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Home My WebLink AboutFIREFIGHTER SELECTION 1-2005 . .,' c \\01 ONHlE \NSI.l~~\"'t. -.. - PROCEED \NOR\\ \AI', Y @l It (r\~s''''l CLER\\ Oi C~U~OC 5 \)J- L OI\IE:~' \ 1 CONSULTANT AGREEMENT c: PefS THIS AGREEMENT made and entered into this 7::-, ~ day of '\.~ , 2005 by [,,@\tW and between Firefighter Selection, Inc., a California corporation (hereinafter "Commltant"), and '1(:1. 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"). N,2005,060 1 RECITALS A. The City desires to retain a consultant having special skill and knowledge in the field of developing written examinations for Fire department personnel. B. Consultant is experienced, knowledgeable, and has the personnel capable of providing the written examination required. C. City desires to rent a written examination for Fire Engineer, prepared and developed by Consultant. Consultant agrees to furnish the City a multiple-choice custom examination for the position of Fire Engineer, to be administered by the City at a time and date to be determined. 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 a. Consultant agrees to develop a written examination for the position of Fire Engineer, based on specific subject matter and course material from International Fire Service Training Association, as set forth in Consultant's Terms and Conditions of Lease, attached hereto as Exhibit A, and incorporated by reference. b. The City will select and, if necessary, edit specific questions after reviewing the certification examinations. c. Consultant will compile the selected exam questions and provide the City with exam booklets. d. Consultant is not responsible for exam validation or candidate qualification and ranking. e. Related inquiries will be referred to the City's authorized representative. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as payment for the services, the rates and charges specified in Exhibit A. The total sum to be expended under this Agreement shall not exceed $10,000.00 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 the date first written above and terminate on June, 30, 2006, unless terminated earlier in accordance with Section 12, below. The term of this Agreement may be extended upon a writing executed by the Executive Director of the Personnel 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. 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. 6. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (I) 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 2 " 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, or if City receives from Consultant information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant and City mutually agree 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. The City agrees that all exam questions and contents shall be reasonably understood to be confidential. City shall not use or disclose such information except in the performance of this agreement. "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 City or Consultant is disclosed in a publicly available source; (c) is in rightful possession of the City or Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or ( e) is independently developed by the City or Consultant without reference to information disclosed by the other party. 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 manner with performance of services specified under this Agreement. 9. 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 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 3 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 telefacsimile (714) 647-6956 With courtesy copies to: Personnel Services Agency City of Santa Ana 20 Civic Center Plaza, M-24 P.O. Box 1988 Santa Ana, California 92702 telefacsimile (714) 647-6930 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: Firefighter Selection, Inc. 2868 Prospect Park Drive, Suite 110 Rancho Cordova, California 95670 telfacsimile (916) 266-4172 A party may change its address by giving notice in writing to the other party. 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 telefacsimile, 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. 10. 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 of this 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. 4 11. 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. 12. 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 perfonned 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 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. 