HomeMy WebLinkAboutRamirez, Daniel 2aAGREEMENT TERMINATION
Please complete this form when the attached agreement is no loa r i0fiv4t * 21
Return form to the Sr. Deputy Clerk of the Council (M -30). Can 647 52-38 rfjrou h0V`any
questions_
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-------- - - - - -- --- - - - - --
Theagreementwith
- O ,rez— 21 No- M� a003- C)CJ6 -Ok
was completed one " � and fmal payment has been made_
Department: A?V—C 2,4
Signature: *—U t &', C&Aao
Bate: (0(31Iq
City of Santa Ana
Revised 8 -7 -03 Clerk of the Council
tV-- A()03",o9b - oj
INSURANCE ON FILE
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES
-11 -to "0'-1
&lERK Of COUNCil
f)A1fE: <1- ao -04
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FIRST AMENDMENT TO
CONSUL T ANT AGREEMENT
THIS FIRST AMENDMENT TO CONSULTANT AGREEMENT is entered into
on S~ IS ,2004, by and between Daniel Ramirez, a sole proprietor
("Consultant") and the City of Santa Ana, a charter city and municipal corporation of the
State of California ("City").
Recitals:
A. The parties entered into Consultant Agreement N-2003-096, dated September 24,
2003, (hereinafter "said Agreement") by which Consultant has provided Folklorico-
Mexican Traditional dance instruction for participants registered through the City's
Parks, Recreation and Community Services Agency.
B. In accordance with the terms and conditions of said Agreement, the parties wish to
extend the term for an additional one-year period and to increase the compensation to
pay for services during the extended term.
Wherefore, in consideration of the covenants contained in said Agreement, and subject
to all the terms and conditions of said Agreement, except those amended in this First
Amendment to Consultant Agreement, the parties agree as follows:
1. Section 2.a., COMPENSATION, shall be deleted in its entirety and replaced with the
following language:
"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 $10,000.00, annually, during the term of this
Agreement. "
2. Section 3., TERM, shall be amended to extend the termination date from June 30,
2004 to June 30, 2005.
3. Except as herein amended, all terms and conditions of said Agreement shall remain in
full force and effect.
II
II
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~dmjnistrative Office
1400 American Lane
Schaumburg, Illinois 60196
N-~OD3-09h
STEADFAST INSURANCE COMPANY
A ZURICH COMPANY
CERTIFICATE OF LIABILITY INSURANCE
Policy Number: EOl5281394-00
Fitness and Wellness Purchasing Group Certificate Number: 0393366
NAMED 0393366 Daniel Ramirez AGENT Fitness and Wellness Insurance Agency
INSURED NAME AND 380 Stevens Avenue, #115
AND 13901 Fernwood MAILING Solana Beach, CA 92075
MAILING ADDRESS
ADDRESS Garden Grove. CA 92843 800-395-8075 - L1C#OD28716
POLICY PERIOD: From: 11/10/03 To: 11/10/04
THIS CERTIFICATE OF LIABILITY INSURANCE FORMS A PART OF THE POLICY REFERENCED ABOVE.
INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED, IS IN FORCEt AND CONVEYS ALL THE RIGHTS AND
PRIVILEGES AFFORDED UNDER THE POLICY. THE INSURANCE COVERAGE PROVIDED UNDER THIS
CERTIFICATE IS SUBJECT TO ALL THE TERMS. CONDITIONS, AND EXCLUSIONS OF THE POLICY
IDENTIFIED ABOVE.
COVERAGES LIMITS OF INSURANCE
Bodily Injury. Property Damage or $1.000.000 Each Occurrence Lim it
Professional Incident
Personal and Advertising Injury Limit $1,000,000 Anyone Person or Organization
-
General Aggregate Limit (Other than $3,000,000
Products/Completed Operations)
Products/Completed Operations $3,000,000 Aggregate Limit
Coverage 0 Medical Expenses $ 2,500 Any One Person
Coverage E Sexual and/or Physical Abuse liability $ 100,000 Each Claim Limit!
$ 300,000 Annual Aggregate Limit
Coverage F Employer's Liability (Only available in Only In State(s) where this Insurance applies:
the following States: NO, OH, WVA. WA and WY) $ 100,000 Bodily Injury by Accident - Each Accident
$ 100,000 Bodily Injury by Disease - Each Employee
$ 500,000 Aggregate Limit - Employer's liability
Damage to Premises Rented to You $ 100,000 Any One Premise
The most we will pay for any occurrence, or related occurrence that triggers Bodily Injury, Property Damage or
Professional Incident or any combination thereof is the each occurrence limit. Payments made under Sexual andlor
Physical Abuse. Medical Expenses, Employers liability (where applicable), and Damages to Premises Rented to You
deplete the general aggregate limit of liability.
