HomeMy WebLinkAboutCAL JUMP SOUTH ORANGE LLC. INSURANCE NOT ON FILE
WORK MAY NOT PROCEED N-2026-179
CITY CLERK
DATE; JUL } 4 2026
6:?Q(1) AGREEMENT BETWEEN CAL JUMP SOUTH ORANGE COUNTY LLC AND
0. UNlan{pa) CITY OF SANTA ANA FOR INFLATABLE EQUIPMENT
THIS AGREEMENT is niade and entered into on this 8`t'day of June,2026 by and between
Cal Jump South Orange County LLC, ("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. The City desires to retain a Consultant to provide inflatable equipment rental for use by the
Santa Ana Police Department.
B. Consultant represents that Consultant is able and willing to provide such services to the
City.
C. 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, Consultant shall perform the services that are described in Invoice No. 56665805-
Exhibit A, attached hereto and incorporated by reference. To schedule services
other than those specifically referenced in Exhibit A, Contractor will provide a
quote to City detailing services and costs for the event,and City will provide a letter
agreement to Contractor, to be executed by the Santa Ana Chief of Police, or their
designee and Consultant. Work by Consultant may not proceed without a letter
agreement, signed by the parties,for a scheduled Event.
b. City grants Consultant the right to enter its property for the purpose of delivery,set-
up, operation, and pick-up on the days of the scheduled Events.
C. The equipment shall be disassembled and removed by Consultant at the conclusion
of each Event.
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d. City shall have the sole discretion as to engagement of Consultant for
services/events not detailed in Invoice No. 56665805 - Exhibit A. The City
reserves the right to administratively change event locations, dates, or services for
any mutually agreed upon services/events.
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COMPENSATION
City does not guarantee any minimum compensation to Contmotor under this
Agreement. Contractor shall be paid only for actual services performed under this
Agrm-nent at the rates and charges mutually agreW upon by the Partics. Upon the
written canf=ation of a scheduled event, as provided for in Section I a, above, City
agrees to pay, and Contmotor agrees to accept as total Payment for its scheduled
for City,the rates and charges agreed upon,in writing,by receipt of invoice
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or quote from the Contractor similar to Invoice No.56665SO5-- Exhibit A, attached
hereto and incorporated by refervnce. The total amount to be expended under this
Ag regiment shall not exceed Five Thousand Dollars and 00/100($5,000).
b. Payment by City shall be made within forty-five(45) days following receipt of proper
invoice evidencing work performed, subject to City accounting procedures. City and
Contractor agree that all payments due and owing under this Agreement shall be made
through Automated Clearing House(ACFD transfers. Contractor agrees to execute the
City's standard ACH Vendor Payment Authorization and provide required
documentation. Upon verification of the data provided,the City will be autborizcd to
deposit payments directly into Con"etoes acco-unt(s) with financial institutions,
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.
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Vk TERM
This Agreement.shall co=ence on the date first written above and continue through July
31, 2028,unless terminated earlier in accordance with Section 15,below.
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 tile City to exercise discretion or control over the professional manner in which Consultant
perfo-tins the services which are the subject matter of this Agreement;however,the services to be
provided by Consultant shall boprovided in a manner consistent with all applicable standards and
regulations governing such services, Consultant shall pay all salaries and wages,employer's social
- es relating to employees and shall be
security taxies, unemployment insuran niilar tax
ce and si
responsible for all applicable withholding taxes.
