dependency, life skills/family issues and community resources.
2. COMPENSATION
a. City agrees to pay, and Consultant agrees to accept as total payment for services an
hourly rate of sixty dollars ($60.00) for all scheduled instructional and counseling sessions. The
total sum to be expended shall not exceed $40,000 during the term of this Agreement.
b. Payment by City. shall be made within thirty (30) days following receipt of proper
invoice evidencing work performed, subject to City accounting procedures. Payment need not be
made for work which fails to meet the standards of performance set forth in the Recitals which
may reasonably be expected by City,
3. TERM
This Agreement shall commence on the date first written above and terminate on June 30,
2022 unless terminated earlier in accordance with Section 12, below.
#125584v2
4. INDEPENDENT CONTRACTOR
Consultant 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 construed to create an employer -employee relationship, a joint venture relationship, or to
allow the City to exercise discretion or control over the professional manner in which Consultant
performs the services which are the subject matter of this Agreement; however, the services to be
provided by Consultant shall be provided in a manner consistent with all applicable standards and
regulations governing such services. Consultant 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.
INSURANCE
Prior to undertaking performance of work under this Agreement, Consultant shall maintain
and shall require its subcontractors, if any, to obtain and maintain insurance as described below:
a. Commercial General Liability Insurance. Consultant shall maintain commercial
general liability insurance naming the City, its officers, employees, agents,
volunteers and representatives as additional insured(s) and shall include, but not be
limited to protection against claims arising from bodily and personal injury,
including death resulting therefrom and damage to property, resulting from any act
or occurrence arising out of Consultant's operations in the performance of this
Agreement, including, without limitation, acts involving vehicles. The amounts of
insurance shall be not less than the following: single limit coverage applying to
bodily and personal injury, including death resulting therefrom, and property
damage, in the total amount of $1,000,000 per occurrence, with $2,000,000 in the
aggregate. Such insurance shall (a) name the City, its officers, employees, agents,
and representatives as additional insured(s); (b) be primary and not contributory
with respect to insurance or self-insurance programs maintained by the City; and
(c) contain standard separation of insureds provisions.
b. Business automobile liability insurance, or equivalent form, with a combined single
limit of not less than $1,000,000 per occurrence. Such insurance shall include
coverage for owned, hired and non -owned automobiles.
C. Worker's Compensation Insurance. In accordance with the provisions of Section
3700 of the Labor Code, Consultant, if Consultant has any employees, is required
to be insured against liability for worker's compensation or to undertake self-
insurance. Prior to commencing the performance of the work under this
Agreement, Consultant agrees to obtain and maintain any employer's liability
insurance with limits not less than $1,000,000 per accident.
d. If Consultant is or employs a licensed professional such as an architect or engineer:
Professional liability (errors and omissions) insurance, with a combined single limit
of not less than $1,000,000 per claim with $2,000,000 in the aggregate.
e. The following requirements apply to the insurance to be provided by Consultant
pursuant to this section:
i. Consultant shall maintain all insurance required above in full force and
effect for the entire period covered by this Agreement.
ii. Certificates of insurance shall be furnished to the City upon execution of
this Agreement and shall be approved by the City.
iii. Certificates and policies shall state that the policies shall not be canceled or
reduced in coverage or changed in any other material aspect without thirty
(30) days prior written notice to the City.
iv. Where the amounts or coverage provided by the certificates of insurance
provides coverage greater than those listed by this Agreement, the amounts
provided by the certificates of insurance shall be incorporated by reference
into the Agreement.
V. Consultant shall supply City with a fully executed additional insured
endorsement.
f If Consultant fails or refuses to produce or maintain the insurance required by this
section or fails or refuses to furnish the City with required proof that insurance has been procured
and is in force and paid for, the City shall have the right, at the City's election, to forthwith
terminate this Agreement. Such termination shall not affect Consultant's right to be paid for its
time and materials expended prior to notification of termination. Consultant waives the right to
receive compensation and agrees to indemnify the City for any work performed prior to approval
of insurance by the City.
6. INDEMNIFICATION
Consultant agrees to and shall indemnify 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 direct
or indirect operations of the Consultant 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.
This indemnity and hold 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. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the
defense of the City, including fees and costs for special counsel to be selected by the City,
regarding any action by a third party challenging the validity of this Agreement, or asserting that
personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal
or property rights arises by reason of the terms of or effects arising from this Agreement. City may
make all reasonable decisions with respect to its representation in any legal proceeding.
