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HomeMy WebLinkAboutCAMBODIAN FAMILY, THE 2AAz AGREEMENT TERMINATION Please complete this form when the attached agreement is no longer in effect. Return form to the Sr. Deputy Clerk of the Council (M -30). Call 647 -5238 if you have any questions. The agreement with ` cct No f�`oZOO� was completed on A- LoQ3-IK cots Revised 8 -7 -03 Department: has been made. I 7eLc City of Santa Ana Clerk of the Council INSURANCE NI ON ME A- 2004 -063 WORK MAY WT_ PROCEED CLERK OF COUNCIL DATE: FIRST AMENDMENT TO AGREEMENT ��. THIS FIRST AMENDMENT TO AGREEMENT is entered into on April 5, 2004, by and between The Cambodian Family ( "Consultant ") and the City of Santa Ana ( "City "). Recitals: A. The parties entered into Agreement A- 2003 -165, dated July 21, 2003, (hereinafter "said Agreement ") by which Consultant has provided vocational /occupational training, employment strategies, education and supportive services to individuals residing in the Federal Empowerment Zone. B. In accordance with the terms and conditions of said Agreement, the parties wish to increase the compensation available to Consultant for additional marketing and outreach efforts provided by Consultant. Wherefore, in consideration of the covenants contained in said Agreement, and subject to all the terms and conditions of said Agreement, except those amended in this First Amendment to Agreement, the parties agree as follows: 1. Section 2.a., COMPENSATION, shall be amended to increase the compensation by $339.00, for a total amount not to exceed $80,339.00 during the term of said Agreement. IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to Agreement on the date and year first written above. ATTEST: PATRICIA E. HEALY Clerk of the Council APPROVED AS TO FORM: JOSEPH W.FLETCHER City Attorney CITY OF SANTA ANA z2x ,4.6L, DAVID N. REAM City Manager CONSULTANT RIFKIHIRSCH Executive Director - ACC D CERTIFICATE OF LIABILITY PRODUCER (714)838 -1912 FAX (714)838 -7568 =1M&WVDD1ffYMYYY) INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION CONFERS NO RIGHTS UPON THE CERTIFICATE Lake Insurance Agency 13891 Newport Ave., Suite 285 ONLY AND HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. POLICY NUMBER PHPK074625 DATE MMIDDIYY 03/09/2004 Li c #0747473 Tustin, CA 92780 INSURED Cambodian Family INSURERS AFFORDING COVERAGE INSURERA: Philadelphia Ind. Ins. Co. NAIC # — INSURER 8: $ 300,000 1111 East Wakeham Avenue INSURER C: X COMMERCIAL GENERAL LIABILITY D CLAIMS MADE a OCCUR Suite E INSURER O: Santa Ana, CA 92705 INSURER E: PERSONAL &ADVINJURY $ 1,000,000 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - LTR NSR TYPE OF INSURANCE GENERAL LIABILITY POLICY NUMBER PHPK074625 DATE MMIDDIYY 03/09/2004 DATE MMIDONY 03/09/2005 LIMITS EACH OCCURRENCE $ 1,000 000 PREMISES Ea occurence $ 300,000 X COMMERCIAL GENERAL LIABILITY D CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5,000 PERSONAL &ADVINJURY $ 1,000,000 A X 0 deductible GENERAL AGGREGATE $ 3,000,000 PRODUCTS- COMPlOPAGG $ included GEN'L AGGREGATE -LIMIT APPLIES PER: X POLICY PRO JECT LOG AUTOMOBILE LIABILITY ANY AUTO PHPK074625 03/09/2004 03/09/2005 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) S A HIRED AUTOS X X NON -OWNED AUTOS $0 Deductible PROPERTY DAMAGE (Per accident) $ X GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC AUTO ONLY: AGO $ ANY AUTO $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR ❑ CLAIMS MADE DEDUCTIBLE RETENTION V, WORKERS COMPENSATION AND ... - _ ... TORY LIMITS I ER E.L. EACH ACCIDENT $ EMPLOYERS' LIABILITY - ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? `" E.LOISEASE- EAEMPLOYE S E.L. DISEASE - POLICY LIMIT $ If yes tlescrioe under SPECIAL PROVISIONS below - A OTHER Abuse & Molestation PHPK074625 03/09/2004 03/09/2005 $1,000,000 Each Claim $3,000,000 Aggregate $0 Deductible DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Employee Dishonesty Liability $200,000 / 0 Ded. ertificate holder is named as additional insured per contract with named insured. Schedule of vehicles and drivers on file. '°10 day notice of cancellation due to non - payment of premium. CERTIFICATE HOLDER CANCELLATION ION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL PMX90(iYIXI MAIL *10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Santa Ana Work Center pIg�XXXxyyp�xq�q�( gQXlKgp67E 7VSQRA9[gGpXX�47(.XgpXIfXXX 1000 Santa Ana Blvd., Suite 200 x�E DP1�x7PilX7k�ERIXXR7�9(�tRXRR xXXXXXXX X Santa Ana, CA 92701 Au�HO ZE; REPRESENTATIVE 11 ACORD 25 (2001/08) v ©ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001108) MAY-013 -2004 09:24 THE CAMBODIAN FAMILY 714 571 1974 P.04 ADDITIONAL .INSURED ENDORSEMENT InsuranCA Company PHILADELPHIA INDEMNITY INSURANCE CO. T is ndor 6 5 rot es such e tInsurance as Is afforded by the provisions Of Policy H 1. The City Of Santa Ma, 20 CM0 Center Plaza, Santa Ana Callfomia 92701; b officers, employees, agents and representatives airs named as additional insureds Cadditional insuredsl with regard to flablilyy and defense of suits arlsing from the operations and t.tses performed by or an behalf of the named hstired. 2. With respect to claims arising out of the aperattons and uses performed by or on behalf of the named kstrred. such insuranoe as i5 afrorded by this parley is primary and is not additional to or contributing with any other insurance carried by or for Vie benefit of the additional irwAvds- 3. . •this rwxgumm apptles separately to eaph Insured against whom claim is, made or suit Is brought weept with rasped to the oampany's fiffft of 12bUity. The Inclusion of any parson or orgatttzadon as an insured shall not allied any right which such person or orgwindon would tam as a Balm m if not so kneaded. • 4. Watt respect to fhe addMonal insureds, this iris xw" sChalt not be cenW ed, or materWy reduced In covemm or limb except Mier thirty N days wribn notice has been given to the city of Santa Arta. 20 CMa Center Plea, Septa AM.Callomia 82701. (Completion of the folkrMng, including counter$Ignat6te, is required to make this endorsement -eftectivo ) Ef ,Mve 03 / 09/ 04 this endorsement form as a part of r Policy # PHPKQZ4625 Issued to • THE CAMBODIAN FAMILY Named Insured Countersigned by - EXHIMIT 0 . TOTAL P.04