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HomeMy WebLinkAboutTKO YOUTH FOUNDATION (2)INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES I. 1. 20Z3 CLERK OF COUNCIL A-2021-187-01 DATE: FIRST AMENDMENT TO FACILITY USE AGREEMENT WITH TKO YOUTH FOUND T FOR USE OF THE FITNESS ROOM AT JEROME COMMUNITY CENTER A ION DEC 2 12022 PHIS FIRST AYIENDMENT to the above -referenced agreement is entered into December 6.2022. by and hetsveen TKO Youth Foundation ("TKO"). and the City of Santa Ana, a chatter city and municipal corporation organized and existing under the Constitution and laws of the State ofCalifomia ("City"). City PACand 1 KO are also collectively referred to herein as the Parties." (sM)1 / RECITALS A- The Parties entered into Agreement No. A-2021-187 t"Agreement") dated September 21. 202I, to Want TKO the limited right to use the Fitness Room in the Cin"s Jerome Community Center to provide boxing classes. training, to hold periodic tournaments and for equipment storage. B. The Agreement is current and in -effect through September 21. 2023. C. The Parties now w ish to amend the Agreement to modify the consideration of the Agreement. The Parties therefore agree: I. Section 3, Consideration, is hereby amended to read as follows: City acknowledges the public benefit provided by TKO to the youth of the City of Santa Ana through its program and the fact that TKO is a non-profit corporation with 501(c)(3) status. Starting September 1, 2022, TKO will no longer pay to City a fee for use Of the Fitness Room for services and activities contemplated by this Agreement. 2. Except as modified by this First Amendment, all terms and conditions of the ,Agreement, shall remain in full force and effect. IN WIT\ESS WHEREOF, the Parties hereto have executed this First Amendment to the Agreement on the date and year first wrinen above. ATTEST Clerk of the Council o.•` APPROVED AS TO FORM 50\L\ R. CARV.ALHO City Attorney Brgnddn Salvatierra Deputy City Attorney CITY OF SANTA ANA KRISTINE RIDGE City Manager TKO YOUTH FOUNDATION M. Rava sidenl l'IRIIRrrlres 00tilifltled off nec! LYI,QCj Page I of 2 Page 2 of 2 "u"�^^-"• Villareal Illareal nets: 2022AL141615:57 USABOXI-01U M'66' DJONES '4k CERTIFICATE OF LIABILITY INSURANCE DATD/1'YVVI 11131213/2022 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 CONTACT The Buckner Company 6660 S Millrock, Suite #300 Salt Lake City, UT B4121 A/C, No, Ext: 8D1 937-6700 AQC, No: ( ) (801) 937.6710 E-MAIL , info@buckner.com INSURERS AFFORDING COVERAGE NAICp INSURERA: State National Insurance Company, Inc. 12831 INSURED INSURER B: INSURERC: USA Boxing, Inc. INSURER D: 1 Olympic Plaza Colorado Springs, CO 80909 INSUR ER E INSUR ER F COVERAGES CERTIFICATE NIIMRFR- RP"'IcAnNI NIUMPER• 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 TR TYPE OF INSURANCE ADDLSUBR INSD WVD POLICY NUMBER POLICY EFF POLICY EXP MMIDDNYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [X] OCCUR OVE0000013-00 1/1/2022 1/1/2023 EACH OCCURRENCE 2,000,000 DAMAGE TO RENTED PREMISES Ea occurs 1,000,000 $ MOD EXP An one arson $ Excluded PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. POLICY jECT I—xI LOC GENERAL AGGREGATE $ 5,000,000 PRODUCTS-COMP/OPAGG $ 1,000,000 PARTICIPANT LEG $ 1,000,000 OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY PerPerson) ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS EODILY INJURY Per accident $ PROPERTVDAMAGE Per accident $ H RED NON -OWNED A TOS ONLY AUTOS ONLY UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAe CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN AApNY PROPRIETOR/PARTNER/EXECUTIVE ❑ 1MantlEPIIry IM NHREXCLUDEDI It yes, describe under NIA I PER OTH- AT UTE ER E,L, EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below EL, DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) Coverage applies as respects the operations of USA Boxing and is contingent upon adherence With all rules and guidelines set forth by USA Boxing. Coverage applies to TKO Boxing Club and TKO Youth Foundation, The City of Santa Ana, its officers, officials, employees, and volunteers are Additional Insureds with respect to General Liability per endorsement CG-GL-CW-0133 (12120). Waiver of Subrogation applies with respect to General Liability per written contract per endorsement #CG-GL-CW-0001 (12120). Coverage is Primary and Non -Contributory with respect to General Liability per written contract per endorsement (pending issuance). CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, City of Santa Ana AUTHORIZED REPRESENTATIVE Risk Management Division Risk Divisicn ^Yp 