HomeMy WebLinkAboutINLAND ROUNDBALL OFFICIALS, INC. (2) INSURANCE ON FILE
ran;, f.1f++" ' �CEED N-2025-193-01
CITY CLEr
DATE:MAR 2 0 2926
FIRST AMENDMENT TO AGREEMENT WITH INLAND ROUNDBALL,INC. FOR SPORTS
W RECREATION OFFICIATING SERVICES
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THIS FIRST AMENDMENT to the above-referenced agreement is entered into on
February 26, 2026, by and between Inland Roundball Officials, Inc., a California corporation
("Contractor") 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. The parties entered into Agreement No. N-2025-193, dated May 16, 2025, by which
Contractor agreed to provide officiating services for various youth and adult sporting
leagues in the City("Agreement").
B. The Agreement is current and in-effect, and expires on May 31, 2027.
C. The parties now wish to amend Exhibit A, as referenced in the Scope of Services section
of the Agreement to add additional officiating services to be provided by Contractor. No
other changes are contemplated by this First Amendment.
The Parties therefore agree:
1. Exhibit A, as referenced in Section 1, Scope of Services, is amended to add the following
language to the "Proposed Rates" list of services:
Adult/Youth Soccer:
o $45 per official for a one-hour game
■ Example (7pm, 8pm, 9pm):
■ I official— $135
■ 2 officials=$270
o $30 per official for a 30-minute game
■ Example (7:30pm, 8pm, 8:30pm):
■ 1 official=$90
■ 2 officials =$180
2. Except as modified by this First Amendment, all terms and conditions of the Agreement shall
remain in full force and effect.
[signatures appear on,following page]
Page I of 2
SIGNATURE PAGE: FIRST AMENDMENT TO AGREEMENT WITH INLAND
ROUNDBALL,INC. FOR SPORTS RECREATION OFFICIATING SERVICES
ATTEST CITY OF SANTA A
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E ALL ='' ALVARO NUNEZ
City Cler City Manager
APPROVED AS TO FORM CONTRACTOR
Sonia R. Carvalho
City Attorney
By: Ja n cgan(Mar 2,2026 19:45:30 EST)
JONATHAN T. MA TINEZ By: Jason Logan
Assistant City Attorney Title: Owner-Inland Roundball
RECOMMENDED FO ROVAL
HAW O
Exec
u e erect
Parks, Recreation and Community Services Agency
Page 2 of 2
ACOR" CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIODIYYYY)
09/0712025
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
NAME:
American Specialty Insurance 8,Risk Services,Inc. PHONE FAX
A/C No Ezt: AIC Na:
dba A.S.I.R.S.I. Insurance Agency(CA License#0E72661) A MAIL
- DRESS:
7609 W.Jefferson Blvd.,Suite 100 INSURER(S)AFFORDING COVERAGE NAIL#
Fort Wayne IN 46804 INSURERA: Arch Insurance Company 11150
INSURED
INSURER B
National Association of Sports Officials(NASD) INSURERC:
2017 Lathrop Avenue INSURER D:
INSURER E:
Racine WI 53405 INSURER F
COVERAGES CERTIFICATE NUMBER: 1002394555 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
(NDICATED. 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 SUER POLICY EFF POLICY EXP
LTR POLICY NUMBER MMiDDNYYY) (MWDDNM LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGET TED
CLAIMS-MADE OCCUR PREM[SES Ea REN occurrence $ 1,000,000
MED EXP(Any one person) $ Excluded
A Y Y SBCGL0279608 08/01/2025 08/01/2026 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000
POLICY ECOT- LOG PRODUCTS-CCMPIOP AGG $ 5,000,000
X OTHER: OFFICIAL $
AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $
Ea accident
ANYAUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY Per accident
AUTOS ONLY AUTOS ( I $
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000
A X EXCESS LIAB CLAIMS-MADE SBFXS0044408 08/01/2025 08/01/2026 AGGREGATE S 9,000,000
DED RETENTION$ S
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANYPROPRI FTORIPARTN ERIEXECUTIV E
OFFICERIMEMBEREXCLUDED? ❑ NIA E.L.EACH ACCIDENT $
(Myyandatory in NH) F.L.DISEASE-EA EMPLOYEE $
If s.describe under
DESCR PTION OF OPERATIONS below — APPROVED E.L. I..L.DISEASE-POLICY MIT S
-7
By Tu Tran Nguyen at 7:34 am,Sep 10,2025 Tran Digitally signed b
Tu Tran Nguyen
Date:2025.09.10
u en 07:34:42-0TOO'
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
-Coverage applies to JASON LOGAN,3925 SCARLET OAK CT,SAN BERNARDINO,CA 92407.
-The Certificate Holder shall be an Additional Insured,but only with respect to the operations of the Named Insured,and subject to the provisions and
limitations of Form CG 2026-Additional Insured-Designated Person or Organization,effective September 07,2025.
CERTIFICATE HOLDER CANCELLATION
City of Santa Ana,Parks, Recreation and Community Services SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
20 Civic Center Plaza
AUTHORIZED REPRESENTATIVE -
Santa Ana CA 92701
I
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:
LOC 4:
Ac"®V ADDITIONAL REMARKS SCHEDULE Pagel of 1
AGENCY NAMED INSURED
American Specialty Insurance&Risk Services,Inc. National Association of Sports Officials(NASD)
POLICY NUMBER 2017 Lathrop Avenue
SBCGL0279608
CARRIER NAIL CODE Racine,Wl 53405
Arch Insurance Company 11150 EFFECTIVE DATE: 08/01/2026
ADDITIONAL.REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE-Certificate#1002394555
-Unintentional Errors&Omissions,$100,000 each occurrence/$100,000 Annual Aggregate per official/assignor (included in,and not In addition to,the limits
shown in the Declarations of this policy)
-Other Named Insured: National Association of Sports Officials(NASD)&NASO-member officials,including officials enrolled by associations,contracted with
NASO,judges,
referees,evaluators or other administrative staff of the officiating crew acting in an officiating capacity.
