HomeMy WebLinkAboutFISHER, KRISTIAN 1AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect.
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Return form to the Sr. Deputy Clerk of the Council (M-30). Call 647-5 3 if you lravd d,a� . 1
questions.
The agreement with 1:-s tilet No. /I -�-ADt75-13
was completed on fes(, / %1i n and final payment has been made_
Department: -7�4�
Signature: NO&
Date: NAWIV O
City of Santa Ana
Revised 8-7-03 Clerk of the Council
INSURANCE NOT ON TILE A-2005-134
WORK MAYO 1_ PROCEED
CLERK OF COMM
DATE. 19 CONSULTANT AGREEMENT
C L , I�S.nf.deli�
THIS AGREEMENT, made and entered into this 20th day of June, 2005 by and between
Kristian Fisher, DVM, an individual, (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").
RECITALS
A. The City desires to retain a consultant having special skill and knowledge in the field of
veterinary medicine.
B. Consultant represents that Consultant is able and willing to provide such services to the
City.
C. In undertaking the performance of this Agreement, Consultant represents that she is
knowledgeable in her field and that any services performed by Consultant under this
Agreement will be performed in compliance with such standards as may reasonably be
expected from a professional in the field.
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:
SCOPE OF SERVICES
Consultant shall perform those 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 her services,
the rates and charges identified in Exhibit A. Maximum amount for reimbursable expenses shall
be $3,000.00. The total sum to be expended under this Agreement, shall not exceed $35,000
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 July 1, 2005 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 Parks, Recreation and
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, agents, volunteers, and employees 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 $1,000,000 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. Professional liability (errors and omissions) insurance, with a combined single limit
of not less than $1,000,000 per claim.
e. The following requirements apply to the insurance to be provided by Consultant
pursuant to this section:
(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.
f 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 affect 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 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 1 of 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. 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
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.
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 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 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 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
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ana, CA 92702-1988
telefacsimile (714) 647-6956
With courtesy copies to:
and
Executive Director
Parks, Recreation and Community Services Agency
City of Santa Ana
888 W. Santa Ana Blvd Ste 200
Santa Ana, California 92702
telefacsimile (714) 571-4235
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: Kristian Fisher DVM
21771 Lake Forest, Suite 111
Lake Forest, California 92630
telefacsimile (949) 855-1070
A party may change its address by giving notice in writing to the other party. Thereafter,
communication shall be addressed and transmitted to the new address. 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, that 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.
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 performed 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
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:
PATRICIA E. HEALY
Clerk of the Council
APPROVED AS TO FORM:
JOSEPH W.FLETCHER
City Attorney
Laura Sheedy
Assistant City Attorney
FOR APPROVAL:
GERARDO MOUET
Executive Director of the
Parks, Recreations and Community
Services Agency
CITY OF SANTA ANA
DAVID N. REAM
City Manager
CONSULTANT
KRISNI FISHER, DVM
Tax ID#
EXHIBIT A
I. SCOPE OF SERVICES
Consultant shall render veterinary services to City at the Santa Ana Zoo at Prentice Park
("Zoo") and in the home practice/place of business on a continuing basis for the duration
of this Agreement, including, but not limited to the following:
A. Serve as a medical officer for the Zoo facilities and collection. Due to the
diversity of the animal collection, multiple consulting veterinarians are needed.
Dr. Fisher's will be primarily responsible for the exotic animal collection.
However, Dr. Fisher may be consulted on any animal in the collection.
B. Serve as caretaker of drugs, narcotics, and pharmaceutical equipment. Consultant
shall administer or supervise the administration of narcotics, pharmaceuticals, and
pharmaceutical equipment to the animals in the Zoo collection.
C. Provide a comprehensive program of preventative and curative medical care for
the designated animal collection.
D. Consult with appropriate zoological and/or human experts and Zoo staff to make
recommendations regarding the nutritional and medical needs of the collection.
E. Visit the Zoo facilities and examine the animal's health and sanitation on average
8 hours per week.
F. Assist the Associate Zoo Curator in establishing and maintaining complete
medical history records for each animal in the collection.
G. Approve the detailed report of medical treatment administered and other services
performed at each visit as prepared by Zoo staff (or by the veterinarian) and sign
the Zoo Vet Visit log for the Zoo files.
H. Exercise his/her best professional judgment and practice and make her best efforts
to maintain the animals and facilities and advise Zoo staff on maintenance of
same so as to insure the best living conditions possible for the collection.
