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HomeMy WebLinkAboutARC MID-CITIES 1A-2008,. INSURANCE NOT ON FILE . WORK MAY NOT PROCEED CLERK OF COUNCIL DATE: ~, yg-off v : pw a (~) ~p~ll N1e.resccQo FIRST AMENDMENT TO GRAFFITI REMOVAL SERVICES AGREEMENT N-2007-070-01 THIS FIRST AMENDMENT TO AGREEMENT, is entered into on April ~~ 2008, by and between ARC MID-CITIES -ORANGE COUNTY, anot-for- profit corporation("Contractor") and the City of Santa Ana, a charter city and municipal corporation of the State of California ("City"). RECTI'ALS: A. The parties entered into Agreement #N-2007-070, dated May1, 2007, (hereinafter "said Agreement") by which Consultant has provided supervision for graffiti removal. services. B. In accordance with the terms and conditions of said Agreement, the parties wish to extend the. term 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 Agreement, the parties agree as follows: 1. Section 2, COMPENSATION, shall be amended to increase compensation by $16,200 to pay for services for an additional one-year term at the rate of $1,350.00 per month. 2. Section 3, TERM, shall be amended to extend the termination date an additional one- year, to June 3Q 2009. 3. 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 Agreement on the date and year first written above. CITY OF SANTA ANA ATTEST: PATRICIA E. HEALY Clerk of the Council APPROVED AS TO FORM: JOSEPH W.FLETCHER City Attorney By La a heedy Assistant City Attorney APPROVED AS TO CONTENT: DAVID N. RE City Manager ARC MID-CITIES ORANGE COUNTY ! ~ G .l ~. w. ~eh G~iSC.~+5Si0V~ 3 .ROSS JOHN WAGNER ive Director - President -Executive Director Works Agency RICK ROB ON Senior Procurement Officer Contract Liaison ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) ,h, 1011412008 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER RFP INSURANCE AGENCY ~ ~ ( ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ~ ' /qo~ EXTEND OR THIS CERTIFICATE DOES NOT AMEND OLDER 5601 WEST SLAUSON AVE., SUITE 250 ^O , . /w I H ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. CULVER CITY, CA 90230 1933 Fax (310) 645-3150 642 310 Ph ~~ qq ~ /~ IV "~~ 7 ~~ l - } one ( INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: NONPROFITS' INS. ALLIANCE OF CA. A+ X ARC MID-CITIES TOWNE AVENUE INSURER B: NORTH AMERICAN ELITE INS. CO. 14208 CA 90061 LOS ANGELES INSURER C: PHILADELPHIA INDEMNITY INS. CO. A+ X , INSURER D: INSURER E: VUVCKF-VCJ IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING THE POLIC TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR I EMENT , ANY REQU R THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH RTAI MAY PE N, POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD' POLICY NUMBER POLICY EFFECTNE POLICY EXPp TION LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1 OOO OOO X COMMERCIAL GENERAL LIABILITY NPO 0823825 7/19/2008 7/19/2009 PREMISES Ea occurenca $ 300 000 CLAIMS MADE a OCCUR - 20 MED EXP (Any one parson) $ 75 000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2 OOO OOO N'L AGGREGATE LIMIT APPLIES PER: G PRODUCTS - COMPJOP AGG $ 2 OOO OOO E POLICY pR~ LOC AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 000 000 ANY AUTO 9/23/2008 9/23/2009 (Ea accident) , , PHPK348858 ALL OWNED AUTOS BODILY INJURY $ C X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) COMP. 8a COLLISION PROPERTY DAMAGE $ DEDUCTIBLE $1,000 (Paraccidant> GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ ~'' AUTO ONLY: AGG $ EXCESSIUMBRELLA LU181LITY / EACH OCCURRENCE S OCCUR ~ CLAIMSMADE ~2UJ011 r~ zax~srss ~ ' AGGREGATE $ 1 t ` pTtlE ~(~~~t $ DEDUCTIBLE ~ ~~~-~~ _ ~'~ ~~ / $ ~ ! RETENTION $ ' $ WORKERS COMPENSATION AND ~ ~ n ~ WC STATU- OTH- ~ 0~ U ~ EMPLOYERS' LIABILITY ~ a E.L. EACH ACCIDENT $ ANY PROPRIETORlPARTNERIEXECUTIVE OFFICERlM EMBER EXCLUDED9 E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT S OTHER 200823628-NPO 7119/2008 7/19/2009 1,000,00012,000,000 A.) PROFESSIONAL LIABILITY 200823628-NPO 7/19/2008 7/19/2009 500,000/500,000 A.) SEXUAL MISCONDUCT 500 000 - DED. $2 250 e.) EMPLOYEE DISHONESTY CBW0007843-00-23628 7/19/2008 7/19/2009 , , DESCRIPTION OF OPERATIONS / LOCATIONS f VEHICLES !EXCLUSIONS ADDED BY ENDORSEMENT J SPECIAL PROVISIONS THE CITY, ITS OFFICERS, EMPLOYEES, AGENTS, VOLUNTEERS AND REPRESENTATIVES IS NAMED AS ADDITIONAL INSURED(S). GEFKI IhIGA I t t1ULUtK F+-uultwnal u7aurcu _ ~.ruw~a.ur r rvr~ CLERK OF THE CITY COUNCIL CITY OF SANTA ANA 20 CIVIC CENTER PLAZA (M-30) P.O. BOX 1988 SANTA ANA, CA 92702-1988 ACORD 25 (2001108) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILnY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATNE 1988 POLICY NUMBER: 200823628-NPO COMMERCIAL GENERAi_ LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ~~~ITiG1~,AL ENSURED _ ®ESiGNATE® ~~RSt~~i or GRG~~lINl~~~~DN . This endorsement modifies insurance provided underfll~,:fi~l~fOwing: COMMERCIAL GENERAL LIABILITY COVERACxE PART 5-CH'ED;l7~.L Name of Person or Organizatior CLERK CITY OF COUNCIL CITY OF SANTA ANA 20 CIVIC CENTER PLAZA (M-30) P.O. BOX 1988 SANTA ANA, CA 92702-1988 {If no entry appears above, infor~rraiin> required to complete this endorsement will be shown in the peclarations as applicable to this endors~inent.} WHO IS AN INSURED {Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your operations or premises owned by or rented to yo'u. CG 20 26''! 'I 85 EXHIBIT B ADDITIONAL INSURED ENDORSEMENT FOR COMMERCIAL GENERAL LIABILITY POLICY Insurance Company NONPROFIT"S ALLIANCE OF CA This endorsement modifies such insurance as is afforded by the provisions of Policy # 7 O..0 R ~ ~ ~ ~ R-NPQ 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 can-led 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 0 7 / 1 9 / 0 8 ,this endorsement form as a part of Policy # 200823628-NPO Issued to ARC MID-C'TTTES --- Named Insured Countersigned by ; ~11~? //. ~/~' ut orized Representative CERTHOLDER COPY 1 A~~ P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION I N S U R A N C E ® CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 10-14-2008 GROUP: 000567 POLICY NUMBER: 0001087-2008 CERTIFICATE ID: 51 CERTIFICATE EXPIRES:07-01-2009 07-01-2008/07-01-2009 CLERK OF THE CITY COUNCIL SC CITY OF SANTA ANA 20 CIVIC CENTER PLZ M-30 SANTA ANA CA 92701-4058 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. THORIZED REPRESENTATI Ck~ `~~G PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2008-10-14 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CLERK OF THE CITY COUNCIL ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-14-2008 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2008-10-14 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CLERK OF THE CITY COUNCIL EMPLOYER ASSOCIATION FOR RETARDED CITIZENS AND MID-CITIES (A NON PROFIT CORP) 14208 TOWNE AVE LOS ANGELES CA 90061 ~#~~~~v i;i~ A." Tn FORM ~~ - ....