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HomeMy WebLinkAboutICMA-RC ADMINISTRATIVE SERVICES AGREEMENTA-2011-258 v 1-_3 )/a_ n?` ADMINISTRATIVE SERVICES AGREEMENT Type: VantageCare RHS Account Number: 803237 Plan number 803237 ADMINISTRATIVE SERVICES AGREEMENT This Agreement, made as of the 28 day of November , 2011 (herein referred to as the "Inception Date"), between The International City Management Association Retirement Corporation ("ICMA-RC"), a nonprofit corporation organized and existing under the laws of the State of Delaware; and the City of Santa Ana ("Employer") a local governmental instrumentality organized and existing under the laws of the State of California with an office at 20 Civic Center Plaza, Santa Ana 92701. RECITALS Employer acts as a public plan sponsor for a retiree health plan with responsibility to obtain investment alternatives and services for employees participating in that plan; Employer desires to make the VantageCare Retirement Health Savings Plan ("RHS Plan" or "Plan") provided by ICMA-RC available to its employees; ICMA-RC makes available the Vantagepoint Funds, a no-load, diversified mutual fund, for investment of public employer plan assets, including RHS Plan assets; ICMA-RC provides a complete offering of services to public employers for the operation of employee retirement and retiree health savings plans including, but not limited to, communications concerning investment alternatives, account maintenance, account record -keeping, investment and tax reporting, form processing, benefit disbursement and asset management. AGREEMENTS 1. Acceptance of RHS Plan Employer agrees to make the RHS Plan provided by ICMA-RC available to its employees. The details of the RHS Plan shall be as mutually agreed between the Employer and ICMA-RC, and in general shall be as set forth in the RHS Plan materials developed by ICMA-RC and provided to Employer. The RHS Plan materials are hereby incorporated by reference and made a part of this Agreement, except that Employer and ICMA-RC may from time to time mutually agree in writing to terms that vary from the RHS Plan materials. RHS plan materials shall include the VantageCare RHS Employer Manual, available electronically through the EZ Link System upon plan adoption. The functions to be performed by ICMA-RC and its agents include: (a) allocation in accordance with participant direction of individual accounts to investment funds ("Funds") made available to Plan participants; (b) maintenance of individual accounts for participants reflecting amounts contributed, Plan number 803237 income, gain, or loss credited, and amounts disbursed as benefits; (c) provision of periodic reports to the Employer and participants of the status of Plan investments and individual accounts; (d) communication to participants of information regarding their rights and elections under the Plan; (e) disbursement of benefits as agent for the Employer in accordance with terms of the Plan; and (f) performance of tax withholding and reporting in conjunction with the Employer for each RHS account. 2. Employer Duty to Furnish Information Employer agrees to furnish to ICMA-RC on a timely basis such information as is necessary for ICMA-RC to carry out its responsibilities with respect to the Plan, including information needed to allocate individual participant accounts to Funds, and information as to the benefit eligibility and employment status of participants, and participant ages, addresses, beneficiaries and other identifying information (including tax identification numbers). ICMA-RC shall be entitled to rely upon the accuracy of any information that is furnished to it by a responsible official of the Employer or any information relating to an individual participant, dependent, or beneficiary that is furnished by such participant, dependent, or beneficiary, and ICMA-RC shall not be responsible for any error arising from its reliance on such information. ICMA-RC will provide account information in reports, statements or accountings. Certain Representations and Warranties ICMA-RC represents and warrants to Employer that: (a) ICMA-RC is a non-profit corporation with full power and authority to enter into this Agreement and to perform its obligations under this Agreement. (b) ICMA-RC is an investment adviser registered as such with the Securities and Exchange Commission under the Investment Advisers Act of 1940, as amended. ICMA-RC Services, LLC (a wholly owned subsidiary of ICMA-RC) is registered as a broker -dealer with the Securities and Exchange Commission (SEC) and is a member in good standing of the National Association of Securities Dealers, Inc. Employer represents and warrants to ICMA-RC that: (c) Employer is organized in the form and manner recited in the opening paragraph of this Agreement with full power and authority to enter into and perform its obligations under this Agreement and to act for the Plan and participants in the Plan number 803237 manner