I. Provide telephone consultation, advice and instructions of prescriptions on a
reasonably unlimited basis, either with staff or other veterinarians employed by
City.
J. Provide a signature as the Zoo consulting/attending veterinarian, for necessary
and required certificates, licenses or permits.
K. Advise on ordering medicine, supplies or instruments.
L. Provide medical malpractice insurance.
II CITY OBLIGATIONS
In order to assist Consultant in execution of her responsibilities under this agreement and
to enhance the care of the animals in the collection, the City shall:
A. Maintain a pharmaceutical safe for the storage of all controlled drugs and
narcotics.
B. Maintain a facility for use in surgery and/or treatment of the collection with
recovery and holding cages and related equipment as necessary at the Zoo.
C. Provide Consultant with staff support from Zoo personnel.
D. Purchase equipment, biological, drugs, narcotics, pharmaceuticals and/or other
medical supplies upon request of Consultant.
E. Provide staff assistance for the capture and treatment of animals.
F. Provide staff treatment of specimens on telephone or written instructions from
Consultant.
G. Provide additional veterinarians, where advisable for emergencies or for services
provided pursuant to this Agreement.
H. Maintain diagnostic or treatment notes filed in Zoo records by backup
veterinarians we may employ, for the Consultant's review or use.
I. Pay for all outside laboratory expenses incurred as a result of Consultant's
supervision of animals in the collection.
Pay all other expenses necessary for the care of the collection when recommended
by Consultant and approved by the Executive Director of the Parks, Recreation
and Community Services Agency or his designated representative.
III. COMPENSATION
Consultant agrees to perform the professional services as set forth herein and City agrees
to pay Consultant for all such services at the rate of $32,000 per year (12 months) for one
day (8 hours) per week at the zoo. Consultant may charge additional services at the
normal clinic rate for animals taken to Serrano Animal and Bird Hospital and for
emergency calls to the Zoo after hours. Beyond 8 hours per week or after hours
emergencies covered by_Dr. Fisher, cost will be $75.00 per hour. City shall pay cost of
materials, supplies and laboratory fees incurred for treatment of zoo specimens taken to
Consultant's home hospital for treatment. The total sum to be paid to Consultant
pursuant to this Agreement shall not exceed $35,000.00 during the term. Said fees shall
be paid not later than 30 days after receipt of invoice from Consultant, subject to City
accounting procedures.
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 Clerk of the Council, 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
10
Authorized Representative
Jun -2O-2005 10:27 am FrDR-NCB INTL IL 3128225358 T-754 P, 001/001 F-038
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PRODUCER
'DATE; MMIODIYYI
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
AVMA Professional LiabilityONLY
Insurance Trust
AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW,
C/O Hub International Illinois
1COMPANIES AFFORDING COVERAGE
55 East Jackson Boulevard
COMPANY
Chicago, IL 60604-4187
A Zurich American Insurance Company
IN6IMED
COMPANY
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Kristian J. Fisher, DVM i...fVl
B
Serrano Animal & Bird Hospital
COMPANY
21771 Lake Forest Dr., Ste 111
c
Lake Forest, CA 92910
CONEANY
D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A80VO FOR THE POLICY PERIOD
IND ICATEO, 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. LIMITS SHOWN NAY HAVE BEEN REDUCED EY PAID CLAIMS.
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/Policy
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SHOULD AMY OF THE ABOVE DEBCNBEO POLICIES EE CANCELLED BEFORE THE
EXPIRATION DAT[ THEBEOP, THE ISSUING COMPANY WILL ENDEAVOR TO MAR
�1Q PAYS WIBYT6N NOTICE TO THE CDITOICATE HOLDER NAMED TO THE LEFT.
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OELICATIYN OR UORITY
OF ANY XWO UPON THE COMPMIY, ITS AGENTS CA REPRE ATIVR.
