HomeMy WebLinkAboutCAMBODIAN FAMILY, THE 5 - 2004
A-2004-203
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CLERK OF COUNCI'Jt
D~TE: II~BO-oT
THIS AGREEMENT, made and entered into this ~ day of ~ ,2004 by
and between The Cambodian Family, Inc. (hereinafter "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 (hereinafter "City").
CONSULTANT AGREEMENT
RECITALS
A. The City, as a grantee of the United States Department of Justice Weed and Seed Grant
Award, pursuant to Title I of the Omnibus Crime Control and Safe Streets Act of 1968,
42 U.S.C. 3701, et. seq. (hereinafter "the Act"), desires to enter this Agreement with
Consultant for the expenditure of Weed and Seed Grant funds to operate a Weed and
Seed Safe Haven site.
B. Consultant represents that it is able and willing to provide such services to the City.
C. The City and Consultant have duly executed this Agreement for expenditure of said
funds.
NOW THEREFORE, it is agreed by and between the parties that the foregoing Recitals are a
substantive part of this Agreement and the following terms and conditions are approved and,
together with all exhibits and attachments hereto, shall constitute the entire Agreement between
the City and Consultant:
1. SCOPE OF SERVICES
Consultant shall provide a Safe Haven Site and services as set forth in Exhibit A to this
Agreement.
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 $13,000.00 during the term of this Agreement.
b. Payment by City shall be made within thirty (30) days following receipt of proper
invoice evidencing work performed, subject to City accounting procedures. Payment need not
be made for work which fails to meet the standards of performance set forth in the Recitals
which may reasonably be expected by City.
3. TERM
This Agreement shall commence on October 1,2004 and terminate on September 30,
2005, unless terminated earlier in accordance with Section 14, below. The term ofthis
,
Agreement may be extended upon a writing executed by the Executive Director of the
Community Services Agency and the City Attorney.
4. INDEPENDENT CONTRACTOR
Consultant shall, during the entire term of this Agreement, 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, a joint 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
employees and shall be responsible for all applicable withholding taxes.
5. 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. Commercial General Liability Insurance. Consultant shall maintain commercial
general liability insurance naming the City, its officers, employees, agents, volunteers and
representatives as additional insured(s) and shall include, but not be limited to protection against
claims arising from bodily and personal injury, including death resulting therefrom and damage
to property, resulting from any act or occurrence arising out of Consultant's operations in the
performance of this Agreement, including, without limitation, acts involving vehicles. The
amounts of insurance shall be not less than the following: single limit coverage applying to
bodily and personal injury, including death resulting therefrom, and property damage, in the total
amount of$I,OOO,OOO per occurrence. Consultant shall supply City with a fully executed
additional insured endorsement in substantially the form attached hereto as Exhibit B upon
execution of this Agreement and shall be approved in form by the City Attorney.
b. Business automobile liability insurance, or equivalent form, with a combined single
limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for
owned, hired and non-owned automobiles.
c. Worker's Compensation Insurance. In accordance with the provisions of Section
3300 of the Labor Code, Consultant, if Consultant has any employees, is required to be insured
against liability for worker's compensation or to undertake self-insurance. Prior to commencing
the performance of the work under this Agreement, Consultant agrees to obtain and maintain any
employer's liability insurance with limits not less than $1,000,000 per accident.
d. The following requirements apply to the insurance to be provided by Consultant
pursuant to this section:
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(i) Consultant shall maintain all insurance required above in full force and
effect for the entire period covered by this Agreement.
(ii) Certificates of insurance shall be furnished to the City upon execution of
this Agreement and shall be approved in form by the City Attorney.
(iii) Certificates and policies shall state that the policies shall not be canceled
or reduced in coverage or changed in any other material aspect without
thirty (30) days prior written notice to the City.
e. If Consultant fails or refuses to produce or maintain the insurance required by this
section or fails or refuses to furnish the City with required proof that insurance has been procured
and is in force and paid for, the City shall have the right, at the City's election, to forthwith
terminate this Agreement. Such termination shall not effect Consultant's right to be paid for its
time and materials expended prior to notification of termination. Consultant waives the right to
receive compensation and agrees to indemnify the City for any work performed prior to approval
of insurance by the City.