CONFIDENTIALITY
If Consultant receives from the City information which due to the nature of such
information is reasonably understood to be confidential and/or proprietary, Consultant agrees that
it shall not use or disclose such information except in the performance of this Agreement, and
further, agrees to exercise the same degree of care it uses to protect its own information of like
importance, but in no event less than reasonable care. "Confidential Information" shall include all
nonpublic information. Confidential information includes not only written information, but also
information transferred orally, visually, electronically, or by other means. Confidential
information disclosed to either party by any subsidiary and/or agent of the other party is covered
by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any
information that (a) has been disclosed in publicly available sources; (b) is, through t1,0 fault of
the Consultant disclosed in a publicly available source; (c) is in rightful possession of the
Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of
law; or (e) is independently developed by the Consultant without reference to information
disclosed by the City.
CONFLICT OF INTEREST CLAUSE
Consultant 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.
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
first class or certified mail, postage prepaid, or sent by telefacsimile or other telegraphic
communication in the manner provided in this Section, to the following persons:
To City: Clerk of the City 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 courtesy copies to:
Santa Ana City Jail — Contract Services Supervisor
City of Santa Ana
20 Civic Center Plaza M-88
P.O. Box 1988
Santa Ana, California 92702
Fax 714- 647.-8116
To Consultant: Luis Raul Martinez
300 West 2"a Street, #201
Santa Ana, CA 92701
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 telefacsimile, 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.
Consultant, 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 Consultant 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 Consultant nor 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.
11. ASSIGNMENT
Inasmuch as this Agreement is intended to secure the specialized services of Consultant,
Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior
written consent of the City and any such assignment, transfer, delegation or subcontract without
the City's prior written consent shall be considered null and void. Nothing in this Agreement shall
be construed to limit the City's ability to have any of the services which are the subject to this
Agreement performed by City personnel or by other consultants retained by City.
12. TERMINATION
This Agreement may be terminated by the City with or without cause upon thirty (3 0) days
written notice of termination. In such event, Consultant shall be entitled to receive and the City
shall pay Consultant compensation for all services performed by Consultant prior to receipt of
such notice of termination, subject to the following conditions:
a. As a condition of such payment, the City Manager may require Consultant to deliver
to the City all work product completed as of such date, and in such case such work product shall
be the property of the City unless prohibited by law, and Consultant consents to the City's use
thereof for such purposes as the City deems appropriate.
b. Payment need not be made for work which fails to meet the standard of performance
specified in the Recitals of this Agreement.
13. NON-DISCRIMINATION
Consultant shall not discriminate because of race, color, creed, religion, sex, marital status,
sexual orientation, gender identity, gender expression, gender, medical conditions, genetic
information, or military and veteran status, age, national origin, ancestry, or disability, as defined
and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization,
promotion, termination or other employment related activities or any services provided under this
Agreement. Consultant affirms that it is an equal opportunity employer and shall comply with all
applicable federal, state and local laws and regulations.
14. 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.
15. PROFESSIONAL LICENSES
Consultant 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. Consultant shall notify the City immediately and
in writing of its inability to obtain or maintain such permits, licenses, approvals, waivers, and
exemptions. Said inability shall be cause for termination of this Agreement.
16. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature herein below has the power,
authority and right to bind their respective parties to each of the terms of this Agreement, and shall
indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages
to City in the event that such authority or power is not, in fact, held by the signatory or is
withdrawn,
b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set
forth in the body of this Agreement.
[signature page to follow]
EXHIBIT A
SCOPE OF SERVICES
1. CITY'S Responsibilities:
The CITY shall provide the following assistance to CONSULTANT:
a. Identify a contact person who shall be responsible for scheduling and coordinating the
services to be provided by CONSULTANT. The subject matter, the number of hours and the
scheduling of hours shall be at the sole discretion of the CITY.
b. Schedule and record CONSULTANT'S time worked during meetings, instruction and
counseling sessions.
c. Provide an adequate facility that will allow CONSULTANT to perform the services required
under this agreement in an efficient and timely manner.
d. Provide prompt notice to the CONSULTANT whenever the CITY observes or otherwise
becomes aware of any defect in the services provided under the terms of the agreement.
