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HomeMy WebLinkAboutSOLOMAN, STEPHEN H. (2)City of Santa Ana G COTC Office Use OnN Clerk of the Council J 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TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect.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 CLERK OF € HE r r have been satisfied prior to signing the termination form. ,,0' 44 j�j PI# 2^ ,t, "' � ��wi:�� Is the agreement(s) a permanent record? YesEl No Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with STEPHEN H. SOLOMON No. N-2022-042 was completed on 06/23/2022 and final payment has been made. (List all amendments. Use space below if needed.) M- ZaZ2--Bt{Z-bl i:14mementsVom Vorm - agreement tenninagon form_goldemodAm Department: Planning and Building Phone/Ext.: X2717 Signature: v' V "— - Date: 08/23/2022 INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES 06 • o l • 7-02Z CLERK OF COUNCIL N-2022-042-01 DATE: FIRST AMENDMENT TO AGREEMENT WITH STEPHEN H SOLOMON TO MAR 0 12022 PROVIDE ADMINSTRATIVE HEARING SERVICES THIS FIRST AMENDMENT to the above -referenced agreement is entered into February 24, 2022, by and between Stephen H. Solomon ("Contractor"), 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"). o : P WAY-14aloe TOYYYV i)C � RECITALS A. The parties entered into an Agreement dated February 13, 2022 ("Agreement"), to retain Contractor to serve as a neutral administrative hearing officer and provide on -call professional administrative hearing services for the City B. The Agreement is current and in -effect through February 12, 2024. C. The parties now wish to amend the Agreement to reduce the insurance requirements. The Parties therefore agree: 1. Section 6, Insurance, is hereby amended to read in its entirety: Prior to undertaking performance of work under this Agreement, Contractor shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Minimum Scope and Limit of Insurance 1. Automobile Liability: ISO Form Number CA 00 01 covering any auto (Code 1), or if Contractor has no owned autos, hired, (Code 8) and non -owned autos (Code 9), with a limit no less than $1,000,000 per accident for bodily injury and property damage. 2. Workers' Compensation: as required by the State of California, with Statutory Limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. 3. Professional Liability (Errors & Omissions): Consultant is required to carry insurance appropriate to the Consultant's profession, with a combined single limit of not less than $1,000,000 per claim. 4. Broader Coverage: if the Contractor maintains broader coverage and/or higher limits than the minimums shown above, the City requires and shall be entitled to the broader coverage and/or the higher limits maintained by the Contractor. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the City. Page 1 of 4 b. Other Insurance Provisions 1. Additional Insured Status: The City, its officers, officials, employees, and volunteers are to be covered as additional insureds on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Contractor including materials, parts, or equipment furnished in connectionwith such work or operations. General liability coverage can be provided in the form of an endorsement to the Contractor's insurance (at least as broad as ISO Form CG 20 10 11 85 or if notavailable, through the addition of both CG 20 10, CG 20 26, CG 20 33, or CG 20 38; and CG 2037 if a later edition is used). 2. Primary Coverage: For any claims related to this contract, the Contractor's insurance coverage shall be primary coverage at least as broad as ISO CG 20 01 04 13 as respects the City, its officers, officials, employees, and volunteers. Any insurance or self- insurance maintained by the City, its officers, officials, employees, or volunteers shall be excess of the Contractor's insurance and shall not contribute with it. 3. Notice of Cancellation: Each insurance policy required above shall provide that coverage shall not be canceled, except with notice to the City. 4. Waiver of Subrogation: Contractor hereby grants to City a waiver of any right to subrogation that any insurer of said Contractor may acquire against the City by virtue of the payment of any loss under such insurance. Contractor agrees to obtain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer. 5. Self -Insured