6. INDEMNIFICATION
Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents,
employees, consultants, special counsel, and representatives from liability: (1) for personal
injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims
for personal injury, including health, and claims for property damage, which may arise from the
direct or indirect operations of the Consultant or its contractors, subcontractors, agents,
employees, or other persons acting on their behalf which relates to the services described in
section I of this Agreement; and (2) from any claim that personal injury, damages, just
compensation, restitution, judicial or equitable relief is due by reason of the terms of or 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 or by reason of the terms
of, or effects, arising from this Agreement. The Consultant further agrees to indemnify, hold
harmless, and pay all costs for the defense of the City, including fees and costs for special
counsel to be selected by the City, regarding any action by a third party challenging the validity
of this Agreement, or asserting that personal injury, damages, just compensation, restitution,
judicial or equitable relief due to personal or property rights arises by reason of the terms of, or
effects arising from this Agreement. City may make all reasonable decisions with respect to its
representation in any legal proceeding.
7. CONFIDENTIALITY
If CONSULTANT receives 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 ofthe other
3
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 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.
8. CONFLICT OF INTEREST CLAUSE
Consultant covenants that it presently has no interests and shall not have interests, direct
or indirect, which would conflict in any marmer with performance of services specified under
this Agreement.
9. SOURCE OF FUNDS
Consultant acknowledges that the funds being provided by City for Consultant's services
are received by City as a grant from the United States Department of Justice, and warrants that
expenditures ofthese funds shall comply with the laws, regulations and policies governing use of
said funds as set forth in Title I of the Omnibus Crime Control and Safe Streets Act of 1968, 42
U.S.C. 3701, et. seq.
10. CONSULTANT CERTIFICATIONS
Consultant agrees to be bound by all the terms and conditions of City's Grant Agreement with the
United States Department of Justice, including but not limited to:
a. Audit Report Requirements. Consultant agrees that if Consultant receives Three
Hundred Thousand Dollars ($300,000.00) or more in federal funds. Consultant shall
have an armual audit conducted by a certified public accountant in accordance with the
standards as set forth and published by the United States Office of Management and
Budget - OMB Circular A-133. Consultant shall provide City with a copy of said Audit
by October I.
b. Record Keeping/Reporting. Consultant shall keep and maintain complete and adequate
records to assist City in meeting and maintaining its record keeping responsibilities
under the Act. City and the United States Goverrunent and/or their representatives shall
have access for purposes of monitoring, auditing and examining Consultant's activities
and performance, to books, documents and papers, and the right to examine records of
Consultant's subcontractors, bookkeepers and accountants, employees and participants
in regard to said program. Nothing herein shall be construed to require access to any
privileged or confidential information as set forth in federal or state law.
c. Use of Funds. Consultant certifies and agrees that it will not use funds provided through
this Agreement to pay for entertainment, meals or gifts.
4
d. Lobbying. Consultant certifies that it will comply with federal law and regulations
found at 24 CFR Part 87, which provide that no appropriated funds may be expended by
the recipient of a federal contract, grant, loan or cooperative agreement to pay any
person for influencing or attempting to influence an officer or employee of any agency,
Member of Congress, or an officer or employee of a Member of Congress in connection
with awarding of any federal contract, the making of any federal grant or loan, entering
into any cooperative agreement and the extension, renewal, amendment or modification
of any federal contract, grant, loan or cooperative agreement.
e. Drug Free Workplace. Consultant certifies that it has established the following drug-
free workplace policy:
I. The unlawful manufacture, distribution, dispensing, possession or use of a
controlled substance is prohibited in the workplace for any employee involved in a
federally funded program.
2. As an employee working in conjunction with a federally funded program, the
employees of Consultant will be required to:
. Abide by the terms above in statement I.
. Notify appropriate officials of Consultant and City officials of any criminal drug
statute conviction for a violation occurring in the workplace not later than five
days after such conviction.
. The United State Department of Housing and Urban Development will be notified
within ten days after receiving notice of any such violation.
. Within 30 days of receiving such notice, appropriate personnel action will be
~en against such employee, up to and including termination.
. Each such employee shall be required to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a federal, state
or local health, law enforcement, or other appropriate agency.
f. Consultant assures and certifies that it will not use any funds appropriated under this
Agreement for religious activity or anti-religious activity, or to promote or oppose any
political candidate, party or belief.
g. Consultant assures and certifies that where applicable, classroom instructors are properly
credentialed, and training curriculums comply with State Education Codes.
h. Consultant assures and certifies that it is in good standing with the California Secretary
of State, Franchise Tax Board and Internal Revenue Service.
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
5
mailed by first class or certified mail, postage prepaid, or sent by telefacsimile or other
telegraphic communication in the manner provided in this Section, to the following persons:
To City:
Clerk of the City Council
City of Santa Ana
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ana, CA 92702-1988
telefacsimile (714) 647-6956
With courtesy copies to:
Executive Director of Community Development
City of Santa Ana
20 Civic Center Plaza (M-25)
P.O. Box 1988
Santa Ana, California 92702
telefacsimile (714) 647-6736
and,
City Attorney
City of Santa Ana
20 Civic Center Plaza (M-29)
P.O. Box 1988
Santa Ana, California 92702
telefacsimile (714) 647-6515
To Consultant:
The Cambodian Family, Inc.