13. 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. 14. 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 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. 15. 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 5 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. 16. 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. ATTEST: /~-- CITY OF SANTA ANA ') ~~~ AVID N. REAM City Manager PATRICIA E. HEALY Clerk ofthe Council APPROVED AS TO FORM: \. ) . . \t.. ..;', Jci~~~~ ~i~E~~~t~ City Attorney RECOMMENDED FOR APPROVAL: wi \ ~. (i (/0- CONSULTANT: /.- "":=;;; ~:c-:::"-? STACEY B:;-l ~ Director /,- ,- >~'/~.~ ::!~," (ENRIQUE/ALVA Executiv9:birect<i1r=Personnel Services TaxID# q\\CO\\~~~ 6 -, E'\ FSI ~ ,-'~ ,"'If }t~ FI REf I G HIER mECTIOH. INC. Promotional/Special Projects FSI Rental/Licensor Rates Effective January 1, 2005 Fire Engineer Written Test Lease Fee Base Fee $500,00 Fire Engineer Written Test Booklets $10,00 each Scoring 1 $50.00 Base Fee plus $.25 per candidate Shipping/Handling 2 At cost plus S% cost of product Restocking Fee 90% refund for unused Test Booklets Customizing fee $1500.00 & $25.00 for any new test item written by FSI I Optional 2 All materials shipped FedEx Express Saver (three~day) nnless otherwise requested. Fire Promotional Assessment Package Written Test Base Fee $500.00 Written Test Booklets $10.00 each Structured lnterview Exercise $750.00' Role Play Exercise $750.00' Fire Scene Scenario Exercise $750.00' Assessment Options: FSI Written Test Scoring I $50.00 plus $.25 per candidate Shipping/Handling 2 At cost plus 5% cost of product Customizing fee $1500.00 & $25.00 for any new test item written by FSI 1 Optional 2 All materials shipped FedEx Express Saver (three-day) unless otherwise requested. 3 Travel at cost. * All Three assessments can be purchased for $1,500.00 EXHIBIT A 1 , FIRE ENGINEER TEST/TEST MATERIALS TERMS AND CONDITIONS OF LEASE (Signature Reqnired) Subject to the following terms and conditions, Firefighter Selection, Inc. (FSI) hereby agrees to provide the Santa Ana, City of (Client) with a multiple-choice test consisting of items from various fire sources identified by the Client. The contract is effective when signed by both parties and ends 90 business days following administration of the Fire Engineer test by the Client unless extended by consent of both parties. Under this contract, both parties agree to the following terms and conditions: I. FSI cannot guarantee compliance with the civil rights laws or the requirements offederal or state enforcement agencies, inasmuch as such laws are subject to interpretation of facts and circumstance. FSI recommends to the Client that ajob analysis and validation study would greatly improve the defensibility of the test. FSI will provide consultation to the Client on a time-and-charges basis, should its test be challenged. 2. The right to use FSl's test materials is leased to the Client for the internal use and benefit ofthe Client only. The Client agrees not to sell, rent, lease, give, lend, or otherwise disclose or provide the test materials to any other employer or entity, or use the test materials for the benefit of any other employer or entity. Test materials may not be reproduced or copied without the written permission of FSI. The Client agrees not to provide, disclose, or otherwise reveal the test materials to any persons except the employees of the Client directly and necessarily involved in test administration and entry-level selections 3. The Client is responsible for the security of the test materials during the lease period. It is understood by the Client that any security breaches may adversely affect FSl's future ability to license or lease this test. The Client understands that FSI will retain the copyrights of this test. 4. The Client agrees that neither it nor its officers, agents, employees, representatives, nor any persons in active concert and participation with it or them, shall modify, adapt, or alter the test materials in any way, or develop any identical or similar tests without the prior consent, in writing, of Firefighter Selection, Inc. which shall retain the copyright to all versions of the test materials. 