2. CONSULTANT'S Responsibilities:
CONSULTANT shall provide the following services to CITY:
a. Deliver instructional and/or counseling services in the following program areas to
selected inmates:
(1) anger management
(2) stress reduction
(3) conflict management/resolution
(4) domestic violence
(5) chemical dependency
(6) life skills/family issues
(7) community resources
b. Coordinate with CITY staff to facilitate delivery of program material.
c. Collect specific diagnostic and statistical information regarding inmates in attendance
and program material.
d. Assign inmates tasks to perform and goals to reach in relation to the program material.
e. Provide inmates in attendance with referrals to other agencies and community resources that
can provide additional instruction and/or counseling as follow-up to the program material already
delivered.
N-2021-169
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first
above written.
ATTEST:
DAISY GO
Clerk of the Council
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney n
By: r L
Tamara Bogosian
Senior Assistant City Attorney
RECOMMENDED FOR APPROVAL:
ID VALENTIN
Chief of Police
CITY OF SANTA ANA
,_ZZ
KRISTINE RIDGE
City Manager
CONSULTANT
uis Raul Maztin
HEALTHCARE PROVIDERS SERVICE
CNA
ORGANIZATION PURCHASING GROUP INHPSO
llgila0efl9n,;,a,pa
'ante
(Tertlf sate of 3hou Francine R.
OCCURRENCE PROFESSIONAL LIABILITY POLICY FORM Villareal Date: 202108.0914:45.49
-07"
Print Date: 7/29/2021
The application for the Policy and any and allsupplementary information, materials, and statements submitted therewith shall
be maintained on file by us or our Program Administrator and will be deemed attached to and incorporated into the Policy as
If physically attached.
PRODUCER BRANCH PREFIX
POLICY NUMBER POLICY PERIOD
018098 970 HPG
0697816243
From: 12/10/20 at 02:09 PM ET to 12/10/21 at 12:0 AAM Std Time
Named Insured and Address:
Program Administered by:
Luis Martinez
Healthcare Providers Service Organization
301 W 2nd St Apt 241
1100 Virginia Drive, Suite 250
Santa Ana, CA 92701-5295
Fort Washington, PA 19034
1-800-982-9491
www.hpso.com
Medical Specialty:
Code:
Insurance Provided by:
Alcohol/Drug Counselor
80723
American Casualty Company of Reading, Pennsylvania
151 N. Franklin Street
Excludes Cosmetic Procedures
Chicago, IL 50606
Professional Liability $ 1,000,000 each claim $ 3,000,000 aggregate
Your professlonaI (lability limits shown above Include the following:
* Good Samaritan Liability * Malplacement Liability
* Personal Injury Liability
* Sexual Misconduct Included in the PL limit shown above subject
to $ 25,000 aggregate sublimit
Coverage Extensions
License Protection
$ 25,000
per proceeding
$ 25,000
aggregate
Defendant Expense Benefit
$ 1,000
per day limit
$ 25,000
aggregate
Deposition Representation
$ 10,000
per deposition
$ 10,000
aggregate
Assault
$ 25,000
per incident
$ 25,000
aggregate
Includes Workplace Violence Counseling
Medical Payments
$ 25,000
per person
$ 100,000
aggregate
First Aid
$ 10,000
per incident
$ 10,000
aggregate
Damage to Property of Others
$ 10,000
per incident
$ 10,000
aggregate
Information Privacy (HIPAA) Fines and Penalties
$ 25,000
per incident
$ 25,000
aggregate
Media Expense
$ 25,000
per incident
$ 25,000
aggregate
General Liability
General Liability $1,000,000 each claim / $2,000,000 aggregate
Fire & Water Legal Liability Included in the GL limit shown above subject to $260,000 aggregate sublimit
Personal Liability $1,000,000 aggregate
Total $ 465.00
Base Premium $465.00
Premium reflects Self Employed , Part Time
Policy Forms and Endorsements (Please see attached list of policy forms and endorsements)
Chairman of the Board
Secretary
Keep this Certificate of Insurance in a safe place. It and proof of payment are your proof of coverage
force unless the premium is paid in full. To activate your coverage, please remit premium in full by
Certificate of Insurance.
Coverage Change Date: 7/29/2021 Endorsement Date: 7/29/2021
CNA93692 (11-2018)
RiakManagemenfDitielon
REVIEWED&APPRDv¢)BY:
AwfRhL�r F'FAA�d�r� 4 R, if
Rulc Management A[tily5[
POLICY FORMS & ENDORSEMENTS
The following are the policy forms and endorsements that apply to your current professional liability policy.
