HomeMy WebLinkAboutMEDINA, ANTHONY (3) N-2026-194
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COUNCIL AIDE PROFESSIONAL SERVICES AGREEMENT
THIS AGREEMENT is made and entered into on this 27" day of July, 2026 by and
between Anthony Medina("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
/L city'9).
RECITALS
A. The City desires to obtain the services of a Consultant to provide administrative,
constituent, and legislative support for a member of the Santa Ana City Council.
B. Consultant represents that Consultant is qualified to perform these services.
C. In undertaking the performance of this Agreement,Consultant represents that Consultant
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 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 during the term of this Agreement,the tasks and obligations
including all labor, materials, tools, equipment, and incidental customary work
required to fully and adequately provide administrative, constituent, and legislative
support services for Councilmember Johnathan Ryan Hernandez
("Councilmember") as provided in this Agreement and in the Scope of Services as
described in subsection b below.
b. At the direction of Councilmember, Consultant shall perform a variety of
administrative, constituent, and legislative functions and tasks, including but not
limited to, conducting complex administrative studies, researching and responding
to constituents' inquiries, drafting written communications involving strategy,
policies, and/ or procedures, coordinating assigned project activities, preparing
creative projects, and serving as a liaison, where necessary.
c. As maybe required for services performed while at City Hall, the City may provide
access to the Councilmember's office space—consistent with City procedures should
Consultant require limited access to perform services required by the
Councilmember. Consultant shall maintain a business location separate from City
and Consultant understands that such access to office space is not required by the
City but provided to the Consultant on an as-needed basis and should only be used
when City Hall is open to the public or while the Councilmember is present.
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2. COMPENSATION
a. City agrees to pay, and Consultant agrees to accept as total payment for its services
for City, the hourly pay rate of $31.00, for services rendered pursuant to this
agreement, and that monthly billing pursuant to this Agreement, shall not exceed a
total sum of five thousand dollars ($5,000) per month. Consultant agrees and
understands that no changes to this pay rate shall be made during the term of this
Agreement. The total sum to be expended under this Agreement shall not exceed
$30,000 during the term of this Agreement.
b. Consultant agrees and understands that the not-to-exceed amount, provided above,
includes reimbursement for all out-of-pocket expenses, including but not limited to,
mileage, copying costs, and mail services authorized at the sole direction of the
Councilmember in connection with the performance of duties under this Agreement.
The City shall not make any separate payments for any of the above expenses.
c. Consultant shall submit monthly invoices to City for work performed during the
billing period. Payment by City shall be made within thirty (30) days following
receipt of proper invoice evidencing work performed, subject to City accounting
procedures. Monthly invoices shall be in substantially the form attached hereto as
Exhibit A.
3. TERM
This Agreement shall commence on July 27, 2026, and terminate on June 30, 2027,
unless terminated earlier in accordance with Section 19, below.
4. INDEPENDENT CONTRACTOR
Consultant shall, during the entire term of this Agreement, be construed to be an
independent contractor and not an employee of the City. This Agreement is not intended nor
shall it be construed to create an employer-employee relationship, a joint venture relationship,
or to allow the City to exercise discretion or control over the professional manner in which
Consultant performs the services which are the subject matter of this Agreement;however,the
services to be provided by Consultant shall be provided in a manner consistent with all applicable
standards and regulations governing such services. Consultant shall pay all salaries and wages,
benefits, employer's social security taxes, unemployment insurance, and similar taxes relating
to employees and shall be responsible for all applicable withholding taxes.
5. POLITICAL CAMPAIGN ACTIVITIES
a. Consultant is prohibited from the following political campaign activities
while this Agreement is in place:
1) Acting as campaign treasurer/manager or a campaign consultant for any
candidate for Santa Ana City Council or Mayor;
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2) Campaigning for any candidate for Santa Ana City Council or Mayor and
at the same time,working pursuant to this agreement and/or charging the
City for the time spent campaigning pursuant to this agreement;
3) Using City equipment, supplies or resources to campaign for any
candidate for Santa Ana City Council or Mayor;
4) Accepting any campaign contributions on behalf of any candidate for
Santa Ana City Council of Mayor;
5) Campaigning while wearing any attire or logo that identifies you as a
Consultant for the City of Santa Ana;
6) Campaigning while using any City room,building, or location that
has not been specifically designated for political speech;
7) Receiving any payment or reimbursement from a campaign candidate
for Santa Ana City Council or Mayor or their campaign account;
and/or
8) Opening a campaign committee or pulling nomination papers to run as a
candidate for Santa Ana City Council or Mayor.
b. Consultant will sign the declaration attached hereto as Exbibit B
acknowledging said prohibitions.