Retentions: Self -insured retentions must be declared to and approved by the City. The City may require theContractor to purchase coverage with a lower retention or provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention. The policy language shall provide, or be endorsed to provide, that the self -insured retention may be satisfied by either the named insured or City. 6. Acceptability of Insurers: Insurance is to be placed with insurers authorized to conduct business in the state with a current A.M. Best's rating of no less than A:VII, unless otherwise acceptable to the City. Page 2 of 4 N-2022-042-01 Verification of Coverage: Contractor shall furnish the City with original Certificates of Insurance including all required amendatory endorsements (or copies of the applicable policy language effecting coverage requiredby this clause) and a copy of the Declarations and Endorsement Page of the CGL policy listing allpolicy endorsements to City before work begins. However, failure to obtain the required documents prior to the work beginning shall not waive the Contractor's obligation to provide them. The City reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time. 8. Subcontractors: Contractor shall require and verify that all subcontractors maintain insurance meeting all the requirements stated herein, and Contractor shall ensure that City is an additional insured on insurance required from subcontractors. 9. Special Risks or Circumstances: City reserves the right to modify these requirements, including limits, based on the nature of therisk. prior experience, insurer, coverage, or other special circumstances. 2. Except as modified by this First Amendment, all terms and conditions of the Agreement, shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: aisy Gomez Clerk or the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: Brandon Sulvatierm Deputy City Attorney CITY OF SANTA ANA Kristine City Manager CONTRACTOR: Ste phet 1. Solomon [signaheres eonrinued on ne i page) Page 3 of 4 RECOMMENDED FOR APPROVAL: Minh Thai Executive Director Planning & Building Agency Page 4 of 4 Francine R. Digitally signed by Francine S. Villareal Villareal ACORO® CERTIFICATE OF LIABILITY INSURANCE °ATE(MMIDDIYYYY) 21a12022 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 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 endorsements . PRODUCER NAMEACT COMPLETE EQUITY MARKETS INC PHONE 847 541-0900 PAX No: 847 541-0444 COMPLETE EQUITY MARKETS INC 1190 Flex Court E MDrsIEss: INSURERS AFFORDING COVERAGE NAIC If Lake Zurich, IL 60047 INSURERA: Underwriters at Lloyd's London In CA: dba Complete Equity Markets Insurance Agency, Inc. CA SL OD44o77 INSURED INSURER B INSURER C: Stephen H. Solomon INSURERD: 18861 Ridgewood Lane INSURER E: Villa Park, CA 92861 NSURER 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 LTR TYPE OF INSURANCE 1NS�L SUER VIVO POLICY NUMBER POLICY SEE MMIDDIYYYY] POLICY EXP IMWDD[YYYY1 LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �DAMAGE � CLAIMS -MADE �' OCCUR TO RENTED PREMISES Ea occunence $ 50,000 MED EXP (AM oneperson) $ $ 000 PERSONAL BADVINJURY $ EXCLUDED A X 1500343 2/5/2022 2/6/2023 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,001111 GEN'L X POLICY ❑ PRO- JECT LOC PRODUCTS - COMPIOP AGG $ 1,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accitlenl $ BODILY INJURY (Per person) S ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per eccaki $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ 8 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE ❑ IM OFFICEREMBER EXCLUDED? NIA PER OTH- STATUTE ER E.L EACH ACCIDENT $ EL. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below EL.DISEASE - POLICY LIMIT $ Each Claim $1,000,000 A Professional Liability X 1801070 6/1/2021 6/112022 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe 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 on both policies but only per the terms S conditions of the endorsement generated for each respective policy and subject to all policy terms, conditions, exclusions and endorsements. Primary/Non-Contributory, Waiver of Subrogatlon and $0 Day Notice of Cancellation applies to the General Liability policy. SURPLUS LINES NOTICE TO POLICYHOLDER- PLEASE SEE ATTACHED 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. OW�s►l ©1988-2015 ACORD ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD [REVIEWED & APPROVED BY. F44b,,� Z W&Wl4 Risk Management Analyst IMPORTANT NOTICE: 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 toll -free number 1-800-927-4357 or internet website www.