5. OWNERS UP 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 intelleewal property
embodied in plans, specifications, studies, drawings,estimates, and other documents or wor-s of
authorsMp fixed in any tangible medium of expression, including but not limited to, physical
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diawings or data magnetically or otherwiso recorded on computer diskettes, which are prepared or
caused to be prepared by Consultant under this Agreement ('Documents & Data"). Consultant
shall require all subcontractom to agree in writing that City is granted a non-exclusive and
perpetual license for any Documents & Data flic subcontractor prepares under this Agreement,
Consultant represents and ivarTatits that Coasultant has the legal right to license any and all
Documents & Data. Consultant makes no such representation and wwTanty in regard to
Documents & Data which were provided to Consultant by the City. City shall Dot be limited in
any way in its use of the Documents and Data at any time,provided that any such use aot within
the purposes intended by this Agreement shall be at City's sole risk
6. INSURANCE
Insarance requirements attached hereto as Exhibit 8,
7, INDEMNIFICATION
Consultant agrees to defend, and shall indemnify and hold harmless the City, its officers,
agents,employees,contractors,special counsel,and representatives frorn liability. (1)for personal
inju:ry,darnagasJust compensation,restitution,judicial orequitable mlief arising out of olaim for
personal injury, including death, and claims for property damage, which may arise from the
negligent operations of the Contractor, its subcontractors, agents, employees, or other pemas
acting on its behalf which relates to the services described in section I of this Agreemeat;and(2)
from any claim that pemnal iniuM damages,just compensation,restitution,judicial or equitable
relief is date by reason.of the terms of or effects arising from this Agreement. This indemnity and
hold harnAess agTee=nt applies to all claims for damages,just compcnsation,restitution,judicial
or equitable reliefsuffered,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 agrms 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 tezms of, or effects arising from this AgreemeaL City may make all reasonable
decisions with respect to its xepresontation in any legal proceeding.Notwithstandimg the fomgoingg,
to the extent Contractor's services are subject to Civil Code Section 2782.8,the above iadernWty
shall be limited, to the extent required by Civil
Code Section 2782.8, to claims that aTisr, out of,
Pertain to, or relate to the negligence,recklessness,or willful misconduct of the Contractor,
81 ENTELLECTUAL PROPERTY INDEMNIFICATION
Consultant shall defend and indemnify the City, its officers, agents,representatives, and
employees against any and all liability, including costs, for inftingeniL-nt of any United States'
letters patent,trademark,or copyright infringement,including costs,Contained in the work product
or documents provided by Consultant to the City pursuant to this Agreement,
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9. RECORDS
Consultant shall keep records and invoices in convection with the work to be performed
under this Agreement. Consultant shall maintain complete and accurate records with respect to
the costs incurred under this Agreement and any services, expenditures, and disbursements
charged to the City for a minimum period of three (3) years, or for any longer period required by
law, from the date of final payment to Consultant under this Agreement. All such records and
invoices shall be clearly identifiable. Consultant shall allow a representative of the City to
examine, audit, and make transcripts or copies of such records and any other documents created
pursuant to this Agreement during regular business hours. Consultant shall allow inspection of all
work:, data, documents, proceedings, and activities related to this Agreement for a period of three
(3) years from the date of final payment to Consultant under this Agreement.
10. 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.
11. CONFLICT OF INTEREST CLAUSE
a. 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.
b. No immediate family members of either the Mayor, City Council Member, or any
appointed City Official, including appointed board and commission members, as
defined under the City's Municipal Code,whose position with the City shall award or
influence the award of this Agreement or any competing contract or amendment �
thereof, shall be employed in any capacity by the Consultant or have any other direct
or indirect financial benefit or interest in this Agreement,
c. The section also prohibits the awarding of any agreement, contract, grant, or any
amendment to those awards, to any former full-tine employee for one-year from date
of employee separation except for any CalPERS retiree as authorized by City Council
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d. The Consultant mast coataply with all oortflict of 40terest lamre'gu , � d�
lations 01v in Of Mt or hereafter to be enacted ding the terms of this Contract,
which Inflict with the p s, and
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gr`eent, or (Irani).(Irani). 'Theonsultattt warrants that it is not now aware � �� facts
m}tib�itins defined above.If the Consultant hereafter
awa of any facts that might reasonably be expects to create a becomes
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must itediatoly rake fall written discdos�of such f �srtIfct of hater est, it
he City, Full
disclosure rratrst inclUten
ude,but is not liWted to, identification of an personsi�I
a a rnple description of all relevant ciric
cumstancea, Failure tated
v comply with the
provisions of this paragraph will be a material breach of this Agreement, �
e. Corrsultan,t c"na is that moons of its directors, omens, employe , or agent shall
participate in selecting or administrating any subcontract supported(ill whole or Shall
by City.ids Ste=-ning m the Agreement where the awarding of the subcontract
has any edit or indirect financial benefit or ' to any individual, as de in
subsections(b)and(c) above.