COMMON POLICY FORMS & ENDORSEMENTS
FORM #
G-121500-D (04-08)
G-121501-C1 (07-01)
CNA96097 (06.19)
CNA94164 (11-18)
G-145184-A (06-03)
G-147292-A (03-04)
GSL15563 (02-10)
GS1_15564 (10-09)
GS1_15565 (03-10)
GSL17101 (02-10)
GSL13424 (05-09)
CNA80051 (09.14)
CNA80052 (10-14)
G-123846-D04 (07-01
CNA81753 (03-15)
CNA81758 (03-15)
CNA82011 (04-15)
ONA89027 (10.17)
CNA79575 (07-14)
G-121504-C (07-01)
G-123827-B (07-01)
G-123828-B (07-01)
G-141231-A (07-01)
CNA89026 (05-17)
FORM NAME
Common Policy Conditions
Occurrence Policy Form - California
Amended Definition of Policy Period Endorsement
Amendment Definition of Claim Endorsement
Policyholder Notice - OFAC Compliance Notice
Policyholder Notice - Silica, Mold & Asbestos Disclosure
Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs
Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion
Healthcare Providers Professional Liability Assault Coverage
Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies
Services to Animals
Amended Definition of Personal Injury Endorsement
Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement
California Cancellation and Non -Renewal
Coverage & Cap on Losses from Certified Acts Terrorism
Notice - Offer of Terrorism Coverage & Disclosure of Premium
Related Claims Endorsement
Entity Exclusion Endorsement
Exclusion of Cosmetic Procedures
General Liability Form
Additional Insured General Liability
Certificate Holder
Additional Insured Healthcare Entity
Media Expense Coverage
PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC
TO YOUR STATE AND YOUR POLICY PERIOD.
For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance
Guaranty Association.
For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement
Foundation Program Fund and the Local Tax is the KY Local Government Premium Tax.
As required by 806 Ky. Admin Regs. 2:100, this Notice is to advise you that a surcharge has been
applied to your insurance premium and is separately itemized on the Declarations page or billing
instrument attached to your policy, as required KRS. §136,392.
For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge.
For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association
- 2012 Regular Assessment.
Form #:CNA93692 (11-2018)
Master Policy k 188711433
Named Insured: Luis Martinez
Policy #: 0697816243
PJAManagomEDIvalon
@RREMEWED & APPfR�OVED 9Y
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PROFESSIONAL LIABILITY INSURANCE ENDORSEMENT
Agreement to Provide Notice of Cancellation
In consideration of the premium paid, it is agreed that if the policy to which this endorsement is attached is
cancelled before the expiration date, we will endeavor to mail notice to the person or entity named below.
However, failure to'mail such notice shall impose no obligation or liability of any kind upon the company,
its agents or representatives.
Person or Entity Name and Address: City Of Santa Ana Risk Management Division
20 Civic Center Plaza 4th Floor
Santa Ana, CA 92072
This endorsement is a part of your policy and takes effect on the effective date of your policy, unless
another effective date is shown below. All other provisions of the policy remain unchanged.
Must Be Completed
ENDT. NO. POLICY NO.
1 697816243
G-123828-B(7/2001)
Complete Only When This Endorsement Is Not Prepared with the Policy
Or Is Not to be Effective with the Policy
ISSUED TO ENDORSEMENT EFFECTIVE DATE
Luis Martinez
12/11/20
uae mariage�neni umamt
Rener�o&PAPPPkRRRovm BY:
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HEALTHCARE PROVIDERS
GENERAL LIABILITY COVERAGE PART ENDORSEMENT
Additional Insured —General Liability
In consideration of the premium paid, and subject to the General Liability limit of liability shown on the
certificate of insurance, it is agreed that the GENERAL LIABILITY COVERAGE PART is amended as
follows:
The person or entity named below (the "additional insured") is an insured under this Coverage Part but
only as respects its liability arising out of named insured's operations, or premises owned by or rented by
the named insured and solely to the extent that:
1. a general liability claim is made against the named insured and the additional insured; and
2, in any ensuing litigation arising out of such claim, the named insured and the additional insured
remain as co-defendants.
In no event is there any coverage provided under this policy for an occurrence that is the direct liability of
the additional insured.
