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HomeMy WebLinkAboutJL GROUP, LLC INSURANCE ON FILE WORK MAY PROCEED UNTIL INSUR CE EXPIRLI A-2025-028-01 CITYCITY­TCLERK DATE. MAY 7 2025 AGREEMENT WITH JL GROUP, LLC TO PROVIDE DlN � � ADMINISTRATIVE HEARING OFFICER SERVICES THIS AGREEMENT is made and entered into on this 18TH day of March, 2025 by and between JL Group, LLC, a California limited liability company ("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("City"). RECITALS A. On October 24,2024,the City issued Request for Proposals No. 24-127,by which it sought Consultants to provide as-needed administrative hearing officer services for various agencies of the City of Santa Ana. The scope of work includes any and all work efforts related to administrative hearings, preparation of hearings as scheduled by City staff, reviewing case documentation submitted with appeals, performing legal research, conducting hearings, and preparing written decisions. B. Consultant submitted a responsive proposal that was among those selected by the City. Consultant represents that it is able and willing to provide the services described in the scope of work that was included in RFP No. 24-127 and attached as Exhibit A. C. Consultant was selected as one of eight (8) vendors which qualified for this engagement. Only those consultants approved by the City Council on March 18, 2025 shall be eligible to be engaged by the City for these services. D. In undertaking the performance 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 a. On an as-needed basis,and at the sole discretion of the City,Consultants shall perform the services that are described in Exhibit A, attached and incorporated by reference as though fully set forth herein. b. When the need for services arise, City may initiate services through use of written correspondence, executed by authorized City staff and the Consultant. Work by the Consultant may not proceed absent a previously engaged or fully executed consultant agreement and authorizing written correspondence for a specific assignment. The Treasury&Customer Service Manager or their designee will maintain the directory of authorized staff who will be permitted to issue assignments to the Consultants. Consultants are prohibited from accepting assignments from City staff whom are not authorized to issue said assignment and work. 4. INDEPENDENT CONTRACTOR Consultant shall, during the entire term of this Agreement, be construed to be an independent Consultant 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. OWNERSHIP OF MATERIALS This Agreement creates a non-exclusive and perpetual license for City to copy, use, modify, reuse, or sublicense any and all copyrights, designs, and other intellectual property embodied in plans, specifications, studies, drawings, estimates, and other documents or works of authorship fixed in any tangible medium of expression, including, but not limited to, physical drawings or data magnetically or otherwise recorded on computer diskettes,which are prepared or caused to be prepared by Consultant under this Agreement ("Documents & Data"). Consultant shall require all subcontractors to agree in writing that City is granted a non-exclusive and perpetual license for any Documents & Data the subcontractor prepares under this Agreement. Consultant represents and warrants that Consultant has the legal right to license any and all Documents & Data. Consultant makes no such representation and warranty in regard to Documents & Data which were provided to Consultant by the City. City shall not be limited in any way in its use of the Documents and Data at any time, provided that any such use not within the purposes intended by this Agreement shall be at City's sole risk. 6. INSURANCE; MINIMUM SCOPE AND LIMIT OF INSURANCE a. Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require any subcontractors to obtain and maintain insurance as described below for the entire Term and Fxtended Term, if applicable, of this Agreement against claims for injuries to persons or damage to property which may arise from or in connection with services,products and materials supplied to City.Total cost of such insurance shall be borne by Consultant. 1. Commercial General Liability (CGL): Insurance Services Office Form CG 00 01covering CGL on an "occurrence" basis, including products and completed operations, property damage, bodily injury and personal & advertising injury with limits no less than $1,000,000 per occurrence and $2,000,000 aggregate. Required policy limits can be met with primary and umbrella/excess insurance policies. 2. Automobile Liability (AL): Insurance Services Office Form CA 00 01 covering Code I (any auto), with limits no less than $1,000,000 combined single limits. In d. Self-Insured Retentions. Self-insured retentions must be declared to and approved by the City. The City may require the Consultant to purchase coverage with a lower retention or provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention e. Acceptability of Insurers. Insurance is to be placed with insurers authorized to conduct business in the State of California with a current A.M. Best rating of no less than AXII, unless otherwise acceptable to City. f. Verification of Coverage. Consultant shall furnish City with original Certificates of Insurance including all required amendatory endorsements (or copies of the applicable policy language effecting coverage required by this clause) and a copy of the Declarations and Endorsement Page of the CGL policy listing all policy endorsements before work begins. However, failure to obtain the required documents prior to the work beginning shall not waive Consultant's obligation to provide them. City reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time. g. Special Risks or Circumstances. City reserves the right to modify these requirements, including limits, based on the nature of the risk, prior experience, insurer,coverage,or other special circumstances. 7. INDEMNIFICATION Consultant agrees to defend, and shall indemnify and hold harmless the City, its officers, agents, employees, contractors, special counsel, and representatives from liability; (1) for personal injury,damages,just compensation, restitution,judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Consultant, its agents, employees, or other persons acting on its behalf which relates to the services described in section 1 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 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.Notwithstanding the foregoing, to the extent Consultant's services are subject to Civil Code Section 2782.8, the above indemnity shall be limited,to the extent required by Civil Code Section 2782.8,to claims that arise out of,pertain to, or relate to the negligence, recklessness, or willful misconduct of the Consultant. sexual orientation, gender identity, gender expression, gender, medical conditions, genetic information, or military and veteran status, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization, promotion, termination or other employment related activities or any services provided under this Agreement. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 13. 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 or 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 is not embodied herein. 14. 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. 15. TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, to the extent required by law, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant satisfactorily and in accordance with the scope of work contained in Exhibit A and all applicable SAMC requirements prior to receipt of such notice of termination.Further,the Executive Director may require Consultant to deliver to the City all work product(s) 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. 16. WAIVER No waiver of breach, failure of any condition, or any right or remedy contained in or granted by the provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the breach,failure, right or remedy.No waiver of any breach,failure or right, or remedy shall be deemed a waiver of any other breach, failure, right or remedy, whether or not IN WITNESS WHEREOF,the parties hereto have executed this Agreement the date and year first above written. ATTEST: CITY OF SA A ANA niter 11 Alvaro Nunez City Cie City Manager APPROVED AS TO FORM: SONIA R. CARVALHO JL GROUP, LL City Attorney By: /1 Y Meli sa M. Crosthwaite J rey B. Love, Esq. Senior Assistant City Attorney rincipal RECOMMENDED FOR APPROVAL: Atsmi (ek T kn (, of Alexander Trinidad(Feb 27,202518:11 PST) Alex Trinidad , Acting Executive Director Finance& Management Services Agency �►' CITY OF SANTA ANA EXHIBIT A SCOPE OF SERVICES Services performed by Consultant shall include, but are not limited to the following: A. GENERAL REQUIREMENTS 1. For firms with multiple neutrals, the City must approve in advance, in writing, any neutrals that may serve as a hearing officer for the City. 2. Comply with the Model Code of Ethics published by the National Association of Hearing Officials. 3. Comply with all City ordinances, municipal code, charter, policies, procedures, rules, and regulations. 4. Prepare for hearings as scheduled by City staff, including notification of the hearing type, date, time, and location to petitioner/appellant. 5. Review case documentation submitted with petitions or appeals, and identifying and communicating potential concerns to the City. 6. Perform legal research, and interpret complex statutes, policies, and procedural guidelines. 7. Instruct participants in hearing of their rights and applicable hearing procedures. 8. Conduct hearings in a fair, impartial, courteous, and professional manner. 9. Hear testimony and evidence from parties regarding the issues. 10. Prepare written decisions, which set forth the legal and evidentiary basis for the decision, and adopt findings as required by the particular provisions of the Santa Ana Municipal Code (SAMC). 11. Perform all other services as outlined in the resulting agreement for services upon award. 12. Hearing Officers will confirm the absence of conflicts before undertaking any new matters for the City. Hearing Officers will inform and seek the consent of the City before representing another client in any matter directly averse to the City (e.g., transactions, negotiations, proceedings, or other representations involving specific parties). 13. Hearing Officer will be required to provide Hearing Officer services upon acceptance of assignments. Failure to comply with statutory or City required timelines for scheduling hearings may be cause for termination of the Agreement with the City. 14. Hearing preparation could include, but is not limited to, reading the file materials and familiarization with SAMC provisions at issue, hearing materials, and rules of evidence. 15. Virtual Hearings: City will provide virtual meeting link to all parties. The dates and times of said hearings shall be designated by the City, but normally will be conducted during the City's Regular Business Hours. City of Santa Ana RFP No.24-127 Page 17 of 34 (9) CITY OF SANTA ANA 2. Environmental Sanitation Violations • SAMC § 1-18.2 and SAMC § 1-21 • Related to administrative citations issued by Sanitation Inspectors for right-of-way obstructions, illegal advertising, and weed/rubbish abatement 3. Buildings and Structures • SAMC § 8 (Various Subsections) • Related to the enforcement of state building standards and the denial of permits, approvals, certificates of occupancy, or completion 4. Rent Stabilization and Just Cause Eviction • SAMC § 8-3145(f) (Per Ordinance No. NS-3052) • Related to the Petition Process involving landlord(s) and tenant(s), under the City's Rent Stabilization and Just Cause Eviction Ordinance (which limits rent increases, mandates "just cause" requirements for termination of tenancies, and establishes a rental registry) 5. Refuse Violations • SAMC § 16 (Various Subsections) • Related to administrative citations issued for the improper dumping and elimination of paper, cans, bottles, ashtray accumulations, refuse, trash, rubbish, or other filth in any public or private properties 6. Public Safety Sensitive Business Establishments • SAMC § 18-90 through 18-105; SAMC § 22-1 through 22-16 • Related to public safety regulation of certain businesses including tobacco retail licenses and massage establishments 7. Non-Regulatory Business License Tax • SAMC § 21-41 • Related to the determination of the amount of license tax due to the City from any business operator(aside from cannabis), with any penalties, interest, and charges (including fees) 8. Cannabis Business License Tax • SAMC § 21-41 • Related to the determination of the amount of license tax due to the City from a cannabis operator, together with any penalties, interest, and charges (including service fees) 9. Hotel Visitors Tax (more commonly known as Transient Occupancy Tax) • SAMC § 35-133 • Related to the determination of the amount of tax due to the City from a transient occupying a hotel based upon the rent charged by the operator 10. Utility Users Tax for Electric, Gas &Telecommunications Services • SAMC § 35-173 • Related to the determination of the amount of tax due to the City from every person using electricity, gas, and telecommunication services within Santa Ana City of Santa Ana RFP No.24-127 Page 19 of 34 JL Group LLC - Administrative Hearing Officer (Final with Exhibits)(2019586. 1 ) Final Audit Report 2025-02-28 Created: 2025-02-27 By: Kristin Andrade(kandrade@santa-ana.org) Status: Signed Transaction ID: CBJCHBCAABAAq-WUQSNWI=uYcL9kOhDmCkOErjGA3hj "JL Group LLC - Administrative Hearing Officer (Final with Exhibi ts)(2019586.1 )" History fJ Document created by Kristin Andrade (kandrade@santa-ana.org) 2025-02-27-5:32:51 PM GMT Cy Document emailed to Alexander Trinidad (atrinidad@santa-ana.org)for signature 2025-02-27-5:33:08 PM GMT Email viewed by Alexander Trinidad (atrinidad@santa-ana.org) 2025-02-28-2:11:02 AM GMT do Document e-signed by Alexander Trinidad (atrinidad@santa-ana.org) Signature Date:2025-02-28-2:11:40 AM GMT-Time Source:server Agreement completed. 2025-02-28-2:11:40 AM GMT Q Adobe Acrobat Sign JLGRO-1 OP ID: MN ACORO CERTIFICATE OF LIABILITY INSURANCE DATE/1512025 04/15l2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER 760-471-7116 CONTACT Michelle A Nowell ME: Alliance Mgt.&Insurance Sery PHONE 760-471-7116 F IC 760 471-9378 355 Via Vera Cruz#7 IAIC,No,Ext): (AIc,No): CA Agent/Broker Lic#0737966 EDDRE :mnowe amiscorp.COm San Marcos,CA 92078 Michelle A.Nowell INSURERS AFFORDING COVERAGE NAIC# INSURER A:Star-Stone Specialty Ins Comp 44776 INs RED INSURER B:HSB Specialty Insurance Co. JL�roup LLC 30025 Alicia Pkwy#327 INSURER C: Laguna Niguel,CA 92677 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXPITR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR X X SGP000321 12/20/2024 12/20/2025 DAMAGPR ETO eocTu ace $ 100,000 X Errors&Omission MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY PRO- ❑ LOC 1.000.000 JECT PRODUCTS-COMPlOP AGG $ OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident $ ANY AUTO WSGP000321 12/20/2024 12/20/2025 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOSS ONLY Per accident $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE WSG0000136 12/20/2024 12/20/2025 AGGREGATE $ 1,000,000 DED I I RETENTIONS WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Cyber 6612216-03 08/17/2024 08/17/2025 Cyber 1,000,000 A Professional Liab WSGP000321 12/20/2024 12/20/2025 Occ/Agg 1/4 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Tu Tran Digitally signed by Tu Tran Nguyen City of Santa Ana, its directors, officers,employees,and agents, are named Nguyen Date:202505.01 en as an additional insured with respects to the work performed by the named 9 Y 10:20:58-07'00' insured. Waiver of Subrogation Applies. Investigations,CA - APPROVED By Tu Tran Nguyen at 10:20 am,May 01,2025 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. Finance&Mgmt Sery Agency 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Ana,CA 92701 a U ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured; and c. Regardless of the date of occurrence or when the injury or damage first occurs or is first discovered, a person's or organization's status as an additional insured under this endorsement ends upon the earliest of: (1) The completion or termination of the contract or agreement between you and the additional insured for the location shown in the Schedule; (2) The date you cease actively performing operations for the additional insured at the location shown in the Schedule; or (3) The expiration or termination date of the policy or this endorsement. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to liability or damages for "bodily injury", "property damage", or "personal and advertising injury": I. Caused by, arising from, or included in the"products-completed operations hazard"; 2. Arising out of the additional insured's sole negligence; 3. Arising out of work or operations performed by you that were completed prior to the effective date of this endorsement; or 4. Which continues or progressively deteriorates after you cease actively performing operations for the additional insured at the location shown in the Schedule, even if the injury or damage first occurred, or is alleged to have first occurred, during the course of your operations for the additional injured. C. Solely for purposes of this endorsement, the following definition is deleted in its entirety and replaced by the following: 1. ""Products-completed operations hazard": a. Includes all "bodily injury" and "property damage" occurring away from premises you own or rent and arising out of"your product" or"your work" except: (1) Products that are still in your physical possession; or (2) Work that has not yet been completed or abandoned. However, "your work" will be deemed completed at the earliest of the following times: (a) When all of the work called for in your contract has been completed; (b) When all of the work to be done at the location shown in the Schedule has been completed if your contract calls for work at more than one location; or (c) When that part of the work done at the location shown in the Schedule has been put to its intended use by any person or organization other than another contractor or subcontractor working on the same project. Work that may need service, maintenance, correction, repair or replacement, but which is otherwise complete, will be treated as completed. D. With respect to the insurance afforded to these additional insureds, the following is added to Section III -- Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CIGL 79 03 18 Includes copyrighted material of Insurance Services Office, Inc. Page 2 of 2 WSGP000321 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, HIRED AUTO AND NON-OWNED AUTO LIABILITY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Coverage Additional Premium A. Hired Auto Liability $ 102 B. Non-owned Auto Liability $ 48 A. Insurance is provided only for those coverages for which a specific premium charge is shown in the Declarations or in the Schedule above. 1. Hired Auto Liability The insurance provided under Coverage A Bodily Injury and Property Damage Liability applies to "bodily injury" or "property damage" arising out of the maintenance or use of a "hired auto" by you or your"employees" in the course of your business. 2. Non-owned Auto Liability The insurance provided under Coverage A Bodily Injury and Property Damage Liability applies to "bodily injury" or "property damage" arising out of the use of any "non-owned auto" in your busi- ness by any person. B. For insurance provided by this endorsement only: 1. The exclusions under Coverage A, other than Exclusions a., b., c., d., e,, f., i., j., k., I., m., n., o., p., and q., and the Nuclear Energy Liability Exclusion, are deleted and replaced by the follow- ing: a. "Bodily injury" to: (1) An "employee" of the insured arising out of and in the course of: (a) Employment by the insured; or (b) Performing duties related to the conduct of the insured's business; or (2) The spouse, child, parent, brother or sister of that "employee" as a consequence of Para- graph (1) above. (3) This insurance does not apply to "bodily injury" or "property damage" arising out of the maintenance or use of a "hired auto" or"non-owned auto"while being used as a public or livery conveyance for passengers or while being used as a conveyance for the delivery of any food or beverage product or the performance of any delivery services. This exclusion applies: (1) Whether the insured may be liable as an employer or in any other capacity; and (2) To any obligation to share damages with or repay someone else who must pay damages because of injury. This exclusion does not apply to: (1) Liability assumed by the insured under an "insured contract"; or U1323-1121 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 3 with its permission. CITY OF SANTA ANA Risk Management a division of Human Resources Managing Risk through Awareness and Action AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE ("Itepresentative").attest that I am an authorized (Name and Titic o vendor Representative) representative of .1-2— �� LL—L (..Company'.).and (Cons�mVCompany Nance) possess the authority to legally bind Company. In my capacity as Representative of Company. I represent and confirm the following.as relates to the agreement between Company and City of Santa Ana,a.-r/cement number ("Agrccmcnt')to provide S"./ j �l�G�-�+ (..Services"): (Services to be provided tinder agreement/contract) During the course and scope of Company's agreement with the City of Santa Ana.Company will not employ any person in any manner so as to become subject to the workers'compensation laws of California.and agree that if Company should become suhiect to the workers'compensation provisions of Section 3700 of the Labor Code.Company shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately. If at any time: it is found that Company is not adhering to any and/or all of the statements in this document and does not maintain the minimum professional liability insurance coverage as required in the Aurccment. it will be considered a breach of Agre cincnt rendering the Agreement null and void and Company will be fully liable for any and all damages. 40A si,nature Date CJ• L/yY� Print Name Az): -rise 01 Contact Intonnation.i.c..Telephone Number and/or Entail Address WARNING: FAILURE TO SECURI:WORKERS'COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PT NALTTES AND CIVIL.FINES U11'170 ONE:I IUNDRED TIIOUSANI'DOLLARS(S100.000).IN ADDITION"rO TI IL'COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF TI IE LABOR CODE. INTERL:Sr.AND ATTORNEY'S FEES. Affidavit of Exemption for Workers'Compensation Insurance 11.12.2024