1111 E. Wakeham Ave., Ste E
Santa Ana, California 92705
telefacsimile (714) 571-1966
Attn: Rifka Hirsch
A party may change its address by giving notice in writing to the other party. Thereafter,
any notice, tender, demand, delivery, or other communication shall be addressed and transmitted
to the new address. If sent by mail, any notice, tender, demand, delivery, or other
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 telefacsimile, any notice, tender, demand, delivery, or
other 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.
6
12. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and
Consultant, 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 ofthis Agreement shall prevail. 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 and conditions hereof, shall not bind or obligate Consultant nor
the City. Each party to 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 upon thirty (30) days written notice of
termination. 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. Payment need not be made for work which fails to meet the standard of performance
specified in the Recitals of this Agreement.
15. DISCRIMINATION
Consultant shall not discriminate because of race, color, creed, religion, sex, marital
status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited
by applicable law, in the recruitment, selection, training, utilization, promotion, termination or
other employment related activities. 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. Both parties further
7
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.
17. PROFESSIONAL LICENSES
Consultant shall, throughout the term of this Agreement, 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 States, the State of California,
the City of Santa Ana and all other governmental agencies. Consultant shall notify the City
immediately and in writing of her inability to obtain or maintain such permits, licenses,
approvals, waivers, and exemptions. Said inability shall be cause for termination of this
Agreement.
18. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature hereinbelow has the power,
authority and right to bind their respective parties to each of the terms of this Agreement, and shall
indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to
City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn.
b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set
forth in the body of this Agreement.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year
first above written.
~,;~d~
PATRICIA E. HEALY
Clerk ofthe Council
CITY OF SANTA h
aA~~
DAVIDN. REAM
City Manager
APPROVED AS TO FORM:
--K;u~aJn~7
JOSEPH W. FLETCHER
City Attorney
CONSULTANT
~~
Executive Director
Tax ID# 9S - j If~'t 8' 3/
8
EXHIBIT A
SCOPE OF SERVICES
Consultant shall develop, coordinate and implement a "Weed and Seed Safe Haven" site
program to provide after-school computer and academic tutoring services. Consultant will serve
a minimum of70 youth from 1st to 12th grade during the term of this Agreement
Academic tutoring will be offered in various subjects. Students will also have access to
computers with Internet access and web site development training.
Consultant will comply with all reporting requirements of the Executive Office for Weed and
Seed. Such requirements include providing monthly report to the City Community Development
Agency, describing the number of clients served and the type and level of services provided.
Consultant shall include the following documentation regarding the program:
Registration forms
Attendance sheets or sign-in sheets
Copies of flyers/marketing materials used to promote the program
Pictures of special events
Pre and post tests to determine program effectiveness
Safe Haven survey
COMPENSATION
Consultant shall be compensated as follows:
Youth Counselor @
$12.00 per hour x 11 hours per week x 51.50 weeks
$6,798.00
Assistant Youth Counselor @
$8.00 per hour x 10 hours per week x 50.50 weeks
$4,040.00
Total Salaries
$10,838.00
Benefits @ 20% total salaries
2,162.00
Total Salaries and Benefits
$13.000.00
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.
"
EXHIBIT B
ADDITIONAL INSURED ENDORSEMENT
FOR COMMERCIAL GENERAL LIABILITY POLICY
Insurance Company
This endorsement modifies such insurance as is afforded by the provisions of Policy
# relating to the following:
1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its
officers, employees, agents, volunteers and representatives 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 cancelled, 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 92701.
(Completion of the following, including countersignature, is required to make this endorsement
effective.)