-Other Named Insured(cont'd):NASD-member officials are only Named Insureds while acting in their capacity as officials during
sports events organized by a recognized sanctioning body or organized by another entity,where the rules of a recognized sanctioning body are followed,such
as a local Park Department or any formal
organized association and/or while attending seminars,conferences,and similar meetings designed
-Other Named Insured(confd):to improve their officiating knowledge and skills and/or mentoring or providing instruction to or
evaluation of another official.
-Other Named insured(cont'd):LLC's that are created by an NASD member officials for the sole purpose of handling payments from officiating and assigning
activities.It Is further understood and agreed that NASO member officials and his/her respective LLC is considered to be one entity for the purposes of coverage
throughout the policy and all amendatory endorsements.
-The excess Aggregate Limit applies separately to each"official"insured under this policy. However,in the event of a suit by one or more plaintiffs against
more than eight"officials",the Aggregate Limit will not apply separately to each"official",and a single aggregate limit of$20,000,000 will apply collectively to all
Individual"officials"covered under this policy.
-The general liability policy does not contain an exclusion for sexual abuse,molestation, misconduct,or simillar offenses.
-The General Liability policy includes Waiver of Subrogation as per Form CG 2404 Waiver of Transfer of Rights of Recovery Against Others to Us.
ACORD 701 (2048I01) ®2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER:SBCGL0279608 COMMERCIAL GENERAL LIABILITY
CG 20 2612 19
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
Name Of Additional Insured Person(s) Or Organization(s):
Any Certificate Holder identified as an additional insured on a Certificate of Insurance issued by American
Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance &
Risk Services Agency, and A S Insurance& Risk Services Agency
Information required to complete this Schedule, If not shown above,will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these
Include as an additional insured the person(s) or additional insureds, the following is added to
organization(s) shown in the Schedule, but only Section III—Limits Of Insurance:
with respect to liability for "bodily injury", '"property If coverage provided to the additional insured is
damage or personal and advertising injury required by a contract or agreement, the most we
caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the
omissions or the acts or omissions of those acting amount of insurance:
on your behalf:
1. In the performance of your ongoing operations; 1. Required by the contract or agreement; or
or 2. Available under the applicable limits of
2. In connection with your premises owned by or insurance;
rented to you. whichever is less.
However: This endorsement shall not increase the
1. The insurance afforded to such additional
applicable limits of insurance.
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance 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.
CG 20 2612 19 O Insurance Services Office, Inc., 2018 Page 1 of 1
POLICY NUMBER: SBCGL0279608 COMMERCIAL GENERAL LIABILITY
CG 24 0412 19
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
ELECTRONIC DATA LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES
POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
RAILROAD PROTECTIVE LIABILITY COVERAGE PART
UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS
SCHEDULE
Name Of Person(s) Or Organization(s): The person or organization with whom the insured has executed an
agreement or contract prior to the loss.
Information re uired 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 against the person(s)
or organization(s) shown in the Schedule above
because of payments we make under this Coverage
Part. Such waiver by us applies only to the extent that
the insured has waived its right of recovery against
such person(s) or organization(s) prior to loss. This
endorsement applies only to the person(s) or
organization(s)shown in the Schedule above.
CG 24 0412 19 O Insurance Services Office, Inc., 2018 Page 1 of 1
CITY OF SA►1►TA ANA
Risk Management a division of Human Resources
Managing Risk through Awareness and Action
AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE
I Jason A. Logan (`Representative"),attest that I am an authorized
{Name and Title of Vendor Representative)
representative Inland Roundball Officials Inc.
p ("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
("Agreement")to provide sports recreation officiating services ("Services"):
(Services to be provided under 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 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 full liable for an and all damages. n,ranVED
P y y g By ru rrare VJguyart at'10:40 am,Mar 17,2026
3/11 /2026
100, Signature h,mte
Jason A. Logan
Print Name
Owner
Title
714-330-0779. Inland round ballofficials@a gmail.com
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($I00,000). 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
CITY OF SANTA ANA
Risk Management a division of Human Resources ,
Managing Risk through Awareness and Action
AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE
I, Jason A. Logan ("Representative"),attest that I am an authorized
(Name and Title of vendor Representative)
representative of Inland Roundball Officials Inc. ("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
("Agreement")to provide sports recreation officiating services ("Services"):
(Services to be provided under agreement/contract)
During the course and scope of Company's agreement with the City of Santa Ana,
Company employees, consultants, representatives, and agents will not use and/or drive
any Company owned/rented/leased/borrowed vehicles to perform Services to, for,or on
behalf of City of Santa Ana.
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 automobile 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.
_ 3/11/2026
Signature Q,3 to
Jason A. Logan
Print Name
Owner
Title
714-880-0779. lnlandroundballofficials@gmail.com
Contact Information,i_e.,Telephone Number and/or Email Address
Affidavit of Exemption for Automobile Liability Insurance 11.12.2024