6. PROHIBITION AGAINST APPOINTMENT TO CITY BOARD OR
COMMISSION
Consultant is prohibited from accepting appointment or continuing with any prior
appointment to any City Board or City Commission set forth in Chapter 2 of the Santa Ana
Municipal Code while this Agreement is'effective.
7. BACKGROUND CHECK
Consultant agrees to submit to a background check including, but not limited to, a live
scan and records check to City's satisfaction. Failure to do so is grounds for termination of this
Agreement.
8. OWNERSHIP OF MATERIALS
This Agreement creates a non-exclusive and perpetual license for City to copy, use,
modify, reuse, or sublicense any and all copyrights, designs, and other intellectual property
embodied in plans, specifications, studies, drawings, estimates, and other documents or works
of authorship fixed in any tangible medium of expression,including but not limited to,physical
drawings or data magnetically or otherwise recorded on computer diskettes,which are prepared
or caused to be prepared by Consultant under this Agreement ("Documents & Data").
Consultant shall require all subcontractors to agree in writing that City is granted a non-
exclusive and perpetual license for any Documents&Data the subcontractor prepares under this
Agreement. Consultant represents and warrants that Consultant has the legal right to license any
and all Documents &Data. Consultant makes no such representation and warranty in regard to
Documents &Data which were provided to Consultant by the City. City shall not be limited in
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any way in its use of the Documents and Data at any time,provided that any such use not within
the purposes intended by this Agreement shall be at City's sole risk.
9. INSURANCE
Insurance requirements are attached hereto as Exhibit C.
10. INDEMNIFICATION
Consultant agrees to defend, and shall indemnify and hold harmless the City, its
officers, agents, employees, contractors, special counsel, and representatives from liability; (1)
for personal injury, damages,just compensation, restitution,judicial or equitable relief arising
out of claims for personal injury, including death, and claims for property damage, which may
arise from the negligent operations of the Consultant, its subcontractors, agents, employees, or
other persons acting on its behalf which relates to the services described in section 1 of this
Agreement; and (2) from any claim that personal injury, damages, just compensation,
restitution,judicial or equitable relief is due by reason of the terms of or effects arising from this
Agreement.This indemnity and hold harmless agreement applies to all claims for damages,just
compensation,restitution,judicial or equitable relief suffered, or alleged to have been suffered,
by reason of the events referred to in this Section or by reason of the terms of, or effects, arising
from this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all
costs for the defense of the City, including fees and costs for special counsel to be selected by
the City, regarding any action by a third party challenging the validity of this Agreement, or
asserting that personal injury, damages,just compensation,restitution,judicial or equitable relief
due to personal or property rights arises by reason of the terms of, or effects arising from this
Agreement. City may make all reasonable decisions with respect to its representation in any
legal proceeding.
11. INTELLECTUAL PROPERTY INDEMNIFICATION
Consultant shall defend and indemnify the City,its officers, agents,representatives, and
employees against any and all liability, including costs, for infringement 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.
12. RECORDS
Consultant shall keep records and invoices in connection 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
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three(3) years from the date of final payment to Consultant under this Agreement.
13. 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.
14. CONFLICT OF INTEREST CLAUSE
a. Consultant represents that neither it nor any of its officers, partners or employees has
a financial interest, as defined in Section 87103 of the Government Code, in the
subj ect matter of this Agreement other than the right to receive payment from City
for services rendered.
b. Consultant agrees that it shall not make,participate in making,or in any way attempt
to use its position as consultant to influence any decision of City in which Consultant
knows, or has reason to know, that any of its officers, partners or employees has a
financial interest as defined in Section 87103 of the Government Code.
c. Consultant warrants that neither Consultant nor any of its officers, partners or
employees,has any financial interest in any real property,building or structure within
2,500 feet of the location of any project or assignment to which this Agreement may
apply in the City of Santa Ana. Consultant agrees to disclose to City any financial
interest in such property as may be acquired by its officers, partners or employees
during the term of this Agreement.
d. In accordance with the City's Conflict of Interest Code, if determined by the City
Manager to be a designated position, Consultant shall file a Statement of Economic
Interests (Form 700)with the Fair Political Practices Commission.
