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Home My WebLink AboutHABITAT FOR HUMANITY OF OC (2)City of Santa Ana Clerk of the Council �•1 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TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect.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 COTC Office Use Only AAA CITY CLERK 21'23 Am10:3? A-2021-068-086 No. was completed on 3 "2��2,3 and final payment has been made. (List all amendments. Use space below if needed.) Department: C D f- Phone/Ext.: Signature: Date: 3 -21-Z3 i:fagreement0orms\form -agreement termination form goldenrod doc N N O N CO MAYOR Vicente Sanniento .e MAYOR PRO TEM y.� Phil Bacerra COUNCILMEMBERS ,- Johnathan Ryan Hernandez Jessie Lopez Nelida Mendoza David Penaloza Thai Viet Phan INSURANCE ON FILL WORK MAY PROCEED UNTIL INSURANCE EXPIRES --4- • 1 - Z2 CLERK OF COUNCIL DATE: LDA (Dfnvta F.) (AV) 0 CITY OF SANTA ANA COMMUNITY DEVELOPMENT AGENCY 20 Civic Center Plaza • P.O. Box 1988 Santa Ana, California 92702 W Ww.santa-ana ora Habitat for Humanity of Orange County, Inc. Attn: Monique Davis, CEO/President 2200 Ritchey Street Santa Ana, CA 92705 May 10, 2022 Re: Extension of Agreement A-2021-068-08 Dear Ms. Davis: A-2021-068-08A CITY MANAGER Kristine Ridge CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Daisy Gomez Pursuant to Agreement A-2021-068-08, entered by Habitat for Humanity of Orange County, Inc. and the City of Santa Ana, dated July 6, 2021, Section I.B., Amount of Grant/Tenn and Monthly Disbursement, the time period of said Agreement is hereby extended for an additional six (6) months, through December 31, 2022. All other terms and conditions of said Agreement remain unchanged and in full force and effect. If you have any questions, please contact David Flores, Community Development Analyst with the Community Development Agency at 714-647-6561. Sincerely, Steven Mendoza Executive Director, Community Development Agency :�!a-N-L 4r CITY OF SANTA ANA Kristine Ridge City Manager APPROVED AS TO FORM: Sonia R.Carvalho Ryan HABITAT FOR HUM TY OF OC, INC. Moniqu Davis CEO/P sident ATTEST: Daisy Gomez 1 L Clerk of the Council SANTA ANA CITY COUNCIL Vicente Sannienb PMt Baca" Thal Viet Phan DaNd Penaloza Jassie Lppez JohnaMan Ryan Hernandez Nelida Mendon Mayor Mayor Pro To., Word Warn Ward2 Word Word WeN6 ySaIT BON(�9anldaod.Dlp pbaca«xa9sante-an, oia Whan0aMtaaoa.orp donab2ffid!sanlaana a jassleloper@santa-anaor mnbemand.ziahanlaa,N cM nmendeld1Q,h,ar,,,, _ I]• A A`C>Ra CERTIFICATE OF LIABILITY INS i e 2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CE' TIFjdAXTE.HOLPEk THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTE H�y�O K FF (1QI ii� BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BBB)N N V95 1 a;AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. �.. V ��rrr ��AAADa IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBRO',ATIOla^1'-��.rx��,� �JJ��11P��t to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certifir Ate doesagy�ptr400t� the certificate holder in lieu of such endorsement(s). PRODUCER NAMECT Lockton £inity, IJ Lockton Affinity, LLC AICNNo Ezt:888-553-9002 Fuc, No•913-652-3967 E-MAIL P. O. Box 873401 ADDRESS: Kansas City, NO 64187-3401 INSURERS AFFORDING COVERAGE NAIC# INSURER A: me aserican maurmce Co. 22667 INSURED INSURER B: ace n Habitat for Humanity of Orange County, rnPe=iY and Casualty z4fi99 Inc. INSURER C: 2200 S. Ritchey Street INSURER D: Santa Ana, CA 92705 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMRFR: RFinSinN NIIMR1=0. 