~.._---- y As~is~au[ L~~y AuorneY, SC [B13,SC] 5C (REV.2-D5) PRINTED 10-14-2008 STATE COMPENSATION INSURANCE FUND N _ 2-0D-7 ~ D7 C - 0 \ IN REPLY REFER TO' FEBRUARY 6, 2009 CLERK OF THE CITY COUNCIL CITY OF SANTA ANA 20 CIVIC CENTER PLZ M-30 SANTA ANA CA 92701-4058 CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION NOTICE ------------------- RE: CERTIFICATE DATED OCTOBER 14, 2008 THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW HAS BEEN CANCELLED EFFECTIVE JANUARY 27, 2009 AT 12:01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EMPLOYER NAMED BELOW EMPLOYER: ARC MID-CITIES 14208 TOWNE AVE LOS ANGELES, CA 90061 POLICY 567-0001087-08 CUSTOMER SERVICES UNIT LOS ANGELES DISTRICT OFFICE (323) 266-5000 1275 Market Street. San Francisco. CA 94103-1410 Mailing Address: PO. Box 420807 . San Francisco, CA 94142-0807 selF 19102 -. ~ ~~~ Zo~l 7-~ icy ~~! 2 Aleorrd C~RTIFICAI'~ 4F LIABtL1TY INSURANCE °"o1r~i~n a ~"'~ PRDDUf~.R HIS C FICATION $SUB AS A M OF NF TION ONLY AN17 CONFERS NO RlC~FIT9 UPON THE CERTIFICAT@ CAIOUO INSURANCE AGENCY HOJ~R, THIS C~RTIFlCATE I>4ES NOT ANNF.~ID , FJ(TEND OR 9100 s. SEPULVFI~A rit.vu. SUITE 109 ALTER THE COVERAGES APFOROE6 BY THG pOIJCI E$ BELOW. LOS ANGELES, GA 90V46 INSURERS AFFQRp1NG COYERAG7= NAIC 11 PH. 310 348-993$ FAX 310 34&9525 -_... .. d- _ IN6UR~ A: LIBERTY MUTUAI-INSURANCE COIdP - INSUR ARC MIP GITIES IHSURr.FI a _ , ._.... _ .... 9i208TOWNEAVENUE INSORt7tC: _ _... ._ ~- -- LOS ~4NGELE=3. CA 90081 INSURER D: - re n ~urureYcen Nf] STANbING THE PO F INSURANCE LISTED EteLpW HAVE a[:Ero 1`.+'SUCO Tv Tne ~n~unr„ rovnw ..o...~ ...., .. ~ . -_.- .. _. -- - -- OOCUtAENT WITH RESPECT TO WHICH THIS CERTIFICATE IMY SE ISSUED OR ATIY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACTOR {17HER EXCLUSIONS AND CONDffIONS OF SUCH THE TERMB BJECT TG Atl S . U MAY PERTAIN, THE INSURANCE AFFOft[7ED SY THE POLICIES OESCRISED kEREIN 1~ , POLICIES. AGGREGJ1l't LIMITS SHOYYN NNT I1AVE 6El:N ItEDUCEP BY PAID CLAlA1S. - -- - .. ..... • • POLICY EiFECTIY! YOLSCY E]CPIRA eV A 'TYPE Of INSURANCE. P°UCY NUMBER DATE MMIOWYY DATE (MMlpplYTYY LTR INS LIMITS „, EACH CIS;CURP;FJ~CC 3 pF.gERAL LIAilILI fY _. ~ OQL1~~~1 s -" COMMERCNLGCNERALLWBILIIY ._ - S ' l (;thtlUSMADL ~ OCCUR xP(AiryORl4lri7AY . .._ - MFbF ' -- i ___ . .... PGRSQKAI. f ADV INJUk'+ .... ~- (jI;I~RALAQCTiOG~TE f .-- (itNL AGGRECa4TE LA~AR APPLES PER: PN(717UCTS • COMPIOP ACG i . . POLICY JECaT LOC i AUT - OMOBILFLIAaLLJTY COMBWEU8INGLFUNR Iho ocddri) i ANY AUTO .. _ _ ..~ ALL OY\IrED RU K)S @ODRY INJURY i IPbr pol7on) SGHEDUU~Alf1OS - _ , . HgtEDAU'TV5 ~PPRO ED AS O FORivI eoDILVINJUHT i ... (Per ~dnN I ...._ NGI~FOWNEp PIl14S ~~. )~ ~ • - ..,.. PROPERTY DAMWP i . ~. %• ~ ~ ~~~ ~ IPeracogaMl ~ , UaHAGt UABII ITY / L ura Stitt Sh dy ~ AuTOO."_Lr'eo''~.'u°eNr s ANYAVTO Assis ant City At orney EA ACC UIH~~ - i '~ AurpoNLr. acs i L~7IClbb f UMBRELLA LYIBWTY F.4CH OCxl1RRENCt •, i _ ... _.. OCCUR u CLAid6 MAl~lo ~ ACNIrLi4'I'C •, S .. '- _ i CTe •• i - " D~DU LE NF: f6NTION i YIORKiRBCONP~11M710NAND 0127!2010 D1/27JZ011 3C ToRYUMfT9 FN. .. A EMPLOY6136' LU1~RY Y! N WCi$I1-43fa0B8-01 U „ • E.L EACH PCCIDP.Ni i 1.~IU,OOO ~- ANY PROPRIETORlPARTHEN~I~CUTIM ~ OFFICER+MENNfFHkxCLU°GD'1 Y,• .