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HomeMy WebLinkAboutWEI, QUING (2) INSURANCE NOT ON FILE WORK MAY NOT PROCEED N-2025-247 CITY CLFgg 3 a 2Q25 DATE-. Q�ti0VY1 uG�TI(� l�z-) September 2, 2025 QING WEI("Speaker/Performer") 630 S Grand Ave., Ste. 116 Santa Ana,CA 92705 Re: Speaker/Performer Engagement Agreement This letter represents your agreement with the City of Santa Ana ("City") as entered into on the above date for the engagement described below: 1. Event Description: Harvest Moon Celebration/ Moon Festival, as described in"Scope of Services - Exhibit A", attached hereto and incorporated herein. 2. Date(s): October 3,2025 3. Event Time(s): 3:00 PM—5:00 PM 4. Location: Delhi Branch Library, 505 E. Central Ave., Santa Ana,CA 92707, Santa Ana("Property") 5. Compensation: not to exceed $1,288.00 (payable by check within 30 calendar days of event); Speaker/Performer must provide IRS form W-9 before payment can be made 6. Equipment provided by City:NONE 7. Equipment provided by Speaker/Performer: All equipment necessary, including without limitation sound technicians, speakers,laptop/music, table,microphone,headphone, and strobe light. 8. City Contact Person(for coordinating purposes only): Dylan Dario 9. Independent Contractor: Speaker/Performer 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 Speaker/Performer performs the services that are the subject matter of this Agreement, however, the services to be provided by Speaker/Performer shall be provided in a manner consistent with all applicable standards and regulations. Speaker/Performer 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. 10. Indemnification: Speaker/Performer,his or her agents, or employees (if applicable) agrees to and shall indemnify, defend,and hold harmless the City,its officers,agents,employees,consultants,special counsel,and representatives from and against all loss, expenses, or liability(including costs and attorney's fees) arising from the negligence or willful misconduct of Speaker/Performer,his or her agents, or employees. 11. Release: Speaker/Performer accepts the Property and any City-provided equipment used in connection with the performance in their "as-is" condition, with all faults. Speaker/Performer fully releases, waives and discharges forever any and all claims, demands, rights, and causes of action of any kind or nature against, and covenants not to sue,City,its elected officials,officers,employees,agents and volunteers,and all persons acting on behalf of,by, through or under each of them, under any present or future laws, statutes, or regulations for any claim or event relating to the condition of the Property or City-provided equipment or Speaker/Performer's use thereof. Letter Agreement—Qing Wei Page 2 12. Insurance Requirements are attached hereto and incorporated herein as Exhibit B. 13. The City shall have the right and royalty-free license to simulcast or produce and show a tape-delayed broadcast of Speaker/Performer's presentation to the City community or general public, through webcast or any other means. This license shall be non-exclusive and the copyright shall remain with the Speaker/Performer. Copies of Speaker/Performer's presentation may be maintained by the City, and Speaker/Performer consents to use of such recordings. 14. Speaker/Performer is solely responsible for payment of royalty fees,performance fees, or similar fees that may be required by unions or similar organizations. Speaker/Performer shall indemnify the City against any liability or damages,including attorney's fees, that may arise as a result of violation by Speaker/Performer of copyright laws. 15. Speaker/Performer shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, disability, or any other basis protected by applicable law in connection with any activities related to this Agreement. 16. This Agreement shall in all respects shall be interpreted, enforced, and governed exclusively by and under the laws of the state of California. Both parties agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of,in connection with or by reason of this Agreement. 17, This Agreement represents the complete and exclusive statement between the City and Speaker/Performer regarding the subject matter herein and supersedes any and all other agreements, oral or written, between the parties. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Speaker/Performer. CITY OF SANTA AN SPEAKERIPERFORMER Austin Qua[h(Sep 3,.202516:21:58 PDT) ALVARO NUNEZ Name: AUSTIN QUACH City Manager Title: CEO ATTEST: APPROVED AS TO FORM: - l B IFER HALL - �r JONATHAN T. MAR EZ City Cler Assistant City Attorney RECOMMENDED FOR APPROVAL: 0...,L Brian Stern erg(Sep 3,2025 09:00:00 PDT} BRIAN STERNBERG, Executive Director, Library Services Agency Letter Agreement—Qing Wei Page 3 EXHIBIT A SCOPE OF SERVICES VENDOR INFORMATION: Name: Qing Wei (Austin Quach) Address: 630 S Grand Ave STE 116, Santa Ana,CA 92705 Phone Number: 714-766-2943 Email Address: gingweibooking@gaxaail.com EVENT: Harvest Moon Celebration/Moon Festival LOCATION: Delhi Branch Library, 505 E. Central Ave., Santa Ana,CA 92707 TERM: One-time event: Friday, October 03,2025—3:00 PM—5:00 PM COMPENSATION: $1,288.00 DESCRIPTION: Qing Wei Lion&Dragon Dance Cultural Troupe will provide a dance presentation—Hong Kong Big Dragon,which includes: • Signature Pair Lions • Happy Buddha • Percussion ensemble • Traditional,yet modernized choreography,with acrobatic stunts and lifts • Gift set&scroll from our group's behalf • Photo ops when lions open large scrolls with blessings in Vietnamese • Photo cps with our lions&Buddha with all guests! The Moon Festival is free to the public, and it will take place at the new Delhi Branch Library. The performance will be in person and attendees will have a chance to enjoy the presentation and meet the lions and dancers.The event will be hosted by Tony Lam, Senior Librarian.This celebration will take place on October 3,2025 from 3.00 PM—5:00 PM.Qing Wei Lion and Dragon Dance Cultural Troupe will be compensated an amount not to exceed$1,288.00 for their presentation. Letter Agreement—Qing Wei Page 4 EXHIBIT B INSURANCE REQUIREMENTS Speaker/Performer shall procure and maintain for the duration of the agreement,the following insurance coverages: MINIMUM SCOPE AND LIMIT OF INSURANCE Speaker/Performer shall maintain limits of insurance coverage in the following minimum amounts and shall be at least as broad as: • Commercial General Liability (CGL): Insurance Services Office Form CG 00 01 covering 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. • Automobile Liability(AL): Insurance Services Office Form CA 00 01 covering Code I (any auto),with combined single limits of $1,000,000. In the event Speaker/Performer does not maintain commercial automobile liability insurance,City will accept evidence of personal automobile insurance with existing limits,which can be lower than $1,000,000. • Workers' Compensation (WC): as required by the State of California, with statutory Iimits, and Employer's Liability Insurance with limit of no less than$1,000,000 per accident,per employee,per policy for bodily injury or disease, This requirement can be waived if Speaker/Performer has no employees. If Speaker/Performer maintains broader coverage and/or higher limits than the minimums shown above, City requires and shall be entitled to the broader coverage and/or the higher limits maintained by Speaker/Performer,Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to City. Other Insurance Provisions The insurance policies are to contain,or be endorsed to contain,the following provisions: i. CGL and AL policies: City of Santa Ana,its City Council,,its officers,officials,employees, agents,and volunteers are to be covered as additional insureds with respect to liability arising out of work or operations performed by or on behalf of the Speaker/Performer including materials,parts,equipment,and personnel furnished in connection with such work or operations. 2. CGL,AL, and WC policies: Insurance company(ies)agrees to waive all rights of subrogation against City,its City Council,its officers, officials, employees, agents, and volunteers for losses paid under the terms of any policy which arise from work performed by Speaker/Performer for City. 3. All required insurance policies: For any claims related to this contract, Speaker/Performer's insurance coverage shall be primary and any insurance maintained by City,its City Council,its officers, officials, employees,agents, or volunteers shall not contribute with it. 4. All required insurance policies: A severability of interest provision must apply for all the additional insureds, ensuring that Speaker/Performer's insurance shall apply separately to each insured against whom a claim is made or suit is brought,except with respect to the insurer's limits of liability. S. Each insurance policy required herein shall provide that coverage shall not be canceled, suspended,voided, reduced in coverage or in limits,non-renewed by the carrier,or materially changed except after thirty(30) days prior written notice has been given to City.Ten(10) days prior written notice shall be provided to City for policy cancellation or non-renewal due to non-payment. 