Additional Insured: City of Santa Ana Risk Management Division
20 Civic Center Plaza
Santa Ana, CA 92702
This endorsement is a part of your policy and takes effect on the effective date of your policy, unless
another effective date is shown below. All other provisions of the policy remain unchanged.
Must Be Completed
ENDT. NO.
1
POLICY NO.
697816243
Luis Martinez
Or Is Not to be Effective with the
with the
G-123827-B(07/2001) .,
' REmEWEo & APPRovaJ BY,
AMERICAN CASUALTY COMPANY OF READING, PA s ,1' F ,� Z V(
�'�' RcekM2n�gement MalysE
HEALTHCARE PROVIDERS
PROFESSIONAL LIABILITY COVERAGE PART ENDORSEMENT
Additional Insured — Healthcare Professional or Entity
In consideration of the additional premium paid, and subject to the Professional Liability limit of liability
shown on the certificate of insurance, it is agreed that the PROFESSIONAL LIABILITY COVERAGE
PART is amended as follows:
The person or entity named below (the "additional insured") is an insured under this Coverage Part but
only as respects its liability for your medical incidents and solely to the extent that:
1. a professional liability claim is made against you and the additional insured; and
2. in any ensuing litigation arising out of such claim, you and the additional insured remain as co-
defendants.
In no event is there any coverage provided under this policy for a medical incident that is the direct
liability of the additional insured.
Additional Insured: City Of Santa Ana Risk Management Division
20 Civic Center Plaza, 4th Floor
Santa Ana, CA 92072
This endorsement is a part of your policy and takes effect on the effective date of your policy, unless
another effective date is shown below. All other provisions of the policy remain unchanged.
Must Be Completed Complete Only When This Endorsement Is Not Prepared with the Policy
Or Is Not to be Effective with the Policy
ENDT. NO, POLICY NO. ISSUED TO ENDORSEMENT EFFECTIVE DATE
1 697816243 Luis Martinez 12/1
?J1
REVIEWED&APPROVED BY:
G-141231-A (07/2001) F'MMaet.E P, V1 ueeA�
Risk Wnagement Analyat
1100 Virginia Drive, Suite 250
Fort Washington, PA 19034-3278
Phone:1-800-982-9491 Fax:1-800-758-3635
W ebs itemm, h pso.co nt
07/29/21
Luis Martinez
301 W 2nd St Apt 241
Santa Ana, CA 92701-5295
Dear Luis Martinez:
Enclosed is the replacement certificate of insurance that you requested.
If you have any questions or need assistance, please call us toll free at 1-800-982-9491. Our
Customer Service Representatives are available weekdays from 8 00 a.m. to 6:00 p.m., EST.
Sincerely,
Customer Service
Enclosure
Dedicated To Serving the Insurance Needs of Healthcare Prov
Healthcare Providers Service Organization is a registered trade name of Affinity Insumnce Sery
244489); in CA & MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Amity Insu
in CA, Ann Affinity Insurance Services, Inc., (OG94493), Ann Direct Insurance Administratorsar
Agency and in NY, As Affinity Insurance Agency.
Risk Managmimi Dktislan
RE1AEWED & APPRov®8v:
Rt%K Managemeat Analyst
CITY OF SANTA ANA
RISK MANAGEMENT. d4,e, a 4 HUMAN RESOURCES
Managing Risk up-e yt) Posfdve Change
WORKERS' COMPENSATION DECLARATION
Luis Martinez, Counselor
(Name/Title)
following declaration:
hereby affirm under penalty of perjury, the
I certify on behalf of Luis Martinez
(Consultant/Company Name)
that during the term
of my contract for Mental Health Counseling services with the City of Santa Ana,
(Type of service 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: July 26, 2021
Print Name: Luis Martinez
Print Title: Counselor
Signature: �17����...�....._
Telephone: 714 469-4011
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 ($100,00Q). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS
PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
I:�RiskMgmt�1nsurnnceRepuiremenfsiWCDeclaration08152p1g s REmEWEoM& RREDBY.
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Rttk Winzgement Analyst
LUIS R. MARTINEZ
COUNSELOR
301 W. 2od Street, Apt, 241
Santa Ana, CA 92701
714 469-4011
luisraul@martinez.net
I, Luis R. Martinez hereby release the City of Santa Ana of any and all automotive
liability. I drive my own vehicle to and from work and I carry my own automotive
insurance.
Luis . Martinez
Date
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