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 POUCIES 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 D INSD adept WVD POLICY NUMBER POLICY EFF MMID POLICY EXP MWD LIMITS A X COMMERCIAL GENERAL LIABILITY y GL1064465-22 D4/01/2022 04/01/2023 EACH OCCURRENCE $1,000,000 CLAIMS -MADE 1XIOCCUft DAMAGETO PREMISES Roccunence 1,000,000 MED EXP (Any one person) .$ $ 0 PERSONAL& ADV INJURY $ 1,000,000 GEd'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY ❑jam n LOC PRODUCTS-COMPIOP AGG $2, 000, 000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OIMNED SCHEDULED AUTOS AUTOS BODILY INJURY eracciEent ) $ NON-0WNED HIRED AUTOS AUTOS PROPERTY DAMAGE raccident) $ B X UMBRELLA U,4B X OCCUR UM1064465-22 04/01/2022 04/01/2023 EACH OCCURRENCE $ 1,000,000 AGGREGATE $1,000,000 EXCESS LUAB CLAIMS -MADE DED X RETENTION$10 000 $ WORKERS COMPENSATION AND EMPLOYERS 'LIABILITY YIN PER OTH- STATUTE ER E.L EACH ACCIDENT $ ANY PROPRIETORIPARTNEWEXECUTIVE ❑ OFFICE"EMSER EXCLUDED? NIA E.L DISEASE - EA EMPLOY $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule. may be attached 8 more space is required) City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured on this policy pursuant to written contract, agreement, or memorandum of understanding. Such insurance as is afforded by this policy shall be primary, and any insurance carried by City shall be excess and noncontributory. Notice of Cancellation initiated by the company - for Non Payment: 10 Days; for Other Reasons: 30 Days; Notice of Non -Renewal initiated by the company: 10 Days. Failure to provide notice will not invalidate the cancellation or non -renewal. CERTIFICATE HOLDER CANCELLATION 1064465 City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza Santa Ana, CA 92702 AUTHORIZgDWRESENTATIVE RiskItteragenentDhiarion RPtll m6APPROV®BV: 01988-2014 ACORD ( q/ o.. ? Xju Am4,s ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD'' Risk Management speaahal 40855821 1064465 CERTIFICATE OF LIABILITY INSURANCE DATE(MMMOIYYYY) B/3012021 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 endomement(s). PRODUCER Arthur J. Gallagher it Co. Insurance Brokers of CA, Inc. LIC #0726293 595 Market Street, Suite 2100 CONTACT PHONE a EMAIL ADDRESS '— San Francisco CA 94105 rNSURERSAFFORDING COVERAGE NAICA INsuRERA: NonProflts' United Ins Vehicle Pool INSURED Habitat for Humanity of Orange County (2100) 22DO Ritchey Street INSURERS: INSURER r. Santa Ana, CA 92705 INSURER D: INSURER E: INSURER F: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN ITO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILSR TYPEOFINSURANCE L U R PO CYNUMBER Pwoo EFF PLO�LIOEXPYYfh NITCOMMERCIAL GENERAL LIABILITYEACH WRHI OCCU3CLAIMS OE ❑ OCCUR DA PR IS SMEO EXP I.3PERSONAL S AGGREGATE UMR APPLIES PER: ❑JET GENERALAGGREGATE 3 GENL PRODUCTS -COMPIOP AGG 3 POLICY DLOC OTHER S A auT0M091LE1.I43ILITY Y NPU1000-27 711/2021 7tt/2G22 EBCIEeO SINGLE OMIT 32,OpQ,ODO X BODILY INJURY(P., P ) S OrEDOANYAUTO OWNED 9CHEDULEp BODILY INJURY (Par accident) 3 RED ONLY NON-"W HA AUTOS ONLY AUTOS ONLY Pof eERTY DAMAGE S S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXO[aS LWB CLAIMS -MADE AGGREGATE S DED RETENTION 3 WORNERSCOMPENSATON ER OTH- ANUEMPLOYERS•LIABILOY YIN STATUTEER E.L. EACH ACCIDENT 3 ANYPROPRIETORMARTNERIEXECUTNE OFFICERIMEMBEREICLUDE9 ❑ NIA Wp.. dtoryln iaxNH) E.L. DISEASE -EA EMPLOYE S E.L. DISEASE -POLICY LIMO S DESCRIPTION OF OPERATIONS below DEWRIPTON OF OPERATONS I LOCATIONS I VEHICLES (ACORO 101, Addiboeal Remarks ScbaeNla, maybe anachaa Umbra space is mnulmd) Any Auto means any covered auto under the NPU Vehicle Insurance Program. City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured on this policy pursuant