AIITHOAIXD REPR[AlryTAT1YE
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Elite - Package 1 'Af ENCOMPASS -
I N $ U F3 A N C E
Policyholder: Agent:
KRISTIAN KRAUSE WALTER MORTENSEN INS
21682 VINTAGE WAY 4701 STOCKDALE HWY
LAKE FOREST CA 92630-5759 BAKERSFIELD CA 93309
PHONE: 661-834-6222
Policy Number: Policy Period:
261211892 03/23/2005 to 03/23/2006 12:01 AM Standard Time
This is a replacement of policy 218450853
Insurance Provided BY:
Encompass Insurance Company
2775 sanders Rd.; Northbrook, IL 60062-6127
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
240-007770-00-'0
Policyholder Since:
03/2004
24 HOUR CLAIM REPORTING 800-588-7400
$ 2,266.00
MOTOR VEHICLE PROTECTION (Coverage applies only if a premium or limit is shown)
261211892
146�
.1 tM
0
Continued on Next Page Page 01 of 05
Vehicle I
Vehicle
Description:
2004 CHEVY TRUC TRAILBLAZER
VIN:
IGNDT13SB42117211
Rated Driver:
KRISTIAN KRAUSE
Use:
Pleasure
Class Code:
661100
Estimated Annual Mileage:
15000
COVERAGES, gQ4.,
z
BODILY INJURY
250,000/500,000
$ 451.00
(per person/per accident)
PROPERTY DAMAGE
$ 25, 000
$ 139.00
(per accident)
MEDICAL EXPENSE
$ 5,000
$ 42.00
UNINSURED MOTORISTS -
BODILY INJURY
$ 250,000/500,000
$ 86.00
(per person/per accident)
COLLISION DEDUCTIBLE
Per Endorsement
$ 18.00
WAIVER
(per accident)
COMPREHENSIVE (Comp)
$ 250 Deductible
$ 145.00
COLLISION (Coll)
$ 500 Deductible
$ 430.00
TOWING
Reasonable Expense
$ Included
261211892
146�
.1 tM
0
Continued on Next Page Page 01 of 05
r/ ENCOMPASS_
I N S U R A N C E
Policyholder: Agent:
KRISTIAN KRAUSE WALTER MORTENSEN INS
21682 VINTAGE WAY 4701 STOCKDALE HWY
LAKE FOREST CA 92630-5759 BAKERSFIELD CA 93309
PHONE: 661-834-6222 240-007770-0000
Policy Number: Policy Period: Policyholder Since:
261211892 03/23/2005 to 03/23/2006 12:01 AM Standard Time 03/2004
This Is a replacement of policy 218450853
Insurance Provided By:
Encompass Insurance Company 24 HOUR CLAIM REPORTING 800-588-7400
2775 Sanders Rd.; Northbrook, IL 60062-6127
YOUR POLICY HAS BEEN CHANGED
A change in name of insured
Chg named insrd to maiden name: Kruase
Revised Annual Policy Premium $ 2,266.00
No change in premium
This Cgyerage Summpri Arov das Yo!t witty 16* "® t�tpnPy it l f tatl9g, 7trdu (i #h� Y4 change and
MOTOR VEHICLE PROTECTION (Coverage applies only K a premium or limit is shown)
Vehicle 1 Vehicle
Description:
2004 CHEVY TRUC TRAILBLAZER
VIN:
1GNDT13S842117211
Rated Driver:
KRISTIAN KRAUSE
Use:
Pleasure
Class Code:
661100
Estimated Annual Mileage:
15000
COVERAGES,
BODILY INJURY
$ 250,000/500,000
$
451.00
(per person/per accident)
PROPERTY DAMAGE
$ 25,000
$
139.00
(per accident)
MEDICAL EXPENSE
$ 5,000
$
42.00
UNINSURED MOTORISTS -
BODILY INJURY
$ 250,000/500,000
$
86.00
(per person/per accident)
COLLISION DEDUCTIBLE
Per Endorsement
$
18.00
WAIVER
(per accident)
COMPREHENSIVE (Comp)
$ 250 Deductible
$
145.00
COLLISION (Coll)
$ 500 Deductible
$
430.00
TOWING
Reasonable Expense
$
Included
261211892
Charman oltlr so.rd
Continued on
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Page Page 01 of 05
'OooO(1CAo6o]010)0910eoo0Woo000100Y
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 this endorsement form as a part of
Policy #
Issued to _
Named Insured
Countersigned by
Authorized Representative
10
WORKERS' COMPENSATION DECLARATION
I S�y, rhMHereby affirm under penalty of perjury, the
(Namerritle)
following declaration
I certify on behalf of that during the term of my
(Organization Name)
contract with the Cfonia Ann. & 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: ' �l 05
By: c Yfl D d I (C 7J
Name: KY I S o V-1 J r sYtur, Dyr; l
Title: Ve f-uY icL rt o� n
Telephone:Ogq)
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
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.
Tkilvc.0 AS 'fO FORM
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