HomeMy WebLinkAboutGEORGE, MARIE DBA ACT ONE ACADEMY OF DANCE (LITTLE STEPS DANCE SCHOOL) 2City of Santa Ana
I �4
Clerk of the Council
AGREEMENT TERMINATION FORM , ------------------- --- ----- ------------ ---- ---- --- ____.-.-.-.-.-._----.-.:
COTC Office Use Only
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11�15
Please complete this form when the attached agreement and all
amendments (if any) are no longer in effect. CITY OF S A N T,I.
Ca`C�`t
Return form to the Clerk of the Council Office (M-30).
Call 647-6520 if you have any questions.
The agreement with George, Marie dba Little Steps Dance Studio, dba Act One Academy of Dance
No. N-2006-060 was completed on 6/30/10 and final payment has been made.
(List all amendments. Use space below if needed.)
N86s6'9°l C�ti,'touslLg.S�zzioniF�ecl�
N-2006-060-02
N-2006-060-03
Department: PRCSA
Phone/Ext.: 5254
Signature:
Date:
167
Revised 08-23-10
INSURANCE NOT ON FILE N-2006-060
WORK MAY ) ff PROCEED
CLERK OF COUNCIL
DATE: "s
-
o
"
pOxs Cx> CONSULTANT AGREEMENT
THIS AGREEMENT made and entered into this 3`d day of April 2006 by and between
Marie George, an individual doing business as Little Steps Dance Studio (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
dance instruction, to teach classes in the City's leisure class program.
B. Consultant represents that Consultant is able and willing to provide such services to the
Citv.
C. In undertaking the pertbnmance of this Agreement, Consultant represents that it is
knowledgeable in its 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 consulting firm 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:
1. SCOPE OF SERVICES
Consultant shall teach dance classes 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
Agreeuent shall not exceed $10,000.00 during the term of this Agreement.
b. City shall collect class fees from each participant during the registration period.
Consultant shall refer all interested participants to City for registration. City shall remit seventy
percent (70%) of the total fees collected within fifteen working days alter completion of the class
session.
3. TERM
This Agreement shall commence on the date first written above and terminate on June 30.
2007, unless terminated earlier in accordance with Section 12, below. Services provided from
January 1, 2006, shall be included within the Scope of Services of this Agreement. l he term of
this Agreement may be extended upon a writing executed by the Executive Director of Parks.
Recreation and Community Services 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 he 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 $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. Worker's Compensation Insurance. In accordance with the provisions of Section
1100 of the Labor Code, Consultant, if Consultant has any employees, is required to be insured
against liability for worker's compensation or to undertake sel Ginsurance. 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.
a The following requirements apply to the insurance to be provided by Consultant pursuant
to this section:
(1) 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 stale 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.
d. 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 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. 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 ofthe terms of, or effects arising from this Agreement. City may make all reasonable
decisions with respect to its representation in any legal proceeding.
CONFIDENTIAL[TV
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.
S. 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
Citv of Santa Ana
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ann, CA 92702-1988
telefacsimile (714) 647-6956
With courtesy copy to:
Executive Director of Parks, Recreation and Community Services
City of Santa Ana
20 Civic Center Plaza (M-23)
P.O. Box 1988
Santa Ana, California 92702
telefacsimile (714) 571-4235
To Consultant: Little Steps Dance School
Marie George
1161 N. Tustin Street
Orange, California 92867
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 lime 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, m 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 ten (10) 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
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 affinns that it is an equal opportunity employer
and shall comply with all applicable federal, state and local laws and regulations.
la. 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. Roth parties further
agree that Orange County, California, shall he the venue for any action or proceeding that may
be brought or arise out of, in connection with or by reason oh this Agreement.
15. PROFESSIONAL LICENSES
Consultant shall, throughout the term of this Agreement, maintain all necessary licenses,
permits and approvals 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 or approvals. Said inability shall be cause
for termination of this Agreement.
16. MISCELLANEOUS PROVISIONS
a. All Fxhibits referenced herein and attached hereto shall be incorporated as if fully set
forth in the body of this Agreement.
IN WITNESS WIIEREOF, the parties hereto have executed this Agreement the date and year
first above written.
