HomeMy WebLinkAboutSASSOON, DR. MAUREEN 1 -20101t~~~a,~~1cE ol~ FILE
tiu0s?~ ~~w1Y° PROCEEG
UNi-(L t~StIRANGE EXPIRE
CLE ~~ 212 2010
DATE:. , __
CONSULTANT AGREEMENT
N-2010-013
~j: Qdrsca^ne.~~' > THIS AGREEMENT, made and entered into this 10th day of February, 2010 by and
between Dr. Maureen Sassoon, 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 to provide professional Occupational and
Environmental Health and Safety Consulting Services for the Personnel Services
Agency.
B. Consultant represents that Consultant is able and willing to provide such services to
the City.
C. Consultant is an independent contractor who, in rendering services, is to exercise her
independent judgment and represents the City only as to the results of her work and not
as to the means whereby the work is to be accomplished.
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 provide services as required to assist the Personnel Services Agency,
including, but not limited to those services set forth in Exhibit "A", attached hereto and
incorporated herein by reference. Consultant shall provide additional services as requested by
the Executive Director or her designated representative.
2. COMPENSATION
a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the
corresponding fees as set forth in Exhibit "B", attached hereto and incorporated herein by
reference. City will provide on-site office space, computer and telephone support necessary in
performance of this Agreement. The total sum to be expended under this Agreement shall not
exceed $25,000.00 during the term of this Agreement.
b. Payment by City shall be made within thirty (30) days following receipt of proper
invoice evidencing work performed, subject to City accounting procedures. Payment need not be
made for work which fails to meet the standards of performance set forth in the Recitals which
may reasonably be expected by City.
3. TERM
This Agreement shall commence on the date set forth above and terminate February 9,
2011, unless terminated earlier in accordance with Section 12, below. The term may be extended
upon the approval of the Executive Director of the Personnel Services Agency.
~~J
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. Due to the nature of the services provided, Commercial General Liability insurance is
not required.
b. 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 and hired
automobiles.
c. Professional liability (errors and omissions) insurance, with a combined single
limit of not less than $1,000,000 per claim.
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 death, and claims for property damage, which may arise from the direct
operations of the Consultant or its contractors, subcontractors, agents, employees, or other
persons acting on her behalf which relates to the services described in section 1 and Exhibit "A"
of this Agreement.
7. 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: Personnel Services Agency
Attention: Carolyn Richard
City of Santa Ana
20 Civic Center Plaza (M-41)
P.O. BOX 1988
Santa Ana, CA 92702-1988
To Consultant: Dr. Maureen Sassoon
P.O. Box 2028
Palos Verdes Peninsula, CA 90274
A party may change its address by giving notice in writing to the other party. If sent by
mail, communication shall be effective or deemed to have been given three (3) days after it has
been deposited in the United States mail, duly registered or certified, with postage prepaid, and
addressed as set forth above. If sent by telefacsimile, communication shall be effective or
deemed to have been given twenty-four (24) hours after the time set forth on the transmission
report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of
calculating these time frames, weekends, federal, state, County or City holidays shall be
excluded.
10. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and
Consultant, and supersedes any and all other agreements, oral or written, between the parties. In
the event of a conflict between the terms of this Agreement and any attachments hereto, the terms
of this Agreement shall prevail. This Agreement may not be modified except by written
instrument signed by the City and by an authorized representative of Consultant.
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
EXHIBIT A
Scope of Services Provided by Dr Maureen Sassoon CIH to the Citv of Santa Ana
1. Conducting the City Safety Committee Meetings, pursuant to the City's Injury,
Illness Prevention program (IIPP), approximately six times per year.
2. Employee Health & Safety Training (i.e., Cal-OSHA mandated training) for City
employees covering such topics as respiratory protection, hearing conservation,
emergency action fire response, hazard communication, hazardous waste, confined
space, lockout/block out, supervisor safety inspections and accident investigations
and hands-on defensive driving on private property.
3. Inspection services as needed by a Certified Asbestos Consultant, per the State of
California.
4. Inspection services as needed from aLead-Certified California Department of Public
Health Consultant.
5. A City-Wide Safety Inspection.
6. Advising the City and if necessary participating in representing the City's interests in
issues involving Cal-OSHA.
7. Other third-party health and safety services on an as needed/required basis (i.e.,
employee work station ergonomic evaluations, indoor air quality surveys and noise
surveys) as requested by Risk Management and/or Human Resources.
8. Conduct an audit of the existing loss control programs with recommendations for
changes, as deemed necessary.
9. Other tasks as requested by the Executive Director of Personnel Services or her
designee.
/"~Cyr`®`" CERTIFiC~1TE aF LI~I,BfLiTY INSURANCE DA~t{MtNDDlYYYY)
bPRIMAiT~-1-1 02/D9/10
`~
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PROaucER
Brakke Sahafnitz West ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
License #0428915 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ite 150
S
t ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
u
,
B 40 Apo11o Stree
El Segundo CA 90245
Phone :310-524-1340 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: Aaatchaetas auxply^ LLnee Ine
N-201 ~-013 INSURER B:
INSURER C:
Dr. Maureen Bassoon
P O $OX 2O9B INSURER D:
Palos Verdes Peninsula CA 90274
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TH£ POLICY PHRIDD INO1l:Ai tu. nw m, na i nnwnw
TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Wi7H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT
,
MAY PERTAIN, THE INSURANCE AFFORDED HY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO Alt THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIM17S SHOWN MAY HAVE BEEN REDUCED 0Y PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POLICY NUMBER PATE MM/DD DATE MMlDDlYYYY LIMCfS
GENERALLUU31L1TY EACH OCCURRENCE S 1 OOO OOO
x COMMERCIAL GENERAL LIABILITY 624061814001 02/17/09 05/01/10 PREMISES Eaoca,rence S 50 000
A ]{ CLAIMS MADE a OCCUR MED EXP (Any one parson} S 5 000
PERSONAL 8 ADV INJURY 5 1 ~ OOO OOO
X 500 Ded/Occur
$2 GENERAL AGGREGATE 52 OOO 000
GEN ,
'LAGGREGATELIMITAPPLIE5PER: PRODUCTS-COMPfOPAGG S2 DOO,000
POLICY PRO LOC
JECT
AUT OMOBILE LU1&LITY COMBINED SINGLE LIMIT S
ANY AlfrO (Es accident}
ALL OWNED AUTOS BODILY INJURY S
SCHEDULED AUTOS {Per person}
HIRED AUTOS BODILY INJURY S
NON-0WNED AUTOS (Per accident)
PROPERTY DAMAGE S
(Per aeeldent}
GARAGE LUU31LlTY AUTO pNLY - EA ACCIDENT S
ANY AUTO OTHER THAN ~` ACC S
AUTO ONLY: AGG 5
D(CESSlUMBRELLALIABWTY r EACH OCCURRENCE S
OCCUR ~ CLAIMS MADE ~' ~~ ~~ AGGREGATE S
y
~t S
o£DUCnBLE ~' Joseph traka ~
RETENTION S S
riOR KER B COMPENSA710N TORY LIMITS ER
ANO EMPLOYERS' LUU3ILITY
ANY PROPRIETORfPARTNERlEXECUTIV~
EL EACH ACCIDENT
S
OFFICERIMFJdHER EXCLUDED?
(Mandatory In NH) E.L DISEASE - EA EMPLOYEE S
If yes, dasai6e under
SPECIAL PROVISIONS bebw
EL DISEASE -POLICY LIMIT
S
OTHER
A Professional Liab. 624061614001 02/17/09 05/01/10 Prof Liab $lmm$2mmP,gg
Incls. Pollution 6 AseEazoe cwci~*•~ eons Deduct. $5 000/Clm
DESCRlp710N OF OPERATIONS I LOCATIONS I VEHICLES! EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVI9IDNS
*10 Days IF aaacelled for nonpayment of premium. The Certificate Holder is
recognized as Additional Insured per endorsement ENV-3100 attached.
u+arm uro non CONCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 7HE EXPIRATION
~.S,~rr~ DATE THEREDF, THE ISSUING INSURER WILL ENDEAYORTD MAIL 3O * DAYS WRITTEN
City Of Banta Ana NDTICE TO THE CERTIFlCATE HOLDER NAMED TD THE LEFT, BUT FAILURE TO DO SO SHALL
Risk Management Division IMPOSE NO OBLIGATION OR LIAHILrfY DF ANY KIND UPON THE W SURER, ITS AGENTS OR
Attn: Carolyn Richard REPRESENTATIVES.