to written contract, agreement, or memorandum of understanding. Such insurance as is afforded by this policy shall be primary, and any insurance carded by City shall be nonocrildbutory excess and The Producer will endeavor to mail 30 days written notice to the Certificate Holder named on the certificate if any policy listed on the certificate is Cancelled prior to the expiration date, Failure to do so shall Impose no Obligation or liability of any kind upon the Producer or otherwise alter the policy terms. �oncrrwrc u City Of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Rift Management Division 20 CIVIC Center Plaza Santa Ana CA 92702 AUTHORIZED REPRESENTATIVE ";aI VV -Ro • �M Divi ID @ 193e•2015 ACORD CORPO TIO . All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD V J 22021 :I IA NAM. LAMBERT. UNITED COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NonProCtts' United Vehicle Insurance Pool Automobile Liability Coverage ADDITIONAL COVERED PARTY ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. The "Who is an Insured" section of your Automobile Liability Insurance is changed by adding the following: Who is covered includes any person or organization from whom you have leased an auto, from which you have received funding for your operations, or for who you provide services. These persons or organization are protected, if they require to be named, and you agree to name them, as an additional insured, if indicated on the attached Certificate of Coverage, but only with respect to liability arising out of the ownership, use, maintenance, loading or unloading of a covered auto. Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named on the certificate, but failure to do so shall impose no obligation or liability of any kind upon the insurer, its agents or representatives. Premium Payments: Those persons or organizations are riot responsible for paying premiums for your coverage. Insured: Policy Number: Effective Date: Authorized Representative: NPU-VIP As shown on the Certificate of Insurance attached. NPU1000-21 July 1, 2021 to July 1, 2022 (or otherwise indicated) 2021-2022 & APPROVED IGEMENT DIVBION 2021 M. LAMBERT UNITED COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NonProfits' United Vehicle Insurance Pool Automobile Liability Coverage PRIMARY & NON-CONTRIBUTORY This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. The "Who is Covered" section of your Automobile Liability Insurance is changed by adding the following: Who is Covered section of the Memorandum of Coverage provided under this endorsement is Primary and insurance maintained by additional covered party is Non -Contributory. Coverage provided under this endorsement is limited to the Limits of Liability stated on the Memorandum of Coverage Declarations. Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named on the certificate, but failure to do so shall impose no obligation or liability of any kind upon the insurer, its agents or representatives. Premium Payments: Those persons or organizations are not responsible for paying premiums for your coverage. Insured: Policy Number: Effective Date: Authorized Representative: As shown on the Certificate of Insurance attached. NPU1000-21 July 1, 2021 to July 1, 2022 (or otherwise indicated) & APPROVED IGEMENT DIVISION NPU-VIP 2021-2022 1 14UI $of I 2021 M. LAMBERT CERTIFICATE OF WORKERS' COMPENSATION COVERAGE E 3an7 2021 PRODUCER NOnProlim' United Workers COmpenSUiDu Group THIS CERTIFICATE 15 ISSUED AS MATTER OF INFORMATION ONLY 610 Fulton Avenue, Suite 200 AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS SueramerRo, CA 95825 