12, NON ISCRM'7 NATI N
Consultant shall;aot discriminate because of race,color,creel,religion,sex,marital s€at�as,
sexual c� en on: g der identity, gender expression, gender, medical co i6o rnfdor. a€ion'or railr -y and veteran stags; age,national ors � any � defined
a.�,d cohabited b � f ter, ot•disability, deed '
p y applicable law, in the recr tmen4 selecdor4 teaching, aizria utr i atic n,
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promotion,tenWnatioa or Other employment related activities or y service trainiprov g under-this A roczxznt, Consultant affirm that ii s an equal opportunity employer and shall comply with all
applicable federal,state and local laws and regulations.
3. EXCLU MW AND AMENDMENT
This Agreement .represents the, complete and exclusive statement bow the City and
Contractor, and supersedes any and all other agreements, oral or written,between the parties, In
the event of a waflict between the term of this Agreement and any attadmeots he to.the terins
of"this Agree ent shall Prevail. This Agreement may not be modified except by Written instr=ent
signed by the City and by an atzthori ed representative of Contractor. The panes agree that any
terms or conditions of any phase order or other instrument that are inconsistent with, or in
addition to,tare terms and conditions herc ?f,shall not bind e}r€�bllga consultant
Valtr t0thig
_ eem t �e mlbd es that no represmtations, inducements, praxises or
ag seems,orally or otherwise,have beeu made by aay party, or anyone acting on behalf of any
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p which is not embodied herein, 1
14. ASSIGNMNT
T
Inasmuch as this Agreement is intended to secure the specialized servi=of+ nsultant,
omultant may not assign,trmsfer, delegate, or, b utract airy interest herein without the pal r
Written.;,XMsent of the City and any such assignment transfer,delegation or subcontract without i
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the City's prior written consent shall be considered null and void.. Nothing in this Agreement shall
tic constved 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 Contractors retained by City.
lS. TERMINATION
f This Agreement may be tcrminated by the City upon thirty (30) days written notice of
termination. in such event,Consultant shall be entitled to receive and the City shall pay Consultant
compensation for all services performed by Consultant prior to receipt of such notice of +
termination, subject to the following conditions:
a. As a condition of such payment, the Chief of Police 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.
b. Payment need not be made for work which fails to meet the standard of
performance specified in the Recitals of this Agreement.
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 sued 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
similar, nor shall any waiver constitute a continuing waiver unless the writing so specifies. l
17. JURISDICTION- VENUE �
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This Agreement has been executed and delivered in the State of California and the validity,
interpretation, performance, and enforcement of any of the clauses of this Agreement shall be
determined and governed by the laws of the State of California. Both parties further 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.
18. PROFESSIONAL LICENSES
Consultant shall, throughout the term of this Agreement, maintain all necessary licenses,
permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder
and required by the laws and regulations of the United States, the State of California, the City of
Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and
in writing of its inability to obtain or maintain such permits, licenses, approvals, waivers, and
exemption. Said inability shall be cause for termination of this Agreement,
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Ids NOTICE
Any notice,teftdcr, detnaud, delivery,or other communication pursuant to this Agreement
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Shall be in writing and shall be deemed to be property given if delivered in person or mailed y
first class or cerdfied mail,postage prepaid,or sent by fax or other telcgrapWc communication in
the inanner provided in this tion,to the following persons:
To City.
City Clerk
City of Santa Ana
20 Civic Center Plaza(M-30)
P.O.Box 1988
Santa Ana,CA 92702-1988
Fax: 714- 647-6956
With courtesy copies to,
Chief of Police
City of Santa Ana
20 Civic Center Plaza(M-96)
P.O,Box 1988
Santa Ana, California 92702
To Consultant
Dwayne Amderson
Cal Jump South Orange County LLC
2717South Orange Ave.Unite D/E
Santa Ana,CA 92702
A party may change its address by giving notice in writing to the other party. Thereafter,
my communication shall be addressed and transmitted to the new address. If sent by mail,
communication shall be zffictive 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 fax, communication shall be effective or deemed to have
been given twenty-four(24)hours after the time set forth on the,tran
simission report issued by the
transmitting facsimile machine, addressed as set forth above. For purposts of calculating these
time frames,weekends, federal, state,County or City holidays shall be excluded.