6, Certificate Holder on each Evidence of Insurance certificate shall be: City of Santa Ana Attention: Library Services,Dylan Dario 20 Civic Center Plaza,M-42 Santa Ana, CA 92701 a. The name and location of event should be included in the Description of Operations section of each certificate—See Sample of COI. Letter Agreement—Qing Wei Page 5 Self-Insured Retentions Self-insured retentions must be declared to and approved by the City. City may require Speaker/Performer 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. 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 ANII,unless otherwise acceptable to City. Verification of Coverage Speaker/Performer 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 to Entity before work begins. However,failure to obtain the required documents prior to the work beginning shall not waive Speaker/Performer'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. Claims Made Policies If any of the required policies provide coverage on a claims-made basis; 1. The retroactive date must be shown and must be before the date of the contract or the beginning of work. 2. Insurance must be maintained and evidence of insurance must be provided for at least three(3)years after completion of work. 3. If coverage is canceled or non-renewed,and not replaced with another claims-made policy form with a retroactive date prior to the contract effective date, Speaker/Performer must purchase"extended reporting"coverage for a minimum of three(3)years after completion of work. Subcontractors Speaker/Performer shall require and verify that all sub-contractors maintain insurance meeting all the requirements stated herein, and Speaker/Performer shall ensure that City is an additional insured on insurance required from sub-contractors. 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. Qing Wei Speaker-Performer Agreement unsigned Final Audit Report 2025-09-03 Created: 2025-09-03 By: Dylan Dario(ddario@santa-ana.org) Status: Signed Transaction ID: CBJCHBCAABAAvCFyT4Gx1FR_BN6OoysS_nbkLOS8heF4 "Qing Wei Speaker-Performer Agreement unsigned" History 7 Document created by Dylan Dario (ddario@santa-ana.org) 2025-09-03-3:17:45 PM GMT Document emailed to Brian Sternberg (bsternberg@santa-ana.org) for signature 2025-09-03-3:17:49 PM GMT Email viewed by Brian Sternberg (bsternberg@santa-ana.org) 2025-09-03-3:58:52 PM GMT dQ Document e-signed by Brian Sternberg (bsternberg@santa-ana.org) Signature Date:2025-09-03-4:00:00 PM GMT-Time Source:server Document emailed to Austin Quach (gingweibooking a@gmail.com) for signature 2025-09-03-4:00:02 PM GMT `i Email viewed by Austin Quach (gingweibooking@gmail.com) 2025-09-03-11:20:55 PM GMT Document e-signed by Austin Quach (gingweibooking@gmail.com) Signature Date:2025-09-03-11:21:58 PM GMT-Time Source:server Agreement completed. 2025-09-03-11:21:58 PM GMT Adobe Acrobat Sign Phone: (714)647-5358 rTE,11MMIDDNYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE099/2025 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 endorsement(s). PRODUCER CONTACT The Wolcott Group, Inc. PHONE The Torres FAX o Ext. (800)309-2161 A/c,No): (949)916-0370 23120 Alicia Pkwy Ste #231 E-MAIL Mission Viejo, CA 92692 ADDRESS: chris@wolcottins.com License #: Ob39360 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: United States Liability Insurance Company INSURED Qing Wei INSURER B Austin Quach INSURER C: 630 S Grand Ave Suite 116 INSURER D: Santa Ana, CA 92705 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00018948-241213112000 REVISION NUMBER: 5 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY Y Y NPP1639374 12/16/2024 12/16/2026 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE DAMAGE TO RENTED X OCCUR PREMISES Ea occurrence $ 100 000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- X POLICY El ECT CI LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A UMBRELLA LIAB X OCCUR XL1663118 12/16/2024 12/16/2026 EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under Digitally signed b DESCRIPTION OF OPERATIONS below Tu Tian 9 9 y E.L.DISEASE-POLICY LIMIT $ Date:en 71 o APPROVED By Tu Tran Nguyen at 7:30 am,Oct 02,2025 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Non-Profit Performers for various events and venues. The city of Santa Ana, its city council, its officers,officials,employees,agents, and volunteers has been added as additional insured to above referenced policy letter A per blanket additional insured endorsement Moon Festival event will take place at Delhi Branch Library(505 E. Center Ave Unit B,Santa Ana, CA 92707),from 3-4:40pm. continued on ACORD 101 Additional Remarks Schedule CERTIFICATE HOLDER CANCELLATION City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attention: Lynn Nguyen (Principal Librarian) & THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Tony Lam (Senior Librarian) ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana Public Library/Delhi Branch Library, AUTHORIZED REPRESENTATIVE M-42 Santa Ana, CA 92707 CRT ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by CRT on 09/19/2025 at 09:17AM AGENCY CUSTOMER ID: LOC#: ACCOR" ADDITIONAL REMARKS SCHEDULE Page 2 of AGENCY NAMED INSURED The Wolcott Group, Inc. Qing Wei POLICY NUMBER Austin Quach N P P 1639374 CARRIER NAIC CODE United States Liability Insurance Company EFFECTIVE DATE:12/16/2024 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance (continued from Description of Operations) Qing Wei will perform dragon dance to celebrate Autumn Harvest ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by CRT on September 19,2025 at 09:17AM UNITED STATES LIABILITY INSURANCE GROUP WAYNE, PENNSYLVANIA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM BLANKET ADDITIONAL INSURED ENDORSEMENT Section II—Who Is An Insured is amended to include as an insured any person, entity or organization that is: 1. A franchisor under a franchise agreement with the Named Insured as franchisee relating to "your work"; or 2. A licensor under a license agreement with the Named Insured as licensee relating to .,your work"; or 3. A co-owner with the Named Insured in premises used for "your work"; or 4. A majority owner with a controlling interest in the Named Insured but only with respect to liability arising out of such owner's (1) financial or operational control of the Named Insured; or(ii) ownership, maintenance or use of premises leased or occupied by the Named Insured for purposes of"your work"; or 5. A mortgagee, assignee or receiver of the Named Insured relating to "your work"; or 6. A lessor, or an agent of a lessor, under a lease agreement with the Named Insured as lessee relating to "your work"; or 7. A grantor of a permit to the Named Insured as permitee relating to "your work". However, if the grantor of a permit is a federal, state or local government or political subdivision, there is coverage under this endorsement only for liability arising from: a. The existence, maintenance, repair, construction, erection or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners or decorations and similar exposures; or b. The construction, erection or removal of elevators; or c. The ownership, maintenance or use of any elevators covered by this insurance; or 8. A lessor of equipment leased to the Named Insured relating to "your work"; or 9. A contributor, benefactor, or supporter who provides financial assistance to the Named Insured in connection with"your work"; but only to the extent the Named Insured is required to add such person, entity or organization as an additional insured to this policy under a written contract, written permit or written agreement relating to "your work". Such person, entity or organization is an insured only with respect to liability for "bodily injury", "property damage" or"personal and advertising injury" that is caused, in whole or in part by your acts or omissions or the acts or omissions of those acting on your behalf in connection with"your work"while such written contract, written permit or written agreement is in effect. L 744 NPP (06-10) Pagel of 2 EXCLUSIONS There is no coverage under this endorsement for loss or expense, including but not limited to the cost of defense for "bodily injury", "property damage" or"personal and advertising injury": 1. That occurs after all of"your work", including materials, parts or equipment furnished in connection with"your work" and performed under a written contract, written permit or written agreement has ended; or When that portion of"your work" out of which the "bodily injury", "property damage" or "personal and advertising injury" arises and performed under a written contract, written permit or written agreement has been put to its intended use by any person(s) or organization(s); whichever occurs first. 2. Arising directly or indirectly from construction or demolition operations of any kind performed by you. 3. Caused or alleged to be caused by the sole negligence of an additional insured under this endorsement. 4. Arising out of"your work" performed for a federal, state or local government or political subdivision under a written permit. 5. Included within the "products-completed operations hazard". CONDITIONS Coverage provided by this endorsement will be excess over any insurance available to any additional insured under this endorsement unless a written contract, written permit or written agreement specifically requires that coverage under this endorsement is primary. All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and takes effect on the effective date of your policy unless another effective date is shown. L 744 NPP (06-10) Page 2 of 2 ENDORSEMENT #1 This endorsement, issued by United States Liability Insurance Company to QING WEI C/O QING WEI AND AUSTIN QUACH forms a part of Policy Number NPP1639374 effective on 9/22/2025 (MO. DAY YR.) at 12:01 A.M. Add/Remove/Amend Coverage In consideration of no change in premium it is hereby agreed and understood that the policy is amended with the following changes: It is hereby agreed that the following form(s) has(have) been amended: CG2404 05/09 -Waiver Of Transfer Of Rights Of Recovery Against Others To Us All other terms and conditions of this Policy remain unchanged. Products/Completed Operations POLICY NUMBER: NPP1639374 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name of Person Or Organization: Effective Date: 12/16/2024 The City of Santa Ana, its city council, its officers, officials, employees, agents, and volunteers Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights of Recovery Against Others To Us of Section IV-Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or"your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 Copyright, Insurance Services Office, Inc., 2008 POLICY NUMBER: NPP1639374 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name of Person Or Organization: Effective Date: 09/22/2025 12:01 AM CITY OF SANTA ANA ATTENTION: LIBRARY SERVICES, DYLAN DARIO 20 CIVIC CENTER PLAZA, M-42 SANTA ANA, CA 92701 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights of Recovery Against Others To Us of Section IV-Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or"your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 Copyright, Insurance Services Office, Inc., 2008 Binder for State Farm Automobile Insurance Applicant Agent AUSTIN QUACH Kelly Duong Insurance Ag 15911 ROCHESTER ST 14256 Beach Blvd WESTMINSTER, CA 92683-7654 Westminster, CA 92683-4562 (714) 891-5500 Vehicle Year: 2020 Make: FORD Model : TRANSIT 350 Bodystyle: MEDIUM ROOF 2WD VIN: 1FBAX2CG5LKA75214 Customized: No The premium shown below must be in compliance with the Company' s rules and rates and is subject to revision. Coverage Applied for: Semi-Annual Limits Premium BODILY INJURY AND 25/50/25 * $504 . 75 PROPERTY DAMAGE LIABILITY MEDICAL PAYMENTS COVERAGE $5000 $65 . 95 COMPREHENSIVE $250 DEDUCTIBLE $179.26 COLLISION $1000 DEDUCTIBLE $561 . 59 EMERGENCY ROAD SERVICE $3 .28 CAR RENTAL/TRAVEL EXPENSES $50/DAY, $1200 MAX $35 . 96 UNINSURED MOTOR VEHICLE 25/50 * $88 . 95 UNINSURED MTR VEH PROP DMG $14 . 90 DEATH, DISMEMBERMENT AND 1 AT $10000 $0 . 78 LOSS OF SIGHT Total $1455 . 42 Total of 6 month premium $1455 . 