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 visit the NAIC's internet website at www.naic.org. The NAIC—the National Association of Insurance Commissioners —is the regulatory support organization created and governed by the chief insurance regulators in the United States. 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. You can find a link to each state from this NAIC internet website: https:Hnaic.org/state—web—map.htm. 6. For non -United States (alien) insurers, the insurer should be licensed by a country outside of the United States and should be on Rlsk Management DWblan 4WREVIEWED S APPRMEM BY: ' fMcw + a P.. V Uir mcl � Risk Management Analyst the NAIC's International Insurers Department (IID) listing of approved nonadmitted non -United States insurers. Ask your agent, broker, or "surplus line" broker to obtain more information about that insurer. 7. California maintains a "List of Approved Surplus Line Insurers (LASLI)." Ask your agent or broker if the insurer is on that list, or view that list at the internet website of the California Department of Insurance: www.insurance.ca.gov/01-consumers/120-company/07- lasli/lasli.cfm. 8. If you, as the applicant, required that the insurance policy you have purchased be effective 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 rive 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. D-2 (Effective January 1, 2020) Risk MwagmiadD slan 9 E, RimE o 6 APPRo m BV: Ems. ® Risk Management Analyst AMENDATORY ENDORSEMENT NO.: 1500343 INSURED: STEPHEN PL SOLOMON EFFECTIVE: February 5, 2022 to February 5, 2023 ADDITIONAL PREMIUM: Included Commercial General Liability CG 20 10 10 01 This endorsement changes the policy. Please read it carefully. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Schedule Name of Additional Insured: The City of Santa Ana, it's officers, employees, agents, and representative (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II - Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2 Exclusions This insurance does not apply to 'bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 10 01 Copyright, ISO Properties, Inc., 2002 All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of Certificate No.: CEM 758 - 21 Dated: January 31, 2022 UNDERWRITERS AT LLOYD'S, LONDON (UMR) B0429BA2101027 PW*1M Complete mty Markets, Inc. dba Complete uity Markets Insm/. u-rya�nw Agency, n In . (CASL#ODW7 Byl.C!//�iLf7fL (_ Lawrence T.P. Molloy Endorsement #22 WakMougementDWian +09" RENEWED&APPROVED BY: s ®- Risk Management Matyst AMENDATORY ENDORSEMENT NO.: 1500343 INSURED: STEPFIEN I-L SOLOMON ADDITIONAL PREMIUM: (Included) EFFECTIVE: February 5, 2022 to February 5, 2023 ADDITIONAT. INST IRF.D (Primary and Waiver) It is hereby agreed and understood that the person(s) or entity(ies) listed below is/are included as Additional Insureds) under the policy number referenced above, but only with respect to claims or damages arising solely out of actions of the Named Insured: The City of Santa Ana, it's officers, employees, agents, and representative 20 Civic Center Plaza Santa Ana CA 92701 The coverage provided hereunder to the above -named Additional Insured shall be primary and non-contributory to any insurance or self-insurance maintained by the Additional Insured. It is further agreed that Underwriters waive all rights of subrogation against the Additional Insured with respect to claims or damages arising out of the Named Insured's actions. All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of No.: NI 9022 Dated: February 2, 2022 LII 442-2 (04/12) (UMR) B0429 P14-357 UNDERWRITERS AT LLOYD'S, LONDON Complete luty Markets, Inc. BA2101027 dba Complete uity Markets Immaance Agency, In . (CASL#OD4407D By 6 ;�517%L 7 Lawrence T.P. Molloy Endorsement #10 R AMuvgemmtDWion �(��\,.