15. NON-EXCLUSIVE
Consultant understands and agrees that this is a non-exclusive Agreement and City may
enter into other agreements with other consultants and may use any of the contractors with whom
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City has contracts and, therefore, the City cannot estimate nor guarantee the volume or amount
of work to be received by Consultant under this Agreement.
16. NON-DISCRIMINATION
Consultant shall not discriminate because of race, color, creed, religion, sex, marital
status, sexual orientation, gender identity, gender expression, gender, medical conditions,
genetic information, or military and veteran status, age, national origin, ancestry, or disability,
as defined and prohibited by applicable law, in any services provided under this Agreement.
Consultant affirms that it is an equal opportunity employer and shall comply with all applicable
federal, state and local laws and regulations.
17. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and
Consultant, and supersedes any and all other agreements, oral or written,between the parties. In
the event of a conflict between the terms of this Agreement and any attachments hereto,the terms
of this Agreement shall prevail. This Agreement may not be modified except by written
instrument signed by the City and by an authorized representative of Consultant. The parties
agree that any terms or conditions of any purchase order or other instrument that are inconsistent
with, or in addition to, the terms and conditions hereof, shall not bind or obligate Consultant or
the City. Each party to this Agreement acknowledges that no representations, inducements,
promises or agreements, orally or otherwise,have been made by any party, or anyone acting on
behalf of any party, which is not embodied herein.
18. ASSIGNMENT
Inasmuch as this Agreement is intended to secure the specialized services of Consultant,
Consultant may not assign,transfer,delegate,or subcontract any interest herein without the prior
written consent of the City and any such assignment,transfer, delegation or subcontract without
the City's prior written consent shall be considered null and void. Nothing in this Agreement
shall be construed to limit the City's ability to have any of the services which are the subject to
this Agreement performed by City personnel or by other Consultants retained by City.
19. TERMINATION
This Agreement may be terminated 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,Consultant may be required 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
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performance specified in the Recitals of this Agreement.
Consultant's term shall automatically terminate immediately if, at any time, the
Councilmember is no longer an elected member or Mayor of the Santa Ana City Council.
20. WAIVE,R
No waiver of breach, failure of any condition, or any right or remedy contained in or
granted by the provisions of this Agreement shall be effective unless it is in writing and signed
by the party waiving the breach, failure, right or remedy. No waiver of any breach, failure or
right, or remedy shall be deemed a waiver of any other breach,failure,right or remedy,whether
or not similar,nor shall any waiver constitute a continuing waiver unless the writing so specifies.
21. JURISDICTION-VENUE
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.
22. 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 exemptions. Said inability shall be cause for termination of this
Agreement.
23. NOTICE
Any notice, tender, demand, delivery, or other communication pursuant to this
Agreement shall be in writing and shall be deemed to be properly given if delivered in person
or mailed by first class or certified mail, postage prepaid, or sent by fax or other telegraphic
communication in the manner provided in this Section,to the following persons:
To City:
City Clerk
20 Civic Center Plaza(M-30)
P.O. Box 1988
Santa Ana, CA 92702-1988
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With courtesy copies to;
City Manager
City of Santa Ana
20 Civic Center Plaza(M-31)
P.O, Box 1988
Santa Ana,CA 92702
To Consultant:
Anthony Medina
A party may change its address by giving notice in writing to the other party. Thereafter,
any communication shall be addresscd and transmitted to the new address, If sent by mail,
communication shall be effective or deemed to have been given three(3) days after it has been
deposited in the United States mail, duly registered or certified, with postage prepaid, and
addressed as set forth above. If sent by fax,communication shall be effective or deemed to have
been given twenty-four(24)hours after the time set forth on the transmission report issued by
the transmitting facsimile machine, addressed as set forth above. For purposes of calculating
these time frames, weekends, federal, state, County or City holidays shall be excluded.
24. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature herein below has the
power, authority and right to bind their respective parties to each of the terms of
this Agreement, and shall indemnify City fully, 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.
b. All Exhibits referenced herein, if any, and attached hereto shall be incorporated
as if fully set forth in the body of this Agreement.
[signatures appear on following page]
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IN WITNESS WHEREOF,the parties hereto have executed this Agreement the date and year
first above written.
ATTEST CITY OF SANTA ANA
r �
ennifer ll `�,��-F:.=
' lvaro Nunez
City Cl rl City Manager
APPROVED AS TO FORM CONSULTANT
SONIA R. CARVALHO
City Attorney
f
By. Anthony Medina(Jul 27,2026 16:36:25 PDT)
Jonathan T. Martinez Anthony Medina
Assistant City Attorney
Page 9 of 9
EXHIBTI'A
Month and Year Invoice
Your Name
Street Address Invoice#:
City, ST Zip Code Agreement #:
Phone pate:
Bill To:
City of Santa Ana
20 Civic Center Plaza Hourly Rate:
Santa Ana, CA 92701 Total Billable Hours:
Amount Due:
Date Start Time Time Out Description of Work Billable Hours
Performed
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
EXHIBIT B
,Acknowledgment Regarding Political Activities Prohibitions
1 Anthony Medina am an independent contractor working as a Council Aide pursuant to this
Agreement.
1. I acknowledge and agree that during the term of this Agreement, I will not participate
or conduct the following political activities:
a) Acting as campaign treasurer/manager or a campaign consultant for any
candidate for Santa Ana City Council or Mayor;
b) Campaigning for any candidate for Santa Ana City Council or Mayor and
at the same time,working pursuant to this agreement and/or charging the
City for the time spent campaigning pursuant to this agreement;
c) Using City equipment, supplies or resources to campaign for any
candidate for Santa Ana City Council or Mayor;
d) Accepting any campaign contributions on behalf of any candidate for
Santa Ana City Council of Mayor;
e) Campaigning while wearing any attire or logo that identifies you as a
Consultant for the City of Santa Ana;
f) Campaigning while using any City room, building, or location that has
not been specifically designated for political speech;
g) Receiving any payment or reimbursement from a campaign candidate for
Santa Ana City Council or Mayor or their campaign account; and/or
h) Opening a campaign committee or pulling nomination papers to run as a
candidate for Santa Ana City Council or Mayor..
2. I acknowledge and understand that failure to abide by any of the above prohibitions are
grounds for immediate termination of this Agreement.
Signed this 27thday of July , 2626.
Anthony Medina Anthony Medina(Jul 27,2026 16:36:25 PDT)
(Name of Consultant) (Signature of Consultant)
27/07/2026
Date
V a_ole
(Name of Witness) (Signature of Witness)
EXHIBIT C
Insurance Requirements
Anthony Medina("Consultant" or "Contractor") shall procure and maintain for the duration of
the agreement, the following insurance coverages:
MINIMUM SCOPE AND LIMIT OF INSURANCE
Contractor shall maintain limits of insurance coverage in the following minimum amounts and
shall be at least as broad as:
• 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 Contractor does not
maintain commercial 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 limits can be met with
primary and umbrella/excess insurance policies.
If Contractor 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 Contractor. 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:
1. City of Santa Ana, its City Council, its officers, officials, employees, agents, and
volunteers are to be covered as additional insureds on Contractor's AL policy with
respect to liability arising out of work or operations performed by or on behalf of the
Contractor including materials, parts, equipment, and personnel furnished in
connection with such work or operations.
2. 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 the Contractor's AL policy which arise from work performed by
Contractor for City.
3. All required insurance policies: For any claims related to this contract, Contractor'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 Contractor'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. The Certificate Holder on each Evidence of Insurance certificate shall be: City of Santa
Ana, Attention: City Manager's Office M-31, Santa Ana, CA 92701. The name and
location of 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
Contractor 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.
Verification of Coverage
Contractor 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 Contractor'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, Contractor must purchase
"extended reporting" coverage for a minimum of three(3) years after completion of work.
Subcontractors
Contractor shall require and verify that all sub-contractors maintain insurance
meeting all the requirements stated herein, and Contractor 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.
State Farm Mutual Automobile Insurance Company
Pfl Box 2358 ^State arm
Bloomington 1L 81702-2358
AT2 A-8761 A
MEDINA, ANTHONY
PREMIUM PAID: $672.00
00 NOT PAY.
Your premium is billed through the State Farm Payment Plan
State Farm Payment Plan Number:
Your State Farm Agent
PEGGY BATES
Policy Number: Office:714-543-0422
Policy Period: June 10, 2026 to December 10,2026 Address:
2014 FORD FOCUS By Tu Tran Nguyen at 7:59 am,Jul 28,2a2s if you have a new ordifferent car,have added any drivers,orhave moved,
Principal Driver: please contact your agent.
ANTHONY MEDINA Thankyou forchoosing State Farm.