P.O. BOX 1988 AUTHOF~D:EDREPRESENTA7NE
Santa Ana CA 92702 )1 ~q~
ACORD 25 (2009101) t6+ lano-soon /avvrw ~.vtcrvrw, rv~~. nn r,yrna rwn~rou.
The ACORD name and logo are registered marks of ACORD
Dr. Maureen Sassoon
EPW I 624061814 001 l ~ / ~ ~ / n q T°
Westchester Surplus Lines insurance Company
Insert the paUcy number. The remainder of iha Information ks to be completed only when this endorsement is Issued subsequent to the praparditon of the policy.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ENDORSEMENT
OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION
This endorsement madifias insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
CONTRACTOR'S POLLUTION LIABILITY COVERAGE
SCHEDULE:
Name of Person or Organizatlon:
Any person or organization that is an owner of real property or personal property on which you are
performing operations, or a contractor on whose behalf you are performing operations, and only at the
specific written request of such person or organization to you, wherein such request is made prior to
commencement of operations:
(If no entry appears above, information required to complete this endorsement will be shown In the Declarations
as applicable to this endorsement.)
A. SECTION it • WHO IS AN 1NSllRED 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 ongoing operations
performed for that insured.
B. With respect to the insurance afforded to these additional insureds, the following exclusion is added:
2. Exclusions
This insurance does not apply to bodily Injury or property damage occurring after
{1) All work, including materials, pads or equipment furnished in connection with such
work, on the project {other than service, maintenance or repairs) to be performed by or
on behalf of the additional insureds) at the si#e of the covered operations has been
completed; or
{2) That portion of your work out of which the injury or damage arises has been put to its
intended -use by any person or organization other #han another contractor or
subcontractor engaged in performing operations for a principal as a part of the same
project.
ENV~10D (08-1M) Includes copyrighted material of Insurance Services office, inc. vullh Its pannission Page 1 of 9
'-' REWIWfFD FfIt7Af TIE ARClNE. TFE ~n1filNµ 1AAIB IOTIpMANY1Mf,~UOEADd7WNH. FORIAIB --'
~.ins~rrarlce,.. pOLww NUMBER: A2074142
to 11.....1..~.1>...r...
SAFECO INSURANCE COMPANY CF AMERICA
AUTOMOBILE POLICY DECLARAT101V5
NAMED INSURED:
MAUREfN SASSOON
PO BOX 7028
PAL05 VERGES PEN CA 90274-802$
AGENT:
NHC INSURANCE SERVICES TNC
796 W 9TH ST
SAN PEDRO CA 90731-3602
RENEWAL
POLICY PEAIpD FROM: MAR, 1 7010
T'O: SEPT 1 2010
at t2:Ot A_M, standard time at
the address of the insured as
stated herein.
AGENT TELEPHONE:
(310) 221-0917
RATED DRIVERS MS MAUREEN SA5500N
200E $MN 328I SULEV 4 DpOR SEDAN Ibi WBAVC53578F284867
L055 PAYEE BMW BANK OF NORTN AMERICA
1986 HONDA CIVIC 1500 4 ODOR SEDAN LDM ]FiMAKT430GS607927
Insurance is afforded only for the coverages for Mhtch lieits of liability or
Preeiue cbaryes are indicAted.
COVERAGES 2008 BMw LIMITS PREMIUMS 19ifi HOND LIRITS PREMIUMS
LIABILITY;
BODILY IN]URY SSOO,ODO S 108.20 5500,000 S 71.00
Each Person Each Person
3500,000 5500.000
Each Occurrence Each Occurrence
PROPERTY DAMAGE 5100,000 64.20 5100,000 46.90
Each Occurrence Each Occurrence
MEDICAL (EXCESS) PAYMENTS SS,D00 6.50 (5,000 4.60
UNINSURED AND UNDERINSURED MOTORISTS:
BODILY IN]URY 5500,000 78.40 SSOO,OOD 55.60
Each Person Each Person
(500,000 5500,000
Each A[cident Each Accident
UNINSURED MOTDR15TS:
PROPERTY DAMAGE
Each AccidenD 3.00
COMPREHENSIVE Actual Cash Value 49.70
Less 1250 Deductible
CDILISION Actual Cash Value 133.70
Less 5500 Deductible
NAIYER OF COLLISION DEDUCTIBLE $.40
ADDITIONAL COVERAGES:
LOSS OF USE SSO Per Day/51200 Max 18.40
AUTO LOAN/LEASE 5.00
ANTI FRAUD FEE .9D .90
RDAp5I0E ASSIST 2.50
TOTAL S 475.90 TOTAL f 182.00
-CONTINUED-
P 0 BOX 515097, LOS ANGELES, to 90051
S~~T~7hP 9.+80 Page 1 of 2 SATE PREPARED: IAN, 25 2010
--RE-Rtl'RED P+Wtt7H6 Mpr/E. THE ORgINALiRA1tl+1CnOH A4lY +R~tUDEAD01M7W1L FORMg '^•
~f1SUl'~fiCC:., POLICY NUMBER: A2074142
....e. a ur.r r..rv,..
5AFEC0 WSURANCE COElPANY OF Ai~IEgICA
AUTOMOBILE POLICY i?ECLARATlONS
(CONTINUED)
TOTAL EACH VEHICLE: 2008 BMY1 S 475.90
198b HOND 182.D8
TOTAL PREMIUM FOR ALL VEHICLES .......................................... 5---657 90
You can pay your premium in full or in installments. If you pa in installments
using automatic deduction, no installment fee will apply to each installment. If
you pay in installments without using automatic deduction, a 54.00 installment fee
will apply to each installment. If there is more than one policy billyd on the
installment bill, only the highest fee amount would be applied to the bill.
CONGRATULATIONS! YOUR PREMIUM INCLUDES DISt0UNT5 AND ADJUSTMENTS FOR:
Ac[ount, Good Driver, Longevity, Multi-Car, Both Side Air Bag
POLICY FORKS APPLICABLE TO THIS POLICY;
SA-Lfi97/EP 9/90, SA-1852/CAEP 12/08, SA-1701/EP 9/90. SA-1414/EP 2/93,
SA-1700/EP 7/09, SA-1696/EP 1/44
S';~~~p 91BQ Page 2 of 2
Z~R~ CERTIFICATE CF LIABILITY INSURANCE OP ID PA """'°"""""'
snsse~-1 oz 11 1D
PRDOUCeR THIS CFRTIFlCATE IS ISSUED AS A NW7TFR OF INFDRAA/LTION
ONLYAND CONFERS NO RlGfffB UPON 7HE CERTIFICATE
NHC InsurAneE Setrvic~a Inc HOLDER. THIS CERTIFICILTE DOES MDTAMENp, FJLTEND OR
7 96 H. 9th 8lxeet ALTEA THE COVERAGE AFFORDED BY THE POUCta:S BELOW.
San Pad=o G 90?31
Phone:310-221-0917 Fpit:3lb-221-0966 IN$URERSAFFORDINGCOYERAGE NAICp
INWRED INSLIRERA: SAFmCO ZHSVRANC6 CCtI~ANY 11070 _
MSVRER O: _~_
~itti'HHII §gEHE0011 INSTIRER C:
P p $ON: 202#
P'Elos V~rdeB Pan. C71 90274 IN`UREa p' _ ~-
~ _
INSURER E:
COVERAt.ES
THE POLICIES OF IHSVRANCE LISTED SELOW NAVE BEEN ISSVED TO THE HSIIRm MSMEO ASG'uE FOR TNf PDIICY PERr00 INDICATED. NOTWITN6TANOILIG
ANY REQUDIELIENT, 7ERMOR CONORION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC) TO INNILN TNIB CERTIFICATE WY 6E fSSUFO OR
MAY PEw TAIN, THE IN6URANGE AFFORDED SY T1E P~ICM:S DE'SCRrED HEREIN 19 SUOJECT TO All THE TERM6, EXCLUSIONS MID CONORIONS OF SUCH
POLICIES. AGGREWTE LIMNS 9NDWN MAY HAVE OEEN REDUCED 8Y PAID CLAIM.
NSR
LTR N TYPE OP r CE POLICY NUyEp! DATE DATE LEfT6
GENERAL IIAEILFTT' ~ EACH OCCURRENCE i
~COerNIERCW.GENETIALLU6ILRY -
PREMISES~ac~ir~- i_
_ CLAIMS 1440E ~ OCCUR I MED EXPfAIry oIy plfaen) !
_ __ ~_- _
~ _ ~_ ._
I
I -_ -
PEIt30NAl AAW INJURY Ti
GENERAL AGGREGATE f
.
GElI'L AGGREGATE LIMB APPLIES PER' I _. ._
PRODUCTS -
COMP/OPAC~O i
POLICY : Pilo- ~ LpL ~-
AllTOMCEIPl,IAEM1In
a ~
ANrAVTG
a2o7a1az
b3lol/10 COI~INED SINGLE LIMIT
og/ol/1D iE.~a.wle _
`
~
ALL OMINED AUTOE i
r _
scHEDULeo AUr06
I DOOILY INJURY
~ f 500000
Iw,PNaon~
I
/TIRED N1106 _
- I}
NDN-O'MVED A1JT06 S~OIDIL~~RY S SDDDDD
- - I
• ~PROPERry DAlI\GE ~ --
aPV~oawnq s10D000
GARAGE L1AwLrrY AUTO ONLY-EA ACCIDE77T f
ANTAUrO .-
OT1iERTHAN EA ACC S
- -
L ~ I AUTO DXIr ACC f
f~ lacESSr uwRriJL LarLm
EACH OCCURRENCE f
OCCUR C~ CLAIMS MADE i AGGREGATE S
I -
I ~ I
DEDUCTNILE -
!
RETENTION L -~ ~ _ -~
rONRER3 CpNlMEA
AND FAIh.CYlRS' LJRNITY
Y!N _
TORY IMIT6 fk
ANV PROPRIETORRARTNERIFXECUTIY _
OFFICER/MEMBER E%CLUDELYJ ~ ~
(Y~MMe71n NXt
I
I E.L. EACH ACCIDENT
~ f _
If r aawLmGe wplf
SPECIAL PROV1610N9 Errlor
I F.l bI6EASf • FA EMPLOYE S
E.L DISEASE-POLN:7lIM1T f
A I PHYSICAL D711D1R',B I A2074I42 I 03/01/10 I 09/01/10 I CCU DED 250
~_ _ I mr.T. DED 500
2008 BEQIi 3282 $17L 88DAt1' VIa# 1DUlVC53578FS8i867.
CBATIFIGTE 8QLD1II2 LIST$D 71$ LOSS PAYB$.
a.crcl InL.nr c nL]LUCK CANCELLATION
aIHOYLD ANTW THE AiOY[ bEECR1EED -DLICrE EECANCELLEO REfCRF THE ERPRUTIpi
OATS TNFRr]P, THE ISfUWO rEURER TYILL ENDEAVOR Ib AWL 1D+ CATS WRITTEN
NOTICETO THE CERTIPIDAT! MOLDER NAEW TO THE LEFT, EVT FAM.VAe TO DO SD 4HALL
HIRE H~ OF 100RTA AE~RIG IMPOSE MOOELRLILTpN 0.m' OFANY RIND LRN]N TNElNSWEf( RS AGENTS OR
PO HOY 650755 REPRESafTAT1VER
I[OlTP ti-ALI,Ei C71 21065-0755 i1A11M0"IQm"E
Patty 1-ZvE,res
ACORD ss (20D9/01) D Hats-7ms Aco co Fo noN. An lfgnc. Ewa.
Thv ACORD IfETIIE End IpyO an roq'stDRDd TnETkE Of ACORD
IMPORTANT
If the certificate holder is an ADDITfONAL INSURED, the poiicy(ies} must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
Jf SUBROGATION iS WANED, subject to the terms and conditions oT the poGCy, certain policies may
require an endorsement. A statement on this certificate does not confer rights tp the certificate
holder in lieu of such endorsement(s).
DISCLAIAAER
This Certificate of Insurance does not constitute a contract between the issuing insurer{s), authorized
representative or producer, and the certifrcate holder, nor does it affirmatively ar negatively amend,
extend or alter the coverage afforded by thQ policies listed thereon.
ACQRD 25
•^"REPRINTED FROM THE ARCHIVE. THE ORIGINAL TRANSACTION MAY INCLUDE ADDITIONAL FORMS •"'
InsuranceT4
~~~~
POLICY NUMBER: UA3442004
SAFECO INSURANCE COMPANY OF AMERICA
PERSONAL UMBRELLA POLICY DECLARATIONS
INSURED: AGENT:
MAUREEN BASSOON NHC INSURANCE SERVICES INC
PO BOX 2028 796 W 9TH ST
PALOS VERDES PEN CA 90274-8028 SAN PEDRO CA 90731-3602
{310) 221-0917
RESIDENCE PREMISES:
27056 SHOREWOOD RD
RCH PALOS VRD CA 90275-2228
POLICY PERIOD FROM: J U N E 2 7 2 009
T0: JUNE 27 2010
at 12:01 A.M. Standard time at
the address of the insured as
stated herein.
RETAINED LIMIT: X250
LIMIT OF LIABILITY: $1 , 000 , 000
SCHEDULE OF UNDERLYING INSURANCE:
The insured agrees:
1) that insurance policies providing the coverages specified on the back of these declarations, if applicable,
are in force and will be maintained in force as collectible insurance for at least the required minimum
limits stated
2) to insure all motor vehicles owned, leased by or used by the insured
3) to insure all residence premises owned, leased by or leased to the insured
4) to insure all recreational vehicles owned, leased by or used by the insured
5) to insure all watercraft owned by the insured
COVERAGES PREMIUM
Basic premium - includes one automobile and primary residence ~ 206.00
In Home Business Coverage $ 30.00
1 Additional automobile in the household $ 79.00
2 Rental units ~ 26.00
TOTAL ANNUAL PREMIUM $ 341.00
You can pay your premium in full or in installments. If you pay in installments
using automatic deduction, no installment fee will apply to each installment. If
you pay in installments without using automatic deduction, a $2.00 installment fee
will apply to each installment. If there is more than one policy billed on the
installment bill, only the highest fee amount would be applied to the bill.
PLEASE SEE REVERSE
ORIGINAL DATE PREPARED APR. 28 2009
P-1075/E P 9/06
G1
`"`" REPRINTED FROM THE ARCHIVE. THE ORIGINAL TRANSACTION MAY INCLUDE ADDITIONAL FORMS """
Type of Policy Required Minimum Limits
Automobile/Motor Vehicle Liability Bodily Injury - 500,000 each person/
(Including motor homes) and - 500,000 each occurrence
Property Damage - 100,000 each occurrence
OR
Single Limit - 500,000 each occurrence
Comprehensive Personal Liability Single Limit - 300,000 each occurrence
Premises Liability Single Limit - 300,000 each occurrence
Recreation Vehicle Liability Single Limits - 300,000 each occurrence
Watercraft Liability
1, a. Powerboats 32 feet or more in length; or
b. Sailing vessels (with or without auxiliary power)
26 feet or more in length Single Limits - 500,000 each occurrence
2, All other watercraft Single Limits - 300,000 each occurrence
Incidental Farm Coverage Single Limits - 300,000 each occurrence