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HomeMy WebLinkAboutARDENT ERGONOMICS (MELGOZA, JORGE)INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES 4 1512.0 CITY CLE h 0 7 2025 DATE: MA N-2025-049 a ; H1G C0 AGREEMENT WITH JORGE MELGOZA, DBA ARDENT ERGONOMICS, TO PROVIDE PREVENTATIVE ERGONOMICS ASSESSMENTS THIS AGREEMENT is made and entered into this I8th day of February, 2025 by and between Jorge Melgoza, an individual doing business as Ardent Ergonomics ("Consultant"), 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"). City and Consultant may be collectively referred to as the "Parties" or individually as a "Party." RECITALS A. The City desires to retain a consultant having special skill and knowledge in the field of preventative ergonomic assessments. B. Consultant represents that it is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its 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 in the same 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 shall perform those services relating to preventative ergonomic assessments including but not limited to those services set forth in Exhibit A, attached hereto and incorporated herein by reference. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit A. The total sum to be expended under this Agreement shall not exceed fifty thousand dollars and zero cents ($50,000) during the term of this Agreement. b. Payment by City shall be made within forty-five (45) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. City and Consultant agree that all payments due and owing under this Agreement shall be made through Automated Clearing House (ACH) transfers. Consultant agrees to execute the City's standard ACH Vendor Payment Authorization and provide required documentation. Upon verification of the data provided, the City will be authorized to deposit payments directly into Consultant's account(s) with financial institutions. Payment need not be made for work which fails to meet the Page 1 of 8 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 continue for a two (2) year term until February 18, 2027, unless terminated earlier pursuant to Section 14, below. 4. INDEPENDENT CONSULTANT During the entire term of this Agreement, Consultant shall 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, ajoint 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 its employees and shall be responsible for all applicable withholding taxes. 5. OWNERSHIP OF MATERIALS This Agreement creates a non-exclusive and perpetual license for City to copy, use, modify, reuse, or sublicense any and all copyrights, designs, and other intellectual property embodied in plans, specifications, studies, drawings, estimates, and other documents or works of authorship fixed in any tangible medium of expression, including but not limited to, physical drawings or data magnetically or otherwise recorded on computer diskettes, which are prepared or caused to be prepared by Consultant under this Agreement ("Documents & Data"). Consultant shall require all subcontractors to agree in writing that City is granted a non-exclusive and perpetual license for any Documents & Data the subcontractor prepares under this Agreement. Consultant represents and warrants that Consultant has the legal right to license any and all Documents & Data. Consultant makes no such representation and warranty in regard to Documents & Data that were provided to Consultant by the City. City shall not be limited in any way in its use of the Documents and Data at any time, provided that any such use not within the purposes intended by this Agreement shall be at City's sole risk. 6. 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. Minimum Scope and Limit of Insurance Commercial General Liability (CGL): Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis, including products and completed operations, property damage, bodily injury and personal & advertising injury with limits no less than $1,000,000 per occurrence. If a general aggregate limit applies, Page 2 of 8 either the general aggregate limit shall apply separately to this project/location (ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit. 2. Automobile Liability: ISO Form Number CA 00 01 covering any auto (Code 1), or if Consultant 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. 3. 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. If the Consultant 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 Consultant. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the Cit b. Other Insurance Provisions 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 Consultant including materials, parts, or equipment furnished in eonnectionwith such work or operations. General liability coverage can be provided in the form of an endorsement to the Consultant'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 Consultant'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,offieials, employees, or volunteers shall be excess of the Consultant'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: Consultant hereby grants to City a waiver of any right to subrogation that any insurer of said Consultant may acquire against the City by virtue of the payment of any loss under such insurance. Consultant agrees to obtain any endorsement that may be necessary to affect this waiverof subrogation, but this Page 3 of 8 provision applies regardless of whether or not the City has received a waiver of subrogation endorsement from the insurer. Self -Insured Retentions: Self -insured retentions must be declared to and approved by the City. The City may require the Consultant 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. Verification of Coverage: Consultant 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 Consultant'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: Consultant shall require and verify that all subcontractors maintain insurance meeting all the requirements stated herein, and Consultant 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 the risk, prior experience, insurer, coverage, or other special circumstances. INDEMNIFICATION Consultant agrees to and shall indemnify, defend, and hold harmless the City, its officers, agents, employees, consultants, counsel, and representatives from liability for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims: (1) for personal injury, including death, and claims for property damage, arising from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on its 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 Page 4 of 8 relief is due by reason of 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. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for counsel to be selected by the City, regarding any action by a third party asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terns of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. E'er ti DLof17 7131 Consultant shall keep records and invoices in connection with the work to be performed under this Agreement. Consultant shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to Consultant under this Agreement. All such records and invoices shall be clearly identifiable. Consultant shall allow a representative of the City to examine, audit, and make transcripts or copies of such records and any other documents created pursuant to this Agreement during regular business hours. Consultant shall allow inspection of all work, data, documents, proceedings, and activities related to this Agreement for a period of three (3) years from the date of final payment to Consultant under this Agreement. 9. CONFIDENTIALITY If Consultant received 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 no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant and disclosed 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. 10. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interest and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. Page 5 of 8 11. 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 facsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: City Clerk City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, California 92702-1988 Facsimile (714) 647-6956 Copies to: Executive Director of Human Resources City of Santa Ana 20 Civic Center Plaza (M-24) P.O. Box 1988 Santa Ana, California 92702 Facsimile (714) 647-5311 To Consultant: Ardent Ergonomics Attn: Jorge Melgoza 6867 Golferest Drive, Ste. 51 San Diego, CA 92119 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 facsimile, 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. 12. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant regarding the subject matter herein, 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 and will serve to fully supersede existing Agreement. 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 or conditions hereof, shall not bind or obligate Consultant nor the City. Each Party to Page 6 of 8 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 are not embodied herein. 13. 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. 14. TERMINATION This Agreement may be terminated by the City with thirty (30) days written notice of termination to the Consultant. 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 Executive Director may require Consultant to deliver to the City all work product(s) 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. 15. 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. 16. 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. The 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. Page 7 of 8 17. PROFESSIONAL LICENSES Throughout the term of this Agreement, Consultant shall 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 Sates, 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. 