contemplated in this Agreement. Execution, delivery, and performance of this Agreement will not conflict with any law, rule, regulation or contract by which the Employer is bound or to which it is a party. (d) Information required to be retained by the Employer shall be set forth in the RHS plan materials developed by ICMA-RC and provided to the Employer. (e) Employer is responsible for determining that there are no state or local laws that would prohibit it from establishing ICMA-RC's VantageCare RHS program. Employer is also responsible for determining that the investments selected for the RHS plan fall within state/local requirements. (f) Employer acknowledges that the RHS plan may be treated as a "health plan" for Health Insurance Portability and Accountability Act ("HIPAA") purposes and therefore may be subject to HIPAA privacy rules. If it is determined that the RHS plan is considered a "health plan", an employer sponsoring RHS would be responsible for complying with the HIPAA privacy and security rules regarding protected health information of RHS plan participants. ICMA-RC has procedures in place to safeguard the protected health information of RHS plan participants. 4. Participation in Certain Proceedings The Employer hereby authorizes ICMA-RC to act as agent, to appear on its behalf, and to join the Employer as a necessary party in all legal proceedings involving the garnishment of benefits or the transfer of benefits pursuant to a medical child support order. Unless Employer notifies ICMA-RC otherwise, Employer authorizes ICMA-RC to determine whether disbursement of benefits to a spouse or child pursuant to a medical child support order is appropriate. 5. Compensation and Payment (a) Absent an explicit agreement to the contrary between ICMA-RC and Employer, participant fees and expenses shall be payable from RHS assets, in accordance with the requirements of the RHS Plan as set forth below. An annual asset fee of 0.40% (40 basis points) will be charged on a quarterly basis, based on the balance in the account on the last day of the previous quarter. In addition to the annual asset fee, a $25 annual account fee will be charged quarterly to each Accountholder's account. Account administration fees are subject to change with appropriate prior notification. Plan number 803237 (b) Compensation for Advisory and other Services to the Vantagepoint Funds. Employer acknowledges that certain wholly -owned subsidiaries of ICMA-RC receive compensation from the Vantagepoint Funds for advisory and other services furnished to the Vantagepoint Funds. The fees referred to in this subsection are disclosed in the Vantagepoint Funds Prospectus and Statement of Additional Information. Employer acknowledges and agrees that ICMA-RC does not assume any responsibility with respect to the selection or retention of the Plan's investment options. Employer shall have exclusive responsibility for the Plan's investment options, including the selection of the applicable mutual fund share class. 6. Custody Employer understands that amounts contributed to the RHS plan are to be remitted directly to Vantagepoint Transfer Agents in accordance with instructions provided to Employer in the RHS plan materials and are not to be remitted to ICMA-RC. In the event that any check or wire transfer is incorrectly labeled or transferred, ICMA-RC will return it to Employer with proper instructions. 7. Responsibility (a) ICMA-RC shall not be responsible for any acts or omissions of any person other than ICMA-RC in connection with the administration or operation of the Plan. (b) The Employer understands that, as a general matter, the Internal Revenue Service ("IRS") may decline to rule on certain design features or provisions that the Employer may request to have added to the RHS plan materials. The Employer agrees to hold ICMA-RC harmless in connection with the addition and administration of any RHS plan feature or provision requested by the Employer for which the IRS will not provide express interpretive guidance. Indemnification ICMA-RC shall not be responsible for any acts or omissions of any person with respect to the Plan or related Trust, other than ICMA-RC in connection with the administration or operation of the Plan. Employer shall indemnify ICMA-RC against, and hold ICMA- RC harmless from, any and all loss, damage, penalty, liability, cost, and expense, including without limitation, reasonable attorney's fees, that may be incurred by, imposed upon, or asserted against ICMA-RC by reason of any claim, regulatory proceeding, or litigation arising from any act done or omitted to be done by any individual or person with respect to the Plan or related Trust, excepting only any and all loss, damage, penalty, liability, cost or expense resulting from ICMA-RC's negligence, bad faith, or willful misconduct. Plan number 803237 9. Term This Agreement shall be in effect for an initial term beginning on the Inception Date and ending 5 years after the