\ REIe D6APPROVEDBv: �SUli:ll.li':J" f4mN.:.r.t P, kuNNI.L �'. Risk Management Analyst Evidence of Insurance Policy Number: 18553-66-95 Policy Edition: 1 st Effective: 6/28/2016 12:01 AM Expiration: Continuous until cancelled Expiration Time: 12:01 AM Insured: Stephen Solomon Cynthia V Lavadia 17853 Santiago Blvd # 107-188 Villa Park, CA 92861-4113 Vehicle Information Year Make 2016 GmcTruck Coverages Coverage Type Bodily Injury Liability Property Damage Liability Permissive User Limit of Liability Medical Coverage Uninsured Motorist Bodily Injury Comprehensive Model Yukon 4D 4X2 Denali Limit/Deductible $500,000 each person $1,000,000each accident $100,000 each accident Full (See Permissive User Limit of Liability in your policy) $5,000 each person $250,000 each person $500,000 each accident $100 Deductible eww"'A FARMERS INSURANCE Underwritten By: Mid -Century Insurance Company 6301 Owensmauth Ave. Woodland Hills, CA91367 YourAgent: Ember Joy Stites PO Box 61644 Irvine, CA 92602-6054 (949)588-0204 FAX: (949) 266-9191 estites@farmersagent.com VIN 1 G KS I CKJXG R261059 Coverage Type Collision Additional Equipment Uninsured Motorist Property Damage with Collision Towing and Road Service Other Limit/Deductible $250 Deductible $1,000 Covered Covered Covered This evidence is subject to all of the terms, conditions and limitations set forth in the policy and endorsements attached to it. It is furnished as a matter of information only and does not change, modify or extend the policy in anyway. It supersedes all previously issued certificates. farmers.com 25-6976 9-13 Ituk rtlatwgnngrt U[Vielpl REVIEwm&APPRW®Br Risk Management Analyst Evidence of Insurance (continued) Loss payable provisions (Applicable only if lienholder is named, and no other Automobile loss payable endorsement is attached to the policy) It is agreed that any payment for loss or damage to the vehicle described in this policy shall be made on the following basis: 1. At our option, loss or damage shall be paid as interest may appear to the policyholder and the lienholder shown in the Declarations, or by repair of the damaged vehicle. 2. Any actor neglect of the policyholder or a person acting on his behalf shall not void the coverage afforded to the lienholder. 3. Change in title or ownership of the vehicle, or error in its description shal I not void coverage afforded to the lienholder. The policy does not cover conversion, embezzlement or secretion of the vehicle by the policyholder or anyone acting in his behalf while in possession under a contract with the lienholder. A payment maybe made to the lienholder which we would not have been obligated to make except for these terms. I n such event, we are entitled to all the rights of the lien holder to the extent of such payment. Authorized Representative farmers.com 25-8976 9-13 The lienholder shal I do whatever is necessary to secure such rights. No subrogation shall impair the right of the lienholder to recover the full amount of its claim. We reserve the right to cancel this policy at anytime as provided by its terms. In case of cancellation or lapse we wi I I notify the lien holder at the address shown in the Declarations. We will give the lien holder advance notice of not less than 10 days from the effective date of such cancellation or lapse as respects his interest. Mailing notice to the loss payee issufficient toeffect cancellation. Thefollowing applies as respects any lossadjusted with the mortgagee interest only: 1. Any deductible applicable to Comprehensive Coverage shall not exceed $250. 2. Any deductible applicable to Collision Coverage shall not exceed $250. 2/15/2022 Date taeic matugnnwu urvie�nn qs;g REVIEWED&APPROVED BY:: Risk Management Analyst CITYOFSANTAANA RISK MANAGEMENT. 4 HumAN RESOURCES �A,1a. -r�tc�m� P7sic ... �r,., ,positive Chr nge Affidavit of Exemption for Workers' Compensation Insurance I, s��pyF l 4 geDz&i ele hereby affirm under penalty of perjury, the (Namelritle) following declaration: I certify on behalf of 14 so�MoA/ S." r- that during the term (Consultant/Company Name) of my contract for, yFop,,'N &- „ EFA--ZcA services with the City of Santa Ana, (Type ofservice 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: 7- %% `6�� '2- Print Name: S rEP#, 4 /�, se).e z--/Mo// Print Title: gay So<o AoAl Signature: �. Telephone: 3q5—g767 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 ATTORNEYS FEES. I:\Risk Mgmt\Insurance Requirements\ Affidavit of Exemption for Workers' Compensation Insurance 2 ..... RiekMvagnnmtDh&bn e' REVEwED 6 APPRW® By. Risk Management Analyst i,'d d6b b0'ZZ 8l qe-i i,'d d6b b0'ZZ 8l qe-i