Effective
Policy #
Issued to
, this endorsement form as a part of
Named Insured
Countersigned by
Authorized Representative
10
. ACORD
- '---TM
PRODUCER (714)838-1912
Lake Insurance Agency
13891 Newport Ave., Suite 285
L ic #0747473
Tustin, CA 92780
'i'NSU'R"ED Cambodian Family _.'~------,
1111 East Wakeham Avenue
Suite E
Santa Ana, CA 92705
INSURER B
!NSURER C
~~SURER 0
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUR~D NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDtN
ANY REQUIREMENT, TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY Pl:::KTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HFREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF sue, I
!=lOLlCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
l~rt4~ TYPE OF INSURANCE POLICY NUMBER OA TE MMmrl~- DATE" jM'iuDO/YY LIMITS
GENERAL.l1A81L1TY PHPJ<074625 03/()9/2004 03/09/2005 EACH OCCURRENCE , 1,000,00
I X COMMFRcrAL GENERAL LIABIUTY ~s!::_~~I~~~~IICe\ , 300,00
I .-n CLAIMS MADE 0 OCCUR
MED Ex,," (Any one ~l;:rsOll) , 5 ,()O,
A I X 0 deductibl e PERSONAL & ADV INJURY , 1,000,001
t- GENERI'IL AGGREGATE , 3,000_,001
rm:N'L AGGREGATf l tMlT APPLIES PER: PRODUCTS. COMPIOP AGG . include.
!Xl UP"O. n
X POLICY JI:CT lOe
AUTOMOBILE liABILITY PHPK074625 03/09/2004 03/09/2005 COMBINED SINGLE LIMIT
t- ANY AUTO (ElIilc.cil..lCnl) .
1,OOO,OO(
- ALL OWNI:D AUTOS
- BODILY INJURY .
SCHWULED AUTOS (Per person)
A X HIRt;D AUTOS
BOQll Y INJURY
X IPereccident) .
NON.QWNEDAUTQS
~ $0 Deductible _.
PROPERTY DAMAGE S
(Per tlccidenl)
GARAGE UABILITY REVlSEIJ AUTO QNL Y . EA ACCIDENT ,
==J ANY AIITO OTHER THAN lOA ACe s
AUTO ONLY: AGG .
EXCESSJUMBR:HLA L1A51L1TY EACH OCCURRENCE .
=:J OCCUR o CLAIMS MAD!: AGGREGATE .
S
1 DEDUCTIBLE .
RETENTION . 1/ f I , J. I
WO'KE'SCOMPENSATIONANOC~t2I 'VtAY'.)t\.(dJ2f;P' ((-""- W.TORYlIMITSI I-ER'
EMPLOYERS' LIABILITY - ~ "'.....- ;:;;.--,
ANY PROPRIETORfPARTNER/EXEC TIVE E,L. EACH ACCIDENT I
OFFICERiMEMBER EXCLUDED? . . E.I" DISEASE. EA EMPLOY_I:! .
l1yel!i, d.escribevnder
5PECIAL PROVJSIQNS below E,L. DISEASE . POLICY LIMIT I
OTHER PHPK074625 03/09/2004 03/09/2005 $1,000,000 Each Claim
buse & Molestation
A $3.000,000 Aggregate
SO Deductible
E~ESCRt...noN Oo!' ?PERATIONSJ LOCATIONS I Vf:IIICLESJ exCLUSIONSADOED BY ENOORSEMENT / SPECIAL PROVISIONS
~mployee Dishonesty liability $200,000 / 0 Ded.
Certificate holder is named as additional insured per contract with named insured.
Schedule of vehicles and drivers on file.
~lO day notic~ of cancella~ion due to non-payment of premium.
CERTIFICATE HOLDER
City of Santa Ana
Community Development Agency
CDBG-M-2S
P.O. Box 1988
Santa Ana, CA 92702
CANCELLATION
SHOULD ANV OF THE ABove DESCRIBI'!D POLICIES Be CANCELLED BEFORE THE
EXPIRATION DAn' THEREOF-, THE ISSUING INSURER Will. ~~ MAIL
~- DAYS WRITTEN NonCE TO THf CERTIFICATE HOLDER NAMED TO THE LEFT.
~K)(~I(I(~II,l(N_)l~J9~!(~KKXXX
~1(~~~~~~~J9~~ ~~XXXXXXXXX
D REPRESENTATIVE
ACORD 25 (2001/08) FAX: (714)571-1974
A.1 A n'
.
MAY-13-2004 09:17
THE CAM~nDIAN FAMILY
714 571 1374
. -\.
ADDITIONAL INSURED ENDORSEMENT
Insurance company PHILADELPHIA INDEMNITY IN'SURANCE CO.
This end()rse~ol mOdllles such Insurance as Is afforded by the pro'ti$iQnS of Policy
" PHPK074bl5 !VlaII"g to the foRewing:
1. Ille Clly ~ Santa NlA, 20 ClYte Center Plaza, SantIl Ana. California 9'27()1;
ItS oIIIcers, employees, agllnb and repnl5elltatMls are named as addltlooel insureds
("a&fJlion31 Insureds") with regard to IIabIly IIIld defense Qf suits arising from the
OQer8llons and uses perfomled bv 01 on behalf of '!he named InsUred.