5. The Client agrees to retum all Test Booklets and Key Sheets within twenty (20) business days after the test administration. Unopened Test Booklets may be retumed for full credit less a 10% restocking fee. The Client agrees to have at least two employees count the Test Booklets upon receipt of each and to provide FSI with telephone or facsimile notification within 48 hours of receipt of any discrepancies between the amount FSI shipped and the amount the Client received followed by written notification within five days. If FSI receives no such notification within the time period specified, it will be assumed for purposes of this agreement that the Client received a complete shipment as recorded by FSI. The Client also agrees to have at least two employees count Test Booklets it returns to FSI and to provide FSI with a written record of the materials returned and an identification ofthose persons who counted them. 6. The Client's lease costs include a $500 base fee in addition to the Test Booklet fee of $10.00. 7. The Client must retum all Test Booklets to FSI within twenty (20) business days after the test administration. The Client will be charged for any Test Booklet(s) not returned within those twenty (20) business days or that are missing one or more pages. The costs associated with developing a replacement test are $35.00 per test item and fee of $2,500 for administrative charges for replacement test development. For example a 100-item test replacement costs would be $6,000 (100 x $35 ~ $3,500 & $2,500 in Senior Consultant billable hours is a total of $6,000). This charge is to cover the development new items and test construction, based upon our current billable rates. 8. IfFSI is to score the tests it will do so within two (2) business days of receipt of the answer sheets unless otherwise agreed upon by the Client and FSI. EXHIP!T J~ ~ '- . Fire Engineer Test Lease, Page 2 9. At the completion of the lease period, FSI will submit an invoice for lease costs to the Client. Payment is due on receipt ofFSI's invoice. A service fee of one and one-half percent (1-1/2%) per month (eighteen percent [18%] per year) will be charged on all unpaid balances in excess of thirty (30) days past due. In the event of a loss of one or more Test Booklets or if one or more pages is missing from a Test Booklet, FSl will submit an invoice to the Client, per Item 7 above, which is due upon receipt. A service fee of one and one-half percent (1-1/2%) per month (eighteen percent [18%] per year) will be charged on all unpaid balances in excess of thirty (30) days past due. 10. Should the Client become the subject of any litigation or investigation by state or federal enforcement agencies arising from the Client's use of the test materials, FSI agrees to assist the Client in its on a time- and-charges basis at such hourly rates as may then be current. Customization Fee (if applicable) $1,500.00 Lease fee (base fee) $500.00 Test Booklet costs $10.00 Scoring fee (optional) $50.00 & .25 per applicant Shipping & Handling At cost plus 5% cost of product * Unused test booklets will receive a 90% credit Client: Name: Title: Signature: Date: Firefighter Selection, Inc. Name: Stacv Bell Title: FSI Director Signature: ~S>-- Date: April 25. 2005 '0 'I " Jun-2H005 10:27am From-HUB INTL IL 312i225158 T-m POOl/DOl F-038 r A' C' O:8D,' X.'I. '!ii1"~~.'11..,1"'::.1' '\~~.':"_')' t ....".\ '. ~"'i'.:~.W,,".' 'I." i'ile\i;i.~ 'I":~c\\ii!ii!iq!'.;'i.:i}.;j.l:.':::j>l,.r' ';~;,;~..,o,;;";,, '~, N - ____ ... ~~~, '~~; :it:(!I~'" " ,'iit~ ';,i;~I'm ' ":'. '(~: :~:J:u' '" .aAm')'> '~i~b~~~ti~\t:^J,J{'::n';t:!~::~~ ';; :.".."",.,.." ..., ,."."",Al,,,.,,,,.,.. ."""<,,,'''>''.:.' "'....:.,,,.:,:. ",'''.."'..~d~,,,.,..,,,.",,,.. ".. ...... , ....,.J.. ,"""..., .,.,..,....'.' :!"" ,..,..'^<...6 /'2 9'/'2 0 05 I'l'IOOUCfll THIS CERTIACATE IS ISSUED A.S A MATTER Of INFORMATION f . 1 'b' 1 ' ONLY ANO CON'EAS NO RIQHTS UPON THE CERTIFICATE AVMA Pro eSS10na L1a 1 1 ty HOLDER. THIS CERTIfiCATe ODES NOT AMINO, EXTENO OR Insurance Trust ALTeR THE COVI"AGE AFFORDED BY THE POLICIES BELOW. C/O Hub International Illinois Cl!.IAPANIES AFPOROING COVEAAGE 55 East Jackson Boulevard co...",., Chica~o IL 60604-4187 A Zurich American Insurance Comnanv 1~"UQg A 3 II CO/lllPAN'Y Kriatian J, Fisher, DVM -;2JJQ5-I, I Serrano Animal I< Bird Hospi ~al COMPANV 217/1 Lake Forest Dr" Ste III C Lake Forest, CA 92630 COM'''' D poV~q~:\~f;::~mJj:~n\'~(\\t!~:tll:*;l:~1'~~i~~:!;;i,~~l:?:l:m:r~M:i~Z!~~~1h~~M~~::b,t;~!'~rmhtiu:!n,};~~'~,~O~1~;:b'l~'h~W.;ltf:~hlj~W'~\:i~~t~1i[;';;~:;~~j/t:::~'~k~W:fi!W:~i'.;:;.