ATTEST:
PATRICIA E. Y1 3 LY
Clerk of the Council
APPROVED AS TO FORM:
JOSEPH W.FLETCHER
City Attorney
Laura . heedy
Assistant City Attorney
RECOMMENDED FOR APPROVAL:
GERARDO t
T
Executive Dirf Parks,
Recreation and Community Services
CITY OF SANTA ANA
DAVID N. RF,AM
City Manager
CONSULTANT
f� J
ARID GEORGE
Owner
Tax ID#
EXHIBIT A
SCOPE OF SERVICES
Consultant shall teach, at her dance studio, an adult Social/Ballroom dance class for adults, a
Parent and Me Song, Dance and Tumbling class and a Creative Song. Dance and -1 a nbling class,
as follows:
• Each class will be taught in seven -week sessions.
• The Social/Ballroom class will focus on Swing, Fox Trot, Waltz and Cha-Cha.
• The Parent and Me class will be for parent and child, no drop offs, and will focus on the
fundamentals of tap, ballet and tumbling.
• The Creative Song, Dance and /Tumbling class is open to children 2 Yz - 3 years old, no
child drop off, and will focus on singing and character dancing.
• 1'he classes will be held at Consultant's dance school at a date and time to be agreed
between Consultant and City. Consultant may, with the approval of City, adjust the
schedule.
• Each class shall have a minimum of 4 and a maximum of 8, registered and paid
participants.
• If the minimum registration has not been reached by the second class, the class may be
cancelled by mutual agreement of Consultant and City, with no compensation owed
Consultant for any cancelled class session.
FEES
• Each Social/Ballroom participant shall pay a registration lee of $38.00 per session.
• Each Parent/Child pair, shall pay a registration fee of $54.00 per session.
• Each participant in Creative Song shall pay a registration fee of $35.00 per session.
• No refunds will be made to participants after the first class unless the class is cancelled
by the Parks, Recreation and Community Services Agency.
• City shall collect registration fees from each participant.
• Consultant shall receive seventy percent (70%) of total fees collected for the classes
within fifteen (I S) working days after completion of each class session. City shall retain
thirty percent (30%) of the fees collected.
• Consultant agrees that City shall be entitled to audit Consultant's records and classes to
ensure compliance with this Agreement and that all participants are registered.
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:
I. 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 snake this endorsement
effective.)
Effective
Policy'i
Issued to
this endorsement form as a part of
Named Insured
Countersigned by
Authorized Representative
D 07/2026 15:43 7145278898 STATE FARM PAGE 02
Policy Number DECLARATIONS PAGE AMENDED JUL 3 2006
92-GA-8133-8
STATE FARM GENERAL INSURANCE COMPANY ,
900 OLD RIVER RD. BAKERSFIELD CA 93311-6000
A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON ILLINOIS
Agent Copy
Named Insured and Mailing Address
23-8621-F790 S
GEORGE, MARIE
DBA LITTLE STEPS DANCE SCHOOL
1186 N TUSTIN AVE
ORANGE CA 92867 6006
N-o2006 - 060
BUSINESS POLICY - SPECIAL FORM 3
Gov A -- Inflation Coverage Index: N/A
Cov B - Consumer Price Index: 199.2
AUTOMATIC RENEWAL - It the POLICY PERIOD is shown as 12 MONTHS, this policy will be renewed automatically
subject to the ppremiums, rules and forms in effect for each succeedingq policy pperiod. ff this policy is terminated, we will
give you and fire Mortgagee/Lienholder written notice in compliance Zh the policy provislonS or as required by law.
Policy Period: 12 Months The policy period begins and ends at 12.01 am standard time at the
Effective Date: JUN 23 2006 premises location
Expiration Date: JUN 23 2007
Location of Covered Premises:
1186 N TUSTIN AVE
ORANGE CA 92867-6006
Coverages & Property
Section I
A Buildings
B Business Personal Property
C Loss of Income - 12 Months
Section II
L Business Liability
M Medical Payments
Products -Completed Operations
(PCO) Aggregate
General Agg regate (Other
Than PM
Farms, Options, and Endarc
Special Form 3
Amendatory Endorsement
Debris Removal Endorsement
Policy Endorsement
Business Policy Endorsement
Glass Deductible - Section I
Terrorism Insurance Gov Notice
Limits of Insurance
Excluded
5,500
Actual Loss
500,000
5,000
1,000,000
1.000-01J0
Your policy is amended JUL 3 2006
SECTION II COVERAGE LIMITS CHANGED
Deductibles - Section I
$ 500 Basic
In case of loss under this policy, the deductible will be
applied to each occurrence and will be deducted from the
amount of the loss. Other deductibles may apply - refer to
Endorsement Premium
Decrease
-r
i
Continued on Reverse Side of Page
Prepared OTHER LIMITS AND EXCLUSIONS MAY APPLY- REFER TO YOUR POLICY
JUL 11 2006 Court igned �QQ
FP 8030.2C
06/1993 NMOP BY / Agent
Your policy consists of this page, any endorsements CHARLENE MA IAKEYAMA
and the policy form. PLEASE KEEP THESE TOGETHER. (7141527-9897
127.46
FP-6143
FE-6205
FE-6451
FE-6506.2
FE-6464
FE-6538.1
FE-6999
Discounts Applied:
Renewal Year
Claim Record
68i07/^026 15:43 714577HH98 STATE FARM
-... Policy Number
.,,,92-GA-8133-8
CONTINUED FROM FRONT. SIDE .I
i
BUSINESS POLICY � SPECIAL FORM 3
Forms,O ptions,and.Endorsements
Amendatory Collapse � ..,
Policy Endorsement -Business
Registered Domestic Partnrship
Teachers Liability Endorsement
Schools Endorsement
Inc Cost and Demolition Cov
Section II Additional Insured
Additional I nsured
FE-6610 ..