20. MISCELLANFOXJS PROVISIONS
a. Each undersigned represents and warrants that its signature herein below has the
power, authority and -right to bind their respective patties to each of the terms of
this Agreement, and shall indemnify City folly, including reasonable, costs and
attorney's fees,for any injuries or damages to City in the event that such authority
or power is not,in fact,held by the signatory or is withdrawn.
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b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully
set forth in the body ofthis Agreement.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first
above written.
.ATTEST:
CITY F AMA A
Cenni City Manager
fr Alvaro Nunez
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APPROVED AS TO FORM:
SONIA R. CARVALHO CAL JUMP SOUTH ORANGE
City ttorney COUNTY LLC:
By: ' ��.
TAMARA BOGOSIAN fDWA E ANDERSON
Senior Assistant City Attorney
RECOMIVIENDED FOR APPROVAL:.
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ROBERT RODRIGUEZ
Chief of Police
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EXHIBIT A
INVOICE NO. 56665805
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Cal j,,Mp SOU O"Mige County.LLC Ordw oats: I "W6
JNF.LATA8I,F V(amj Ana CA 9270
2717 S,)Li Th OrarVo Av
phaj-f&-1855 4,67 SN7
Sj,art 08joMMS: 7-,2-A 2026 11 OOROI
LAII = ✓ n#dI Dats,7Wnwd O7W,2'3-207r22631 -
7 D04M
DVury
9 Ma- :
Datio Gaften PlCk-Up VAndOW
2627, W McFaddon Av* 7 OOPM
Santa Ana CA 42"04
Coll 1714) -91-10 77 SUrfaCq* SandSags
75' Stars and Stripes Obstacle Course 01 OC
45 Pool Party Obstacle GOutse OC
SO DO
watwsbde-Pool
20'Roaring Rapids Dual Lane OC
$0.00
Waierslide- Pool
00
Impact Mai OC 3 $60
AMM
$1 47TOO
Rentals utatntal $0 OD
Sales Tax $1,477.00
Total S50 M
Deposit Due $00.0
Amount Paid $1,47700
Balance Due
Parl,ong lot
�XH[131`�' fi
INSURANCE REQUIREMENTS
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Inslirance Rtquiremeats
Consultant shall Procure and maintain for the duration of the agreement, the folJOWing if)Vrance
coverages.
MMMIUNI SCOPE AND LIMIT OF INSURANCE
Consultant shall maintain limits of insumce coverage in tote following minimum amounts xad
shall be nt least as broad as,
Commercial General Liability (CGL). Insurance Services MOO FOrm CG 00 01
covering COL on an "occurrence' basis, including products and completed operations,
property damage, bodily injury and personal & advertising iniuU with limits no less than
$1,000,000 per occurrence and$2,000,000 aggregate.
Automobile Liability (AL)-. It m=nce Services Of Fonn CA 00 01 covering Code I
(any auto), with combined single limits of$1,000,000. In the evat Consultant does not
maintain covimercial automobile liability insurance, City will accept evidence of personal
automobile insurance,provided that such policy is endorsed for business use and provides
coverage with a minimum limit of$1,000,000. Required policy bits can be met with,
primary and umbrella/excess insurance policies,
Workers' Compensation (WC)- as required by thr, stutr, of California, with statutory
limits, and Employer's Liability Insurance with limit of no loss than $1,000,000 Per
accident, per employee, per policy for bodily injury ar disease. This requirement can be
waived if Consultant has no employees.
If Consultant maintains broader coverage and/or higher limits than the mini-mums shown
above, City requit,es and shall be entitled to the broader coverage and/or the 1�gher limits
maintained by Consultant. Any availitble insurance pmeceds in excess of the specified
nArtirnum 11a9ts of insurance and coverage shall be available to City.
