HomeMy WebLinkAboutSt. Clare, Elisabeth 1aC, 2�1os
AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longeriri Mck i
Return form to the Sr. Deputy Clerk of the Council (M -30). Call 64' if X238 you have a
questions.
The agreement with �� N_ OQq;n50
was completed on �?r� L and final payment has been made.
Q - ac)()T 0!i ;O— 0 1
%}'ac)c) L SD—O
Revised 8 -7 -03
Department:_
Signature:
Date:
City of Santa Ana
Clerk of the Council
JJ -;;"00""- 050 - 01
INSURANCt.lil]! Ui~ riLE
WORK MAY NQ~[ PROCEED
CLERK OF COUNCIL
DA IE l:>.- 30-0'1
G'J)e.J!>
U.~
FIRST AMENDMENT TO
CONSULTANT AGREEMENT
THIS FIRST AMENDMENT TO CONSULTANT AGREEMENT is entered into
this 30....... day of t).v:.<a1LIo...... ,2004, by and between Elisabeth St. Clare dba
Tustin Martial Arts Academy ("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 Agreement N-2004-050, dated May 14, 2004, (hereinafter
"said Agreement") by which Consultant has instructed kickboxing classes through the
City's leisure class program.
B. In accordance with the terms and conditions of said Agreement, the parties wish to
renew said Agreement for an additional one-year period.
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 3, TERM shall be amended to extend the term through December 31, 2005.
2. Except as hereinabove amended, all terms and conditions of said Agreement shall
remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to
Consultant Agreement on the date and year first written above.
CITY OF SANTA ANA
APPROVED AS TO FORM:
~~Af~Qgti
(V fOSEPH W. F TCHE
City Attorney
%t~~
GERARDO MOD T
Executive Directo - Parks, Recreation and
Community Services Agency
Ma~ 20 04 02:32p
p.2
p.2
/BRANCH
21
BIA
PRODUCER NUMBER IDATE OF ISSU !RENEWAL OR REPLACEMENT Nol
0003252 (21.0) . 1212/2003 NEW
SPORTS GENERAL LIABILITY POLICY . ,_ -'LJ/),J-osO
OCCURRENCE POLICY IV owv"1'
PURCHASING GROUP POLICY NUMBER: GL2-3000101
Item I DECLARATIONS CERTIFICATE NUMBER: GLS - 2031104
1- , Named Insured Tustin Manial Arts
i .
! ADDRESS . 7133 Grove Wood lane
NII~, &. 51~el. Town. COlJflty, Slale & lip No . Orange. CA 92869
Policy Period; From: 11/24/2003 11/24/2004 --
2. To
1Z;OI AM. S:aJ)ljDIl1Tim~'" L(lCahCrl olPromllioCi D(lG~l'loled in Itam 1
COVERAGE , LIMITS OF LIABILITY , PREMtUM
3. , ,
! I
Soor1s Gef1tlrtllliEtbi~t\' $ 1.000.000 ea<:ttoccurrence : $ 2.000.000 aggregate S 385.(0
$ 1,000,000 PO:f50~al end AUverh~'f19l.iabihty i $ 2.000,000 PFlJdwc:s . GOmp:f1\lKI Operations AOOlR!Ji!I'l'I
$ 50,000 Fire DliIl1lilQ4{any one nre) 1$ 0 MediCal Expe~" (arly()oo Person)
: Termri:sm Ri:>k In:5untl1ce Act- Certified Acts Cuverage 0 Covered l!J Not Covered S 0.00
i Minimum Earned Premium $ 300.00
4 I Deductlble $ NONE eMhOCCUrteflct!'
5. I R!p~t:atlon: Thl:' Na~ Insurec! r~prl!Sent5 th",= acdOent lnsul<!nce lfl ~ alTl();Jot specified will be In full force and effect of each partjOD/Kllln MY and "illlthletic
progrilms covered by lhl.'i po/JCy.
i Ad:lden~ In~urallCC represented .:moJot: $ 25.000
6. I JtliS polICY ~ wcldt> Clod dCcep{Rf subject to ttle printed cooditiorlS iIllhl$ pOliCy lvgethef wit~ the prolliSiO/ls. stiPttlatlons aM o9rE:e1l'lClltS oXHltain in (he fOllOwUlg
(1;1rI'11!;(S) Ot en<!Ori:lelTlet'Tt(s).