2. With respect 10 clUns amIng out 01 the operaUof1l and UJl86 performed by
or on bllhall of U'lB FllImlld .-.,ured. SLIllh Insnnce es is all'Orded by tnis poliCy is primary
8I'ld is not addItIoN/tc Of CXlntrlbullng with any Clner inliurunOll C8II'il!d by or fot' l/'l!l
beneftt of the SlddtiolI8l ircureds.
3_ 'ThI$ lI'lSUnlI...... appaes separately to e3Plln&ured against whom daim i$
made or suit Is brought -.cept with respect to !he company'$ imlls of 12bl11ty_ The
InoIusion of any plIfSOl'l or OI1lanlzadon as an imured shall not affect eJ'ltI Aght which such
Dersorl or otganlzatlon WQUd ha\Ie as a ClaImant if not $0 k'II'II'r:Jed.
4. WIIh'"i*tI01he 8ddiIIo......1nsureds, Ihis InIurw1ce shall net be cenceIIlld,
Of materially reWced In CCM!!r8Q8 Df imilS eQpt 1fter If1Ir1y (aD) day$ written netlce hils
been glvento the Cl1 d Santa Me. 20 CMo CllnI8r PI&za. Santa Ana,.CaIlfomi8 92701.
(ComploUon ot tIl& tollowtng, including coun(tt8Ign~tLite, is requIred to make this
endorsement 'efteOtiVe.)
Erfe<<lvo 03/09/ D4
.
, this endol'3omen' form as B part of
POlicy" PHPK074625
I$$uad to .THE CAMBODIAN FAMILY
HameCI Insured
.
~ro~
CDun~g"ed by
EXIIlftlT D
X~f,(.dj/;;;;!./-
/
./
o,~.
TOTAL P.02
. , DATE (MM/OOIYYVY)
ACORD. CERTIFICATE OF LIABILITY INSURANCE OP 10 J9
THECA-1 06/24/04
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Chapman & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
License #0522024 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. O. Box 5455 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Pasadena CA 91117-0455
Phone: 626-405-8031 Fax:626-405-0585 INSURERS AFFORDING COVERAGE NAIC#
--~._--_._-_.-~--
INSURED INSURER A: State Compensation In. J'und
-- ---"~-
INSURER B:
The Cambodian Family INSURER c:
1111 E. Wakeham Ave., Suite E INSURER 0:
Santa Ana CA 92705
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.
LTR NSR TYPE OF INSURANCE POLICY NUMBER PDA';!~ 'iJ'~DEn,w}E P~k~l.oll~~b~~N LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
f-- PREMISES (E~~~~~~nce) .___.n__
COMMERCIAL GENERAL LIABILITY $
I CLAIMS MADE D OCCUR MED EXP (Anyone person) $
-.------
I- I PERSONAL & ADV INJURY $
-~---~-- -~----_._- - ---'-
I GENERAL AGGREGATE .
.-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
II ,nPRO' n
POLICY JECT LOC
~OMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Eaaccidenl)
- ,'1JI
ALL OWNED AUTOS VO\' BODILY INJURY
- 0 $
SCHEDULED AUTOS /'.S ~ (Per person)
- --
- HIRED AUTOS O'-l~D BODILY INJURY
fi;~// $
NON-QWNED AUTOS /'.'?'?~ ~ (Peraccidenl)
--
1'""1 PROPERTY DAMAGE .
r;?--..:..\\\.\ J '"' t<\c" (Per accident)
<\n'
GARAGE LIABILITY ~. aU\<- . C\ ~ AUTO ONLY. EA ACCIDENT $
'" .
=1 ANY AUTO S\'3-\.\"- EA ACC $
p...'6~\ OTHER THAN
AUTO ONL V: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
=:J OCCUR D CLAIMS MADE AGGREGATE .
, $
=1 ~EDUCTIBLE .
f--
RETENTION . $
WORKERS COMPENSATION AND X I TOR/LIMITS I IV~"
EMPLOYERS' LIABILITY
A ANY PROPRIETOR/PARTNER/EXECUTIVE 1696570 06/30/03 06/30/04 E.l. EACH ACCIDENT $1000000
-.---.,.