Other Insurance Provisions
h
The insurance policies are to contain, or be endorsed to contain,t e 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 behalfof the Consultant
including materials,parts,equipment, and pffsotmel furnished in connection with such
-work or operations,
2ts of, CGL, AL, and WC Policies, Insurance company(ies) agrees to waive Al ri&O
of eu
subrogation against City,its City Council,its 0 ceis,officials,employees,writs,and
volunteers for losses paid under the terns of any policy which arise from -work-
tlmnt for CitY,
performed by Cons
3, All required insurance policies: For any claims rclated to this contract, Consultant's
insurance coverage shall be primary and any insurmce maintained by City, its city
Council, its offlem, officials, employees, agents, or volunteers shall not conthibute
with it.
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4. Ali required insurance policies. A :severability of interest provision s apply for all
the additional insureds, ensuring, that Consultant's insurance shall apply separately to
each insured against whom a claim is made or suit is brought, except with respLet to
the insurer's limits of liability.
5. Each insurance policy required herein sliall 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 tWaty(30) days prior written notice has been given. to
City.Ten(10)days prior written notice shall be provided to City for policy ca.necuation
or non-renewal clue to non-payment, 1
6. Certificate Holder on each Evidence of Insurance certificate shall be: City of Santa j
Ana, Attention: Dario (anon, 20 Civic Center plaza, M-96, Santa Ana, CA 92701.
The name and location of the event should be:included in the Description of Operations
section of each certificate.
Self-Insured Retentions
Self-insured retentions must be declared to and approved by the City. City may require
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.
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 A:VII, unless otherwise acceptable to City.
Verbcation 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 CCL
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 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.
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, Consultant must purchase
"extended reporting" coverage for a minimum of three(3) years after completion of work.
Subcontractor
Consultant shall require and verify that all sub-contmctor maintain insurance
meeting all the requirements stated herein, and Consultant shall ensure that City is
an additional insured on insurance required from sub-contractor.
Special Risks or Circumstances
C AY reserves the right to modify these requirerncrits, including limits, based on the nature of
the risk, prior experience, insurer, coverage, or other special circumstances.
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CITY OF SANTA ANA
Risk Management a division of Human Resources
Managing Risk through Awareness and Action `
AI~FIDAvrr OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE
I, I U & ii)) `r 2 ("Representative"),attest that I am an authonzed
iN and l ttl�Irl 111IL1llr RepretillitatFlcl
representative of (a E lwrip 5 rn g 01/m (mh4, Z/1�, _{"Companc'"I, and
i °rnrlud4mt C'1111panv Name)
possess the authonty to legalh bind Compan}
In m\ capaciti as Representative of Company, l represent and confirm the folloN%I�rn�f,as relates to the
agreement bemeen Compan} and City of Santa Ana,agreement number ,jC�t 6 0V_
�G
("Agreement`)to provide � �!�'S ("Services")
fServ'icas to be provided under agreement contract
During the course and scope of Compam's agreement%%lth the City of Santa Ana,Company 1+ill
not emploN any person in any manner so as to become subject to the«orkers` compensation la"s
of California,and agree that if Company should become subject to the Nvorkers' compensation
provisions of Section 3700 of the Labor Code,Company shall forth"ith compl} with the
provisions and provide proof ofkvorkers' compensation coverage immediately
If at anv time it is found that Company is not adhering to am and/or all of the statements in this
document and does not maintain the minimum workers'compensation insurance coverage as
required in the Agreement, it tivill be considered a breach of Agreement rendering the Agreement
null and void and Compan\ will be fully liable for any and all damages.
.Z?tY"Vr2_ aIV61111_� /z,02
5ionature t-late
Print Name
Contact InIonnation,i e Tdephatne Vum yr and&Email Wdress
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 t�ltlii,f>fdt11 IN ADDITION TOTHE C'OSTOF
COhIPENSA'rION.DAMAGES AS PROVIDED FOR IN SECTION 170h OF THE LABOR CODE.