18. WAIVER No waiver of breach, failure of any condition, or any right or remedy contained in or granted by the provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the breach, failure, right or remedy. No waiver of any breach, failure or right, or remedy shall be deemed a waiver of any other breach, failure, right or remedy, whether or not similar, nor shall any waiver constitute a continuing waiver unless the writing so specifies. IN WITNESS WHEREOF, the Parties hereto have executed this Agreement the date and year fist above written. APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney 'BYa—ndon Salvatierra Deputy City Attorney RECOMMENDED FOR APPROVAL: 6�24 - Lori Schnaider Executive Director Human Resources Agency CITYl�FrIA ANA Alvaro Nuiiez City Manager CONSULTANT Jorge Wbza wrier Page 8 of 8 EXHIBIT A ARDENT ERGONOMICS 6867 Golfcrest Drive, Ste. 51 San Diego, CA 92119 760-390-5553 November 8, 2021 To: Samantha M. Lambert, Risk Management Supervisor City of Santa Ana I Human Resources Department I Risk Management Division Ardent Ergonomics appreciates the opportunity of providing the following quote to the City of Santa Ana for completion of preventative ergonomics assessments. Scope of Services Ardent Ergonomics understands the scope of services and can comply with all components. We will: ❑ Systematically assess each current Job Description. ❑ Determine risk factors and make written recommendations to reduce these risk factors by conducting and providing. ❑On -site assessments and modifications ❑Employee education []Ergonomic equipment recommendations ❑Equipment Set Up/Training Approach to Project Ardent Ergonomics will: ❑ Coordinate a time to meet with the City of Santa Ana HR/RM personnel Dept Manager/ Supervisor and employees ❑ Observe and each employee performing his or her job, take measurements of workstation including furniture and equipment used to perform job, provide written documentation of each assessment with adjustments and equipment recommendations. ❑ Discuss adjustments and equipment recommendations with HR/RM personnel Dept Manager/ Supervisor. ❑ Identify and discuss alternate and or modified job duties when possible. Fee rate is $110.00 hr. Professional time, $70.00 hr. Travel time and mileage is at current IRS rate. Comments: The above recommendations do not consider potential delays caused by business interruptions during the completion of assessments. Submitted by: W,; : Jorge Melgoza, CEAS, REAS Bilingual -Fluent Spanish Certified Ergonomic Assessment Specialist 760-390-5553 ®�� CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 12/04/2024 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 endorsement(s). PRODUCER CONTACT LAZARO NETO NAME: Statefarm LAZARO NEfO (619)-229-6799 plc No: (619)-229-6796 ift 3924 EL CAJON BLVD. gk:d�,—.,T,.ro.neto.m36f@statefarm.com aooesss: lazaro.neto.m36f@statefarm.com INSURERS AFFORDING COVERAGE NAIC N INSURERA: State Farm General Insurance Company 25151 SAN DIEGO CA 92105 INSURED INSURER e : State Farm Mutual Automobile Insurance Company 25178 MELGOZA, JORGE B INSURER C : 6867 GOLFCREST DR APT 51 INSURER D INSURER E: SAN DIEGO CA 92119 INSURER 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. ILT R. TYPE OF INSURANCE ADDLSUBR Man "D POLICYNUMBER POLICYEFF MM/DDIYYYY PODCYEXP MM/DD/YYYY LIMITS COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurzence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 A Y Y 90-E3-K874-5 10/15/2024 10/16/2025 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY D PRO- ❑ LOG JECT GENERALAGGREGATE $ 2.000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY 583 7885-Dl5-55 10/15/2024 04/15/2025 COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Par person) $ 1,000,000 ANY AUTO BODILY INJURY Per accident) ( ) $ 1,000,000 A OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per acoidem $ 1,000,000 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DEO RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED' NIA STATUTE ER E.L. EACH ACCIDENT $ $ (Mandatory in NH) If yes, describe under E.L. DISEASE - EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City, its officers, officials, employees, and volunteers are to be covered as additional insureds and waiver of subrogation on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Consultant including materials, parts, or equipment furnished in connection with such work or operations oisaalq:�9,,.a Tu Tran 9 . �n APPROVED Nguyen emy By Tu Tran Nguyen at 9:12am, Feb 26, 2025 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SANTA ANA ACCORDANCE WITH THE POLICY PROVISIONS. 20 CIVIC CENTER PLAZA AUTHORIZED REPRESENTATIVE SANTA ANA, CA 92702 4"a&9 Xl/P OE) 1988-2015 ACORD CORPORATION. All rinh$s resarvud ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2015 Policy No. 90 E3K874 0332-FAC7 CMP-4786.1 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CMP-4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 90 E3x874 Named Insured: MELGOZA, JORGE B 6867 GOLFCREST DR APT 51 SAN DIEGO CA 92119 2444 Name And Address Of Additional Insured Person Or Organization: CITY OF SANTA ANA ITS OFFICERS OFFICIALS EMPLOYEES & VOLUNTEERS 20 CIVIC CENTER PLZ SANTA ANA CA 92.701 4058 SECTION II — WHO IS AN INSURED of SECTION II — LIABILITY is amended to in- clude, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for "bodily injury", "property damage", or "personal and advertis- ing injury" caused, in whole or in part, by: a. Ongoing Operations (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing opera- tions for that additional insured; or b. Products — Completed Operations "Your work" performed for that additional insured and included in the "products - completed operations hazard". However, Paragraph 1. above is subject to the following: a. The insurance afforded to the additional insured only applies to the extent permit- ted by law; b. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance provided to the additional insured will not be broader than that which you are required by the contract or agreement to provide for such addition- al insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. We have no duty to defend or indemnify the additional insured under this endorsement un- til a claim or "suit' is tendered to us. O, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTINUED 2. Any insurance provided to the additional in- sured shall only apply with respect to a claim made or a "suit' brought for damages for which you are provided coverage. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION If — LIMITS OF INSURANCE: If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of 5• Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an "occurrence" or an of- fense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the "occur- rence" or offense took place; CMP-4786.1 Page 2 of 2 (3) The nature and location of any injury or damage arising out of the "occur- rence" or offense; b. Tender the defense and indemnity of any claim or "suit' to us and to all other insur- ers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II — LIABILITY. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II —LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insurance available to the additional insured, provided that the additional insured is a named in- sured under such other insurance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. There will be no refund of premium in the event this endorsement is cancelled. (2) The names and addresses of any in- jured persons and witnesses; and All other policy provisions apply. CMP-4786.1 1007033 148011 08-21-2014 O, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with Its permission. Policy No. 90 E3K874 5 0332-FAC7 CMP-4787 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 90 E3K874 5 Named Insured: MELGOZA, JORGE B 6867 GOLFCREST DR APT 51 SAN DIEGO CA 92119 2444 Name And Address Of Person Or Organization: CITY OF SANTA ANA ITS OFFICERS OFFICIALS EMPLOYEES & VOLUNTEERS 20 CIVIC CENTER PLZ SANTA ANA CA 92701 4058 The following is added to Paragraph 10.1b. of SECTION I AND SECTION 11 — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMP-4787 1006225 137715.1 11-19-2013 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2008 Includes copyrighted material of Insurance Services Office, Inc., with its permission. State Form e Providing Insurance and Financial Services PO Box 2366 Bloomington IL 61702.2368 StateFarm • •• Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted by a law enforcement agency or your Department of Motor Vehicle office, please contactyour agent to receive additional assistance. The nk you for choosing State Farm for your insurance needs. IMPORTANT - IDENTIFICATION CARDS STATE FARM StateFarm CALIFORNIA StateFarm THIS CARD MUST BE KEPT IN THE INSURED MOTOR • �, INSURANCE CARD � VEHICLE FOR PRODUCTION UPON DEMAND. NUMBER 5887885-015.55A I_ MAKE HONDA _. HUU1 Company 30ZA, MUTL VOL EFFECTIVE OT 15 2024 TO APR 15 2025 P2F82CA082866 INC 2CCl-886 5178 THE MINIMUM LIABILITY LIMITS IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Get names, addresses, and phone numbers of persons involved and witnesses. Also get driver license numbers of persona involved and license plate numbers/states of vehicles. 2. Don't admit fault or discuss the accident wrath anyone but Stets Farm or police. 3. Prompt] notify your agent, log an to statetarmooma, or use the State Farm mobile Spin to files olelm. Far EMERGENCY ROAD SERVICE use the State Farm nmbile app,log on Is stetefarmcom or cell 14877AR7.5757. EXAM/NE POLICY EXCLUSIONS CAREFULLY. THIS FORMM' DOES NOT CONSTITUTE ANY PART OF YOURINSURANCE POLICY. How to identity your coverage. See policy for full name and definition A debility H Emergency Roed Service U Uninsured Motor Vehicle C Medical Poynter. L Physical Damage Ul Uninsured Motor Vehicle PO D Comprehensive In Car Rental endTrevel Expenses Z Loss of Earnings D Collision S Death, Dismemberment end KEEP A CARD IN YOUR CAR, THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES, THE FORM MAYBE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD, OR A PHOTOCOPY OF A CARD. WITH YOUR VEHICLE REGISTRATION RENEWAL. Emergency Road Service Information Is located an your insurance card. IMPORTANT - IDENTIFICATION CARDS STATE FARM StateFarm CALIFORNIA StateFarm THI • 3 INSURANCE CARD . s S CARD MUST BE KEPT IN THE INSURED MOTOR W VEHICLE FOR PRODUCTION UPON DEMAND. Automobile Insurance Company NUMBER 5687885-D15.55A 2 MAKE HONDA THE Ih HUM MUTL VOL EFFECTIVE 24 TO APR 152025 4082366 2CC1-B86 MUM LIABILITY LIMITS IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Got names, addresses, and phone numbers of persona involved and witnesses. Also get driver license numbers of persona involved and license plate numberltates of vehicle.. 2. Don't admit fault or discuss the accident with anyone but State Farm or police. 3. Promptly rich your agent, lop on to stetefarmoom®, or use the State Farm mobile sop to file a c elm. For EMERGENCY ROAD SERVICE use the Stale Farm mobile app. log on to stetefarmcom or cell 1-87PS17S757. EXAMINE POLICY EXCLUSIONS CAREFULLY. THIS FORM DOES NOT CONSTITUTE ANY PART OF YOUR INSURANCE POLICY. How to Identify your coverage. See policy for full name and definition A babilay H Emergency Roed Service U Uninsured Motor Vehicle C Medical Nymems L Physical Damage UI Uninsured Motor Vehicle PD U Comprehensive al Car Rental and Travel Expenses Z Lass of Farrion, G Collision S DemkOismemberment and KEEP A CARD IN YOUR CAR, THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED, KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES, THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD. OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL ._.