OFFICER/MEMBER EXCLUDED? El. DISEASE. EA EMPLOYEF.: .!..1000000___
If yes, describe under --
SPECIAL PROVISIONS below E.l. DISEASE. POLICY LIMIT $1000000
OTHER
DESCRIPTION OF OPERATIONS fLOCATIONS {VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT {SPECIAL PROVISIONS
Evidence of Coverage
CERTIFICATE HOLDER
CANCELLATION
SANTANA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUT ED REPRE
City of Santa Ana
P.O. Box 1988
Santa Ana CA 92702
@ACORD CORPORATION 1988
ACORD 25 (2001/08)
SC
CERTHOLDER COpy
STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807
COMPENSATION
INSURANCE
FU N D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 06-30-2004
GROUP:
POLICY NUMBER: 1696570-2004
CERTIFICATE ID: 3
CERTIFICATE EXPIRES: 06-30-2005
06-30-2004/06-30-2005
CITY OF SANTA ANA
PO BOX 1988
SANTA ANA CA 92702
SC
A - ADO 1- 08''1 - ()<f
A- ?JDdI- - 1&1
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days' advance written notice to the employer.
We will also give you fO days'advance notice should this policy be cancelled prior to its normal expiration.
This certificate ofirisurance is not an insurance policy and does not amend. extend or alter the coverage afforded
by the policies listed herein. Notwithstanding any requirememt, term, or condition of any contract or other document
with respect to which this certificate ofmsurance may be issued or may pertaln,the insurance afforded by the
policies described herein is subject to all the terms, exclusions and conditions of such policies.
~
t\~c
&L-
AUTHORIZED REPRESENTATIVE PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS.: $1,000,000.00 PER OCCURRENCE.
VED AS TO FORM
APPRO '
~ -.-.---
... . . -_.......-~..
v Laura .:1l,.1 -,. ,
.. Ctty AtI.Orn(:)'
AS:;lstant
on ''0- ~1.o~;i).7'O~ F'r-i
I "...;<..... ,-,ii""..
n",'"
;];'<'-1
EMPLOYER
LEGAL NAME
THECAMBOOIAN FAMILY
1111 WAKEHAM AVESTE E
SANTA ANA CA 92705
THE CAMBODIAN FAMILY
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF 10265
IREV.3-03)
PRINTED' 05/17/2004 P040B
RPR-29-2005 11:06
,
THE C0~BODIRN FRMILY
714 571 1'374
F' . '32134
.
ACORQ. CERTIFICATE OF LIABILITY INSURANCE I O;~~;~)
..n' _
..oouc.. (7H)l34-1912 FAX (714)134-7561 THIS CERTIFICATE IS IS8UED AS A MATTER OF INFORMATION
Lake Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLD!fl THIS CERTIFICATE DOES NOT AMeND, eXTEND OR
13891 Newport AVO!" Suite 2&5 AL Tf:R THE COVERAG~ ,y'fORDED BY THE POLlCIE8 BELOW,
...
Lie '0747473
Tust;n, CA 92780 INSURERS AFFORDING COVERAGE NAle,
l.suO'. caOibiidiait'fa..ny-- .... .__n. - ............ -_..._- 'Ins, -.~.
INlUMR lie Ph i1"'~,l phi a Ind. Co.
p. -;;<UY-!-087'07 ..
1111 EAst Wakeham Avenue IHSUIltR 8: .'--
Suite E A- .;<<ld-/- i~1 --_._- .-....
lf4l1R'AC:
..
Santa Ana, CA 92705 A- ;;;C-o'f-.;;<o3 INlLlfW' D:
;1,- =5- O!S-bDW h.. ..-... . ..
INll,J1IR r
In
THE POLICIES OF 1N$UIlANCE LISTED 8ELOWHAVE BEEN ISSUED TO THI INSURED N.....ED ABOVE FOR THE POLICY PERIOD INDIC~TED NOTWITHSTANDING
ANY REQUlItEMENT, TERM OR CONaTION OF ANY CONTRACT OR On-tER DOCUMENT WTH RESPECT TO WHICH THIS CER:TIFICATF MAY BE IS~UEO OR
OlAV PERTAI~, THE INSURANCE AF'ORDED BY THE POLICIES DESCRIBED HEREIN IS SU8JECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS or SUCH
,'i':~~~u~~TE LIMITS SHOWN.....V KAVE BEEN REDUCED BY P~ID C~IM~ .. ,0..._. ..
'rt: i'i.~'r TYPE a. ........c. I'OUCY NU...~._ _.. . _ ."ali! Inrc n- UMI!~._.. . !.!19.9,000
':"........ ".."rry PHPKll044J 03/09/2005 OJ/09/2006 !ACH OCCURRENCE .
T~-'- DAii\GE'TO REII1tD . 100,00~
. ~.J (:1 AIUS WAOF l!J Qt;f'.t1R .. ._.....h~
"'ED E,lC"IMr 0fIe 1*'10'1] .
-
A X 0 deduetibl e PEllUONAl & Ar:N INJI"lRV . 1,000,000
._ ___..~ _N__.