FE-5383
FE-6359
FE-6389 '
FE-6587
FE-6609
FE-6320
PAGE 03
Li
IMPORTANT NOTICE:
California law requires us to provide you with information for filing complaints with the State Insurance
Department regarding the coverage and service provided under this policy.
Complaints should be filed only after you and State Farm or your'agent or other company representative
have failed to reach a satisfactory agreement on a problem.
Please forward such complaints to: California Department of Insurance
Consumer Services Division
300 South Spring Street
Los Angeles, CA 90013
Prepared Or call toll free: 1-800.927-HELP
JUL 11 2006
(012176,) (o 1 * T 754)
08i07/2026 15: 30 7145P/RR9R STATE FARM PAGE 02
06/07/06 NON 14: 28 FAX 805 093 2089 N COAST I6f
0 002
SH Policy No. 92-GA-8133-8
F(ye00
SECTIDN II ADnMONAL INSURED ENDORSEMENT
�s
Policy No.: 92 -GA- l
Named Insured. GEORGE, MARIE
Additional Insured (Include address):
CITY Cr SANTA ANJA
THEIR CFFICERS & EMPLOYE.FS
898 W SANTA /N7A HLvO STE 200
SANTA "A CA 92701
WHO IS AN INSURED, under SECTION II oESIGNATION OF INSURED, is amended to include as an insured the
Additional Insured shown above, but only to the extent that liability is imposed On that Additwnal Insured solely
because of your work perform®d for that Additional Insured shown above,
Any Insurance to the Additional Insured
damages for whichich youu are provided coverage, apply shall only with respect to a claim made or a suit bro
y
ughlfor
The Primary Insurance coverage below applies only when there Is an "X" In the box.
fxl P .
rnmary Insurance The Insurance provided to the Additional Insured shown above shall be
insurance Any insurance canted by the Additional Insured shall be noncontributo w
coverage provided in primary
you. ry ith respect to
All other policy provisions apply
PE-0do9
>rnted In U S A
08/01i2026 16:45 7145278898 STATE FARM PAGE 03
Fire Policy Status
@ ADDL INSURED - SECTION II
CITY OF ANAHEIM
ANAHEIM REDEVELOPMENT AGENCY
201 S ANAHEIM BL. FL 2
ANAHEIM CA 92805-3826
ADDL INSURED - SECTION II
CITY OF SANTA ANA
20 CIVIC CENTER PLZ
SANTA ANA CA 92701-4058
ADDL INSURED - SECTION II
CITY OF ORANGE
300 E CHAPMAN AVE
ORANGE CA 92866-1508
AUGUST 01, 2006
Prem adj- RENYR $ 67 /CHR
Move -in: W
Entry: JUL-21-05
FMP seg: 03
C 20.08
PROPERTY LOCATIONS
1OC CMPX ADDRESS LIABILITY
STCLS BLD AMT CONTENTS PREMIUM EXPOSURE LIMIT PREMIUM
003 1186 N TUSTIN AVE ORANGE CA 92267
124 5600 22 2000 500000 764
08/01/2026 16:45 7145278898 STATE FARM PAGE 02
AUGUST 01, 2006
Fire Policy
Status
B Ph.