20 Civic Center Plaza �% v REVIEWED&APPROV®Sr. Santa Ana C 92702 . .. ACORD 25 (2016103) ©1988-2015 ACORD C '�'— The ACORD name and logo are registered marks of ACORD 'Kux kranagemenr An, lysr ENDORSEMENT NO. ATTACHED TO AND ENDORSEMENT EFFECTIVE DATE FORMING A PART OF (12:01 A.M. STANDARD TIME) NAMED INSURED AGENT NO. POLICY NUMBER n/a OVR-0000013 1/1122 USA Boxing, Inc. dba USA Boxing THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSUREDS OWNERS AND/OR LESSORS OF PREMISES, SPONSORS OR CO -PROMOTERS This insurance modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART A. SECTION II —WHO IS AN INSURED is amended to include as an additional insured any per- son(s) or organization(s) of the types indicated by an "x" in any boxes shown below, but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" caused, in whole, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to an additional insured owner and/or lessor of premises, this insurance does not apply to: a. An "occurrence" or offense which takes place while you are not a tenant in possession of the subject premises. b. 'Bodily injury" or "property damage" arising out of: (1) Structural alterations, new construction or demolition operations performed by or on behalf of the owner and/or lessor of premises; (2) Any design defect or structural maintenance of the premises; or (3) Any premises defect. B. With respect to the insurance afforded to these additional insureds, the following is added to SECTION III —LIMITS OF INSURANCE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. .rc. 3F RAMan ,went D[v bn '4 REVIEWED&APPROVm BY: CG-GL-CW-0133 (12/20) Includes material copyrighted by ISO Properties, Inc., with its perrr F;k,r z W RiAmanagement Analyst It POLICY NUMBER: OVE0000013-00 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY BROADENED COVERAGE ENDORSEMENT This endorsement modifies coverage provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM A. Subparagraph 2.g.(2) of COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY (SECTION I — COVERAGES) is deleted and replaced with the following: (2) A watercraft you do not own that is: (a) Less than 51 feet long; and (b) Not being used to carry persons or property for a charge; B. Subparagraphs 21. and 2.c. of COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY (SECTION I — COVERAGES) are deleted and replaced with the following: b. 'Personal and Advertising Injury" arising out of publication of material, including, but not limited to, oral, written, televised, videotaped or electronically transmitted publication of material, it done by or at the direction of the insured with knowledge of its falsity; c. 'Personal and Advertising Injury" arising out of publication of material, including, but not limited to, oral, written, televised, videotaped or electronically transmitted publication of material, whose first publication took place before the beginning of the policy period; C. Subparagraphs 1.b. and 1.d. of SUPPLEMENTARY PAYMENTS — COVERAGES A AND B (SECTION I —COVERAGES) are deleted and replaced with the following: b. Up to $1,000 for the cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work. D. Subparagraph 3.a. of SECTION II -WHO IS AN INSURED is deleted and replaced with the following: a. Coverage under this provision is afforded only until the 120th day after you acquire or form the organization or the end of the policy period, whichever is earlier; E. Subparagraphs 2.e. and 2.f are added to SECTION IV— COMMERCIAL GENERAL LIABILITY CONDITIONS: e. Knowledge of the 'occurrence", offense, claim or "suit' by the agent, servant, or "employee" of an insured shall not in itself constitute your knowledge unless one of your officers, manager or partners has received notice of the 'occurrence", offense, claim or "suit'. M-1111 RA Mar V mentlPvi = REvIE+YIED & APPRov07 By: CG-GL-CW-0001 (12/20) Includes material copyrighted by ISO Properties, Inc., with its per � I A f " P, V Risk Management Analyst f. Failure by the agent, servant or "employee" of an insured (other than an officer, manager or partner) to notify us of an "occurrence" shall not constitute a failure to comply with subparagraphs 2.a. and 2.b, of this Section. F. Paragraphs 10. is added to SECTION IV— COMMERCIAL GENERAL LIABILITY CONDITIONS as follows: 10. Waiver of Right of Recovery We waive all rights of recovery when you have agreed to waive your rights of recovery when required by a written contract. However, this provision only applies if the written contract was executed prior to the date of the "occurrence". G. Paragraphs 3. and 14. of SECTION V — DEFINITIONS are deleted in their entirety and replaced with the following: 3. "Bodily Injury" mean bodily injury, sickness or disease sustained by a person. This includes mental anguish, mental injury, shock, fright, humiliation, emotional distress or death resulting from bodily injury, sickness or disease. 