Inception Date. This Agreement will be renewed automatically for each succeeding year unless written notice of termination is provided by either party to the other no less than 60 days before the end of such Agreement year. 10. Amendments and Adjustments (a) This Agreement may not be amended except by written instrument signed by the parties. (b) The parties agree that an adjustment to compensation or administrative and operational services under this Agreement may only be implemented by ICMA- RC through a proposal to the Employer via correspondence or the Employer Bulletin. The Employer will be given at least 60 days to review the proposal before the effective date of the adjustment. Such adjustment shall become effective unless, within the 60 day period before the effective date, the Employer notifies ICMA-RC in writing that it does not accept such adjustment, in which event the parties will negotiate with respect to the adjustment. (c) No failure to exercise and no delay in exercising any right, remedy, power or privilege hereunder shall operate as a waiver of such right, remedy, power or privilege. 11. Notices All notices required to be delivered under Section 10 of this Agreement shall be delivered personally or by registered or certified mail, postage prepaid, return receipt requested, to (i) Legal Department, ICMA Retirement Corporation, 777 North Capitol Street, N.E., Suite 600, Washington, D.C, 20002-4240; (ii) Employer at the office set forth in the first paragraph hereof, or to any other address designated by the party to receive the same by written notice similarly given. 12. Complete Agreement This Agreement shall constitute the sole agreement between ICMA-RC and Employer relating to the object of this Agreement and correctly sets forth the complete rights, duties and obligations of each party to the other as of its date. Any prior agreements, promises, negotiations or representations, verbal or otherwise, not expressly set forth in this Agreement are of no force and effect. 13. Governing Law This agreement shall be governed by and construed in accordance with the laws of the State of California applicable to contracts made in that jurisdiction without reference to Plan number 803237 its conflicts of laws provisions. In Witness Whereof, the parties hereto have executed this Agreement as of the Inception Date first above written. CITY OF SANTA ANA By ( L�@ t' Date z- .c. -t l Signature Paul Walters, City Manager Name and Title (Please Print) INTERNATIONAL CITY/COUNTY MANAGEMENT ASSOCIATION RETIREMENT CORPORATION By Angela C. Montez Assistant Corporate Secretary APPROVED AS TO FORM LISA E. STORCK Assistant City Attorney ATTEST: MARIA D. HUIZAR v CLERK OF THE COUNCIL �' �® CERTIFICATE OF LIABILITY INSURANCE DATE /2011 IYYYY) 12/08/2011 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 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 MARSH USA INC. SUITE 400 1255 23RD STREET, N.W. WASHINGTON, DC 20037 CONTACT NAME: PHONE FAX A/ (A/C. No): E-MAIL — — - ADDRESS` _ INSURER(S) AFFORDING COVERAGE - NAIC # INSURER A: St. Paul Protective Insurance Company 19224 040356-Bond.-EO+FI-11-12 INSURED ICMA RETIREMENT CORP. INSURER B : Federal Insurance Company 20281 — INSURER C : St. Paul Fire & Marine Ins Co 24767 ATTN: BARBARA STOTLER 777 NORTH CAPITOL ST., N.E. WASHINGTON, DC 20002 INSURER D : Standard Fire Insurance Company 19070 INSURER E : Great American Insurance Co. — 16691 INSURER F : COVERAGES CERTIFICATE NUMBER: CLE-003743124-01 REVISION NUMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY FS06805895 08/01/2011 08/01/2012 EACH OCCURRENCE $ 1,000,000 MMERCIAL GENERAL LIABILITY -MADE M OCCUR t DAMAGE TO RENTED PREMISES Eaoccurrnce 1,000,000 $CLAIMS MED EXP (Any one person) $ 10,000 TRACTUAL COV. INCL. PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2.000,000 -4 D A$ `� GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO-jECT LOC y J��� _ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS _ AUTOS i r gT 1`CCA G� �IJ CA) ^1/(Ea RCK {�°rC18�i COMBINED SINGLE LIMIT accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) —-------- - $ NON -OWNED HIRED AUTOS AUTOS Assista nt z, DAMAGE Per accident $ 11 _ _ -- --- _ ,PROPERTY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ - AGGREGATE ----------_._.