- .. E.L.016tASE-EA6IYWI.OYt: 1 1,000,000 - t A~~w OaNV~ 6.L DkiEA9E' I'UI IGY UNIIi i 1,~0,~ OTMFft i DP.'JGRtPTtlN Oi OPEMl10Nb! I.QCATIONII14li1MCLE4lfJlCl-UER)W6ADnE~f1Y ENDORiLMENTIiPECfAL M'CYISYONS EMPLOYER'S LIABILITY LIhAITS INCLUdINO L)EFEN5E COSTS: 31,000,000 PE.R OCCURENCE. ENDORSEMENT ENTITLELI WAVER OF 51JBRAGATION EFFECTIVE 01R7h010 lS ATTAGHCD TO ANO FO RMS A PART OF THIu POLICY. THIRD PARTY NAME: CiERK OF THE CITY COUNCIL, CITY OF SANTA ANA C,LE42K Of-THE CITY COUNCIL Cf1Y OF $AN•fA ANA 2V CIVIC CENTCFi I'1A7J1 M-30 SANTA ANA GA 92701-4058 TION m N]ULD ANY v 7HK ABO4E D84~lrStlCllb BP• GNC~I~TYEF(i1lE TNR l11MNATR741 Ti TNe~elOF, b~E IN51ALL'R YMLL DIPEAMOR 70 M11R . ~ vwYi IAlliUll'rEH TiGF. S>5 ~ CERTUICP.7R QLflER NAMED Tit YH6 LEiT, 1yIJT FAR.YRk'YD Fm SCI SHALL 109E NO .MiA7%)II OR C1r AN`~la~ UPON T4~ RIYURER, RS AOCNTD WR ACOI~D 25 (2gQW01} ~ RG7~)~ '~T b~rxz. •~ ®1862009 ACi The ACOR4 narrls snd logo are regl64~r*d mark! 41 ACORD Zd IJdSS:~O 0I0Z SZ '~EI.1 6~£~~BI£: 'ON :{H~ TK)N. All rids reserved 5~ I l I ~-Q I bJ72ki : W0~ CERTIFICATE OF WORKERS' COMPENSATION COVERAGE T Feb 3 2012 PRODUCER NonPro£ts' United Workers' Compensation Group THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY 431 1 Street, Suite 200 AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. Sacramento. CA 95814 Phone- (916) 764-005 6 THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE Fez: (916) 880.5251 COVERAGE AFFORDED BY THE POLICIES BELOW. Marsh Risk 8c Insurance Services 345 California Street Suite 1300 _ San Francisco, CA 94104 INSURERS AFFORDING COVERAGE INSURED INSURER A Non Profits' United Workers' Compensation Group Association tDr Retarded Citizens Mitl-Cities INSURER B: ACE American ]nsurance Company [NAIL a 22667) '14208 Towne Ave. Los Angeles, CA 9006'1 N,?OU'7-O?O INSURER C: ? / Y / t ? U '? t - INSURER D- - ? Z ? U y ? ? INSURER E COVERAGES This Certificate is not intended to s eci all entlort;emenls, Covera es, terms, contlitions aril exdusions of the olicies shown. THE POLICIES OF COVERAGE LISTED BELOW HAVE BEEN ISSVED TO THE AFFILIATE MEMBER NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREM ENT, TERM, OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS GE RTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE COVERAGE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SVBJECT TO ALL THE TERMS, E%CL USIO NS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDVGED BY PAID CLAIMS. INSR LTR TYPE OF COVERAGE POLCY NUMBER POLICY EFFECTIVE DATE POLICY E%PIRATON DATE LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY RRE DAMAGE (Any one fire) $ CLAIMS MADE OCCUR MED EXPENSE (Any one person) $ GENERAL AGGREGATE LIMIT APPLtE9 PER: PERSONAL 8 ADV IWURY $ POLICY PROJECT LOC GENERAL AGGREGATE $ PRODUCTS-GOMPIOP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (??.>_?TTTa (? ?? , O 1 (Each aori0enl) $ ALL OWNED AVTOS ? ?? ?"? d (_? AA'' )?D??,?p?tURY $ SCHEDULED ALROS \- (Per pereo^I $ HIRED AUTOS -°?rr?. -'__: ? BODILY INJVRY $ NON-OWNED AUTOS j-[I ( `. _, ,? (Per ecotlent) --- $ ?. SSI.tiI R;] -, ,I;?r(1y l ?: [ PROPER TY DAMAGE $ y /f, I f ? ? 