Location of all premises you own. rent or occupy:
1) Various
Premium:
RPG FEE:
Taxes/Filing Fees:
234.00
Included
Included
IF YOU HAVE ANY QUESTIONS CONCERNING THIS CERTIFICATE CONTACT:
FITNESS AND WELLNESS INSURANCE AGENCY - 800-395-8075
Jeffrev E. Frick
Authorized Representative
Form #: Cert1
NOVEMBER 17.2003
Date
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ADDITIONAL .INSlJRP.D BNDORSEMEW'
fOR cpMMijRCrAL G~, ~lUJY pqLlCY
...~~~
IJuunmce Company . JUI.fdt> 1S"
.. ..
n i3 ~ mod.i.fies such iuorance as is afforded by tho pro'Y1i11'()ns of Policy
#/. ~~Ob relatiugto the foI!owina:
, '~~fI"a~?JMJ;(.,
1. The Cityof'SantaAna, 20 Civic OenterPlaza, SIU1IaAua. Ci1ir0mla~2101; its
of icers, cmplo~apatsJ "'oblnteeraJUthup,(~jti#..,es'a:emc.r.!.Maddki=a1blsurads .._...... u, ...........
C'. .ddilicmal insureds' with regard to liability aDd defense of suillllriaiDg from 'the operations.
at 1 uses pafonned by or ou bc:baIi' cf the named insured;-
2. With:l:e!lpCCt to cJatms arisiJlg out of the o~ 8Dd uses pafiMmed by or 0'11
be bait of the Dlmcd insured, &ud:1 ~4OCO 8$ is aft4Jrded by thi. policy ia primIry and b not _
a< ditioaal. to 'or cClfltr1~ with any o1hfS' insuracce carried by or .fur the 'beneBt of the
a< ditiOl1ll imuJeis,
. ...... ..
3, Tbis.~ applies seplntc:ly to Clach ~ against whom ~laUn if made ~t
$1 it i, brouaht except with ~t to th.d company's limits of liability. The UidtlSiOa of any
p nOD. or o:rpoizarion iI$ m ins1Ired sJWl Dot atf'= 8t3Y right which St1.Gb. penon or org,wzauon
'" ,uld hav~ a a dahrwlt if not SO inchlded. l.... /" .
4. Wiib. x~ to tile adai1iOtW ~ 1his iDwIancG almI1 not be ~11cd, or
II aterlall1 rcdu.:<<l in ~ -or limits t:lO:ept after thirty (30) days' written n.otice bu be~
g ven to the City of SentaAaa, 20 Civic Center Plaza, Santa. Ana. c.1ifumia 92101.
(' :OmpletiOJ:l of the ful1owin;. includins ~1:tu:fl. is required to man this codooemeIlt
e fedi-ve.)
f ffed:i.;~ Jl J L r; 1 ~ - Il/lD IC4 thD e~aJ.t form as a part of
IJIicylF "'~~4-00Caz:n"CAI)="'~~!,l,c, .
IsUDdIo ~k~'~ : =-
Named bURd
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ACORD
INSURED
DANIEL RAMIREZ
13901 FERNWOOD
GARDEN GROVE CA
..1\9<lncy Lic#,' OD28l1L ~___
IV- Jot>3 - o9b
tJ- .J.w.l- 0%-01
92843 '-'
I. DATE (MMlDDIYYYY)
10/04/2004
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
QNL Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HDLOER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
AL fER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
I
, INSURERS AFFORDING COVERAGE tAlC #
I~~URERA:,_, ' Ste-ad f,a st I~SU,ranc~ c,omp'~n, y' __ -". _."._ '. -- _ .' -=-
INSURER B:
-_._--_...__._._-_._-_...~_..._--
INSURERC: ___ __ _~_' __ _l~_
~SURER_~___.________--+_________
i INSURER E: '
TM,
CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
FITNESS AND WELLNESS INSURANCE AGENCY
380 STEVENS AVENUE, SUITE 206
SOLANA BEACH CA 92075
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
'~i~',~~~~ TYPE OF INSURANCE
GENERAL LIABILITY
-,:i<J..c.OMMERCIAL GENERAL L1ABILlr;
moD CLAIMS MADEI~ OCCUR
IGEL AGGREGATE L1..;T APPLIES PER:
.7: POLICY PROJECT 'I LOC
-~_..~....-
POLICY NUMBER
---,
POLIC"EFFiii:CTIVE
DATE MMIODIYY
11/10/03
-I PCU~~-EXFIAAT1~-~ r---
DATE MM/DDlYY
LIMITS
EOL5281394-Q0
11/10/04
EACH OCCURRENCE __ $ 1 ~OOO.OOO
': DAMAGE TO RENTED $ _~OO,OOO_