--- EXCESS LIAB _ i_ CLAIMS -MADE DED RETENTION $ $ D WORKERS COMPENSATION UB-6508M89-4-11 08/01/2011 08/01/2012 X WC STATu- OTH- ANDEMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below !N/A E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE _ _ --. $ 1,000,000 E.L. DISEASE - POLICY LIMIT ----------- $ 1,000,000 B BANKERS PROF. LIAB. 8211-6261 04/19/2011 04/19/2012 LIMIT 17,500,000 C BANKERS PROF. LIAB. EC09004016 04/19/2011 04/19/2012 SIR 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CITY OF SANTA ANA ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS 20 CIVIC CENTER PLAZA M-34 SANTAANA, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Timothy M. Sasser U 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ACORO® AGENCY MARSH USA INC. POLICY NUMBER CARRIER AGENCY CUSTOMER ID: 040356 LOC #: Washington ADDITIONAL REMARKS SCHEDULE NAMED INSURED ICMA RETIREMENT CORP. ATTN: BARBARA STOTLER 777 NORTH CAPITOL ST., N.E. WASHINGTON, DC 20002 NAIC CODE EFFECTIVE DATE: ITHIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Other Policy Covers FIDELITY BOND/CRIME Policy Details Insr Ltr: E (Great American Insurance Co.) Policy Number: FS 234-63-54-02 EH. Dt. 04/19/2011 Exp. Dt. 04/19/2012 Limits LIMIT: 25,000,000 DEDUCTIBLE: 250,000 AC(1Rn ina r,3nnain-ii Page 2 of 2 - - • kV zuUd ACVKU CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ICM/RC Building Retirement Security PRIVATE LETTER RULING ON INTEGRAL PART TRUST Internal Revenue Service Index Number: 115.02-00 City = Trust = State = Dear Department of the Treasury Washington, DC 20224 Contact Person: Telephone Number: In Reference to: CC:DOM:FI&P:2 PLR-116685-99 Date: December 28, 1999 This is in response to a letter dated October 12, 1999, and prior correspondence, requesting a private letter ruling that Trust is an integral part of City. FACTS City is a political subdivision of State. City currently maintains one or more post -retirement welfare benefit plans (collectively, the "Plan") that provide its eligible employees ("Participants") and their beneficiaries ("Beneficiaries") with life, sickness, medical, disability, severance and other similar benefits through insurance and self -funded reimbursement plans. City intends to establish Trust to hold assets and income of the Plan for the exclusive benefit of Participants and their Beneficiaries. Trust's Declaration defines "Beneficiaries" tc include a Participant's spouse, any child of the Participant or the Participant's spouse who iS a m1nOr Or a StllClent Within `he meaning of section. 151(c)(4) of the Internal Revenue Code, anv other minor child residing with the Participant, and any other individual who is a person described in section 152(a) of the Code. Death benefits may be provided to anv Beneficiar;r designated by a Participant under the terms of a death benefit program or an insurance contact form na part or `�� D -_•_ct 03/2000 10 PLR-116685-99 2 may provide benefits by cash payment, and may reimburse a Participant, City, or Trust's Administrator for insurance premiums or other payments expended for permissible benefits under the Plan. Under Trust's Declaration, City will be the Administrator of Trust. City may appoint one or more investment managers to manage and control all or part of the assets of Trust. Under Trust's Declaration, the Trustee will hold assets only as titleholder. Persons having custody or possession of assets may include City, the Administrator of Trust, the investment manager, and their agents and subagents, but not the Trustee. The Trustee will have no discretion or authority with regard to the investments of Trust and will act solely as a directed Trustee with respect to the assets to which it holds title. The Trustee will not be responsible or liable for any loss or expense that may arise or result from complying with any direction from the City, the Administrator, the investment manager, or such agents to take title to any assets, or from the Trustee's refusal or failure to comply with any direction to hold title, unless it involves or results from the Trustee's negligence or intentional misconduct. The Trustee may refuse to comply with any direction if it deems such direction illegal. City indemnifies and holds the Trustee harmless from any actions, claims, demands, liabilities, losses, damages or reasonable expenses of any kind in connection with or arising out of (i) any action taken or omitted in good faith in accordance with its directions, (ii) any disbursements made in accordance with directions, or (iii) any action taken by or omitted by the Trustee with respect to an investment managed by an investment manager in accordance with any direction of the investment manager or any inaction regarding any investment in the absence of directions from the investment manager. City, however, has no responsibility to the Trustee under the indemnification if the Trustee fails negligently, intentionally, or reckless to perform its duties. City will contribute to Trust such amounts as specified in the Plan or by resolution. No other person or persons will be Permitted to make any contributions. The Plan must provide a formula for determining the value of a Participant's accrued vacation leave, sick leave, or both, in excess of a threshold number of hours of such leave. City :may contribute amounts so determined to Trust. The Plan will contain a forfeiture provision that will prevent Participants and their Beneficiaries from receiving cash in lieu of a contributicn to Trust in their behalf. Contributions, investment income, realized and unrealized gains and losses, and forfeit::r_s �e deposited into an account in Trust In the lame of the