(714)615-8540
GEORGE, MARIE
GENL
Policy: 92-GA-9133-8
G Y,r i5sd: 20C2
DBA LITTLE STEPS DANCE
SCHOOL,
Xref:
11B6 N TUSTIN AVE
ORANGE CA 92667-6006
Location:
1186 N
TUSTIN AVE
ORANGE
CA 92867
Term.-
CONT
Type: BUSINESS - MISC
Renew date: JU14-23-07
Coverage information
Premium:
1,183.00 Written
date: SEP-06-02
H-BUSN PROP 5600
C-LOSS INC ACT LOSS
End act 07/C3/06
L-BUSN LIAR 500000
Amount due:
SFPP
GEN AGGREGT 1000000
Date due:
SFPP
PCO AGGREGT 1000000
Bill to:
SFPP
M MED/FERSN 5000
Prev prem:
1,062
Prev risk: 5,400 SFPP acct:0404-0556-23
Deductibles applied: 500 ALL PER OTHER DED MAY APPLY
Messa(1e5:
Year built: 1951
Zone: 59
Sub zone: 01
Constr: FRAME
Policy Number
DECLARATIONS PAGE AMENDED JUN 23 2007
92-GA-8133-8 STATE FARM GENERAL INSURANCE COMPANY O
9000LD RIVER RD, BAKERSFIELD CA 93311-6000
A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS
23-8821-F790 S
BUSINESS POLICY - SPECIAL FORM 3
Named Insured and Mailing Address
GEORGE, MARIE
DBA ACT ONE ACADEMY OF DANCE
1186 N TUSTIN AVE
ORANGE CA 92867-6006
Cov A: Inflation Coverage index: NIA
Cov B - Consumer Price -Index: 203.9
AUTOMATIC RENEWAL -If the POLICY PERIOD is shown as 12 MONTHS, this pol' will be renewed automatically
subject to the remiums, rules and forms in effect for each P ceeding_policy pew In . If, t!1is P requlreld by law. a will
give you and tie Mortgagee/Lienhol er written notice in com Nance wi the Pa
Policy Period: 12 Months The policy period begins and ends at 12:01 am standard time at the
Effective Date: JUN 23 2007 premises location.
Expiration Date: JUN 23 2008
Location of Covered Premises:
1186 N TUSTIN AVE
ORANGE CA 92867-6006
Coverages & Property
Section I
A Buildings
B Business Personal Property
C Loss of Income - 12 Months
Section II
L Business Liability
M Medical Payments
Products -Completed Operations
(PCO) Aggregate
General Aggregate (Other
Than PCO)
and Endorsements
Special Form 3
'Section II Additional Insured
Amendatory Endorsement
Debris Removal Endorsement
Policy Endorsement
Business Policy Endorsement
Glass Deductible - Section I
New Form Attached
Limits of Insurance
Excluded
$ 5 800
$ Actual Iloss
1,000,000
5,000
2,000,000
2,000,000
FP-6143
FE-6609
FE-6205
FE-6451
FE-6506.2
FE-6464
FE-6538.1
Your policy is amended JUN 23 2007
ADDL INSURED NAME & ADDRESS ADDED
ENDORSEMENT FE-6609 ADDED
Deductibles - Section I
500 Basic
In case of loss under this policy, the deductible will be
applied to each occurrence and will be deducted from the
amount of the loss. Other deductibles may apply - refer to
Endorsement Premium
Increase $ 120.00
Discounts Applied:,'
Renewal Year
Years in Business l
Claim Record
Continued on Reverse Side of Page
OTHER LIMITS AND EXCLUSIONS MAY APPLY - REFER TO YOUR POLICY
Prepared Countelsigned_
JUL 06 2007
FP-8030.2C A3TN By.
06/1993 CHARLENE HATAKEYAMA
Your policy consists of this page, any endorsements (714) 527.8897
and the policy form. PLEASE KEEP THESE TOGETHER.
d a7
Agent
(0112172b)
SB Policy No. 92-GA-8133-8
FE-6609
SECTION 11 ADDITIONAL INSURED ENDORSEMENT A
Policy No.: 92 -GA- 813 3 - 8
Named Insured: GEORGE, MARIE
DBA ACT ONE ACADEMY OF DANCE
Additional Insured (include address):
CITY OF SANTA ANA
THEIR OFFICERS & EMPLOYEES
888 W SANTA ANA BLVD STE 200
SANTA ANA, CA 92701-4561
WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include as an insured the
Additional Insured shown above, but only to the extent that liability is imposed on that Additional Insured solely
because of your work performed for that Additional Insured shown above.
Any insurance provided to the Additional Insured shall only apply with respect to a claim made or a suit brought for
damages for which you are provided coverage.
The Primary Insurance coverage below applies only when there is an "X" in the box.