MED. EXP {Any one person) ,$ 2,500
.PERSON~~ & ADV INJURY---~-~OO,OOO
i GENERAL AGGREGATE $ 3,000,000
PR~~UCTS-CO~P/OP AGG. $ ~_Q.~_'OOO
A
AUTOMOBILE LIABILITY
--1 ANY AUTO
j ALL OWNED AUTOS
: SCHEDULED AUTOS
HIRED AUTOS
i NON-OWNED AUTOS
COMBINED SINGLE LIMIT
(Eaaccident)
$
BODILY INJURY
{Per person)
PROPERTY DAMAGE
(Per accident)
-t
,$
BODILY INJURY
; (Per accident)
GARAGE LIABILITY
.,
, ANY AUTO
AUTO ONLY. EA ACl;:IDENT
$
~_ACC $
$
i OTHER THAN
AUTO ONLY:
1=1
DEDUCTIBLE
RETENTlor~ $
/1 2-:
EACH OCCURRENCE ~$ ~_
AGGREGATE $
-----
, $
C--=-=-, ~=~$ --
$
EXCESS I UMBRELLA LIABILITY
=.J OCCUR 0 CLAIMS MADE '
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
, ANY PROPRIETORlPARTNERlEXECUTIVE
QFFICERlMEMBER EXCLUDED?
Ifye',deacrlbeunder
SPECIAL PROVISIONS below
OTHER
$
..-
E.L DISEASE.EA EMPLOYEE ,$
E,L. DISEASE.POLlCY LIMIT $
OTHER:
DESCRIPTION OF OPERATlONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER ADDED AS ADDITIONAL INSURED ONLY AS THEIR INTERESTS MAY APPEAR.
The City of Santa Ana
20 Civic Center Plaza
Santa Ana CA 92701
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL to
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT
FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER. Irs AGENTS OR REPRESENTATIVES.
CERTIFICATE HOLDER
AUTHORIZED REPRESENTATIVE
dJL~~
dj~~. Frick, CEO
OD28716 @ACORDCORPORATION 1988
Attention:
ACORD 25 (2001/08)
Certificate #
9293
.
POLICY NUMBER: EOL5281394-00
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED-OWNERS, LESSEES OR
CONTRACTORS (Form B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY
SCHEDULE
Name of Person or Organization; The City of Santa Ana
20 Civic Center Plaza
Santa Ana CA 92701
(If no entry appears above. information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization
shown in the Schedule, but only with respect to liability arising out of "your work' for that insured by
or for you
~?'z/~
CG 20 10 11 85
Copyright. Insurance Services Office, Inc., 1984
Certificate # 9293
02/02/2005 16'1~ 7145
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lrpOM FIT',F3S Ar~D WE~LJ\lfSS ir"S~)R,\tJCE
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9 2 '1 (16 1 -'l : r:: 8 S T I,,"' IJ, IJ., f:i ~:,> fJ 4 2 Cl >3 B ,;:
ACORD CERTIFICATE OF LIABILITY INSURANCE ) DATE (MMfDDlYYVY)
TM 031051/2006
PRODUCER Phone: (BOO) 3ll5-8075 Fax: (858j519..()822 THIS CERTIFICATE IS ISSUEO AS A MAnER OF INFORMATION
FITNESS AND WELLNESS INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIfiCATE
380 STEVENS AVENUE, SUITE 206 ~~~:R. THIS CERTIFICATE DOE~ :';>~:J:MEND. EX~~~ nO:
SOLANA BEACH CA 82075
INSURERS AFFORDING COVERAGE NAIC'
., lief 0026716 i------
-------- --- ----~-_._.
INSURED N- d-VO?;-rfi(p-O;;L INSURER ~: Zu!iCh American Insurance Company t--- --
DANIEL RAMIREZ N -;).(;o3-v9~-O' INSURER B:
13901 FERNWOOD ._..~
I~NSURER C
GARDEN GROVE CA 92843 IV -;).003-090 'NSURER-D~ - --[----
u_ --
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LtSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMeD ABOVE FOR THE F'OLICYP[RIQD INDICATED, NOtWITHSTANDING
ANV REQUIREMENT, TERM OR CON DillON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTlf"ICATE !MY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDI~IONS OF SUCH
POL!CIES_ AGGREGATE LIMITS SHOWN MAV fil\VE BEEN REDUCED lJV PAlO CLA!MS.
H;;R ~~ .. -----.-
LTR INSR[] TVPi OF INSURANCE I POLICY NUMBER
~NERAL LIABILITY I
! X CO".,.,ERCIAl GENERALLIABIUTYI'
I CLNMS MADE [E OCCUR
~i"~~~
~;~t:Y,=~N
LIMITS
EOL9012327-D1
01/10/06
01/10/07
EACH OCCURRENCE
DAMAGE!o.RENi!D
PREMISE"StF.OGGu~"")
MED. [J(p (Anyone F"rson:
.
.
1,0~
.~~
2,~_~_
1,000,000
. ___ 3,~0~
3,000,000
A
f--
f---~------
GENl AGGREGATE LIMIT APPLIES PER:
f-c-, .~PRO ~
X I POLlCY ! I JEer . 'LOC
PERSCNAl &ADV INJURY _ _~_
GENERAL AGGREGATE $
I
~~oou CT~_~COMP~'~~ ~~~.
.
AUTOMOBILE LlAEUl..rrY
8 . :::Y:~~DAUTOS
SCHEDULED AUTOS
HIREO AUTOS
I NON-OWNED AUTOS
-
-
COMBINED SINGLE LIMIT
(Eaaccide-nt) $
J
BODILY INJUHV
'IIP!lfpar$Onl
BODILY INJURY
(P9l"oocid9tit)
s
.
GARAGE LIABiliTY
=] ANY AUTO
~e:SS I UMBRfL.U\ L.lA8tuTY
~. OCCUR 0 CLAIMS MADE
HI--, DEDUCTIBLE
RETENllON S
I
I
Pp:~~~I~AMAGE
.
AUTO ONl.. Y : EA ACCIDENT
.
OTHER THAN
AUTO ONLY
EA ACC S
AGG $
.
.
~---
.
'-
; EACH OCCURRENCE
,
~(;ATE
WORKERS COIIPENSATlON AND
EMPLOYERS' LIABIL(TY
I ""Wi PItOPRlETORIPAJlTNe~eUTIVE
OFl'lCl!l'lmEMIlEIt.EXCLUDEO?
,~,",duc:I'lIlIIUIIdW
ISPEClAlPROVISlOta_
LjJ:(j / j I /-,
fVL '.7'+'.
.
~!iT"'T\J-~L~
TOPl_VLlMIT1; O~R - --
E.L. EACH ACCIDENT .
E.L DISEASE-EA EMPLOYEE . --
E_L DISEASE-POUCv. IM/T .
I OTHER:
I
i
I
. DESCRIPTION OF OPERATIONS/LOCATIONSNEJiICLESJEXCLUSIONS ADDED BY ENDORSEMENTI SPECIAl PROVISIONS
It is understood and agreed that thQ following eoUty Is added as an additional Insured but onty as respects the operations of the ~med insured
except that Uability resulUng from the additional insureds sole negligence.
CERTIFICATE HOLDER
CANCELLA TlON
Tho Cjty of Santa Ana
20 C'vlc Centeor PIau!.
santa Ana CA 92702
SHOULD PJfV OF THE ABOVE DESCRIBED POL,CII:.S BE CANCELLE"Q BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURfR WILL MAIL 10 DAYS WRI-:-TEN
NOTlCF TO THE CERTWtCATF HOLDER NAMED TO THF LEFT
AUTHORIZED REPRESENTATIVE
~~~
Jeffrey E. Frick, CEO
@ACORDCORPORATION19Ba
Attention: FX: CARLA THOMPKINS 714-571~209
ACORD 25 (2001108) Certificate #
37082
I'::""', Y
.
. ~~~v F!T~ESS AND WELLN~SS INSURANCE
\ T H 'J) MA '" 9 2 C Li G 1 -l C, B /'; I 1 4 I~ -;' /I'J '-' F f< '2 (4::' n" 8 ':' p
POLICY NUMBER EOL9012327-01
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED-OWNERS, LESSEES OR
CONTRACTORS (Form B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY
SCHEDULE
Name of Person or Organization; The City of Santa Ana
20 Civic Center Plaza
Santa Ana CA 92702
(If no entry appears above. information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization
shown in the Schedule, but only with respect to liability arising out of "your work' for that insured by
or for you
Primary and noncontributory
~~
CG20 10 1185
Copyright. Insurance Services Office, Inc, 1984
Certificate # 37082