Pa pant 03/2000 m z PLR-116685-99 3 for the exclusive benefit of the Participant and his or her Beneficiaries. A Participant may direct the investment of amounts in her or his account among investments selected by City. No amount in any account will be subject to transfer, assignment, or alienation, whether voluntary or involuntary, in favor of any creditor, transferee, or assignee of City, the Trustee, Participant or Beneficiary. City or the Administrator, investment manager, or other agent designated by City will receive contributions and will hold, invest, and administer contributions without distinction between principal and income. The Trustee will not be responsible for the calculation or collection of contributions, but will hold title to property received as directed by City or its designee. The Trustee will not be required to keep accounts of the investments, receipts, disbursements, and other transaction of Trust except as necessary to perform its title - holding function. City or its designee will maintain all books and records. City reserves the right to alter, amend, or terminate Trust at any time for any reason without the consent of any person. No amendment affecting the Trustee is effective without the Trustee's consent, and no termination can result in any part of Trust's assets being used for or diverted to purposes other than the exclusive benefit of Participants and Beneficiaries. If City adopts other plans providing life, sickness, accident, medical, disability,. severance, or other benefits and designates Trust as part of such plan, City or its agent will hold contributions to such plan in Trust. The contributions may be commingled for investment purposes, but the books and record of Trust must show the portion of Trust allocable to each plan. Upon the satisfaction of all liabilities under the Plan to provide benefits, any amounts remaining in any account must be returned to City. LAW & ANALYSIS Income of an integral part of a state or political subdivision of a state is not taxable absent specific statutcry authorization. See Rev. Rul. 87-2, 1987-3, C.B. 18; section 511 (a) (2) (B) of the Code, GCM 14407, C.B. XIv-1, 103 (1935) , superseded by Rev. Rul. 71-131, 1971-1 C.B. 28. Whether an enterprise is an integral part depends on facts and circumstances such as the state's degree of control over the enterprise and its financial commitment to the enterprise. If an enterprisc is an integral part of a state or political subdivision of a state, it will not be treated as a separate entity for federal tax purposes, though it may have been formed as a separate enti`-.- 03/2000 12 11 03/2000 PLR-116685-99 4 under state law. Section 301.7701-1 (a) (3) of the Procedural and Administrative Regulations. City has made a substantial financial commitment to Trust by providing all of its funding. City retains complete control over Trust because it may amend or terminate Trust at any time. City retains control over the daily operation of Trust by its power to appoint or remove agents who manage daily operation. The Trustee is merely a title holder with no power to manage Trust. CONCLUSION Provided that City is the only person that makes contributions to Trust, and Trust accepts or holds only amounts of money contributed by City, Trust will be an integral part of City, and any income earned on amounts in Trust will not be subject to federal income tax. This ruling is directed only to the. taxpayer that requested it. Section 6110(k)(3) of the Code provides that it may not be used or cited as precedent. Except as specifically provided otherwise, no opinion is expressed on the federal income tax consequences of the transaction described above. In accordance with the terms of a power of attorney on file in this office, a copy of th' letter is being sent to your authorized representative. Sincerely, Assistant Chief Counsel (Financial Institutions & Products) By: William Coppersmith William E. Coppersmith Chief, Branch 2 13 iCnMARC Building Retirement Security City of Santa Ana, CA NAME OF EMPLOYER RETIREE WELFARE BENEFITS PLAN RETIREE WELFARE BENEFITS PLAN ICM ^RC Table of Contents Building Retirement Security Article 1 Preamble 1.01 Establishment of Plan 1.02 Purpose of Plan Article 11 Definitions 2.01 "Benefits" 2.02 "Code" 2.03 "Dependent" 2.04 "Eligible Medical or Dental Expenses" 2.05 "Employer" 2.06 "Entry Date" 2.07 "Participant" 2.08 "Plan Administrator" 2.09 "Plan Year" 2.10 "Retiree" 2.11 "Spouse" Article III Eligibility 3.01 General Requirements Article IV Amount of Benefits 4.01 Annual Benefits Provided by the Plan 4.02 Cost of Coverage Article V Payment of Benefits 5.01 Eligibility for Benefits 5.02 Claims for Benefits Article VI Plan Administration 6.01 Allocation of Authority 6.02 Provision for Third -Party Plan Service Providers 6.03 Several Fiduciary Liability 6.04 Compensation of Plan Administrator 6.05 Bonding 6.06 Payment of Administrative Expenses 6.07 Timeliness of Payments 6.08 Annual