I GLO-2065{09/96),CGOOOl (01196J,GLE-2002(12197),GLE-8049(08/99},GLE.201 3(03/00).CG2147(1 0/93),ILOO03(11/85),
I LOOI7(11198).IL0021 (11185),EUE-8050(01 1lI4).GlE-8060(04/00).GLE8023(08I93),GLE8046(12198).CG2135(10IQ3 ),CG
: 2026( 11185), MSE~6001(2/95). ,GL387!l(1103)
i
I CHICAGO INSURANCE COMPANY
EXECUTNE OFFICES: 55 E. MONROE STREET, CHICAGO, ILLINOIS 60603
REPRESENTATIVE Agent or broker . Midland Insurance Group, Inc. !
Office Add ress . 1730 Park Street Ste. 207
City, State, lip . Naperville.IL 60563
I Additional 2% CA SUlthsr,. $ 'JJIJ
, INTERSTATE
I INSURANC
,
GROtJP
i GLP 2010 {01/0JI
I
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03/18/2005 15:51 FAX 16305980476
ALLE, J FLOOD
~002
..
AAIC
Amllrt!o:.lttn_ld:l.. ......n~. CDrpaI'iIIlon
555 Cdl'S1e Road East
Pri"celOnN,J.OIS.t!-5212
MEMBER CERTIFICATE
COMMERCIAL GENERAL LIABILITY
Named wured Member DDd Addn::u;
Tustin Martill1 Art:i
624 Efl,~t Firsl Stre:d
.~ Tu,tin, CA 92780
:s+.. (ktH'-t') <t:L.fRk>-d::t----
Member Certificate No. 76A2GL1OO3477-00
Policyholder;
Spoch IIDd Rt;crc~tioD Pro"'id~r;: ^'$ociation Rhk
Management, lac.
1 776 South Napervillc Road, Bldg-B
Wheaton IL 60189
n ,.)Ic"1 ~o5c:
/J .xc.,LI- C:)C C/
Policy No. 76A1GLOOOOOOI-00
Certifil;ate CoverAge Perind:
'l:Omm:
1/25105 To
1/25106 at 1201 AM Standard Time
at the address of the Named Insured Member
Form of Bu.iD~U: ;
1&1 Individual
o Partnership
o Joint Venture
o Limited Liability CompllIlY
D Organization (Other Than Partnership. Jomt Vc:ntwe Or Limlled LwbiliLy Company)
THE TERMS. EXCLUSIONS AND CONDITIONS OF THE lI'SURANCE PROVlDED UNDER TIllS CERTIFICATE ARE com AlNED
IN THE COMMERlCAL GENERAL LIABILITY POLICY (CGll ISSUED TO SPORTS AND RECREATION PROVIDERS
ASSOCIATION RTSK MANAGF.MENT JNc. THE COMPLETE COL POLICY IS AVAILABLE FOR YOUR REVIEW AND/OR
INSPECTION UPON YOUR REQUEST TO THE PROGRAM ADMINISTRATOR SliOWN BELOW THE rNSURAI'CE AFFORDED BY
THIS CERTIHCA TE SHALL NOT AMEND OR ALTER THE TERMS. EXCLUSIONS AND CONDITIONS OF THE CGl POLICY
lI'1)lCA TW ABOve
51,000.000
Each Occun'tllce Limit
o (If ch~cktd: Hired and Non.Owned AulO Liabillt)! covsroge is provid,d.j
Damages To Premises Rented to You (anyone premises)
Medical Expense (anyone pClson)
Limits
Of
InsUI1IDCe
$300000
NOT
COVERED
$1 000 000
$2 IlOO 000
$1 0000011
N/A
Pl,..T:J:onal and Advertising lnjury Limit
GcncTul Aggregate Limit (per certificate of insurnnce)
Products-Completed Operations Aggrcga{c Limit
Eaeh ClalID
Deductible
::ow;.r' .. ;,,,r
Athletic Program, - Amateur
:P.tI.nafthto'Q~.~'Md,::~;Qi..'1\lmi:: ':''''t"rir.,t~>. ~~H:;:'i,t/ '!:f'(l'. ,-..",..' ,.,.., '. .;,,:i;1~';;li~;:,l ;:::;:;t,!:,;')>\,'ii:;)';.n,:'i. :,:,.\;:;:::;";:;t<::~~:g:r:::!)'iA:.:<:
a~s of Prem.ium) Rate Minimum aDd Dc osit Premium
80 Panicipants
S6.75
554000
SRGL100 (08/04)
Copyrighl ~004 Arne-rice" Atter"aUve Inlluronce Corporlltlon.