Phone: (916) 868-6231 CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE Fax: (916) 880-5251 COVERAGE AFFORDED BY THE POLICIES BELOW. Arthur J. Gallagher & CO Insurance Brokers oFC.I forma, hm 1255 Battery Street #450 San Francisco, CA 9411I I INSURERS AFFORDING COVERAGE INSURED INSURER A NonProfits' United Workers' Compensation Group Habitat for Humanity of Orange County 2200 Ritchey Street INSURER a Safety National Casualty Natil Clty Corp [NA1C#15105 1 Santa Ana, CA 92705 INSURER C: Response Indemnity Company of California [NAIC N 109701 INSURER 0: INSURER E COVERAGES This Certificate Is not intended to specify all endorsements coverages terms Conditions and exclusions of the pol'des shown THE POLICIES OF COVERAGE LISTED BELOW HAVE BEEN ISSUED TO THE AFFILIATE MEMBER 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 COVERAGE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS MISS LTR TYPEOFCOVERAOE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATIDN OATS LIMITS GENERAL UABLLITY EACHOCCURRENCE COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (My ane are) $ CLAIMS MADE OCCUR MED EXPENSE (Any one $ GENERAL AGGREGATE UNIT APPLIES PER: PERSONAL& ADVINJURY $ POLICY PROJECT I LOG GENERALAGGREGATE $ PRODUCTSCOMP/0P AGO $ AUTOMOBILE LIABILITY - COMBINEDSINGLELIMIT (Each umid.tj $ ALL OWNED AUTOS BODILY INJURY erson (Perperson) $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY S X I PERT U ETA IS T WORKERS' COMPENSATION E.L. EACH ACCIDENT $ 500,000 A AND NPO-WCGO0I-202I 1/1/2021 1/1/2022 EMPLOYERS LIABILITY E.L DISEASE -EA EMPLOYEE $500,000 DISEASE -COVERAGE LIMIT $ SOO,000 C I XSWC-BufferLayer ABL1000013-00 11112121 1/1/2022 IXS.f$500,000 $250,000(EL & WC) B XSWC SP4064079 ]/1/2021 1/1/2022 1 XS of$750,000 $2,000.000(EL) XS of $750,000 1 Statutory (WC) DESCRIPTION OF OPERATIONSJLOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAUPROVISIONS Waiver of Subrogation provided by Endorsement No. NPLTWCG-1-rHOC-05R City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Based on ACORD 25 (2016103) r 14 02 2021 M. LAMBERT NONPROFITS; UNITELi' THIS ENDORSEMENT CHANGES THE MEMORANDUM OF COVERAGE PLEASE READ IT CAREFULLY WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Nonprofits' United Workers' Compensation Group Memorandum of Coverage: NPU-WCG 001-2021 This endorsement modifies the coverage provided under the following: Memorandum of Coverage: PART ONE: WORKERS' COMPENSATION COVERAGE Paragraph H. RECOVERY FROM OTHERS is amended with respect to the following: Name and Address of Person or Organization: City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 91702 DESCRIPTION OF OPERATIONS/LOCATIONS ADDED RY ENDORSEMENT: - City of Santa Ana, its officers, officials, employees, and agents as regards contract with the named insured. NPU-WCG waives any right of recovery it may have against the person or organization shown above because of payments made by NPU-WCG for injury or damage arising out of the Members' operations done under a contract with that person or organization shown above and included in the coverage provided by the Memorandum of Coverage. This waiver applies only to the person or organization shown on the Schedule Above. This endorsement is part of the Memorandum of Coverage and is effective on the date shown below. All other terms and conditions remain unchanged. Effective Date: January 1 2021 Expiration Date January 1 �n�� Member: Habitat for Humanity of Orange County Endorsement No:_NPUWCG-HHOC-OSR Date Issued: Jan 7 2021 NPU-WCG Aut orizeo Representative far NPU-WCG Page 1 REVIEWED & APPROVED By RIB MANAGEMENT DIVISION M. LAMBERT