~it~;:l:?Yr):~N~Wt. THjS IS TO CEATrFY THAT THI fOLICtES OF INSUf\ANCIi 1.15TED BEI.Ow HAlli BEEN ISSUliO TO T~E INSUA&O NAMED ABOvi FOA THE jII01.ICV PERIOD INDICATiO, NOTWrTHSTANPING AN.... AEQUIREI\o1INT, TERM OR CONOIT.ON Of ANV CONTIIACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TI1IS CS"T1FICATE MAV a.ISSUED OR MAY PERTAIN, THE INSURANca AFFORDED Err THI P'OUCIES DfSCl\IBED HEREIN IS SUBJECl TO ALL THE TEAMS, EXCLUS10NS AND CONDITIONS OF SIJCJoI POLICIES. LIMITS SHOWN MAY HAv!! 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Policyholder: KRISTIAN KRAUSE 21682 VINTAGE WAY LAKE FOREST CA 92630-5759 Policy Number: 261211892 ":;;.;; Agent: WALTER MORTENSEN INS 4701 STOCKDALE HWY BAKERSFIELD CA 93309 PHONE, 661-834-6222 240-007770-00'0 Policy Period: 03/23/2005 to 03/23/2006 12:01 AM Standard Time Policyholder Since: 03/2004 This is a replacement 01 policy 218450853 Insurance Provided By: Encompass Insurance Company 2775 Sanders Rd.; Northbrook, IL 60062-6127 24 HOUR CLAIM REPORTING 800-588-7400 YOUR POLICY HAS BEEN CHANGED A change in name of insured Chg named insrd to maiden name: Kruase Revised Annual Policy Premium No change in premium $ 2,266.00 This COVerasl& Summ~rY ~pre5..nl$.l'9Ur *~'L_^ MOTOR VEHICLE PROTECTION (Coverage applies only II a premium or limit is shown) Description: VIN: Rated Driver: Use: Class Code: Estimated Annual Mileage: c;PV~~~G~.!,!~:~"j~j!~*At~~f:'~~if:~~f~.\[lt~1; BODILY INJURY (per person/per accident) PROPERTY DAMAGE (per accident) MEDICAL EXPENSE UNINSURED MOTORISTS - BODILY INJURY (per person/per accident) COLLISION DEDUCTIBLE WAIVER (per accident) COMPREHENSIVE (Camp) COLLISION (Call) TOWING 261211892 Vehicle 1 Vehicle 2004 CHEVY TRUC TRAILBLAZER lGNDT13S842117211 KRISTIAN KRAUSE Pleasure 661100 15000 ~'M.h~~wi!~l~l~,f~~~~ i_!iMjt~~ $ 250,000/500,000 $ 451.00 R~l'~I\I!lf,!.;,c~ $ 25,000 $ 139.00 $ 5,000 $ 42.00 $ 250,000/500,000 $ 86.00 Per Endorsement $ 18.00 $ 250 Deductible $ $ 500 Deductible $ Reasonable Expense $ 145.00 430.00 lncluded ~~,~ Ch.Hl'nlln af~hfI Board S-.:r.,. ~OOOOOCA050JD10J031l0600000DO0004002" ~ Continued on Next Page Page 01 of 05 '~ ENCOMPASS_ INSURANCE USP Elite.. Packa.ge ': ~~mended Policy COV. :1 ,",,,,,,,,:,..,..,>. "<"..";;":':.~:;)';';':f:j 1I :;":AL'."'" ;'~ /;/;,;,;";.;,,,. . Policyholder: KRISTIAN KRAUSE 21682 VINTAGE WAY LAKE FOREST CA 92630.5759 i:i""'" ::'~.:.~',,:::;. '{:f Agent: WALTER MORTENSEN INS 4701 STOCKDALE HWY BAKERSFIELD CA 93309 PHONE: 661.834.6222 240.007770.0000 Policy Number: .6121189. Policy Period: 03/23/:<1005 to 03/23/2006 12:01 AM Slandard Time Policyholder Since: 03/:<1004 This Is a replacement of policy 218450853 Insurance Provided By: Encompass Insurance Company 2775 Sanders Rd.; Northbrook, IL 60062.6127 24 HOUR CLAIM REPORTING 800.588,7400 YOUR POLICY HAS BEEN CHANGED A change in name of insured Chg named insrd to maiden name: Kruase $ 2,266.00 Revised Annual Policy Premium No change in premium TIlls C9v8l'1lge SU/1lmJl",pro,v1d~ I'llPrul!ll~,rQUr~I(~~.,,,", MOTOR VEHICLE PROTECTION (Coverage applies only If a premium or limit Is shown) Description: VIN: Rated Driver: Use: Class Code: Estimated Annual Mileage: C()VJ;RA<OJ;s:j)'r0'!l!:j\l,!1'N0i!:i;l',~~~ BODILY INJURY (per person/per accident) PROPERTY DAMAGE (per accident) MEDICAL EXPENSE UNINSURED MOTORISTS - SODIL Y INJURY (per person/per accident) COLLISION DEDUCTIBLE WAIVER (per accident) COMPREHENSIVE (Camp) COLLISION (Call) TOWING 261211892 ~~,~ CII.irmiln gf tM BNnI KOOOOQCAC603010303110iOOOOO000004002'" Vehicle 1 Vehicle 2004 CHEVY TRue TRAILBLAZER lGNDT13S842117211 KRISTIAN KRAUSE Pleasure 661100 15000 iitMd~"!ft,~~~i~m;J~.~ g_MJ)Ui~2 $ 250,000/500,000 $ 451.00 P1U\MlUM~i!: $ 25,000 $ 139.00 $ 5,000 $ 42.00 $ 250,000/500,000 $ 86.00 Per Endorsement $ 18.00 $ 250 Deductible $ $ 500 Deductible $ Reasonable Expense $ 145.00 430.00 Included ~ Continued on Next Page Page 01 of 05 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: L 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 materiaUy 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 WORKERS' COMPENSATION DECLARATION I kx I ~t\C{V) J f1 O,W,v,t)W1Iiereby affirm under penalty ofpeIjury, the (Name/fitle) following declaration: I certifY on behalf of (Organization Name) contract with the .5'l\\1\'o.. fWlo.. Ceo that during the term of my , City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. DATE: 9;(../0'5 By:c VU-r. IlJ Name: (Ull J. h ShJ 1", lJ V YY) Title: l/ekvlnL.lVlClVl Telephone: 0:140') '65s-_ciTYY WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND 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. 'PI{()Vio,].J AS TO FORM ;"'.51 ., !-, ~\.tlY (l,L ...;.1 SLtt shee# ',-:'1: City Attorney