__ __-`- ._ ----- . -- -.__ :_.."'__ _. nur_ A ones State Farm Mutual Automobile Insurance Company PO Box 2368 Bloomington it 61702-2368 j&StateFarm' AT2 A-2CC1 A MELGOZA, JORGE B & MELGOZA, ANNA 6867 GOLFCREST DR APT 51 SAN DIEGO CA 92119-2444 Policy Number: 583 7885-D15-55A Policy Period: October 15, 2024 to April 15, 2025 Vehicle: 2012 HONDA ACCORD Principal Driver: JORGE B MELGOZA Notice of insurance information collection practices - personal, family, or household insurance transactions: We may collect customer information from persons other than the individual or individuals applying for coverage. Such customer information as well as other personal or privileged information subsequently collected may, in certain circumstances, be disclosed to third patties without your authorization as permitted by law. Policy Number: 583 7885-D15-55A Prepared August 23, 2024 1004583 AUTO RENEWAL PREMIUM PAID: $838.94 DO NOT PAY. Your premium is billed through the State Farm Payment Plan State Farm Payment Plan Number:1235506212 Your State Farm Agent LAZARO INSURANCE AGENCY INC Office:619-229-6799 Address: 3924 EL CAJON BLVD SAN DIEGO, CA 92105-1023 If you have a newordilierent car, have added anydrivers, orhave moved, please contact)our agent. Thank you for choosing State Farm. You have the right to submit a written request to access, correct, amend, or delete your personal information and the right to receive a response within 30 days of submitting your request. If we deny your request, you have the right to file a statement with us containing the information you feel is accurate and fair along with the reasons you disagree with our denial. Instructions on how to file such request and our full privacy notice can be found (continued on next page) Page number 1 of 5 143562 202 01-15-2018 Thanks for being part of our neighborhood. You mean a lot to us. If you need anything, call State Farm° Agent LAZARO INSURANCE AGENCY INC at 619-229-6799. TP31 AStateFarm www.statefarm.com/customer-care/privacy-security/privacy or contact your State Farm Agent. Your auto insurance rates are impacted by the mileage your vehicle is driven. To ensure we've priced our insurance coverage accurately based on the number of miles you drive, we obtained valid mileage information for this vehicle through a third party provider and/or from you. Annual mileage was determined using this data and applied. Please contact your State Farm agent with questions within 30 days of your policy's renewal date. When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will not receive your check back from your financial institution. VEHICLE INFORMATION Review your policy information carefully. If anything is incorrect, or if there are any changes to your vehicle information, please let us know right away. Vehicle Identification Vehicle Description Number (VIN) Who principally drives this vehicle? How is this vehicle normally used? 2012 HONDA ACCORD 1 HGCP2F32CA082366 JORGE MELGOZA, a married individual, Business. who will have 47 years of driving experience as of October 15, 2024. Other Household Vehicle(s) Your premium may be influenced by other State Farm policies that currently insure the following vehicle(s) in your household: 2020 JEEP GR CHEROKE The premium on the expiring policy term was based on 12,800 miles per year. The premium on the renewal policy term was based on 17,600 miles per year. Premium Adjustment Each year, we review our medical payments and personal injury protection coverages claim experience to determine the vehicle safety discount that is applied to each make and DRIVER INFORMATION Assigned Driver(s) The following driver(s) are assigned to the vehicle(s) on this policy. model. In addition, we review the comprehensive, collision, bodily injury and property damage claim experience annually to determine which makes and models have earned decreases or increases from State Farm's standard rates. If any changes result from our reviews, adjustments are reflected in the rates shown on this renewal notice. Driving Experience as of Marital Name October 15, 2024 Status JORGE B MELGOZA 47 years Married Policy Number: 583 7885-D15-55A Page number 2 of 5 Prepared August 23. 2024 StateFarm, Other Household Driver(s) In addition to the Principal Driver(s) and Assigned Driver(s), your premium may be influenced by the drivers shown below and other individuals permitted to drive your vehicle. This list does not extend or expand coverage beyond that contained in this automobile policy. The drivers listed below are the drivers reported to us that most frequently drive other vehicles in your household. ANNA MELGOZA Principal Driver & Assigned Drivers premium may be influenced by the information shown for For each automobile, the Principal Driver is the individual these drivers. who most frequently drives it. Each driver is designated as an Assigned Driver on the household automobile that they most frequently drive. Your COVERAGE AND LIMITS see yourpolicy for an explanation of these coverages Bodily Injury 1,000,000/1,000,000 Property Damage 1,000,000 $465.71 D 500 Deductible Comprehensive $38.64 G 500 Deductible Collision $163.86 H Emergency Road Service $4.74 U Uninsured Motor Vehicle Bodily Injury 500,000/1,000,000 $160.94 U1 Uninsured Motor Vehicle Property Damage $5.05 Total Premium $838.94 If any coverage you carry is changed to give broader protection with no additional premium charge, we will give DISCOUNTS These adjustments have already been applied to your premium. you the broader protection without issuing a new policy, starting on the date we adopt the broader protection. Multiple Line ✓ Multicar ✓ Driving Safety Record ✓ California Good Driver ✓ Loyalty ✓ Total Discounts $2,175.25 Policy Number: 583 7885-D15-55A Page number 3 of 5 Prepared August 23, 2024 State Farm Other Available Discount(s) You may be eligible for additional discounts See the enclosed insert for more information. Mature Driver SURCHARGES AND DISCOUNTS Driving Safety Record Rating Plan Your driving safety record, along with other rating factors, determines what you pay for Liability, Medical Payments, Comprehensive, Collision, and Uninsured Motor Vehicle Coverages. Policyholders with no accidents and convictions pay less than those with accidents and convictions. The Driving Safety Record Rate Level that is assigned to your policy moves up, down, or stays the same every policy renewal, depending upon your driving record. For every 12 months since the renewal following the occurrence of a chargeable accident or the conviction of a minor violation, the initial assigned Driver Record Level for that chargeable accident or conviction shall be lowered by 1 level. For each 12 month period since the conviction of a major violation, the initial assigned Driver Record Level for that conviction shall be lowered by 2 levels. The Rate Level is increased if there are subsequent chargeable accidents or convictions. Definition of Chargeable Accidents Chargeable accidents for new business are those which resulted in bodily injury or death or in payment(s) by an insurer due to damage to any property in the amount of ADDITIONAL INFORMATION IMPORTANT NOTICE For your protection California law requires the following to appear with this policy: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. more than $1000. For accidents occurring prior to December 11, 2011, an accident shall be chargeable provided it resulted in death or in payment(s) by an insurer due to damage to any property in the amount of more than $750. For applicants without prior insurance at the time of the accident, an accident shall be chargeable provided it resulted in damage to any property in the amount of more than $1000 (more than $750 if the accident occurred prior to December 11, 2011). Chargeable accidents for renewal business are those which resulted in bodily injury or death or State Farm claim payments totaling more than $1000 (more than $750 for accidents occurring prior to December 11, 2011) under property damage liability coverage and collision coverage combined. For more information about the rating plan, please contact your State Farm agent. Superior Driver Rate Level If any information on this renewal notice is incomplete or inaccurate, or if you want to confirm the information we have in our records, please contact your agent. For additional information regarding discounts or coverages, see your State Farm agent or visit statefarm.com®. Important Notice Regarding Your Premium State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile insurance is determined by many factors including: • The coverage you have • Where you live • The kind of car you drive • How the car is used • Who drives the car Any premium adjustment is reflected on this Auto Renewal. If you have any questions, please contact your agent. (continued on next page) Policy Number: 583 7885-D15-55A Page number 4 of 5 Prepared August 23, 2024 .• StateFarm' Buying a new car? Remember to contact your agent! When you buy an additional car or one that replaces a car already on your policy, you need to report the change to your agent promptly. Even though the dealership you purchased the car from may offer to notify your agent or insurance company, you, as the named insured, are responsible for reporting all changes to your auto policy. By contacting your agent, you can help: • avoid any complications or lack of coverage in the event of an accident or loss, • avoid insurance verification problems with a lienholder, the police, or the department of motor vehicles, and • ensure that you receive any new discounts you may be entitled to. Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited number of days after you take possession of the car. Please refer to your policy for the number of days that applies in your state. If you have any questions about coverage for a newly acquired car, please contact your State Farm agent. Disclaimer: This message is provided for informational purposes only and does not grant any insurance coverage. The terms and conditions of coverage are set forth in your State Farm Car Policy booklet, the most recently issued Declarations Page, and any applicable endorsements. Policy Number: 583 7885-Di5-55A Page number 5 of 5 Prepared August 23, 2024 CITY OF SANTA ANA Risk Management a division of Human Resources Managing Risk through Awareness and Action AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE I Jorge S. Melgoza-President ("Representative"), attest that I am an authorized (Name and Title or Vendor Representative) representative of Ardent Ergonomics ("Company"),and (Consultant/Company Name) possess the authority to legally bind Company. In my capacity as Representative of Company, I represent and confirm the following, as relates to the agreement between Company and City of Santa Ana, agreement number N2022-027 ("Agreement") to provide Preventative Ergonomic Evaluations ("Services"): (Services to be provided under agreement/contract) During the course and scope of Company's agreement with the City of Santa Ana, Company will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if Company should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, Company shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately, If at any time it is found that Company is not adhering to any and/or all of the statements in this document and does not maintain the minimum professional liability insurance coverage as required in the Agreement, it will be considered a breach of Agreement rendering the Agreement mill and void and Company will be fully liable for any and all damages. a-3 jj,L",___,._.