14. "Personal and advertising injury" means injury, including consequential "bodily injury", arising out of one or more of the following offenses: a. False arrest, detention or imprisonment; b. Malicious prosecution or abuse of process; c. The wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room, dwelling or premises that a person occupies, committed by on or on behalf of its owner, landlord or lessor; d. Any publication of material including, but not limited to oral, written, televised, videotaped or electronically transmitted publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services;; e. The use of another's advertising idea in your "advertisement"; or f. Infringing upon another's copyright, trade dress or slogan in your "advertisement". H. The word fire is replaced with the phrase fire or explosion where it appears in: a. Subparagraph 2.j. of COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY (SECTION I — COVERAGES); b. Paragraph 2. of COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY (SECTION I —COVERAGES); c. Paragraph 6. of SECTION III - LIMITS OF INSURANCE; d. Subparagraph 4.b.(1) of SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS I. I. The following is added to SECTION III — LIMITS OF INSURANCE: The Limit of Insurance applicable to Damage to Premises Rented to You is $300.000 unless a higher limit is specified on the Declarations. All other terms, conditions and exclusions remain unchanged. Rlak MmtsgwtentDiv! m r , 1 @REmEWED & AP1PeR,)vm By:: 8 I!'"1A.AMr�MC M'KGIktiBdcC CG-GL-CW-0001 (12/20) Includes material copyrighted by ISO Properties, Inc., with its perrr "�----�'� Xnkmanagement Analyst POLICY NUMBER: OVE0000013-00 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - WHERE REQUIRED UNDER WRITTEN CONTRACT OR WRITTEN AGREEMENT (PRIMARY AND NON-CONTRIBUTORY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS / COMPLETED OPERATIONS COVERAGE PART SECTION II — WHO IS AN INSURED is amended to include any person or organization to whom you become obligated to include as an additional insured under this policy, as a result of any written contract or written agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy, but only with respect to liability arising out of your operations or premises owned by or rented to you. However, the insurance provided will not exceed the lesser of: a. The coverage and/or limits of this policy; or b. The coverage and/or limits required by said contract or agreement. Coverage afforded to these additional insured parties will be primary to, and non-contributory with, any other insurance available to that person or organization. CG-GL-CW-0058 (12/20) Includes material copyrighted by ISO Properties, Inc. Aa,$e RA MVWgm nt DhblOR �% i �% RE ie i) & APPRova] Br. 87 "'`� n k",' " with its par Risk Management Analyst C7TYGFSAN'rAAnA PUSH NMANAGWENT a &� es HUMANRESOURCES Affidavit of Exemption for Workers' Compensation Insurance John M. Raya, rtaunder/president hereby affirm under penalty of perjury, the (Nnmer7Cie) following declaration: I certify on behalf of TKO Youth Foundation i''°TKo'ri _ that during the term jConsulcant/Cprnpnny NarmeJ of my contract, for afterachool youth program services with the City of Santa Ana, (Type of serZe prowded) 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.e Print Narne:....a}C.Hr9 _r`i A PrintTitde: M700 �R. J- Tele ha�ne.- f�.• �' a 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, r.a,Rlsk Mgmt\lmuranee Requirements\ Affidavit o4 Ewemption For Workers' compensation Insurance 2021. AfekMav�mrnfDh7dor� „� g(�vIEWEo&ArHm�pV{mBY): I"�LN�bs1.8 :F.' �nAfMML = Rislc Mana9wnentAmlyS[ NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor USA Boxing Inc Sponsor Club TKO Boxing Club Name: Project A-2021-187-01 Number: First Amendment To Facility Use Agreement With TKO Youth Project Foundation For Use Of The Fitness Room At Jerome Name: Community Center The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: POLICY EXPIRATION TYPE OF INSURANCE COI DATE FILE NAME NUMBER DATE GENERAL LIABILITY OVE000001301 01/01/2024 12/28/2022 Certificate.pdf WORKERS COMPENSATION AND WAIVER 10/26/2023 10/27/2022 Scan_0003.pdf EMPLOYERS' LIABILITY Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 1/5/2023 11:12 AM