42 Payment received SFPP * Denotes thousands Balance due SFPP BINDERCA Continued on Page 2 Binder for State Farm Automobile Insurance Page 2 QUACH, AUSTIN 2020 FORD TRANSIT 350 MEDIUM ROOF Binder Effective Date: December 06, 2023 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois, hereby binds coverage for the insurance applied for as of the requested effective date for a period of 60 days from such date, subject to all the terms and conditions of the applicable policy and endorsements in current use by such Company. Coverage under this binder will terminate (1) when the Declarations Page of a policy is issued to you or (2) when canceled in accordance with law. State Farm considers the representations you have made about the licensing and driving record(s) to be material. Any concealment or misrepresentation - whether fraudulent, intentional, or unintentional - about your driving record could result in State Farm's re-rating, cancellation, or rescission of your auto insurance policy. A rescission could result in your auto policy being void from its inception, as if no auto policy ever existed. For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Evidence of a valid US or Canadian license for all drivers in your household must be provided to State Farm within 12 months in order to continue coverage. IMPORTANT NOTICE: THE MINIMUM AUTO LIABILITY COVERAGE LIMITS REQUIRED UNDER CALIFORNIA LAW ARE $15,000 PER PERSON/ $30,000 PER ACCIDENT FOR BODILY INJURY AND $5,000 FOR PROPERTY DAMAGE. WE ARE LEGALLY REQUIRED TO FURNISH THESE LIMITS AND WILL, IF REQUESTED. DRIVING SAFETY RECORD RATING PLAN Your driving safety record, along with other rating factors, determines what you pay for liability, medical payments, comprehensive, collision, and uninsured motor vehicle coverages. Policyholders with no accidents and convictions pay less than those with accidents and convictions. The Driving Safety Record Rate Level that is assigned to your policy moves up, down, or stays the same every policy renewal, depending upon your driving record. If the policy is assigned to Rate Level 2 or higher, has been at the same level for 12 months, and has no chargeable accidents or convictions that have not been previously considered, the Rate Level is reduced by 1 level. The Rate Level is increased if there are subsequent chargeable accidents or convictions. A policy may qualify for our best(superior) rate level if all drivers assigned to the policy have had no chargeable accidents or convictions in the last 6 years. DEFINITION OF CHARGEABLE ACCIDENTS - Chargeable accidents for new business are those which resulted in death, or damage to any property in the amount of more than $1,000*. Chargeable accidents for renewal business are those for which State Farm paid more than $1,000* under the Property Damage Liability and Collision Coverages combined. *$150 or more if the accident occurred prior to December 11,2011. For more information about the rating plan, please contact your State Farm agent. You were offered Uninsured Motorist Property Damage Coverage. This policy does not include Uninsured Motorist Property Damage Coverage if you did not accept that offer. BINDERCA Continued on Page 3 Binder for State Farm Automobile Insurance Page 3 QUACH, AUSTIN 2020 FORD TRANSIT 350 MEDIUM ROOF Notice of insurance information collection practices — personal, family or household insurance transactions: We may collect personal information from persons other than the individual or individuals applying for coverage. Such personal information as well as other personal or privileged information subsequently collected may, in certain circumstances, be disclosed to third parties without your authorization as permitted by law. If you would like additional information about the collection and disclosure of personal information, please contact your State Farm agent. You may also act upon your right to see and correct any personal information in your State Farm files by writing your State Farm agent to request this access. By submission of this application, you agree that: (1) you have read this application, (2) your statements on this application are correct, (3) statements made on any other applications on this date for automobile insurance with this company are correct and are made part of this application, (4) you are the sole owner of the described vehicle except as otherwise stated, and (5) the limits and coverages were selected by you. IT IS FURTHER UNDERSTOOD AND AGREED THAT NO INSURANCE IS EFFECTIVE UNDER THIS AGREEMENT (A) UNLESS THE BINDER IS COMPLETED DESIGNATING THE COMPANY ACCEPTING THIS APPLICATION OR (B) UNTIL THE DATE THE POLICY OR BINDER IS ISSUED BY THE COMPANY ACCEPTING THIS APPLICATION. Consumer reports may be ordered in conjunction with this application. These reports provide information that assists with determining your eligibility for insurance and the price you are charged. ECHO App # 75 —2D5F—P31 App date and time: 11/22/2023 03 : 10 PM BINDERCA o. ........ ........... ....._............_,........................ . ..... t3rr California Evidence . Allstate . of Liability Insurance Allstate Northbrook Indemnity Company NAIC# 364S5 PO Box 660598, Dallas,TX 75266-OS 8 Sonny Quach,Thanh Vuong 211 Charity Ct San Jose CA 95116-3063 This policy complies with Sections 16056 or 16500.5 of the Callfornia Vehicle Code. POLICY NUMBER YEAR f MAKE/MODEL � 967742063 2008 Toyota Sl+enna EFFECTIVE DATE 05/30/2S VEHICLE ID NUMBER EXPIRATION DATE 11/30/ 5 5TDZK23C68S1S8046 i Evidence of financial responsibility shall at all times be carried in the vehicle. l Insurance information hos already been submitted directly to the DMV electronkollyrsubmit this document to DM V only if specifically requested by I DM V. Renewal auto policy declarations Policy number: 967 742 063 ®Allstate Policy effective date: May 30,2025 Page 3 of 4 Coverage detail for 2008 Toyota Sienna Coverage Limits Deductible Automobile Liability Insurance Premium Not applicable $386.94 •Bodily Injury $100,000 each person $300,000 each occurrence •Property Damage $100,000 each occurrence Auto Collision Insurance Actual cash value $500 Waiver of deductible applies $157.83 Auto Comprehensive Insurance Actual cash value $500 Rental Reimbursement up to$30 per day for a maximum of 30 Not applicable $38.33 days $41.64 Towing and Labor Costs $100 each disablement Not applicable Uninsured Motorists Insurance for Bodily $4.28 $100,000 each person Not applicable $251.30 Injury $300,000 each accident Automobile Medical Payments $5,000 each person Not applicable Coordinated Medical Protection Not purchased* $32.11 Sound System Not purchased* Tape Not purchased* Total premium for 2008 Toyota Sienna $912.43 This coverage can provide you with valuable protection. To help you stay current with your insurance needs,contact your Allstate agent to discuss coverage options and other products and services that can help protect you. VIM 5TDZK23C68S158046 Rating Information Your premium is determined based on certain information,including the following: •This vehicle is driven 0-3 miles to work/school, unmarried on licensed 08 years. Allstate uses mileage Information as one factor to help determine your premium amount Important Note:The annual mileage figure applicable to this vehicle for the expiring policy period was:17,500-71,999.The annual mileage figure applicable to this vehicle for the current policy period Is:11,s00-11,999. The required odometer information to calculate your annual mileage for the current Policy was Illegible,could not be obtained or the most recent odometer reading we received was less thaniod a p evio streading.d,was If any of the Information shown above is incorrect,missing or changes in the future,please contact your Allstate representative.Please keep in mind that a change In any of the Information may result In an adjustment to your premium. Additional coverages AutomoWe Death Indemnity Insurance Not purchased• rcont/need.) CITY OF SANTA ANA Risk Management a division of Human Resources Managing Risk through Awareness and Action 0- AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE I, AUSTI N QUACH ("Representative"), attest that I am an authorized (Name and Title of Vendor Representative) representative of QING WE[ LION & DRAGON CULTURAL TROUPE ("Company"), and (Consultant/Company Name) 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,agreement number N-2025-247 ("Agreement")to provide LION AND DRAGON DANCE (Services to be provided under agreement/contract) ("Services"): 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 subject 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 Agreement,it will be considered a breach of Agreement rendering the Agreement null and void and Company will be fully liable for any and all damages. ,RGlz 5-/a t,) Cga4 9/4/2025 Signature Date AUSTIN QUACH Print Name EXECUTIVE DIRECTOR Title 7147662943 Contact information,i.e.,Telephone Number and/or Email Address WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANT DOLLARS($100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. Affidavit of Exemption for Workers'Compensation Insurance 11.12.2024