- 02-19-2025 Dam .Jorae B. Presedent 760-390-5553 Contact Information, to-, Telephone Number and/or Email Address WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SMALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANT 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. Affldavlt of Exemption for Workers' Compensation Insurance 11.12.2024 "51faterarm IM)State Farm Mutual Automobile Insurance Company .. . " PO Box 2368 Bloomington IL 61702-2368 NAMED INSURED 00711 55-2CC1-3 A E 000712 0058 MELGOZA, JORGE B & MELGOZA, ANNA 6867 GOLFCREST DR APT 51 SAN DIEGO CA 92119-2444 DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. IF AN AMOUNT IS DUE. THEN A SEPARATE STATEMENT IS ENCLOSED. 38798-3-A MATCH 00711 MUTL VOL DECLARATIONS PAGE PAGE 1 OF 2 POLICY NUMBER 583 7885-D15-55B POLICY PERIOD FEB 24 2025 to OCT 15 2025 12:01 A.M. Standard Time STATE FARM PAYMENT PLAN NUMBER 1235506212 AGENT LAZARO INSURANCE AGENCY INC 3924 EL CAJON BLVD SAN DIEGO, CA 92105-1023 PHONE: (619)229-6799 YOUR CAR YEAR MAKE MODEL BODY STYLE VEHICLE ID. NUMBER CLASS 2012 HONDA ACCORD 4DR 1 HGCP2F32CA082366 6030BV19 A Liability Coverage $68& 88 Bodily Injury Limits Each Person, Each Accident $1,000,000 $1,000,000 Property Damage Limit Each Accident $1,000,000 D Comprehensive Coverage - $500 Deductible $51.19 G Collision Coverage - $500 Deductible $ 2 .79 H Emergency Road Service Coverage $6.70 U Uninsured Motor Vehicle Coverage $259.21 Bodily Injury Limits Each Person, Each Accident $500,000 $1,000,000 U1 Uninsured Motor Vehicle Property Damage Coverage $& 13 IMPORTANT NOTICE For your protection California law requires the following to appear with this policy: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Replaced policy number 5837885-55A. Notice of insurance information collection practices - personal, family, or household insurance transactions: We may collect customer information from persons other than the Individual or individuals applying for coverage. Such customer information as well as other personal or privilegedInformation subsequently collected may, In certain circumstances, be disclosed to third parties without your authorization as permitted by law. You have the right to submit a written request to access, correct, amend, or delete your personal information and the right to receive a response within 30 days of submitting your request. If we deny your request, you have the right to file a statement with us containing the information you feel is accurate and fair along with the reasons you disagree with our denial. Instructions on how to file such request and our full privacy notice can be found www.statefarm.com/customer-care/privacy-security/privacy or contact your State Farm Agent. Your total renewal premium for APR 15 2025 to OCT 15 2025 is $1,003.48. APPROVED By Tar Tram Nguyen at : a a pm, Mar 12, 202 Digitally signed Tu Tran by Tu Tran Nguyen Nguyen i155559-0700? 161610111►1I1A. 12960/08381 See Reverse Side 155-3666 CA.2 05-2002 (ola025fc) 11SXON (ola025te) This policy is issued by State Farm Mutual Automobile Insurance Company. MUTUAL CONDITIONS 1. Membership. While this policy is in force, the first insured shown on the Declarations Page is entitled to vote at all meetings of members and to receive dividends the Board of Directors in its discretion may declare in accordance with reasonable classifications and groupings of policyholders established by such Board. 2. No Contingent Liability. This policy is non -assessable. 3. Annual Meeting. The annual meeting of the members of the company shall be held at its home office at Bloomington, Illinois, on the second Monday of June at the hour of 10:00 A.M., unless the Board of Directors shall elect to change the time and place of such meeting, in which case, but not otherwise, due notice shall be mailed each member at the address disclosed in this policy at least 10 days prior thereto. In Witness Whereof, the State Farm Mutual Automobile Insurance Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. Secretary President Important ... California law requires us to provide you with information for filing complaints with the State Insurance Department regarding the coverage and service provided under this policy. Complaints should be tiled only after you and Stat@ Farm or your agent or other company representative have failed to reach a satisfactory agreement on a problem. Please forward such complaints to: California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 Or file a complaint through the Department of Insurance's Internet Web site (www.insurance.ca.gov) Or call toll free 1-800-927-HELP (4357) NOTICE We are required to furnish you with the following information: 1. An automobile liability insurance company may cancel a policy before the end of the current policy period for reasons described in the provision titled Cancellation which is located in the General Terms section of your policy (refer to the Contents in the beginning of your policy for the page number). 2. An automobile liability insurance company may increase the premium or refuse to renew the policy for any of the following reasons: a. Accident involvement by an insured, and whether an insured is at fault in the accident. b. A change in, or an addition of, an insured vehicle. c. A change in, or addition of, an insured under the policy. d. A change in the location of garaging of an insured vehicle. e. A change in the use of the insured vehicle. f. Convictions for violating any provision of the Vehicle Code or the Penal Code relating to the operation of a motor vehicle. g. The payment made by an insurer due to a claim filed by an insured or a third party. An automobile liability insurance company may increase the premium or refuse to renew the policy for reasons that are not listed above but which are lawful and not unfairly discriminatory. c b2 B10 38798-3-A MATCH 00711 MUTL VOL 1 State Farm Mutual Automobile Insurance Company " PO Box 2368 Bloomington IL 61702-2368 00711 NAMED INSURED 111712 ooss 55-2CC1-3 A A MELGOZA, JORGE B & MELGOZA, ANNA 6867 GOLFCREST DR APT 51 SAN DIEGO CA 92119-2444 I DECLARATIONS PAGE I PAGE 2 OF 2 POLICY NUMBER 583 7885-D15-55B POLICY PERIOD FEB 24 2025 to OCT 15 2025 12:01 A.M. Standard Time STATE FARM PAYMENT PLAN NUMBER 1235506212 FORM 9805BY ANDSANYSENDORSEMENTSLTHATIAPPLY, BCLUDINGLTHOSEOOISSUED TO YOU WITH ANY SOBSEYUENT RENEWAL NOTICE. 01 6028BU ADDITIONAL INSURED -CITY OF COSTA MESA, 77 FAIR DR, COSTA MESA CA 92626-6546. 02 6028BU ADDITIONAL INSURED -CITY OF SANTA ANA ISAOA, 30 CIVIC CENTER PLZ, SANTA ANA CA 92701. 6125A AMENDATORY ENDORSEMENT. 6126MD EXCESS COVERAGE FOR PERSONAL VEHICLE SHARING. 6129J AMENDATORY ENDORSEMENT. 6196AA - WAIVER OF SUBROGATION UNDER THE LIABILITY COVERAGE FOR THE CITY OF SANTA ANA ISAOA. 12961/08381 155-3866 CA .2 05-2002 (ola025fc) (ola0254c) 13SXO (ola025vd) Agent: LAZARO INSURANCE AGENCY INC Telephone: (619)229-6799 Prepared MAR 12 2025 2CC1-1386 This policy is issued by State Farm Mutual Automobile Insurance Company. MUTUAL CONDITIONS 1. Membership. While this policy is in force, the first insured shown on the Declarations Page is entitled to vote at all meetings of members and to receive dividends the Board of Directors in its discretion may declare in accordance with reasonable classifications and groupings of policyholders established by such Board. 2. No Contingent Liability. This policy is non -assessable. 3. Annual Meeting. The annual meeting of the members of the company shall be held at its home office at Bloomington, Illinois, on the second Monday of June at the hour of 10:00 A.M., unless the Board of Directors shall elect to change the time and place of such meeting, in which case, but not otherwise, due notice shall be mailed each member at the address disclosed in this policy at least 10 days prior thereto. In Witness Whereof, the State Farm Mutual Automobile Insurance Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. Secretary President Important ... California law requires us to provide you with information for filing complaints with the State Insurance Department regarding the coverage and service provided under this policy. Complaints should be tiled only after you and Stat@ Farm or your agent or other company representative have failed to reach a satisfactory agreement on a problem. Please forward such complaints to: California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 Or file a complaint through the Department of Insurance's Internet Web site (www.insurance.ca.gov) Or call toll free 1-800-927-HELP (4357) NOTICE We are required to furnish you with the following information: 1. An automobile liability insurance company may cancel a policy before the end of the current policy period for reasons described in the provision titled Cancellation which is located in the General Terms section of your policy (refer to the Contents in the beginning of your policy for the page number). 2. An automobile liability insurance company may increase the premium or refuse to renew the policy for any of the following reasons: a. Accident involvement by an insured, and whether an insured is at fault in the accident. b. A change in, or an addition of, an insured vehicle. c. A change in, or addition of, an insured under the policy. d. A change in the location of garaging of an insured vehicle. e. A change in the use of the insured vehicle. f. Convictions for violating any provision of the Vehicle Code or the Penal Code relating to the operation of a motor vehicle. g. The payment made by an insurer due to a claim filed by an insured or a third party. An automobile liability insurance company may increase the premium or refuse to renew the policy for reasons that are not listed above but which are lawful and not unfairly discriminatory. c b2 B10 �o z� v o� w v: 6125A Page 1 of 1 AMENDATORY ENDORSEMENT This endorsement is a part of the policy. Except for the changes this endorsement makes, all other provisions of the policy remain the same and apply to this endorsement. PHYSICAL DAMAGE COVERAGES Limits and Loss Settlement— Comprehensive Coverage and Collision Coverage Item 1.a. is changed to read: 1. We have the right to choose to settle with you or the owner of the covered vehicle in one of the following ways: a. Paythe cost to repairthe covered vehicle minus any applicable deductible. No deductible applies to the repair of windshield glass. (1) We have the right to choose one of the following to determine the cost to repair the covered vehicle: (a) The cost agreed to by both the owner of the covered vehicle and us; (b) A bid or repair estimate approved by us, or (c) A repair estimate that is written based upon or adjusted to: (i) reasonable repair costs and labor rates as determined by us for the repair market where the covered vehicle is to be repaired; (if) the prevailing competitive price. Prevailing competitive price means prices charged by a majority of the repair market as determined by a survey made by us for the area where the covered vehicle is to be repaired; (iii) the lower of paintless dent repair pricing established by an agreement we have with a third party or the paintless dent repair price that is competitive in the market: or (iv) a combination of (i), (ii), or (iii) above. If asked, we will identify at least one facility that will perform the repairs with the pricing and labor rates identified by us. The repair estimate will include parts sufficient to restore the covered vehicle to its pre -loss condition. You agree with us that the repair estimate may include new, used, recycled, and reconditioned parts. Any of these parts may be either original equipment manufacturer parts or non -original equipment manufacturer parts, and you agree these parts are sufficient to restore the covered vehicle to its pre -loss condition. You also agree that replacement glass need not have any insignia, logo, trademark, etching, or other marking that was on the replaced glass. (2) The cost to repair the covered vehicle does not include any reduction in the value of the covered vehicle after it has been repaired, as compared to its value before it was damaged. (3) If the repair or replacement of a part results in betterment of that part, then you or the owner of the covered vehicle must pay for the amount of the betterment; 6125A C, Copyright.. State Farm Mutual Automobile Insurance Company, 2023 6126MD EXCESS COVERAGE FOR PERSONAL VEHICLE SHARING This endorsement is apart of the policy. Except for the changes this endorsement makes, all other provisions of the policy remain the same and apply to this endorsement. LIABILITY COVERAGE a. Exclusions Exclusion 15. is replaced by the following: TITERE IS NO COVFRACE FOR AN I,VSL'RED FOR THE OWN- ERSIITP, MAINTENANCE, OR USE. OF YOUR CAR OR AAT, REY ACQUR&D CAR WHILE USED IN PFRSONAL 1TIIICI,E SHARING. This exclusion does not apply to you and resident rela- tives when, and only if, the full amount of all available limits of all other liability bonds, policies, and self-insurance plans that apply have been used up by payment ofjudg- ments or settlements, or have been offered in writing. b. If Other Liability Coverage Applies The first paragraph of item 2. is changed to read: The Liability Coverage provided by this policy applies as primary cov- erage for the ownership, mainte- nance, or use of your car or a trailer attached to it, except while your car or a trailer attached to it is used in personal vehicle sharing. The Liability Coverage provided by this policy applies as excess cover- age for the ownership, mainte- nance, or use of your car or a trailer attached to it while your car or a trailer attached to it is used in personal vehicle sharing. 2. MEDICAL PAYMENTS COVERAGE a. Exclusions (1) Exclusion 3. is replaced by the fol- lowing: THERE IS NO COVERAGE FOR AN IS'SURT;D TN'IIO IS OCCUPIEW A VEHICLE WHILE IT IS RENTED OR LEASED TO OTHERS BY AN INSURED. This exclusion does not apply to you and resi- dent relatives while occupying your car or a newly acquired car while used in personal vehicle sharing when, and only if, the full amount of all availa- ble limits- of all other sources of medical payments coverage or similar vehicle insurance that apply have been paid. (2) Exclusion 15. is replaced by the following: TTILRE IS NO COVERAGE FOR AN INSURED WHO IS OCCli, 1101,71? CAR OR A NEA,LY ACQUIRED CAR WT 111 . USED IN PERWV. AL VEHICLE SHARING This exclusion does not apply to you and resident relatives when, and only if, the full amount of all available limits of all other sources of medical payments coverage or similar vehicle insurance that apply have been paid. Page 1 ol'3 6126MD C, Copyright, State Farm Mutual Automobile Insurance Company, 2013 b. If Other Medical Payments Coverage or Similar Vehicle Insurance Applies The first paragraph of item 3. is changed to read: The Medical Payments Coverage provided by this policy applies as primary coverage for an insured Who sustains bodily injury, while occupying your car or a trailer attached to it except while your car or a trailer attached to it is used in personal vehicle sharing. The Medical Payments Coverage provided by this policy applies as excess coverage for you and resident rela- tives who sustain bodily injury while occupying your car or a trailer attached to it while your car or a trailer attached to it is used in personal vehicle sharing. UNINSURED MOTOR VEHICLE COVERAGE a. Exclusions Exclusion 6. is replaced by the following THERE IS NO COVERAGE FOR AN INSURED WHO IS OCCU- P1ZVG YOL%R CAR OR A NEW- LY ACQUIRED CAR WHILE USED IN PERSONAL I XICLE SUARING. This exclusion does not apply to you and resident rela- tives when, and only if, the full amount of all availablc limits of all other sources of uninsured motor vehicle coverage that apply have been paid. b. If Other Uninsured Motor Vehicle Coverage Applies The first paragraph of item 2. is changed to read: The Uninsured Motor Vehicle Cov- erage provided by this policy ap- plies as primary coverage for an insured who sustains bodily injury while occupying your car, except while your car is used in personal vehicle ,sharing. The Uninsured Motor Vehicle Coverage provided by this policy applies as excess coverage for you and resident rela- tives who sustain bodily in while occupying your car while your car is used in personal vehi- cle sharing. 4. PHYSICAL DAMAGE COVERAGES a. Exclusions (1) Exclusion 2. is replaced by the fol- lowing: THERE IS NO COVERAGE FOR ANY COT T;RT;D ITIII- CLE WHILE IT IS RENTED OR LEASED TO OTHERS BY AN INSURED. This exclusion does not apply to your car or a nerdy acquired car while used in personal vehicle sharing when, and only if, the full amount of all available limits of all other sources of physical damage coverage or similar coverage that apply have been paid. (2) Exclusion 20. is replaced by the following: THERE IS NO COVERAGE FOR YOUR CAR OR A.NEW- LYACQUIRF19 CAR WHILE, USED IN PERSONAL VEHI- CIT SHARING_ This exclu- sion does not apply when, and only if, the fill avotmt of all available limits of all other sources of physical damage coverage or similar coverage that apply have been paid. b. If Other Physical Damage Coverage or Similar Coverage Applies The first paragraph of item 3. is changed to read: The physical damage coverages provided by this policy apply as primary coverage for a loss to your car, except while your car is used in personal vehicle sharing. The physical damage coverages provid- ed by this policy apply as excess coverage for a loss to your car While it is used in personal vehicle sharing. Page 2 of 3 61261,D Page 3 of., 6126MD C, Copyright, State Farm Mutual Automobile Insurance Company, 2013 C, Copyright, State Farm Mutual Automobile Insurance Company, 2013 StateFarm State Farm Mutual Automobile Insurance Company 38798-3-A MATCH 00711 MUTL VOL PO Box 2368 DECLARATIONS PAGE Bloomington 1L 61702-2368 PAGE 1 OF 2 NAMED INSURED 00711 55-2001-3 A A POLICY NUMBER 583 7885-D15-55B 000712 0058 POLICY PERIOD FEB 24 2025 to OCT 15 2025 MELGOZA, JORGE B & MELGOZA, 12:01 A.M. Standard Time ANNA AST DR APT 51 SAN DIEGO STATE FARM PAYMENT PLAN NUMBER SAN IEGO CCA 92119-2444 1235506212 AGENT LAZARO INSURANCE AGENCY INC 3924 EL CAJON BLVD SAN DIEGO, CA 92105-1023 PHONE: (619)229-6799 DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSED. YOUR CAR 2012 HONDA ACCORD 4DR 1 HGCP2F32CA082366 6030BV19 ..: A Liability verge $ $ Bodily Injury Limits ..: Each Peon, :Each Accident ...: ..: ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... $1,000,000 $1,000,000 Froperty Damage Lirt .. .. .. .... Each Accident ..: $1 ,}} .... .. ..... D Comprehensive Coverage - $500 Deductible $51.19 Oaliisien coverage - $00 >eductible ....: $22 , ..... H Emergency Road Service Coverage $6.70 U t irxsured Motor Vehicle Coverage .... .. $M.21 Bodily Injury Limits ..: Eacl�I Prscn, :Each Accident $500,000 $1,000,000 L11 Urtinsurecl lUlotor Vehille Pro Derma e Covers e .13 IMPORTANT NOTICE For your protection California law requires the following to appear with this policy: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Replaced policy number 5837885-55A. Notice of insurance information collection practices - personal, family, or household insurance transactions: We may collect customer information from persons other than the Individual or individuals applying for coverage. Such customer information as well as other personal or privilegedInformation subsequently collected may, In certain circumstances, be disclosed to third parties without your authorization as permitted by law. You have the right to submit a written request to access, correct, amend, or delete your personal information and the right to receive a response within 30 days of submitting your request. If we deny your request, you have the right to file a statement with us containing the information you feel is accurate and fair along with the reasons you disagree with our denial. Instructions on how to file such request and our full privacy notice can be found www.statefarm.com/customer-care/privacy-security/privacy or contact your State Farm Agent. Your total renewal premium for APR 15 2025 to OCT 15 2025 is $1,003.48. APPROVED By Tu Tran Nguyen at 3:55 pm, Mar 12, 2025 Digitally signed Tu Tran byTuTran Nguyen Nguyen 1155559-0700? CONTINUED 12960/08381 See Reverse Side 155-3966 CA.2 05-2002 (ola025fc) IMON (M 025te) This policy is issued by State Farm Mutual Automobile Insurance Company. MUTUAL CONDITIONS Membership. While this policy is in force, the first insured shown on the Declarations Page is entitled to vote at all meetings of members and to receive dividends the Board of Directors in its discretion may declare in accordance with reasonable classifications and groupings of policyholders established by such Board. 2. No Contingent Liability. This policy is non -assessable. 3. Annual Meeting. The annual meeting of the members of the company shall be held at its home office at Bloomington, Illinois, on the second Monday of June at the hour of 10:00 A.M., unless the Board of Directors shall elect to change the time and place of such meeting, in which case, but not otherwise, due notice shall be mailed each member at the address disclosed in this policy at least 10 days prior thereto. In Witness Whereof, the State Farm Mutual Automobile Insurance Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. Secretary Important ... �Te(i:A�9�4Y� President California law requires us to provide you with information for filing complaints with the State Insurance Department regarding the coverage and service provided under this policy. Complaints should be filed only after you and Stat@ Farm or your agent or other company representative have failed to reach a satisfactory agreement on a problem. Please forward such complaints to: California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 Or file a complaint through the Department of Insurance's Internet Web site (www.insurance.ca.gov) Or call toll free 1-800-927-HELP (4357) NOTICE We are required to furnish you with the following information: 1. An automobile liability insurance company may cancel a policy before the end of the current policy period for reasons described in the provision titled Cancellation which is located in the General Terms section of your policy (refer to the Contents in the beginning of your policy for the page number). 2. An automobile liability insurance company may increase the premium or refuse to renew the policy for any of the following reasons: a. Accident involvement by an insured, and whether an insured is at fault in the accident. b. A change in, or an addition of, an insured vehicle. c. A change in, or addition of, an insured under the policy. d. A change in the location of garaging of an insured vehicle. e. A change in the use of the insured vehicle. f. Convictions for violating any provision of the Vehicle Code or the Penal Code relating to the operation of a motor vehicle. g. The payment made by an insurer due to a claim filed by an insured or a third party. An automobile liability insurance company may increase the premium or refuse to renew the policy for reasons that are not listed above but which are lawful and not unfairly discriminatory. cavb2 B10 StateFarm State Farm Mutual Automobile Insurance Company PO Box 2368 Bloomington IL 61702-2368 00711 NAMED INSURED 000712 ooss 55-2CC1-3 A A MELGOZA, JORGE B & MELGOZA, ANNA 6867 GOLFCREST DR APT 51 SAN DIEGO CA 92119-2444 I:yk-1* ►yu_1061:<IIIYAS0kyil1iIIMM61I I DECLARATIONS PAGE I PAGE 2 OF 2 POLICY NUMBER 583 7885-D15-55B POLICY PERIOD FEB 24 2025 to OCT 15 2025 12:01 A.M. Standard Time STATE FARM PAYMENT PLAN NUMBER 1235506212 YOUR POLICY CONSISTS OF THIS DECLARATIONS PAGE THE POLICY BOOKLET - FOTH 9805ANY B�1BAND ANY ENDORSEMENTS NDORSEMEN ICEHAT APPLY, INCLUDING THOSE ISSUED TO YOU 01 6028BU ADDITTIONAL INSURED -CITY OF COSTA MESA, 77 FAIR DR, COSTA MESA CA 92626-6546. 02 6028BU ADDITIONAL INSURED -CITY OF SANTA ANA ISAOA, 30 CIVIC CENTER PLZ, SANTA ANA CA 92701. 6125A AMENDATORY ENDORSEMENT. 6126MD EXCESS COVERAGE FOR PERSONAL VEHICLE SHARING. 6129J AMENDATORY ENDORSEMENT. 6196AA - WAIVER OF SUBROGATION UNDER THE LIABILITY COVERAGE FOR THE CITY OF SANTA ANA ISAOA. 12961 /08381 155-3866 CA.2 05-2002 (cla025fc) (cla0254c) 13SXO (cla025vd) Agent: LAZARO INSURANCE AGENCY INC Telephone: (619)229-6799 Prepared MAR 12 2025 2CC1-B86 This policy is issued by State Farm Mutual Automobile Insurance Company. MUTUAL CONDITIONS Membership. While this policy is in force, the first insured shown on the Declarations Page is entitled to vote at all meetings of members and to receive dividends the Board of Directors in its discretion may declare in accordance with reasonable classifications and groupings of policyholders established by such Board. 2. No Contingent Liability. This policy is non -assessable. 3. Annual Meeting. The annual meeting of the members of the company shall be held at its home office at Bloomington, Illinois, on the second Monday of June at the hour of 10:00 A.M., unless the Board of Directors shall elect to change the time and place of such meeting, in which case, but not otherwise, due notice shall be mailed each member at the address disclosed in this policy at least 10 days prior thereto. In Witness Whereof, the State Farm Mutual Automobile Insurance Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. Secretary Important ... �Te(i:A�9�4Y� President California law requires us to provide you with information for filing complaints with the State Insurance Department regarding the coverage and service provided under this policy. Complaints should be filed only after you and Stat@ Farm or your agent or other company representative have failed to reach a satisfactory agreement on a problem. Please forward such complaints to: California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 Or file a complaint through the Department of Insurance's Internet Web site (www.insurance.ca.gov) Or call toll free 1-800-927-HELP (4357) NOTICE We are required to furnish you with the following information: 1. An automobile liability insurance company may cancel a policy before the end of the current policy period for reasons described in the provision titled Cancellation which is located in the General Terms section of your policy (refer to the Contents in the beginning of your policy for the page number). 2. An automobile liability insurance company may increase the premium or refuse to renew the policy for any of the following reasons: a. Accident involvement by an insured, and whether an insured is at fault in the accident. b. A change in, or an addition of, an insured vehicle. c. A change in, or addition of, an insured under the policy. d. A change in the location of garaging of an insured vehicle. e. A change in the use of the insured vehicle. f. Convictions for violating any provision of the Vehicle Code or the Penal Code relating to the operation of a motor vehicle. g. The payment made by an insurer due to a claim filed by an insured or a third party. An automobile liability insurance company may increase the premium or refuse to renew the policy for reasons that are not listed above but which are lawful and not unfairly discriminatory. cavb2 B10 6125A Page 1 of 1 6126MD EXCESS COVERAGE FOR PERSONAL VEHICLE SHARING AMENDATORY ENDORSEMENT This endorsement is a part of the policy. Except for the changes this endorsement makes, all other provisions of the policy remain the same and apply to this endorsement. PHYSICAL DAMAGE COVERAGES Limits and Loss Settlement — Comprehensive Coverage and Collision Coverage Item 1.a. is changed to read: 1. We have the right to choose to settle with you or the owner of the covered vehicle in one of the following ways: a. Pay the cost to repair the covered vehicle minus any applicable deductible. No deductible applies to the repair of windshield glass. (1) We have the right to choose one of the following to determine the cost to repair the covered vehicle: 6125A (a) The cost agreed to by both the owner of the covered vehicle and us; (b) A bid or repair estimate approved by us; or (c) A repair estimate that is written based upon or adjusted to: (i) reasonable repair costs and labor rates as determined by us for the repair market where the covered vehicle is to be repaired; (ii) the prevailing competitive price. Prevailing competitive price means prices charged by a majority of the repair market as determined by a survey made by us for the area where the covered vehicle is to be repaired; (iii) the lower of paintless dent repair pricing established by an agreement we have with a third party or the paintless dent repair price that is competitive in the market; or (iv) a combination of (i), (ii), or (iii) above. If asked, we will identify at least one facility that will perform the repairs with the pricing and labor rates identified by us. The repair estimate will include parts sufficient to restore the covered vehicle to its pre -loss condition. You agree with us that the repair estimate may include new, used, recycled, and reconditioned parts. Any of these parts may be either original equipment manufacturer parts or non -original equipment manufacturer parts, and you agree these parts are sufficient to restore the covered vehicle to its pre -loss condition. You also agree that replacement glass need not have any insignia, logo, trademark, etching, or other marking that was on the replaced glass. (2) The cost to repair the covered vehicle does not include any reduction in the value of the covered vehicle after it has been repaired, as compared to its value before it was damaged. (3) If the repair or replacement of a part results in betterment of that part, then you or the owner of the covered vehicle must pay for the amount of the betterment; ©, Copyright, State Farm Mutual Automobile Insurance Company, 2023 This endorsement is a part of the policy. Except for the changes this endorsement makes, all other provisions of the policy remain the same and apply to this endorsement. 1. LIABILITY COVERAGE a. Exclusions Exclusion 15. is replaced by the following THERE IS NO COVERAGE FOR AN INSURED FOR THE OWN- ERSHIP, MAINTENANCE, OR USE OF YOUR CAR OR ANEWLY ACQUIRED CAR WHE,E USED IN PERSONAL VEHICLE SHARING. This exclusion does not apply to you and resident rela- tives when, and only if, the full amount of all available limits of all other liability bonds, policies, and self-insurance plans that apply have been used up by payment of judg- ments or settlements, or have been offered in writing. b. If Other Liability Coverage Applies The first paragraph of item 2. is changed to read: The Liability Coverage provided by this policy applies as primary cov- erage for the ownership, mainte- nance, or use of your car or a trailer attached to it, except while your car or a trailer attached to it is used in personal vehicle sharing. The Liability Coverage provided by this policy applies as excess cover- age for the ownership, mainte- nance, or use of your car or a trailer attached to it while your car or a trailer attached to it is used in personal vehicle sharing. 