Notice of insurance information collection practices- You have the right to submit a written request to access,
personal,family, or household insurance transactions: correct, amend,or delete your personal information and the
We may collect customer information from persons other right to receive a response within 30 days of submitting your
than the individual or individuals applying for coverage. request. If we deny your request,you have the right to file a
Such customer information as well as other personal or statement with us containing the information you feel is
privileged information subsequently collected may, in certain accurate and fair along with the reasons you disagree with
circumstances, be disclosed to third parties without your our denial. Instructions on how to file such request and our
authorization as permitted by law. full privacy notice can be found
(continued on next page)
Policy Dumber:737 4537-F10-75C Page number 1 of 5
Prepared April 17,2026
1004583 143562 202 01-15-2018
CONVENIENCE SAVES
TIME, MONEY
Sol AND
TREES,
You have the option to pay your bills online by opting
for ePayment an statefarm.com".
Get to a better State'". 1PC0
.' StatelFarm.
www.statefarm.com/customer-care/privacy-security/privacy When you provide a check as payment,you authorize us
or contact your State Farm Agent. either to use information from your check to make a
Your auto insurance rates are impacted by the mileage your one-time electronic fund transfer from your account or to
vehicle is driven.To ensure we've priced our insurance process the payment as a check transaction. When we use
coverage accurately based on the number of miles you information from your check to make an electronic fund
drive,we obtained valid mileage information for this vehicle transfer,funds may be withdrawn from your account as soon
through a third party provider and/or from you.Annual as the same day we receive your payment,and you will not
mileage was determined using this data and applied. Please receive your check back from your financial institution.
contact your State Farm agent with questions within 30 days
of your policy's renewal date.
VEHICLE INFORMATION
Review your policy information carefully.If anything is incorrect,or if there are any changes to your vehicle information,please
let us know right away.
Vehicle Identification
Vehicle Description Number(VIN) Who,principally drives this vehicle? How is this vehicle normally used?
2014 FORD FOCUS ANTHONY MEDINA,a single individual, To Work,School or Pleasure.
who will have 11 years of driving
experience as of June 10,2026.
Other Household Vehicle(s)
Your premium may be influenced by other State Farm
policies that currently insure the following vehicle(s)
in your household:
2002 FORD F150
2015 HONDA ACCORD
2004 BMW 5301
2016 BMW 4281
2013 DODGE CHALLENGER
2014 FORD FIESTA
1997 SATURN SATURN
The premium on the expiring policy term was based on The premium on the renewal policy term was based on
9,700 miles per year. 9,600 miles per year.
DRIVER INFORMATION
Assigned Driver(s)
The following driver(s)are assigned to the vehicle(s)on this policy.
Driving Experience as of Marital
Name June 10,2026 Status
ANTHONY MEDINA 11 years Single
Policy Number:737 4537-F10-75C Page number 2 of 5
Prepared April 17,2026
:. StateFarm'
Other Household Driver(s)
In addition to the Principal Driver(s)and Assigned
Driver(s), your premium may be influenced by the
drivers shown below and other individuals permitted to
drive your vehicle, This list does not extend or expand
coverage beyond that contained in this automobile
policy, The drivers listed below are the drivers reported
to us that most frequently drive other vehicles in your
household.
SANDRA MEDINA
ANTONIO R MEDINA
ALEXIS MEDINA
It is your responsibility to inform us of all regular For business related vehicles, also include the
drivers of your vehicles and changes to those drivers business owner(s)and employee(s)that drive the
throughout the life of your policy. Failure to disclose vehicle(s) in any capacity
drivers may result in denial of coverage. Regular Principal Driver&Assigned Drivers
drivers, regardless of their relationship to the primary For each automobile,the Principal Driver is the individual
named insured or their residence address, include: who most frequently drives it.
• All drivers who drive the vehicle(s)on the policy Each driver is designated as an Assigned Driver on the
once or more in a typical month household automobile that they most frequently drive.Your
• All drivers who regularly drive the vehicle(s)at premium may be influenced by the information shown for
least three months of the year these drivers.
COVERAGE AND LIMITS See yourpolicy for an explanation of these coverages.
A Liability
Bodily Injury 30,000/60,000
Property Damage 25,000 $548,74
H Emergency Road Service $3.41
U Uninsured Motor Vehicle
Bodily Injury 30,000/60,000 $92.47
U1 Uninsured Motor Vehicle
Property Damage $27.38
Total Premium $672.00
If any coverage you carry is changed to give broader you the broader protection without issuing a new policy,
protection with no additional premium charge,we will give starting on the date we adopt the broader protection.
DI SC OU NTS These adjustments have already been applied to your premium.