1"rl C (Per accoenfJ $ WC STAT X OTHER WORKERS' COMPENSATION LIMITS A AND NPLJ-WCG OOI-2012 1/27/12 I/1/l3 E.L. EACH ACCIDENT $500,000 EMPLOYERS LIABILITY E.L. DISEASE - EA EMPLOYEE $ $00,000 E.L. DISEASE -COVERAGE LIMIT $ $00,000 OTHER B EXCESS Workers' Compensation WCL 046245283 1/27/12 I/1/13 535,000,000 x E500,000 WC $2,000 000 x $500.000 EL DESCRIPTION OF OPERATIONSA_OCATIONSNENICLES/E%CLUSIONS ADDED BY ENDORSEMENT/SPECIAUPROVISIONS Evidence of Workers' Compensation Coverage: Waiver of Subrogatio n provided by Endorsement No. NPUWCG-ARCMIDC-06 CERTIFICATE HOLDER woDlnoNAL INSURED; INSURER LETTER: CANCELLA"1'1(lN NPUWCG-ARC MIDC-W SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Cit f S nta Ana BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED y o a IN ACCORDANCE WITH THE POLICY PROVISIONS. Clerk of the City Council 20 Civic Center Plaza PO Bor 1988 Santa Ana,CA 92 702-1 988 ? " ? ? ??? ? ? Based on ACORD 25 (2009/09) POLICY CHANGE DOCUMENT POLICY NO.: PHPK733498 Philadelphia Indemnity Insurance Company 110917 Caiquo Insurance Agency NAMED INSURED Arc Mid-Cities MAILING ADDRESS 14208 Towne Ave Los Angeles, CA 90061-2653 POLICY PERIOD: FROM 07/19/2011 TO 07/19/2012 at 12.0 A.M. Standard Time at your mailing address shown above. CHANGE EFFECTIVE 04/26/2012 CHANGE # 2 DESCRIPTION In consideration of the premium reflected, the policy is amended as indicated below: Added: Additional Insured The City of Santa Ana its officers, employees, agents volunteers and representatives 20 Civic Center Plaza Santa Ana, California 92701 CG2026 Additional Insured-Designated Person or Organization Only as respects the primary insured's operations Per attached Path ID 6185976 Total Annual Additional/Return Premium $ 0.00 NO CHANGE Total Prorate Additional/Return Premium $ 0.00 NO CHANGE COUNTERSIGNED BY (Date) Insurance Policy (Authorized Representative) Page 1 of 1 POLICY NUMBER= PHPK733498 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE The City of Santa Ana its officers, employees, agents volunteers and representatives Section 11 -Who Is An Insured is amended to in- clude as an additional insured the person(s) or or- ganization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property dam- age" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 ©ISO Properties, Inc., 2004 Page ? of ? O NONPROFIT uivz-rEr?? THIS ENDORSEMENT CHANGES THE MEMORANDUM OF COVERAGE PLEASE READ IT CAREFULLY WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Non Profits' United Workers' Compensation Group Memorandum of Coverage: NPU-WCG 001-2012 This endorsement modifies the coverage provided under the following: Memorandum of Coverage: PART ONE: WORKERS' COMPENSATION COVERAGE Paragraph H. RECOVERY FROM OTHERS is amended with respect to the following: Name and Address of Person or Organization: City of Sonta Ano 20 Civic Center P/ozo, PO Box 1988 Sonto Ano, CA 92 702-1 988 DESCRIPTION OF OPERATIONS/LOCATIONS ADDED BV ENDORSEMENT: - With regard to the City, its Officio/s Officers, Agents and emp/ogees. NPU-WCG waives any right of recovery it may have against the person or organization shown above because of payments made by NPU-WCG for injury or damage arising out of the Members' operations done under a contract with that person or organization shown above and included in the coverage provided by the Memorandum of Coverage. This waiver applies only to the person or organization shown on the Schedule Above. This endorsement is part of the Memorandum of Coverage and is effective on the date shown below. All other terms and conditions remain unchanged. Effective Date: January 27. 2012 Expiration Date: January 1. 2013 Member: Association for Retarded Citizens Mid-Cities Endorsement No: NPLlWCG-ARCMIDC-06 Date Issued: Feb 3. 2012 Aut prize epresent to ve fior P -W NPU-WCG Page 1 MOC: NPCi-WCG 001-2012