® Primary Insurance. The insurance provided to the Additional Insured shown above shall be primary
insurance. Any insurance carried by the Additional Insured shall be noncontributory with respect to
coverage provided to you.
All other policy provisions apply.
FE-6609 Printed in U.S.A.
07/28/2009 16:31 7145278898 STATE FARM PAGE 02
DECLARATIONS PAGE COVERAGE SUMMARY
Policy Number JUL 20 2009
82-CiA 8i33-8 WATE FARM GENERAL INSURANG6 COMPANY I ""4
900 OLD RIVER RD, BAKERSFIELD CA 93311.6000
ASTOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS
Named Insured and Mailing23�ddrref F790 S
QEORGE, MARIE
DBA ACT ONE ACADEMY OF DANCE
1156 N TUSTIN AVE
ORANGE CA 92867-6006
R 00l - OGO,
Cov A - Inflation Coveragge Index., N/A .
BUSINESS POLICY - SPECIAL FORM 3 Cov B - COASUMOt Prlcelndex: 220.0
AUTOMATIC 14ENEWAL - If the POLICY PERIOD Is showwnn as 12 MON�I S, th s o iRWit be renewed autornaticall�
s b eat to the rem(urns, ruleq and fo rnwri�te noticerIn comS�i an @ce Iwmt the p�lia pro�is(ond or a10 r qu�rej y law. s w
give you and tie Mortgageell-ienholde P
Policy Period:12 Months The policy
pert onbegins and ends at 12�1 am standard time at the
Effective Date., JUN 23 2009 P
Expiration i?ate: JUN 23 2010
Named Insured: Ind —Mal Requested By: Additional Insured
Location of Covered Premises:
1186 N TUSTIN AVE
ORANGE CA 92867.6006
Coverages & Properly
Section I
A Buildings
H Business Personal Property
C Loss of income - 12 Months
Section II
L Business Liability
M Medical Payments
Produote-Completed Operations
(PCO) Aggregate
General Aqgg regate (Other
Than PCO3
Limits of Insaranoe
Ex101u300
Actual loss
1,9:���
2,D0000,
2,000,000
Forms Options, and Endorsements
Special Form 3
FP-6143
Amendatory Endorsement
F8-6205
Debris Removal Endorsement
FE-6451
Policy Endorsement
FE-6506.2
Business Policy Endorsement
FE-6484
Glass Deductible - Section I
FE-6638.1
Terrorism insurance Cov Notice
FE-6999.1
Deductibles - 9eo00111 I
600 Basic
in case of loss under this policy the deductible will be
applied to each occurrenoe and wfll be deducted from the
amount of the loss. Other deductibles may apply - refer to
Policy Premium
Discounts Applied:
Renewal Year
Years In Business
Claim Record
Continued on Reverse Side of Page i
Prepared OTHER LIMITS AND EXCLUSIONS MAY APPLY- REPER
JUL Prepared
Count signed
FP-8
8j93.2C CUTO BY
Your oficyeonststs of this page, anyendomemants CHARLENE HATAKEYAi
and the policy form. PLEASIE KEEP THESE TOGETHER. (714) 827-8897
,090.0
p0 .X00 r
0-6- , Aaent
(0112 i7Rb)
37/28/2009 15:31 7145278898 STATE FARM PAGE 03
CORD POUCy NO,: 92-(3A 8133-8 FE-
8600
SECTION 11 ADDITIONAL INSURED ENDORSEMENT
Policy No.: 92-GA 8133-8
Named Insured: GEORGE, MARIE DBA: ACT ONE ACADEMY OF DANCE
Additional Insured (include address):
CITY OF SANTA ANA
THEIR OFFICERS & EMPLOYEES
888 W SANTA ANA BLVD STE 200
SANTA ANA CA 92701-4561
WHO IS AN INSURED, under SECTION 11 DESIGNATION OF INSURED, is amended to include as
an insured the Additional Insured shown above, but only to the extent that liability Is Imposed on that
Additional Insured solely because of your work performed for that Additional Insured shown above.
Any Insurance provided to the Additional Insured shall only apply with respect to a claim made or a
suit brought for damages for which you are provided coverage.
The Primary Insurance coverage below applies only when there is an "X" In the box.
j Primary Insurance. The Insurance provided to the Additional Insured shown above shall be
primary insurance. Any Insurance Carried by the Additional Insured shall be noncontributory
with respect to Coverage provided to you.
All other policy provisions apply.
FE-0609 Pdnled In 11.5.A,