Multicar ✓
Driving Safety Record
(continued on next page)
Policy Number:737 4537-F10-75C Page number 3 of 5
Prepared April 17,2026
Awl StateFarm-
DISCOUNTS continued
California Good Driver
Loyalty ✓"
Total Discounts $2,024.06
SURCHARGES AND DISCOUNTS
Driving Safety Record Rating Plan more than $1000. For accidents occurring prior to
Your driving safety record,along with other rating factors, December 11, 2011,an accident shall be chargeable
determines what you pay for Liability, Medical Payments, provided it resulted in death or in payment(s) by an insurer
Comprehensive, Collision, and Uninsured Motor Vehicle due to damage to any property in the amount of more than
Coverages. Policyholders with no accidents and convictions $750.
pay less than those with accidents and convictions. For applicants without prior insurance at the time of the
The Driving Safety Record Rate Level that is assigned to accident, an accident shall be chargeable provided it
your policy moves up,down,or stays the same every policy resulted in damage to any property in the amount of more
renewal, depending upon your driving record. For every 12 than$1000 (more than $750 if the accident occurred prior to
months since the renewal following the occurrence of a December 11, 2011).
chargeable accident or the conviction of a minor violation, Chargeable accidents for renewal business are those which
the initial assigned Driver Record Level for that chargeable resulted in bodily injury or death or State Farm claim
accident or conviction shall be lowered by 1 level. For each payments totaling more than$1000 (more than $750 for
12 month period since the conviction of a major violation, accidents occurring prior to December 11,2011) under
the initial assigned Driver Record Level for that conviction property damage liability coverage and collision coverage
shall be lowered by 2 levels. The Rate Level is increased if combined.
there are subsequent chargeable accidents or convictions. For more information about the rating plan, please contact
Definition of Chargeable Accidents your State Farm agent,
Chargeable accidents for new business are those which Superior Driver Rate Level
resulted in bodily injury or death or in payment(s) by an
insurer due to damage to any property in the amount of
ADDITIONAL INFORMATION
IMPORTANT NOTICE If any information on this renewal notice is incomplete or
For your protection California law requires the inaccurate,or if you want to confirm the information we have
following to appear with this policy: Any person who in our records, please contact your agent. For additional
knowingly presents false or fraudulent information to information regarding discounts or coverages, see your
obtain or amend insurance coverage or to make a claim State Farm agent or visit statefarm.com®,
for the payment of a loss is guilty of a crime and may be Endorsement 6130Q effective JUN 10 2026.
subject to fines and confinement in state prison.
Important Notice Regarding Your Premium
State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile
insurance is determined by many factors including:
• The coverage you have
• Where you live
• The kind of car you drive
• How the car is used
• Who drives the car
Any premium adjustment is reflected on this Auto Renewal. If you have any questions, please contact your agent.
(continued an next page)
Policy Number:737 4537-F10-75C Page number of 5
Prepared April 17,2026
Aw StateFarm
Buying a new car? Remember to contact your agent!
When you buy an additional car or one that replaces a car already on your policy, you need to report the change to your agent
promptly. Even though the dealership you purchased the car from may offer to notify your agent or insurance company,you, as
the named insured, are responsible for reporting all changes to your auto policy. By contacting your agent, you can help:
• avoid any complications or lack of coverage in the event of an accident or loss,
• avoid insurance verification problems with a lienholder,the police,or the department of motor vehicles, and
• ensure that you receive any new discounts you may be entitled to.
Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited
number of days after you take possession of the car, Please refer to your policy for the number of days that applies in your state.
If you have any questions about coverage for a newly acquired car, please contact your State Farm agent.
Disclaimer: This message is provided for informational purposes only and does not grant any insurance coverage. The terms and
conditions of coverage are set forth in your State Farm Car Policy booklet, the most recently issued Declarations Page, and any
applicable endorsements.
Policy Number:737 4537-F10-75C Page number 5 of 5
Prepared Aprii 17,2026
CITY OF SANTA ANA
Risk Management a division of Human Resources
Managing Risk through Awareness and Actions-:m
AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE
1 Anthony Medina ("Representative"),attest that I am an authorized
(Name and Title of Vendor Representative)
representative of Medina Solutions ("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 TBD
("Agreement")to provide Council aide 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 fully liable for any and all damages.
An trd7z0e®alt CiB �8AL7jT) 'J 6
Signature Date
Anthony Medina
Print Name
Self
Title
Contact Information,i.e.,Telephone Number and/or)=mail 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.
Iffidavit of Exemption for Workers'Compensation Insurance 11.12.2024