INTEREST, AND ATTORNEYS FEES
Affidavit of Exemption for workers'Compensat ton Insurance 11 11.2014
UMR: B1284UB25A969A
Effective date of this Endorsement: 5/5/2026
This Endorsement is attached to and forms apart of Policy Number: ZISMB2420 03
Zodiac Insurance,A World Company Referred to in this endorsement as either the"Insurer"or
the"Underwriters"
ADDITIONAL INSURED PRIMARY AND NON CONTRIBUTORY AND WOS ENDORSEMENT
This endorsement modifies insurance provided under the following:
ENTERTAINMENT EQUIPMENT OPERATOR GENERAL LIABILITY CLAIMS MADE AND
REPORTED INSURANCE
In consideration of the premium charged for this policy, it is understood and agreed that:
1. Section III. PERSONS INSURED is amended to include as an Insured the person or
organization shown in the Schedule at paragraph 2. below, but only with respect to liability
caused, in whole or in part, by the Named Insured's performance of ongoing operations for that
Insured. However:
a) The insurance afforded to such additional insured only applies to the extent permitted by
law; and
b) If coverage provided to the additional insured is required by written"insured contract",the
insurance afforded to such additional insured will not be broader than that which you are
required by the written"insured contract"to provide for such additional insured.
c) This coverage is provided on a primary and noncontributory basis.
2. SCHEDULE
Name of Person or Organization:
City of Santa Ana,its City Council,Officers, Officials, Employees,Agents,and Volunteers
Attn: Dario Gaitan, Police Department
60 Civic Center Plaza, M-23
Santa Ana,CA 92701
Event Date: 07/23/26
Any person or organization
n for whom the Named Insured has agreed by written"insured contract"to designate as an additional
insured subject to all provisions and limitations of this policy.
(If no entry appears above, information required to complete this endorsement will be shown in
the Declarations as applicable to this endorsement)
3. The Named Insured waives any right of recovery the Named Insured may have against any
person or organization,where required by the Insured's written contract with the additional
insured, because of payments made by the Named Insured for Damages and Claims
Expenses arising out of the Named Insured's operations.
All other terms and conditions of the Policy remain unchanged.
UMR: B1284UB25A969A
Effective date of this Endorsement: 515/2026
This Endorsement is attached to and forms a part of Policy Number: ZISMB2420 03
Zodiac Insurance,A World Company Referred to in this endorsement as either the"Insurer"or
the"Underwriters"
ADDITIONAL INSURED ENDORSEMENT
This endorsement modifies insurance provided under the following:
ENTERTAINMENT EQUIPMENT OPERATOR GENERAL LIABILITY CLAIMS MADE AND
REPORTED INSURANCE
In consideration of the premium charged for this policy, it is understood and agreed that:
1. Section III. PERSONS INSURED is amended to include as an Insured the person or
organization shown in the Schedule at paragraph 2. below, but only with respect to liability
arising out of the Named Insured's operations or premises owned by or rented to the Named
Insured.
2. SCHEDULE.
Name of Person or Organization:
City of Santa Ana, its City Council, Officers, Officials, Employees,Agents, and
Volunteers
Attn: Dario Gaitan, Police Department
60 Civic Center Plaza, M-23
Santa Ana, CA 92701
Event Date: 07/23/26
Any person or organization for whom the Named Insured has agreed by written"insured contract"to
designate as an additional insured subject to all provisions and limitations of this policy.
(If no entry appears above, information required to complete this endorsement will be shown in
the Declarations as applicable to this endorsement).
All other terms and conditions of the Policy remain unchanged.
PAGE 5
GARRISON PROPERTY and CASUALTY ADDL INFO ON NEXT PAGE MAIL MCH-M-I
INSURANCE COMPANY RENEWAL OF
1 (A Stock Insurance Company) State 10 5 1 \(eh POLICYNUMBER
USAX 9800 Fredericksburg Road-San Antonio,Texas 78288 CA P 3 81 03412 03 3 3 R 7101 9
CALIFORNIA AUTO POLICY POLICYPERIOa: (12:01 A.M.standard time)
RENEWAL DECLARATIONS EFFECTIVE FEB 14 2026 TO AUG 14 2026
ATTACH TO PREVIOUS POLICY) OPERATORS
Named Insured and Address 01 DWAYNE ANDERSON
DWAYNE ANDERSON
4162 W 156TH ST
LAWNDALE CA 90260-2230
Description of Vehlcle s q VEH USE* WaWBUCM
la
\tEH TRADE NAME MODEL BODYTYPE MIL IDENTIRCAT10N NUMBER SYM
05 23 FORD F-150 4D 18250 1FTEW1CP3PKE19252 P
The Vehicle(s)described herein is principally garaged at the above address unless otherwise stated.]*WGWokZchocI;a=Buslness:F-=Farm7p=Plcwun=
VEH 05 LAWNDALE CA 90260-2230
This o icy provt es those coverages where a premium is shown below. a omits shown
may �e reduced by policy provisions and may not be combined regardless of the number of
vehicles for which a oremit is listed unless specifically authorized elsewhere in this policy.