2. MEDICAL PAYMENTS COVERAGE a. Exclusions (1) Exclusion 3. is replaced by the fol- lowing: THERE IS NO COVERAGE FOR AN INSURED WHO IS OCCUPYING A VEHICLE WHILE IT IS RENTED OR LEASED TO OTHERS BY AN INSURED. This exclusion does not apply to you and resi- dent relatives while occupying your car or a newly acquired car while used in personal vehicle sharing when, and only if, the full amount of all availa- ble limits of all other sources of medical payments coverage or similar vehicle insurance that apply have been paid. (2) Exclusion 15. is replaced by the following: THERE IS NO COVERAGE FOR AN INSURED WHO IS OCCUPYING YOUR CAR OR A NEWLY ACQUIRED CAR WHILE USED IN PERSON- AL VEHICLE SHARING This exclusion does not apply to you and resident relatives when, and only if, the full amount of all available limits of all other sources of medical payments coverage or similar vehicle insurance that apply have been paid. Page 1 of 3 6126MD C, Copyright, State Farm Mutual Automobile Insurance Company, 2013 m Cl) w 0 N 0 0 r W 3 b. If Other Medical Payments Coverage or Similar Vehicle Insurance Applies The first paragraph of item 3. is changed to read: The Medical Payments Coverage provided by this policy applies as primary coverage for an insured who sustains bodily injury while occupying your car or a trailer attached to it, except while your car or a trailer attached to it is used in personal vehicle sharing. The Medical Payments Coverage provided by this policy applies as excess coverage for you and resident rela- tives who sustain bodily injury while occupying your car or a trailer attached to it while your car or a trailer attached to it is used in personal vehicle sharing. UNINSURED MOTOR VEHICLE COVERAGE a. Exclusions Exclusion 6. is replaced by the following THERE IS NO COVERAGE FOR AN INSURED WHO IS OCCU- PYING YOUR CAR OR A NEW- LY ACQUIRED CAR WHILE USED IN PERSONAL VEHICLE SHARING. This exclusion does not apply to you and resident rela- tives when, and only if, the full amount of all available limits of all other sources of uninsured motor vehicle coverage that apply have been paid. b. If Other Uninsured Motor Vehicle Coverage Applies The first paragraph of item 2. is changed to read: The Uninsured Motor Vehicle Cov- erage provided by this policy ap- plies as primary coverage for an insured who sustains bodily injury while occupying your car, except while your car is used in personal vehicle sharing. The Uninsured Motor Vehicle Coverage provided by this policy applies as excess coverage for you and resident rela- tives who sustain bodily injury while occupying your car while your car is used in personal vehi- cle sharing. 4. PHYSICAL DAMAGE COVERAGES a. Exclusions (1) Exclusion 2. is replaced by the fol- lowing: THERE IS NO COVERAGE FOR ANY COVERED VEHI- CLE WHILE IT IS RENTED OR LEASED TO OTHERS BY AN INSURED. This exclusion does not apply to your car or a newly acquired car while used in personal vehicle sharing when, and only if, the full amount of all available limits of all other sources of physical damage coverage or similar coverage that apply have been paid. (2) Exclusion 20. is replaced by the following: THERE IS NO COVERAGE FOR YOUR CAR OR ANEW- LYACQUIRED CAR WHILE USED IN PERSONAL VEHI- CLE SHARING. This exclu- sion does not apply when, and only if, the full amount of all available limits of all other sources of physical damage coverage or similar coverage that apply have been paid. b. If Other Physical Damage Coverage or Similar Coverage Applies The first paragraph of item 3. is changed to read: The physical damage coverages provided by this policy apply as primary coverage for a loss to your car, except while your car is used in personal vehicle sharing. The physical damage coverages provid- ed by this policy apply as excess coverage for a loss to your car while it is used in personal vehicle sharing. Page 2 of 3 6126MD Page 3 of 3 6126MD 0, Copyright, State Farm Mutual Automobile Insurance Company, 2013 C, Copyright, State Farm Mutual Automobile Insurance Company, 2013 A� " CERTIFICATE OF LIABILITY INSURANCE DATE Y) 10/15/15025 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 endorsement(s). PRODUCER CONTACT LAZARO NETO NAME: StateFarm LAZARO NETO INSURANCE AGENCY A/CONNo Ext: (619)229-6799 FAX No: (619)229-6796 E-MAILLAZARO@LAZARONETO.COM = • 3924 EL CAJON BLVD INSURER(S) AFFORDING COVERAGE NAIC # SAN DIEGO, CA 92105 INSURER A: State Farm General Insurance Company 25151 INSURED INSURER B: State Farm Mutual Automobile Insurance Company 25178 INSURER C: MELGOZA, JORGE B INSURER D: 6867 GOLFCREST DR APT 51 INSURER E: SAN DIEGO, CA 92119 INSURER 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 ADD INSD SUB WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A Y 90-AP-K491-7 10/15/2025 10/15/2026 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO - POLICY LOC JECT X PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY 583 7885-D15-55 10/15/2025 04/15/2026 EOa aBINEDtSINGLE LIMIT $ BODILY INJURY (Per person) $ 1,000,000 ANY AUTO X BODILY INJURY (Per accident) $ 1,000,000 B OWNED SCHEDULED AUTOS ONLY AUTOS Y HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ccident Per accident) $ 1,000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? ❑ NIA PER OTH- STATUTE ER $ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) APPROVED By Tu Tran Nguyen at 10:42 am, Oct 23, 2025 Tu Tran Digitallysignedby Tu Tran Nguyen Nguyen 110.4326-07'003 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SANTA ANA ACCORDANCE WITH THE POLICY PROVISIONS. 20 CIVIC CENTER PLAZA AUTHORIZED REPRESENTATIVE SAN ANA , CA 92702 / G/! d /(/O� v @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.14 04-13-2022 CM P-4787 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number:90-AP-K491-7 Named Insured: MELGOZA, JORGE B Name And Address Of Person Or Organization: City of Santa Ana, its City Council, officers, officials, employees, agents, and volunteers 20 Civic Center Plz Santa Ana CA 92701-4058 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMP-4787 1008498 2001 151229 201 05-14-2019 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2008 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CM P-4786.2 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 90-AP-K491-7 Named Insured: MELGOZA, JORGE B Name And Address Of Additional Insured Person Or Organization: City of Santa Ana, its City Council, officers, officials, employees, agents, and volunteers 20 Civic Center Plz Santa Ana CA 92701-4058 SECTION II —WHO IS AN INSURED of SECTION II — LIABILITY is amended to include, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for "bodily injury", "property damage", or "personal and advertising injury" caused, in whole or in part, by: a. Ongoing Operations (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for that additional insured; or b. Products — Completed Operations "Your work" performed for that additional insured and included in the "products -completed operations hazard". However, Paragraph 1. above is subject to the following: a• The insurance afforded to the additional insured only applies to the extent permitted by law; b. If coverage provided to the additional insured is required by a contract or agreement, the insurance provided to the additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (1) Is allowed for the satisfaction of a defense or indemnity obligation by California Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such additional insured. We have no duty to defend or indemnify the additional insured under this endorsement until a claim or "suit" is tendered to us. 2. Any insurance provided to the additional insured shall only apply with respect to a claim made or a "suit" brought for damages for which you are provided coverage. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION II — LIMITS OF INSURANCE: CMP-4786.2 1008243.CA.2 1008243 2002 150755 202 12-27-2022 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2022 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CM P-4786.2 Page 2 of 2 If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the applicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occurrence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an 'occurrence" or an offense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the "occurrence" or offense took place; (2) The names and addresses of any injured persons and witnesses; and (3) The nature and location of any injury or damage arising out of the "occurrence" or offense; b. Tender the defense and indemnity of any claim or "suit" to us and to all other insurers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insurance the additional insured has for defense or damages for which we would provide coverage under SECTION II — LIABILITY. 5. With respect to the insurance afforded the additional insured, the following replaces SECTION II — LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insurance available to the additional insured, provided that the additional insured is a named insured under such other insurance. b. Regardless of any agreement between you and the additional insured, this insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional insured has been added as an additional insured on other policies. All other policy provisions apply. CMP-4786.2 1008243.CA.2 1008243 2002 150755 202 12-27-2022 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2022 Includes copyrighted material of Insurance Services Office, Inc., with its permission. State Farm Mutual Automobile Insurance Company PO Box 2368 Bloomington IL 61702-2368 AT2 A-2CC1 A MELGOZA, JORGE B & MELGOZA, ANNA 6867 GOLFCREST DR APT 51 SAN DIEGO CA 92119-2444 APPROVED By Tu Tran Nguyen at 4:46 pm, Apr 14, 2026 Policy Number: 583 7885-D15-55C Policy Period: April 15, 2026 to October 15, 2026 Vehicle: 2012 HONDA ACCORD Principal Driver: JORGE B MELGOZA Notice of insurance information collection practices - personal, family, or household insurance transactions: We may collect customer information from persons other than the individual or individuals applying for coverage. Such customer information as well as other personal or privileged information subsequently collected may, in certain circumstances, be disclosed to third parties without your authorization as permitted by law. Policy Number: 583 7885-D15-55C Prepared February 20, 2026 1004583 AUTO RENEWAL PREMIUM PAID: $800.61 DO NOT PAY. Your premium is billed through the State Farm Payment Plan State Farm Payment Plan Number: 1235506212 Your State Farm Agent LAZARO INSURANCE AGENCY INC Office: 619-229-6799 Address: 3924 EL CAJON BLVD SAN DIEGO, CA 92105-1023 If you have a new ordierent car, have added any ddvers orhave moved, please contact your agent. Thank you for choosing State Farm. You have the right to submit a written request to access, correct, amend, or delete your personal information and the right to receive a response within 30 days of submitting your request. If we deny your request, you have the right to file a statement with us containing the information you feel is accurate and fair along with the reasons you disagree with our denial. Instructions on how to file such request and our full privacy notice can be found (continued on next page) Page number 1 of 5 143562 202 01-15-2018 ONVENIENE SAVES TIME, MONEY ... AND TREES. You have the option to pay your bills online by opting for ePayment on statefarm.corff. Get to a better State`. r A * StateFairm www.statefarm.com/customer-care/privacy-security/privacy or contact your State Farm Agent. When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use VEHICLE INFORMATION information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will not receive your check back from your financial institution. Review your policy information carefully. If anything is incorrect, or if there are any changes to your vehicle information, please let us know right away. Vehicle Identification Vehicle Description Number (VIN) Who principally drives this vehicle? How is this vehicle normally used? 2012 HONDA ACCORD 1HGCP2F32CA082366 JORGE MELGOZA, a married individual, Business. who will have 49 years of driving experience as of April 15, 2026. Other Household Vehicle(s) Your premium may be influenced by other State Farm policies that currently insure the following vehicle(s) in your household: 2020 JEEP GR CHEROKE The premium on the expiring policy term was based on 13,000 miles per year. The premium on the renewal policy term was based on 13,000 miles per year. Premium Adjustment Each year, we review our medical payments and personal injury protection coverages claim experience to determine the vehicle safety discount that is applied to each make and DRIVER INFORMATION Assigned Driver(s) The following driver(s) are assigned to the vehicle(s) on this policy. model. In addition, we review the comprehensive, collision, bodily injury and property damage claim experience annually to determine which makes and models have earned decreases or increases from State Farm's standard rates. If any changes result from our reviews, adjustments are reflected in the rates shown on this renewal notice. Driving Experience as of Marital Name April 15, 2026 Status JORGE B MELGOZA 49 years Married Other Household Driver(s) In addition to the Principal Driver(s) and Assigned Driver(s), your premium may be influenced by the drivers shown below and other individuals permitted to drive your vehicle. This list does not extend or expand coverage beyond that contained in this automobile policy. The drivers listed below are the drivers reported to us that most frequently drive other vehicles in your household. ANNA MELGOZA Policy Number: 583 7885-D15-55C Page number 2 of 5 Prepared February 20, 2026 .� � State Farm Principal Driver & Assigned Drivers For each automobile, the Principal Driver is the individual who most frequently drives it. Each driver is designated as an Assigned Driver on the household automobile that they most frequently drive. Your premium may be influenced by the information shown for these drivers. COVERAGE AND LIMITS See your policy for an explanation of these coverages. A Liability Bodily Injury 1,000,000/1,000,000 Property Damage 1,000,000 $461.05 D 500 Deductible Comprehensive $31.83 G 500 Deductible Collision $143.79 H Emergency Road Service $5.36 U Uninsured Motor Vehicle Bodily Injury 500,000/1,000,000 $153.76 U1 Uninsured Motor Vehicle Property Damage $4.82 Total Premium $800.61 If any coverage you carry is changed to give broader you the broader protection without issuing a new policy, protection with no additional premium charge, we will give starting on the date we adopt the broader protection. DISCOUNTS These adjustments have already been applied to your premium. Multiple Line ✓ Multicar ✓ Driving Safety Record ✓ California Good Driver ✓ Loyalty ✓ Total Discounts $2,198.91 Other Available Discount(s) You may be eligible for additional discounts See the enclosed insert for more information. Mature Driver SURCHARGES AND DISCOUNTS Driving Safety Record Rating Plan Your driving safety record, along with other rating factors, determines what you pay for Liability, Medical Payments, (continued on next page) Policy Number: 583 7885-D15-55C Page number 3 of 5 Prepared February 20, 2026 Stat eFarm Comprehensive, Collision, and Uninsured Motor Vehicle Coverages. Policyholders with no accidents and convictions pay less than those with accidents and convictions. The Driving Safety Record Rate Level that is assigned to your policy moves up, down, or stays the same every policy renewal, depending upon your driving record. For every 12 months since the renewal following the occurrence of a chargeable accident or the conviction of a minor violation, the initial assigned Driver Record Level for that chargeable accident or conviction shall be lowered by 1 level. For each 12 month period since the conviction of a major violation, the initial assigned Driver Record Level for that conviction shall be lowered by 2 levels. The Rate Level is increased if there are subsequent chargeable accidents or convictions. Definition of Chargeable Accidents Chargeable accidents for new business are those which resulted in bodily injury or death or in payment(s) by an insurer due to damage to any property in the amount of more than $1000. For accidents occurring prior to December 11, 2011, an accident shall be chargeable ADDITIONAL INFORMATION IMPORTANT NOTICE For your protection California law requires the following to appear with this policy: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. provided it resulted in death or in payment(s) by an insurer due to damage to any property in the amount of more than $750. For applicants without prior insurance at the time of the accident, an accident shall be chargeable provided it resulted in damage to any property in the amount of more than $1000 (more than $750 if the accident occurred prior to December 11, 2011). Chargeable accidents for renewal business are those which resulted in bodily injury or death or State Farm claim payments totaling more than $1000 (more than $750 for accidents occurring prior to December 11, 2011) under property damage liability coverage and collision coverage combined. For more information about the rating plan, please contact your State Farm agent. Superior Driver Rate Level If any information on this renewal notice is incomplete or inaccurate, or if you want to confirm the information we have in our records, please contact your agent. For additional information regarding discounts or coverages, see your State Farm agent or visit statefarm.com®. Endorsement 6130Q effective APR 15 2026. Important Notice Regarding Your Premium State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile insurance is determined by many factors including: • The coverage you have • Where you live • The kind of car you drive • How the car is used • Who drives the car Any premium adjustment is reflected on this Auto Renewal. If you have any questions, please contact your agent. Buying a new car? Remember to contact your agent! When you buy an additional car or one that replaces a car already on your policy, you need to report the change to your agent promptly. Even though the dealership you purchased the car from may offer to notify your agent or insurance company, you, as the named insured, are responsible for reporting all changes to your auto policy. By contacting your agent, you can help: • avoid any complications or lack of coverage in the event of an accident or loss, • avoid insurance verification problems with a lienholder, the police, or the department of motor vehicles, and • ensure that you receive any new discounts you may be entitled to. (continued on next page) Policy Number: 583 7885-D15-55C Page number 4 of 5 Prepared February 20, 2026 A* StateFarm Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited number of days after you take possession of the car. Please refer to your policy for the number of days that applies in your state. If you have any questions about coverage for a newly acquired car, please contact your State Farm agent. Disclaimer- This message is provided for informational purposes only and does not grant any insurance coverage. The terms and conditions of coverage are set forth in your State Farm Car Policy booklet, the most recently issued Declarations Page, and any applicable endorsements. Policy Number: 583 7885-D15-55C Page number 5 of 5 Prepared February 20, 2026 IMPORTANT - IDENSTATE FAQ FOLD TOP AND BOTTOW1 OF CARD ON PERFORATION 5tateFarm CALIFORNIA INSURANCE CARD Stata Farm Mutual AutomobII- Insurance company PO Box 2368 Bkoomingto,IL 6i702-2388 MUTL INSURED MANNAOZA, JORGE 6 & MFLGOZA, VOL N €FF€eTlve ¢, POLICY NUMBER 583 7885-D15.55C APR 15 2026 TO OCT 15 2026 YR 2012 MAKE HONDA VIN 1HGCP2F32CA082366 MODEL ACCORD No NN8 2CC1-B86 AGENT LAZARO INSURANCE PHONE ib229.6799 AiG2517 THE POLICY MEETS THE MINIMUM LIABILITY LIMTS GPVIBY PR€ GRiBED BY LAW GOVRAGES A 0600 G SO E REVERSE SIDE FOR AN EXPLANAiIDN. KEEP A CARD IN YG SUBMIT 12759124112 KEEP YOUR CURRENT CAR© UNTIL THE 141066.2 61-12-Z6i8lclpccalcl ww1v) CITY OF SANTA ANA Risk Management a division of Human Resources Managing Risk through Awareness and Action AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE I, Jorge Melgoza, President ("Representative"), attest that I am an authorized (Name and Title of Vendor Representative) representative of Ardent Ergonomics ("Company"), and (Consultant/Company Name) possess the authority to legally bind Company. In my capacity as Representative of Company, I represent and confirm the following, as relates to the agreement between Company and City of Santa Ana, agreement number ("Agreement") to provide Preventative Ergonomic ("Services"): (Services to be provided under agreement/contmet) During the course and scope of Company's agreement with the City of Santa Ana, Company will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if Company should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, Company shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately. If at any time it is found that Company is not adhering to any and/or all of the statements in this document and does not maintain the minimum workers' compensation insurance coverage as required in the Agreement, it will be considered a breach of Agreement rendering the Agreement null and void and Company will be fully liable for any and all damages. Signature Jorge Melgoza President Title Contact Information, i.e., Telephone Number and/or Email Address Date WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANT DOLLARS (V00,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. Affidavit of Exemption for Workers' Compensation Insurance 11,12,2024