Statements Table of Contents (continued) Article VII Claims Procedure 7.01 Procedure if Benefits are Denied Under the Plan 7.02 Requirement for Written Notice of Claim Denial 7.03 Right to Request Hearing on Benefit Denial 7.04 Disposition of Disputed Claims 7.05 Preservation of Other Remedies Article Vlll Amendment or Termination of Plan 8.01 Permanency 8.02 Employer's Right to Amend 8.03 Employer's Right to Terminate Article IX General Provisions 9.01 No Employment Rights Conferred 9.02 Payments to Survivor 9.03 Nonalienation of Benefits 9.04 Mental or Physical Incompetency 9.05 Inability to Locate Payee 9.06 Requirement of Proper Forms 9.07 Source of Payments 9.08 "tax Effects 9.09 Multiple Functions 9.10 Gender and Number 9.11 Headings 9.12 Applicable Laws 9.13 Severability Name of Employer RETIREE WELFARE BENEFITS PLAN ARTICLE I Preamble THIS INSTRUMENT made and published by City of Santa Ana (hereinafter called "Employer") on the 28 day of November 20 11 creates the City of Santa Ana Retiree Welfare Benefits Plan, as follows: 1.01 Establishment of Plan The Employer named above hereby establishes a Retiree Welfare Benefits Plan as of the 28 day of November , 20 11 1.02 Purpose of Plan This Plan has been established to reimburse the eligible Retirees of the Employer for medical and dental expenses incurred by them, their Spouses and Dependents pursuant to the Employer's VantageCare Retirement Health Savings (RHS) Plan. ARTICLE II Definitions The following words and phrases as used herein shall have the following meanings, unless a different meaning is plainly required by the context: 2.01 'Benefits" means any amounts paid to a Participant, Spouse or Dependents in the Plan as reimbursement for Eligible Medical and Dental Expenses incurred by the Participant during a Plan Year by him, his Spouse or his Dependents. 2.02 "Code" means the Internal Revenue Code of 1986, as amended. 2.03 "Dependent" means any individual who is a dependent of the Participant within the meaning of Code Sec. 152, as arriplified by Internal Revenue Service Notice 2004-79, 2004-49 I.R.B.898.. 2.04 "Eligible Medical Expenses" means those expenses designated by the Employer as eligible for reimbursement in the VantageCare Retirement Health Savings Plan Adoption Agreement. 2.05 "Employer" means the unit of state or local government creating this Plan, or any affiliate or successor thereof that likewise adopts this Plan. 2.06 "Entry Date" means the first day the Participant meets the eligibility requirements ofArticle III as of such Date. 2.07 "Participant" means any Retiree who has met the eligibility requirements set forth in Article III. 2.08 "Plan Administrator" means the Employer or other person appointed by the Employer who has the authority and responsibility to manage and direct the operation and administration of the Plan. 2.09 "Plan Year" means the annual accounting period of the Plan, which begins on the 28 day of November , 20 11 , and ends on Elie 31 day of December 20 11 , with respect to the first Plan Year, and thereafter as long as this Plan remains in effect, the period that begins on January 1 and ends on month/day December 31 , �x a .. P s 2.10 "Retiree" means any individual who, while in the service of the Employer, was considered to be in a legal employer - employee relationship with the Employer for federal withholding tax purposes, and who was part of the classification of employees designated as covered by the Employer's VantageCare Retirement Health Savings Plan. 2.11 "Spouse" means the Participant's lawful spouse as determined under the laws of the state in which the Participant has his primary place of residence. All other defined terms in this Plan shall have the meanings specified in the various Articles of the Plan in which they appear. ARTICLE III Eligibility Each Retiree who meets the eligibility requirements outlined in the Employer's VantageCare Retirement Health Savings Plan shall be eligible to participate in this Plan. ARTICLE IV Amount of Benefits 4.01 Annual Benefits Provided by the Plan Each Participant shall be entitled to reimbursement for his documented, Eligible Medical Expenses incurred during the Plan Year in an annual amount not to exceed the account balance of the Participant in the Employer's VantageCare Retirement Health Savings Plan. 4.02 Cost of Coverage The expense of providing the benefits set out in Section 4.01 shall be contributed as outlined in the Employer's VantageCare Retirement Health Savings Plan. ARTICLE V Payment of Benefits 5.01 Eligibility for Benefits a) Each Participant in the Plan shall be entitled to a benefit hereunder for all Eligible Medical Expenses incurred by the Participant on or after the Entry Date of his or her participation (and after the effective date of the Plan), subject to the limitations contained in this Article V, regardless whether the mental or physical condition for which the Participant makes application for benefits under this Plan was detected, diagnosed, or