COVERAGES LIMITS OF LIABILITY VEH VEH VEH VEH
05
("ACV,MEANS ACTUAL CASH VALUE) D=DED 6 PREMIUMH D=DED PREMIUM D=DE➢ PREMIUM D=QED I PREMIUM
AMOUNT $ 4,MOUNT $ AMOUNT $ MOUNT $
PART A - LIABILITY
BODILY INJURY EA PER $ 30, 00
EA ACC $ 60, OOC 235 . 67
PROPERTY DAMAGE EA ACC $ 25, OOC 198 . 61
PART B - MEDICAL PAYMENTS
EA PER $ 5, OOC 23 . 08
PART C - UNINSURED MOTORISTS
BODILY INJURY EA PER $ 30, 00
EA ACC $ 60, OOC 125 . 56
PART D - PHYSICAL DAMAGE COVERAGE
COMPREHENSIVE LOSS ACV LESS D1000 259 . 96
COLLISION LOSS ACV LESS D1000 989 .36
VEHICLE TOTAL PREMIUM 1832 .44
6 MONTH PREMIUM $ 1832 .44
PREMIUM DUE AT INCEPTION. THIS I NOT A BILL, STAT MENT jOF0 LOW.
$ 362 .55 INCLUDED IN PREMIUM FO VEH 05 AS RES T OF CON ICTION(S) .
ADDITIONAL MESSAGE (S) - SEE FOLLOWING PAGE (S)
LOSS PAYEE
EH 05 FORD MOTOR CREDIT COMPANY, MINNEAPOLIS MN
ENDORSEMENTS : ADDED 02-14-26 - NONE
REMAIN IN EFFECT (REFER TO PREVIOUS POLICY) - A200CA(01) RSGPCW(01) 5100CA(02)
INFORMATION FORMS : CRARPPCA(04) CADS (05) 40CA 01 13580 03
v
H1051 RSM11 01 x H
n WITNESS WHEREUF,we have caused this policy to a signedby our resident and Secretary at an Antonio, exas,
on this date JANUARY 9, 2 6
Tom Eck,Secretary Randy Termeer,President
5000 R 05-12
51492-05-12
PAGE 4
CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY - _ - _a cv -- -- - -- - - - - - -- -
Name and Address of Insured NAIC 21253 California Evidence of Financial Responsibility
Keep this card.
DNAYNE AEIKeep
4162 W 156TH ST IMPORTANT: Evidence of financial responsibility shall
LAWNDALE CA 90260-2230 at all times be carried in the vehicle. Under vehicle
code (Section 16028) every driver involved in an
accident must provide evidence of financial
responsibility at the scene. Failure to comply is an
infraction and shall be punishable by fines,
impoundment or license suspension.
f
0
1
d
ONAYNE ANLRJN
Insurance Company
CUN PFCP AND CAS INS CAD
Policy Number I Effective Date Expiration Date
03412 03 33R 7101 9 02/14/26 08/14/26
Vehicle Make/Vehicle Identification Number Year Additional copies available at usaa.com
FCRD 1 FfEW1 CP3PKE19252 2023
This policy complies with Sections 16056 of the CONTACT US: 210-531-USAA(8722)
California Vehicle Code.This policy provides at least the OR 8 0 0-5 3 1-USA A
minimum amounts of liability insurance required by CA
VEH CODE for the specified vehicle and named 9800 Fredericksburg Road,San Antonio,Texas
insureds and may provide coverage for other persons 78268
- _a�tddth�r"Gi$hPct��a�PrUvrdCd-fe7tnEFii7sdrTnde-p '-,-- - ----- -- -- --- - - -- - -- -- - --- - -- - - - - -- -- - -- - - - - -- - -
�lifornia Automobile Insurance Identification Cards
These identification cards are evidence of liability insurance for your vehicle(s). These cards are valid only as
long as liability insurance Kevrtsil¢bp9eeof the ID card in your vehicle at all times.