GENEfW.. J.G.CM:GATf: I 3,000,~!l0
GEN'l,A,GGReGA.1l: LNtT .a.PPLliS PiA PROOUCT!I - COMPoOf' AGG t.~_.. included
.111.a_Lf.yO.!~d~.:..~ --
AUTOIIC)aLE UAWlY ... ....jijjPKiio443 ijjjo9)2'ociS' jji7ii9iz006 COMIIltED S1NOlE UMIT I
-. .
ANY AUrO (1!1MICWIIr't) 1,000,900
.-- AU. OMEn AlJros IIOD... y I~JUlty
SCMiOUIEO AUtos (P'.,pereon) .
A X 11lRfD NJT~ .__on
8ool'. Y INJUFlY
X HlJN.()WhED AUTOS (P.~l .
X I SO Deductible PR()PEA~-C~~~--
i 1"'1Il'~1
--.-. --.---
GAAAGE LIA.UlY NJTO OHt Y . EA ACCIDENT .
=:r ~_<A.UT~" 'n --
OTHER n-wo E"''''CC .
.~.APPROy-' D AS TO FORM. Auro ONL V AM; .
..... ._-. ._-~,~_.,._..'"... ___.....__M"_._ Vj---~;, ,I
tlCCUlNIIIJW.LA ~TY A EACH OCCURRENCE .
I OCCUR r-I ""'..."""" '- t -._,.....
AOOlilEOIl.Tf .
.......-_.._---....-
Lall fa Stitt Sheed " I
:i: .~._--_.-
DfoueTIILf .
... Mt!.nNlION Assist nt City Atto ney ...-.
I .
WORK!Q COMPENSA1lON.....D I we 'TAW-, I 10rH.
!M~O'I'EU.LI48IL.ITV TOR" LIMIT!! E~
~N~~ROPR~T~~lN~~1XECUT~' .~_~_~~ ACCIDENT I
U"U~E.~utEltCt.uDEO' EL DISf"SE.E~_~~E .
"r.: _u_
..- .Jlli.~"'~'tJ!l!'$..J!!!:!'__ .._..,_.............~_._-.'""" 'l DISCAS'. POlM:Y LWIT .
1l.T>l.R PHPKll044J '03709i2'005- OU09/2006 S1,000,Ooo Each ClaiM
use . MOlest~tion
A Sl,ooo,OOO Aggregate
SO DeGuctib1 e
o~""nON Of r.~"o''', L'Ano..'.....". / EllJL~"'$8 """ED:?; EJlDOI'2""'{" ''''''jljP.OY'''r.'&o
mp oyee 0 S onesty 200,000 De ,00 Pro eSSlona Li~bi ity 1. 0,000 Each,Occ/l Mil Aggregat.
ertificate holder is named as additionAl insured per eon~raet with uIIled insured.
chedule of vehicles and drivers on file.
'Non-Profit Organization "
~10 day notice of cancellation shall be given in the event of non-paYMent of premiuII
C1~y of Santa Ana
Community DevelopMent Agency
CDBG-M-25
P,O, Box 1938
Santa Ana, CA 92702
SHOULD ANY Of' mE A.ov! OElCAlalC I"OUCIES H CANCILU!D "FORI! THe
fltJtllU,TION DATE TMIIIlEOF, TMlllSUtHC I....U.ERWlU. ~~ .....IL
*10 DAys""""mt.l N011ClTOTHE CI!Imfl'IC4~ HOLl)f:Jl;NANIDTO TifE lEFT
~VlU"14)Y'."""lIIl.llllx.16l~l"D.X".~MK-YA'I'...xX
lID ~_XXXXXXXX
CACORD CORPORATION 198&
AUT" "
ACORD 25 (2ot11/0S) FAX: (714)571-1974
APR-29-2005 11:06
,
THE CPMBODIAN FAMILY
714 571 1974
F'.OJ'D4
POLICY NUMBER: PHPK110443
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POUCY. PLEASE READ IT CAREFUllY.
ADDITIONAL INSURED - DeSIGNATED PERSON OR
ORGANIZATION
Thi. endorsement madlfiec insurance provided undllr lIle folowlng:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Harrllt of Person or OrgenlZllllon:
CITY OF SANTA ANA, ITS OFFICERS, ITS
AGENTS &. EMPLOYERS CDGB M.34
(If no enll)' appears lIbo.,., information required to complet. this endorsement will be shown in the Oeclaratio"s
a. appNClIbIe to lIlis endorsement)
WHO IS AN INSURED (Section II) is amended to Include as an insured the person or organization shown in the
Schedule as an ins\.nd but only with respect \0 6abilily arlslng oul of your operations or premises owned by or
rented \0 you.
APPROVED AS TO FORM
:/53 z/j,
Laura Stitt Sheedy
Assistant City Attorney
CG202tl,,85
Copyright, Insunt"ce Services Office, Inc., '984
Page 1 of ,
o
APR-29-2005 11:07
.
THE C0~BODIAN FAMILY
714 571 1974 F' .04.-/[14
.
ADDnlONAL INSURED ENDORSEMENT
IRlIu..ao..... Compan,
P/!I1AIl!:LPIII :oonm1Y IN5t.1RA1a (Xl.
..
ThI8 endorsement madIieI cuch nUl'<nl8 as .. afforded by ltIa pravIsIcnI at Policy
# PHPKl1 cv.i.. ~ __ Ill' '\ lQ 10 the ratow'o1g: .
t. 1M cay of .... AnI. :OlO CI\Ac QtntlIr PIaD, SIIr1lII AnII, CaIlJomla 82701;
ill cIIIceIs. ~ll" egents Ind l'Ipr r I ~.III are nemed IS eddIlIllllllllnIurIds
('aCJdIIIonIII ......, wIIh (IQ8I'd to RmlIIty end d8f.we of sUIs arfalg from 1he
operaIIa . and U$e$ perti:lcmed bY a on bthII of ltIe nI/1'I!d hsUted.
!L WIt! reepecc to clIImt IIfIInSI out d tile ope.cdbll WId UAS pet1bm'IId ~
lll' aJ bIhIIr orb named DIAd, IUCh ~ as is Mbdlld by 1nIS poley 18 primary
8I'ld is not ....~ to Cll" c:anIrIluIIncl wIh IilP/ olha' Iranr108 ~ by 01' for f10
benIIIt of the ..d:ilIb f' InwredI.
3. thIS II1IlnnC8 BAilS ~ to eec:h InIur8d agIIInIt wtlam c:IIim it
made or ..at Is Ilrought tll~ wilt ruplCl ~ Ihe ~. ImIII of 1IabIIy. 1118
IncUIcn d WFf~ tII ~ I d. -, . en nur.d ... not 6cI WI)' rtght 1IIf1k:h8UCh
perscI'I 01' .......ih.ttL.i Wl:UI.... . ~lt. not so Indudlld. '
4.. \WI '~1Df'8 tdlIIonIlIntreds. ttlIaNll1lasf1el nctbe~WlIIed,
01' n.... taIy r-dl1OIId ~ COlIldg8 or 1mb IDlllIIPt Iller tNrty CSO) d8ya ... 111M nolIoI h8s
bttn given to fie Qly ci Santa Me, 20 CMo Genter Pfeu, SIInIII Ma,.0a/iI0trie 92701,
(com,.aon of 1M fOIJoWIng, including counlerillgn.td&it., is required to mBlca this
,"dOPement~)
Efiecave 03/09/2005
-".
Polley /I PHl'lG.l~3
, this endorlement lonn as a part of
18CUGCI to
nlE CNlOODIAN FAMILY
Nm.d Insured
Co~/gned by
~ r---~~~ J/,Js'
APPROVED AS TO FOKM
~56
EXHIBH D
Laura Stitt Sheedy'
Assistant City Attorn.;;'\
TDTAL F'. 04
SC
CYHOLDER COpy
STATE PO BOX 807, SAN FRANCISCO,CA 94142-0807 RECEIVED HAY 2 6 2005
COMPENSATION
INS U ~AN C E
FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE, 06-30-2005
GROUP,
POLICY NUMBER 1696570-2005
CERTIFICATE ID: 3
CERTIFICATE EXPIRES, 06-30-2006
06-30-2005/06-30-2006
CITY OF SANTA ANA
PO BOX 1988
SANTA ANA CA 92702
SC
This is to certify that we have issued a valid Work.ers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days' advance written notice to the employer.
We will also give you 10 days'advance notice should thiS' policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policies listed herein. Notwithstanding any requirement. term, or condition of any contract or other document
with respect to which this certificate 01 insurance 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.
~
/!~c
&L-
AUTHORIZED REPRESENT A TIVE PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE.
APPROVED AS TO FORM
it!i"-V' ~4
, Laura Stitt syedY
Assistant City Attorney
EMPLOYER
LEGAL NAME
THE CAMBODIAN FAMILY
1111 WAKEHAM AVE STE E
SANTA ANA CA 92705
THE CAMBODIAN FAMILY
(REV.3-0J)
PRINTED: 05/17/2005 P0409
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND se" >0".