Includes copyrighled ",..tarlal ofltla !nSUr.llnC9 Service, Offico. Inc_.....,1h if& permi&&IOn
\.PPROVED
,.')
Page 1 of 4
~---~,
'03/18/2005 15:52 FAX 16305980476
ALLEN J FLOOD
~004
.z=r.
AAIC
AMI.1cM ..ruUva.......... Cort-dlon
5$5 Cdlqe Road Ealt
~ Pffn121M N.J. 08Ul.5212
MEMBER CERTIFlCA TE
COMMERCIAL GENERAL LIABILITY
\
.i;lli'l'il'fo;tm'F6RMS;;um;IDilj)' "'liiiroms'c1lBmlbii:tEiit'ti. ...... ,,,
form H Edition DII,tc Fonn Natn~
CL 2000 (01/96) Common Poli~y Dee
lLOO17 (\J 98) Common Policv Conditions
GUOOO.. 01196) GL Covemllc Part Dec.
VLCWOl (05/96) Sign.o.rure Endot"$ernc:nt
CG 00 01 1001 Commercial General Liabihrv Covera,Qc Fonn
CG 00 62 1202 EXl;!u5ion- War Liabilitv
CG OJ 99 1093 JJ1iooi~ Chanac5
CG 02 00 0487 Illinois Chanlilcs - CUlccllation And NOI1.Renewat
CG 21 35 1001 E'tclu5ion~ COVCfllllC C- Medical Payments
CG 21 46 0798 I Exclusion- Abwc 01 Molestation
CG 21 47 0798 Exclwilon- EmoloYmcnt Related Practice!
CG 2149 0999 Exclusion- Total Pollution
CG 21 67 0402 Exelusion- Fun~i Or Blac1c:ri1l
CG 21 75 1202 Exclusion ~Ccrtificd Acl~ Of T crrori:trn And Other Acts Ofr errorism
GL Z004 II/OJ Exclusion- Asbestos
GL2005 1lI03 Exclmllon- Lead
IL 00 21 0487 Exclusion- Nuclear En~r8Y LiabilJ!r_
SRGLlOO 0804 Menl~1' Cel;1ificatc - Commercial General Liability
SRGLIOI 0804 tIlred D.rtd Non-Owned Automobile Liability
SROL102 0804 A$sociation Amendatorv
SRGLl 03 0804 Condition Monthly R.Dortmg .
SRGLlO4 0604 COJJditi,on - Umc:iC;rved Sc:atiD2.
SRGL 105 0804 Condition - Wuivcr and Relcl\sC
SRGLI06 0804 Contin~wofCover~e
SRGLl 07 0804 Exc1usil)n- A_reraft, AutOs or Watcn::Il\f1:
SRGLl 08 0804 Exclusion- ColJao5e of T ~1lIT Structures
SRGLI09 0804 Exclusion- Desie.nated CJperations or Acti'\litic~
SRGL I 10 0804 Exclusion- Expected Or Intended TniuT'V
SRGLIII 0804 Exclusion- Hecatitis TSE: mv, un. v or AIDS
SRGLl12 0804 -LExel.u$\OO- Profelj,ional Liability
SRGLI13 0804 I Exclusion- Pyrotechnics
IIIlI UlrIISIf F-. AIlI EllUlfMlllJs APPU:Aaf II .. lDTJlCAII AT IUllE II . "'1lIl/l8 fir ....... till .. AM1lIIII
.II1II....... my h8VI _ '-d III8r lIlI r.... or llIII nMIl1c11J II Y1IL To...... VlllIID8111 _ _18' II I'8lIIV8 8
or 1lI8 "Y. 8IIn8 cullllct lJII....................
SRGL100 (08104)
CopyrighI200' AlTI6tk:J" Altom.,tj~ I05urlilnCll Corporllll6n
Includlls copyrighted material 0' tho InSUnlnC8 S8Nice5 Office. lne. wI!h lis pArl"l'llnloR.
AS TO f'Uh.<>
APPROVED ._
~+') <' l> ______.
-:~~,z<< 'It Sheedy
La-ld L. '.' A.ttorney
AssisU:.\IlL L
Page 3 of 4
03/18/2005 15: 52 FAX 16305980416
,
ALLEN J FLOOD
~005
.
AAIC
.....,tc.. A_I"'" a....nc. ClN'par..ton
555 CGllege RMd EI!lt
PrI"cdoll N.J. ot54t.5Z12
MEMBER CERTIFICATE
COMMERCIAL GENERAL LIABILITY
Srhedult ur AdditioDJll Insuu:d,'ili;
The below entities an: added DS additiollol msurcd(s) to the certificate :mb)cc\ tolhc: 3chcdulcd applicabl~ additional in;:;ul;Cd
j endorsement
:
Applicable Additiorwllnsured c:;:ndOrsr:mr;nb mt;:lude;
Form No. Edition Endorsement Title
Dn'~
CG 20 II 0704 Additional Insl1red~ Lessor of Premise!> (De!leribe Lctl$cd Premises below.)
CG 20 12 0798 Additional In,ured- State or Political SUbdivision-Pa-mitll
(Designate St.:lte or POlitill.ol Subdlvi~ion Below.)
CG 20 15 010' Additionallntured_ Vendors (D~scriM "Your Product" below.)
: CG 2028 0104 Additional Insured~ Lessor ofEquJpment
SCHEDULE
Form No. Nume aftd AddR!<i' of AdditionallD.!Iured: Form No. Nllmc nod Addn:s, of AdditioaallJ:uured: ,
CC 20 11 Pan Pacific Properties CC 20 15
PO Box 6000
San FtfUlCisco, CA 94160
Desimlltion of Premises (Part Leased to You): ("Y~ur Product'!)
Landlord
CG 20 12 City of San," Ana CG 20 28
Parks, Recreation & CommunitY
Services Agency - M23
888 Wes.t Sanlo Ana Blvd., 2nd Floor
P.O. Box 1988
Santa Ana, CA 92702
State or Polilil;:lil Subdivision:
MuniciDality
I i
Copyrlg;ht 2004 Amarle_" Alternaotivo rn5I.1r.11"'9 CorporatIon.
1I1Clud81i cOPYrighted material of lno Il"ltl.ltQnce Services Office. Il'Ic. with It~ porml"Ion.
SRG1100 (08104) Page 4 of 4
APPROVED AS TO FOK:n
"---:1::""".' "/ <
/ .i) ) .
Laura'-<,i~ ~;':cedy
J\ssistarll ~._1!\ ,,' ~rney
.
II
ADDITIONAL INSURED
II
Policyholder: Sports and Recreation Providers Association Risk Management, Inc.
Tustin Martial Arts
Insurance Company: American Alternative Insurance Corporation
Policy Number: 76A2GLOOOOOOI-00/76A2GLI003477-00
Effective Date: 1/25/05 at 12:01 AM Standard Time at the address of the Policyholder
This Endorsement changes the policy. Please read it carefully.
WHO IS AN INSURED (Section III) is amended to include as an insured the person or
organization listed below as an insured but only with respect to liability arising out of your
operations or premises owned or rented to you.
Name of Person or Organization:
CITY OF SANTA ANA PARKS, RECREATION AND COMMUNITY SERVICES AGENCY - M23
888 WEST SANTA ANA BLVD., 2ND FLOOR
P.O. BOX 1988
SANTA ANA, CA 92702
APPROVED AS TO F01~JVj
~5 C;/c;-
Laura Stitt Sheedy
\ ,;sistant City AttOfll(;\
PLEASE ATTACH THIS ENDORSEMENT TO YOUR POLICY.
In every other way, the policy remains as is.
Dale Issued; 3122/05
03/18/2005 15:51 FAX 16305980476
ALLDi J FLOOD
~003
.
'.
~
AAIC
....,11::... AIIIn1lattn ~ COt'peIanon
$65 e~e ft_d b!t
Prlllce"" N.J, 0I5.,.52t2
MEMBER CERTIFJCA TE
COMMERCIAL GEN.ERAL LIABILITY
:i!
-IlOY'EkA:filtAl'lJ)-'tltdulalO1!ls.'-,,':.: ,_, -'):i, :," >',-, i, ',; ,- "
',i/+,:~~:/~'~J~: ,,':.:<>, ::i.;)~;;,'Z:-':;:(f;<,~,/) ":: <\:;;~f)
Who .Jt Conred
This progrum providc5 proLcctiOl1 for your coache5, volunte..:rs, officers, directors. team or lell~ue again::lt clai",:! ofbodiJ)' injury
liability, property damage liability I QIl,d per:iQI1I1IIUld. adverti.:iwg mjury liu.bility, and for the litigllbQn co,ts 10 defend against 3ucb
claims. Coverage is offered through Spons and Recreation Providers Association Risk Management,Ine There is no deductible
amount
What Is Covered:
& All activities necessary to conduct of
pradiccs or gIlIll.e:l'
IE Cost of investigation and defense of claims.
even jf aroundless
m General negligence claims
/ZJ HO.9t liquOt liability (llOl"l-profit)
Optional Coverage:
. Addnional Insureds - subject to approval.
.. Hired and non-owned auto li4bihty coveroge is ovoilnble in all SUltes (except ILl LA. VI). This coverage prOvides
liability protection for rented, borrow'ed and othl:J non-owned vehicles driven on league or 1eam business.
/ZJ In]Ul)' or d.a1h or partiClpllnts
lEI Injuty or d(;Bth of :JplO:ctaton
lEI Injwy or death of volunteers
/FJ Ownership, use or maintenance of fields or practice areas
fSJ Property damt\ge li.ir.bility
Wbllt il f:xduded:
Refer to the Commercial General Litlbillty Covl!J:use FOlJ1l for excl~loJ::ls Thf! roUow;iog 11f~ addltional ~xt':JU8ions by
endorsement to the "policy", ("Policy" mqmtJ" Dtlc/a"atiom, EXlt111Sinn SchqdlJlt1~, Covc,.agq Fa"" and all (Jpphcablq
endor"menlJ.)
[gJ Abuse or Molestation
I8J Aittraft, Autos or Watercraft
tEl All Acts Of T e:rronml
[gJ Asbestos Liability
ill Assault And Battery
/EJ CQn8p~ Of Tem.porary Strur:tures.
m Designarcd Activities..
lEl Employment Related Practi~s
[gJ Fungi and Bacteria
/EJ Hepatitis, (HIVI HTL V or AIDS), and T ronsmi!>sibll;:
Spongifonn Encephalopathy
IEJ Lead Poisoning
lEI M~dic81 Paymmts
& Nuclear Energy liability
lFJ Profe!:sionaJ I jability
/ZJ Pyrotechnic. Aclivity
lEI Total Pollution
IFl War l1abihty
.. There is no liability COVel'UgC for claimli arising out of any of the following designAt~ actlvitles:
ill All Motor Sporls lEI Rodeo Or any Equ"strian Related Sports
&J Ballooning lEI S.1lelManufacturing Distnbuuon of AtWetic Equipment
/Xl Bungec Jumping (/f/ Skin & Scubn Diving
lE1 CheerlClldmg Pyrtmid' lEI Snow Skim;;
lXl GynUll5tics IK1 Squash
1!7 Luge 111 Ioboss:u)ins
lEI MOWltain Climbing lEI Use of Saunas or Ttuming Devil;CS
m hraclluting lEI Use of 'trampolines
IE Polo & Water Slides
t2J Rock Climbing lEJ While Water Rufung
IIIB II81ARY If IaJVfIWE AND Wl_1II8Wn aImV8 i8 . _tillltl fir rlllllbg tIIIJ 1IIItir8_.
Tn 1'IIIllIiv11ll .ti'8 P*Y. contactlb8 PrlIaram Adm~IDr_
SRGl100 (08104)
Copyright 2004 American MernatIW lr'isu","C~ Corpor.tign.
Ir'icludes copyrighted rrw.teri3/ 0' 1M In!l.u,:anec SClNI~Ill~ Off'IC., Inc. witt. it5 p.rmi$llion
PRO' ,) AS 10 tv;'.....,,!
AP >I..:.: . ,.
" I
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La'.lD \1 it' ,!1eedy
i\ <;";,SUl 01 orney
Pag@ 2 of 4