You may be required to produce your identification card at vehicle registration, inspecti on, applying for a driver's
license, after an accident, or by law enforcement officer request. Insurance information has already been
submitted directly to the DMV electronically, submit this document to DMV only if specifically requested by DMV.
53CA1 Rev. 06-25 01/09/26 55047-0625_01
CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY b a c k
Name and Address of Insured NAIC 21253
California Evidence of Financial Responsibility
DNAYNE AnDEFSCJN Keep this card.
4162W1%7HST
LAWNDALE CA 90260-2230 IMPORTANT: Evidence of financial responsibility shall
at all times be carried in the vehicle. Under vehicle
code (Section 16028) every driver involved in an
accident must provide evidence of financial
responsibility at the scene. Failure to comply is an
infraction and shall be punishable by fines,
f impoundment or license suspension.
0
1
d
DNAYNE A 43ERSCN
Insurance Company
Policy Number Effective Date Expiration Date
03412 03 33R 7101 9 02114/26 08/14/26
Vehicle Make/Vehicle Identification Number Year
FCD 1FTEW1CP3PKE19252 2023 Additional copies available at usaa.com
This policy complies with Sections 16056 of the CONTACT US: 210-531-USAA(8722)
California Vehicle Code.This policy provides at least the OR 8 0 0-5 3 1-USA A
minimum amounts of liability insurance required by CA
VEH CODE for the specified vehicle and named
insureds and may provide coverage for other persons 9800 Fredericksburg Road,San Antonio,Texas
and other vehicles as provided by the insurance policy. 78288
® DATE(MMIDDIYYYY)
Ac"R® CERTIFICATE OF LIABILITY INSURANCE
05/05/2026
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 1NSURER(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 Tony Cannizzaro
FAX
First Commercial Insurance Agency PHONE Exfl, (386)775-1781 WC No):
P.O.Box 295 nb�`DRles : tony@firstcommf#.com
1NSURER S AFFORDING COVERAGE NAIC q
Cassadaga FL 32706 INSURER A: BEAZLEY I CERTAIN UNIDEPWRITERS AT LLOYG 37540
INSURED INSURER B:
Cal Jump South Orange County LLC INSURER C:
2717 S Orange Ave Unit DIE INSURER D:
INSURER E:
Santa Ana CA 92707 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.
]NSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDDY EFF IYYYY MM POLICY
LIMITS
LTR
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE X CLAIMS•MADE FOCGUR PREMSESOaoccOnce $ 300,�p0
X 3 year extended reporting period MED EXP(Any one person) $ 25,000
A X Retroactive Date: 0 511 212 0 2 3 X X ZISMB2420 03 05/12/2026 05/12/2027 PERSONAL&ADV INJURY $ 1,000,000
GGEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY 0 j'o El LOC PRODUCTS-COMPIOPAGO $ 2,000,000
OTHER:
AUTOMOBILE LIABILITY Ea accciCBIdentS1NGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY I]AMAGE $
AUTOS ONLY AUTOS ONLY Per accl e
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ TH $
WORKERS COMPENSATION STATUTEi
ER
AND EMPLOYERS'LIABILITY
IN
ANY PROPRIETORIPARTNERIEXECUTIVE Y NIA
E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE•EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
City of Santa Ana,.its City Council,officers,officials,employees,agents,and volunteers are named as Additional Insured with Waiver of Subrogation as regard
the General Liability policy when required by written contract subject to the terms,conditions,and exclusions of the policy.
Event Date:07/23/26
Project Manager Name:Dario Gaitan,Police Department,2627 W McFadden Ave,Santa Ana,CA 92704
AFPR(1VD.,... �
CERTIFICATE HOLDER CANCELLATION Sy Tu Tran Nam[IV at 2th,Jun 02,2026'
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
City of Santa Ana
Attn:Dario Gaitan,Police Department AUTHORIZED REPRESENTATIVE
60 Civic Center Plaza,M-23
Santa Ana CA 92701
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD