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HomeMy WebLinkAboutTaller San Jose 3as✓ AGREEMENT TERMINATION Please complete this form when the attached agreement is no longer in effect. Return form to the Sr. Deputy Clerk of the Council (M -30). Call 647 -5238 if you have any questions. The agreement with Joil CV I QM ,®%D sE Gk , No.A - �?oo4 -!4 was completed on , and final payment has been made. (}Z A - 31003 -,c�s- Department: C U Signature: n_� V f 1 Date: City of Santa Ana Revised 8 -7 -03 Clerk of the Council A- aao-,f -i I q AMENDMENT TO AGREEMENT tbft �) THIS AMENDMENT, made and entered into this 1st day of July, 2004, by and between Taller San Jose Tech ( "Contractor ") and the City of Santa Ana, a charter city and municipal corporation duly organized and existing under the Constitution and laws of the State of California ( "City "). RECITALS A. The City and Contractor entered into that certain Agreement dated October 1, 2003, hereinafter referred to as "said Agreement ", to provide career preparation and basic skills services for disadvantaged youth who are out -of- school. B. The parties hereto now desire to amend the "City's Obligations" amount found in Section 2 and the "Time Period of Agreement" term of Section 3 of said Agreement, as well as substituting an updated Exhibit B 1. WHEREFORE, in consideration of the mutual and respective covenants and promises hereinafter contained and made, and subject to all of the terms and conditions of said Agreement as hereby amended, the parties hereto do hereby agree as follows: The "City's Obligation" section of said Agreement will be amended to read: ..a sum not to exceed S1 12,015 „ 2. The "Time Period of Agreement" section of said Agreement will be amended to read: "... shall have been performed by Silly 10,2005." 3. "Exhibit B" to said Agreement will be replaced by 2004/05 Program Activity Work Plan commencing on July 1, 2004 ( "Exhibit B I"), attached hereto and incorporated herein by this reference. 4. Except as hereinabove modified, the terms and conditions of said Agreement remain unchanged and in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Amendment to said Agreement the date and year first above written. ATTEST:�J Patricia E. IV'—Clerk of the Council APPROVED AS i O FORM: -(- By: Lisa E. Storck Assisgdyt City Attorney FOR Patricia C. WhitaYer, ExMutive D: Community Development Agency CITY OF SANTA ANA David N. Ream, City Manager TALLER SAN JOSE Sister Eileen McNerney Executive Director INSURANCE ON FILE WORK MAY PROCEED UNT L INSURANCE EXPIRES CLERK OF COUNCIL, �1 DATE:. 1-,4— 0- Provider Name: TALLER SAN JOSE Program Name: Taller Tech (TSJT) ✓ OUT -OF- SCHOOL BUDGET Line Item Budget FY 2003 -2005 (10/01/03 — 6/30/05) * See Budget Narrative — separate sheet following detailing these costs Revised 7/16/2004 EXHIBIT 8 1 Administrative Pro ram Total WIA Match/in Kind Personnel Expenses Salaries* $0 $410,500 $55,500 $355,000 Benefits $0 $60,250 $0 $60,250 Other — StudentA rentices* $0 $101,200 $25,000 $76,200 Total Personnel $0 $571,950 $80,500 $491,450 •O erat ng Expenses Rent or User Fee $24,955 $24,955 $0 Utilities - - Telecommunications Parking Fees Security Maintenance Insurance Equipment Rental Fees Purchase Vehicle Lease Charges Office Expenses (consumables) Accounting Services Legal Services Auditing Services Indirect Costs Staff Training Staff Travel/Mileage Customer Training Support Services* Profit (for profits only) - - - - Other — Uniforms & Instructional Materials* $0 $6,560 $6,560 $0 Total Operating Expenses $0 $6,560 $6,560 $0 GRAND TOTAL $0 $603,465 $112,015 $491,450 * See Budget Narrative — separate sheet following detailing these costs Revised 7/16/2004 EXHIBIT 8 1 • Provider Name: TALLER SAN JOSE Program Name: Taller Tech (TSJT) ✓ OUT -OF- SCHOOL BUDGET Proposed BUDGET NARRATIVE FY 2003 -2005 Personnel Expenses: Budget: Staff Salary • Jerry Lazzari, Training Instructor (.50) $39,000 • Daniel Suarez, Training Coordinator (.25) $16,500 Student Wages (375 hrs @ $7.50/hr) $25,000 Sub -Total Personnel: $80,500 Operating Expenses: Rent or User Fee (15% of $9,435 monthly payment) $24,955 Other — Uniforms & Instructional Supplies • Includes project materials tool belt, hand tools, safety gear, book and workbook, uniform and boots $6,560 Sub -Total Operating: $31,515 Total Budget: $112,015 Revised 7/16/2004 EXHIt3li- B I El w � s � G CD k % � : k § & @ IL ) z \ } IL a- \ PD CD } \ \ j LLI R « e k § 0 LLI m k � b Q& / § @ � oa: =3y .±a »e|;�f . : oo'aED )/63X3) a )CC _ � k \ mo0 2 = /\ �0 �§ 2 !_« )( j) \ * .� } \ \ }�\ }\ may) o } \ ƒ`3 �� co I� / \ \ PD CD } \ \ j LLI R « e k § 0 LLI m k � $ / k / § @ � EX H |b|| 81 � � � -1— I� 0 } °o U O 7 c 0 0 L N c L O a m c y w c m a °: m a N E a to 0 0 0 N a (a a `o V E L cm Q CL w M 1 z O a w m_ � I co 0 z O a W ( l\ 111 to 1 v rVd4 e ' > W \ , IL \\ C1 1 � � EXHIBIT BI a 9 A m ACORD�, CERTIFICATE OF LIABILITY INSURANCEPage 1 of 2 07/07/2004 PpDDUCEP 877- 945 -7378 Willis North America, Inc. - Regional cart Center THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26 Century Blvd. POLICY EXPIRATION A D 6/30/2005 P. O. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE INSURED Sisters of St. Joseph of Orange INSURER A. American Unity Group Ltd C0929 -001 Santa Ana Work Center 480 South Batavia INSURER B. INSURER C: Orange, CA 92B68 INSURER D' $ INSURER E. 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. INSR TR A TYPEOFINSURANCE GENERAL LIABILITY POLICY NUMBER DNI- CGL -04- 01-020 POLICYEFFECTIVE 6/30/2004 POLICY EXPIRATION A D 6/30/2005 LIMITS EACHOCCURRENCE $ 2,000,000 aaWba- ` xa�wxer uA> f�, xX) xxlxmnc�ax�rlmclxcrliOxizt >rr�tlw�ssaixxx�sa�rx Santa Ana Work Center X COMMERCIAL GENERAL LIABILITY 1000 E. Santa Ana Blvd. gUTi{D IZEO Suite 20D0 FIRE DAMAGE (Any one fire) $ CLAIMSMADE 1 OCCUR MED EXP(Any one person) $ PERSONAL &ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accitlenq $ BODILY INJURY (Per person) $ LHIRE(DAUTOS BODILY INJURY $ - PROPERTYDAMAGE (Peraccitlent) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S OTHERTHAN EA ACC AUTO ONLY: AGG $ ANY AUTO S EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR CLAIMS MADE - -_,r S 0VV'D '`O't... �S $ DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY � )- '� p\ 'K {1OPI }" H- TN RY STATIU LIMT OTR $ E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L.DISEASE- POLICYLIMF $ l OTHER DESCRIPTION OF OPERATIONWLOCATIONSNEHICLESIE XCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS The Certificate Holder is named as Additional Insrued by endorsement to the policy subject to the terms set forth in the endorsement. Re: SSJO dba Taller San Jose, Block Grant - 810 N. Poinsetta, Santa Ana, CA 92701 H OLDER INSURED' INSURER LETTER: CANCELLATION CERTIFICATE ADDITIONAL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL 2 WOh°76RXXX MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEF 'i>;6Q]['J.'7GNffiKXIXDt4C9WG7PYLL aaWba- ` xa�wxer uA> f�, xX) xxlxmnc�ax�rlmclxcrliOxizt >rr�tlw�ssaixxx�sa�rx Santa Ana Work Center i5�7C4G1f65X %X 1000 E. Santa Ana Blvd. gUTi{D IZEO Suite 20D0 Santa Ana, CA 92701 �ESENTATVE 1 ACORD 25- S(7197) Coll:1036362 Tp1:280941 Cert ?4564914 ©ACORDCORPORAM. 1988 ACORDTN CERTIFICATE OF LIABILITY INSURANCEpage 1 of 2 DATE 06/25/2004 PRODUCER 877- 945 -7378 Willis North America, Inc. - Regional Cert center THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26 Century Blvd. POLICY EXPIRATION P. D. Box 305191 Nashville, TN 372305191 INSURERS AFFORDING COVERAGE INSURED Sisters of St. Joseph of Orange INSURERA: Hartford Insurance Company of the Midwest 37478 -001 Santa Ana Work Center 480 S. Batavia Street INSURERS: INSURER C: Orange, CA 92868 INSURER D: G ENERALLIABILITY INSURER E'. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING REQUIREMENT, ANY OR CONDITION OF ANY CONTRACT OR O DOCUMENT RESPECT O CERTIFICATE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 5 SUBJECT TO AL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEF1XWXXXNNIKXOEC0951GN1LL TYPE OF Santa Ana Work Center N32X86K�7[HV�6g 1000 E. Santa Ana Blvd, EACH OCCURRENCE $ G ENERALLIABILITY It A!`llon rn PPnRaTInfJ 1QRR FIRE DAMAGE (Any one Sire) $ COMME RCIAL GENERAL LIABILITY CLAIMS MADE F7 OCCUR M ED EXP(Any one person) $ PE RSONAL B ADV INJU RY $ G ENE RAL AG GREGATE $ PRODUCTS- COMPADPAGG $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOD AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (EaecciGent) $ ANYAUTO ALL OWNED AUTOS BODILY INJURY (Per Person) $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY (Per accident) $ NON -OW NED AUTOS PROPERTY DAMAGE (Peraccident) $ GARAGE LIABILITY ANY AUTO ii ..; • ?(N ru� - -�' - AUTO ONLY - EA ACCIDENT $ EAACC OTHERTHAN AUTO ONLY AGG $ S EXCESS UABILRY OCCUR CLAIMS MADE 'A �, "��� _,eta h S� P�terl�e� key,,. / U`y EACH OCCURRENCE $ AGGREGATE $ $ DEDUCTIBLE A RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY 72WNC93300 5/31/2004 5/31/2005 WC STATU- DTH- }. T Y IT E.L. EACH ACCIDENT $ 21 00 ,000 E.L. DISEASE -EA EMPLOYEE $ 2,500,000 EL. DISEASE - POLICY LIMIT $ 2,500,000 OTHER 7 DESCRIPTION OF OPERATONSLOCAnONBNEHICLESIE XCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS Re: SSJO dba Taller San Jose, Block Grant - 810 N. Poinsetta, Santa Ana, CA 92701 CERTIHICA It RULLILM I I ADDnIDHAL ma11ncu; irveuncry �ci ice,.. — ^•--- - --- -- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL Xff2U6 2EK MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEF1XWXXXNNIKXOEC0951GN1LL �i:IKQEfiIQENKX1KXli(I NEE'} EK` iQiQ�. ESKIY .ENSKiEQ�5n1Q'KiEE�IiA�fF}. Santa Ana Work Center N32X86K�7[HV�6g 1000 E. Santa Ana Blvd, AUTHORIZED REPRESE TATI Suite 2000 Santa Ana, CA 92701 It A!`llon rn PPnRaTInfJ 1QRR ACORD 25- S(7197) Coll:1027012 Tpl:2 /ZouA cerc: xevvxii X1004 07 /1Z /zee4 11,:00 FAR 714 :147 TABB g.Tor RT RtC r1ANAGRMF.NT ADDITIONAL INSURED ENDORSEMENT FOR CO1V WRCIAL GENERAL LIABILITY POLICY Insurance company: AMMWMV111i � This endommneat modifies such insurance as is afforded by the provisions of Policy # 01- 02()ti 1AM1 -nn-W relating to the following: uF>� ].. The City of Serifs Ana 20 Civic Center Plaza, Santa Ana, California 92701; its cers employees, agents, volunteers and representatives are named as additional of$ with nieureds (` and us pmfomrod b behalf of the named sue. suits arising from the operate" 2, With respect to claims arising out of the operations and uses performed by or on behalf of the named insured. sucb insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect to the additional insureds, this insurance shall not be cancelled, or been given to the ity of Santa Ana�20 Civic Center PlazSanta days na, Ca forma noticc 2701 (Completion of the followin& including countersignature, is required to hake this endorsement effective.) Endorsement A3 Effective 0[+/10104 to 06/30/05, this endorsement form as a part of Policy# I -Q - 04 -01- 02011 - 14601-00 -041. Issued to St roseoh Health Svstem Named Insured 217-PROVED AS TO FCCountcrsignedby Aurhori1W Representative LISA E. Z TI UM R City Attorney MISSION r RUI'I I HLLCK bHN It'-11 08/16/9006 18129 PAX 71.4 AA7 76RR rH /14J ¢.TUC RTAR MANACRMFVT Sep. 09 2005 09:39PM P2 Z002 ACORD„ CERTIFICATE OF LIABILITY INSURANCE P, e 1 of 2 07/08/2005 IRN TWHOP [IIMMC9 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ►waUCIR 877 -945 -7378 ONLY AND CONFERS NO RIGHT3 UPON THE CERTIEFICATE 3 NOT AMEND, EXT NO OR willia Marty America, 300. - Regional Cart Center HOLDER, THIS CERTIFICATE 00 ALTER THE :OVIERAQE AFFORDED BY THE POLICIES BELOW. 26 Century Blvd, ONWRA4 P. o. boa 398191 IraPhville, M 312305191 INSURERS AFFORDING COVERAGE INSURER& AeeriaJa Onit Oro Ltd -- NJUCM 00999 -D03 mull= Sisters ar Bt, .Toas9h of Orange t - 490 South Batavia orange, CA gloss PBRSONALIADVINJURY W8IJPER E 1i47v H L1 'o THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N07WITHSTANOING ANY REgUB(�EMTXT, TERM OR CONDITIIO�NN OF7AN�YpCONTRACT OR OTHER DOCUMENT WITH RIEBPECT TO WHICH THIS CERTIFICATE MAY BE 189UE0 CR MAY IqE�& AGONEGATE INSURANCE BHO_WN MAV HAVE BEENREpUCDESCRIBED E 6 I CLAIM616 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH "r IRN TWHOP [IIMMC9 P01JCYNW IM Y 6/30/2003 Jalrawir 6/30/2006 LIM11 TI A ONWRA4 LIABILITY COMMBRCIALOENEMUANUTY OIAIMSMADB OCCUR U141- O43L -05 -01 -021 68ONOCCURRENCE ., lEALarJ[0 MEDEIP Ma e11T),.. f OOD.000 5 t PBRSONALIADVINJURY f (f_09_~ G JWER!j_AGORE"Tq. f �• yQaQ-_ 0 OBNIAODMOAT _ UMR APPLIES PER: PRODUCT$- COMPAOPADO I Pouw vIOMOIBA UAMLDY ANYAUTO OOWIW031NMR UNT IEs saoMMq f - .--,- 3 ALL OWNED AUT06 SCHPDLILPDAUT02 BODILY INJURY (P[rpwwA) 0001LYINJURY (Parawld"11 t______.._.._..._._ t HIREOAUTDS NON- OWIRDAUTOB ry' PROPERTY DAMAGE (P.rsaNdM9 OMAOS LIABILITY 1,, In AUTO ONLY - EA ACCLgFp_! S , f ANYAUTO 1'yL ✓ pRGK OTHERTHHpAN EAACC AUTO Ora Y. 900 INCP"LMAILRY OCCUR n CIAIMSMADE X. ASSISI t ow AtLOr ` GAON OCCURRENCE —.- AGGREGATE.... b 5 f _. DEDUOTHU RETENTIONc;TpTU WOWJMCOMPINDATMNANO EWLOWRS' UAMUTV PROPoETARfNER ficume UNSC .MMBaOOIIUUiiSSDD ELEACHACCIDENT ;WFIUEO FLDIGEASE -FA EMPLt E �OISEASC- POLICY f nfBR OpCMPr4NOPOMMTWN"OCATNHNINMM M9CWMONaAON10MBN MMONTWWALPRMSI)NS Certificate Holder added an Additional lnsurad by endorsament to policy Subject to the terms Sat forth in the endorsement. BBJO dba Taller Ban Jose, Block grant, BID N. Poineetta, Santa Ana, CA 92701 City of Santa Ins, its ofrioare, agents and 1 a Ooamweity Development Agency 20 Cic Canter Plana NO. M23 - P.O. Sea 1980 Atcal Lucy ►loree Santa Ana, CA 92702 INOULOANYOPTN4ABOVIONICR tWDPOUCH! WCANCBLLIDNBPORPTNBBIPIItATION DAT/ TNIRIOP, THE IIBUINC INIURIR WILL VAW�rMAL 30 DAYS WRIITBN WOMB TO THI CBIITIPICATI NOLORR MAMBO TO TH9 LIFT+ ---- •�--- i-- -••��r vouaaaw'Fee yp11389028 Cert I39B92o7 OACORO CORPORATION 1989 r KUM .IHLLtK bHN ILUM 08/15/2005 18:24 FAX 714 347 756A FHK NU. : e145b'J0'J41 9199 RISK MANACRXRVT Sep. 09 2005 09:40AM P3 121004 &Q8?r. ANY REQUIREMENT, TERM OR CONDITION ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR CERTIFICATE OF LIABILITY INSURANCE;*js 2-of 2 1 05/2711005 PNOOuca 877 -945 -7378 THIS CERTIFICATE 16 ISSUED AS A MATTER OF INFORMATION ONLY AND CON W5 NO RIGHTS UPON THE CERTIFICATE Millis North AINars", 1a0. - Regional Cart Center 36 century fivd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EMEND OR ALTER THE (:OVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAICM P. D. Aar 103191 Naahville, TO 372309191 INEUR60 Sisters Of gt. Joseph cE Orange INSURERN farCMrd insurance Company of the nidvast 37478.001 ego South Aetavia Orange, CA 97163 NBVRERE -_- -- ,_....- _.__....— ...._.._'-' NTED MEO Ex &JAne e"00.2_ wBURENc -- -._, S BVBURER6 -„_ R E: d•713TT117:1 THE POLICIES OF INSURANCE LIST80 BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR DOFF MAY PERTAIN AIN THe INSURANCE IM Y A FN THE POLICIES OEBCRISED.IEAEI91S SUBJEOT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH VE BEEN REDUI.EO BY PAID CL I _..— _..— __._._.._. _....... TrrrGPINEURANDE YRU P �JCY�Py1 DN LMara SSR�GU NRIPALUAaLT• -ACHOCCURRENOE '�0 6 — CaMMENCIALGEHQNPLUA01LRY CLAIWMAIM ED OCCUR NTED MEO Ex &JAne e"00.2_ $ -- -._, S -„_ PERSONAIAADVINJURY GBNEAALAGGREOATE GDN'LAOGRgO7j;ITAPPLRe PER PRODUCTS- COMNOPAGO S -- POUCY AUTONOBRELMNLRY AMY AUTO i]ED CU Q Fc.. EASMAMgSINCLE LIMIT S ALL OWNED AUTOS 11CHEDULEDAUTOO HIREDAUTOB NONCWNEDAJr08 _ _- _...._, ._....�......._ 1 >- �(SA pssistan t $' j C" Y, ��ty Attorne BODILY INJURY (P+TPmm) $ a00LYINJURY (Permenenq ._ ....... ... a PROPERTYOANWCE (PM.ncMPnO a GARAGE UAfR11Y AUTOO/LY.EAACCIDENT S OTHERTHAN EAACC AU ONLY: ADD S ANYAJTO S EECSfs L1AaRTTT OCCUR CIAINBABWE FAH CURRENCE S AGGREGATE _ i f DEDUCTIBLE _ a RETENTION 6 A VWOAMBCCOMPN`ITONAND 72WSC93300 5/31/2005 5!31/2006 r-)ISEA4E-6A!LMPLOYEE. EACI1 ACCIDENT •,,. .._ 9 a,,Qf�_Q,AQQ, OTflc6MAfiBRE E% 110EDPofiXEDUTNE OPFICEfUMEBRE % U fAWLF1 dR IALP D18EASE- POIJOY OTHER DEEOIPTION OF GnRA7w1BA. YICMFMHMAaMUUfNNa Amron •aNGOafBNR!wNSreG1ALPRrnnfwNe Rol 69JO dba Taller Ban Jose, Block Giant, 910 N. POinnotta, .3anta ADa, CA 99701 City of asnu an&, Lea officer., &genes and 6gloy.. Community Develol.eant Ago"y 30 Civic Center Plaza NO. N33 - P.O. Has 1880 ateno Lnay Flora& gout* Ana, Ch 97702 SHOULD AMY OPTMIAIOVE0"0409D rouCMB of CANOELLED 9CPOK TK ""RATION DATE THEAEOP. THI! MOVING INSURER WILL MAIL 30 DA" WRITTEN M071M TO THE CIHTIPICATB NOLDER NAMIP TO THE LEPf L AcvlRD 23 poolmo; 001111308867 Tpl.,374004 C tlsgo 14 OACORDCORPORA ION 1989 rnn ivy. r i"oovr VV l yep. n7 eolaJ 0 .0; 4t9H9 H4 ADDITIONAL INSURED ENDORSEMENT Insurance Company: American Unity Group, Ltd. This endorsement modifies such insurance as Is afforded by the provisions of Policy # UNI - CGL -05 -01 -020 (1 -14601 -00 -05 ) relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92702; its officers, employees, agents and volunteers are named as additional insureds ( "additional Insureds ") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named Insured, such Insurance as Is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional Insureds. 3. This insurance applies separately to each Insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an Insured shall not affect any right which such person or organization would have as a claimant if not so Included. 4. With respect to the additional insureds, this insurance shall not be canceled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92702. (Completion of the following; Including countersignature, is required to make this endorsement effective.) Effective 06/30/05 to 06/3010 this endorsement form as a part of Policy# UNI- CGL- 05 -01- 020(1- 14601 -00 -05) Issued to St. Joseph Health System