treated before the Participant became covered by the Plan. b) In order to be eligible for benefits, the Participant must meet the benefit eligibility criteria outlined in the Employer's VantageCare Retirement Health Savings Plan Adoption Agreement. c) A Participant who becomes totally and permanently disabled (as defined by the Social Security Administration) will become immediately eligible to receive medical benefit payments from the Plan. Pursuant to Section 9.02 and Employer's VantageCare Retirement Health Savings Plan Adoption Agreement, the surviving Spouse and Dependents shall become immediately eligible to receive or to continue receiving medical benefit payments from the Plan upon the death of the Participant. r 5.02 Claims for Benefits No benefit shall be paid hereunder unless a Participant, his Spouse or Dependent has first submitted a written claim for benefits to the Plan Administrator on a form specified by the Plan Administrator, and pursuant to the procedures set out in Article VI, below. Upon receipt of a properly documented claim, the Plan Administrator shall pay the Participant, his Spouse or Dependent the benefits provided under this Plan as soon as is administratively feasible. ARTICLE VI Plan Administration 6.01 Allocation of Authority The Employer shall control and manage the operation and Administration of the Plan. The Employer shall have the exclusive right to interpret the Plan and to decide all matters arising thereunder, including the right to remedy possible ambiguities, inconsistencies, or omissions. All determinations of the Employer with respect to any matter hereunder shall be conclusive and binding on all persons. Without limiting the generality of the foregoing, the Employer shall have the following powers and duties: a) To decide on questions concerning the Plan and the eligibility of any Employee to participate in the Plan, in accordance with the provisions of the Plan; b) To determine the amount of benefits that shall be payable to any person in accordance with the provisions of the Plan; to inform the Plan Administrator, as appropriate, of the amount of such Benefits; and to provide a full and fair review to any Participant whose claim for benefits has been denied in whole or in part; and c) To designate other persons to carry out any duty or power which would otherwise be a fiduciary responsibility of the Plan Administrator, under the terms of the Plan. d) To require any person to furnish such reasonable information as it may request for the purpose of the proper administration of the Plan as a condition to receiving any benefits under the Plan; e) To make and enforce such rules and regulations and prescribe the use of such forms as he shall deem necessary for the efficient administration of the Plan. 6.02 Provision for Third -Party Plan Service Providers The Plan Administrator, subject to approval of the Employer, may employ the services of such persons as it may deem necessary or desirable in connection with operation of the Plan. The Plan Administrator, the Employer (and any person to whom it may delegate any duty or power in connection with the administration of the Plan), and all persons connected therewith may rely upon all tables, valuations, certificates, reports and opinions furnished by any duly appointed actuary, accountant, (including Employees who are actuaries or accountants), consultant, third party administration service provider, legal counsel, or other specialist, and they shall be fully protected in respect to any action taken or permitted in good faith in reliance thereon. All actions so taken or permitted shall be conclusive and binding as to all persons. 6.03 Several Fiduciary Liability To the extent permitted by law, neither the Plan Administrator nor any other person shall incur any liability for any acts or for failure to act except for his own willful misconduct or willful breach of this Plan. 6.04 Compensation of Plan Administrator Unless otherwise agreed to by the Employer, the Plan Administrator shall serve without compensation for services rendered in such capacity, but all reasonable expenses incurred in the performance of his duties shall be paid by the Employer. 6.05 Bonding Unless otherwise determined by the Employer, or unless required by any Federal or State law, the Plan Administrator shall not be required to give any bond or other security in any jurisdiction in connection with the administration of this Plan. 6.06 Payment of Administrative Expenses All reasonable expenses incurred in administering the Plan, including but not limited to administrative fees and expenses owing to any third party administrative service provider, actuary, consultant, accountant, attorney, specialist, or other person or organization that may be employed by the Plan Administrator in connection with the administration thereof, shall be paid by the Employer, provided, however that each Participant shall bear the monthly cost (if any) charged by a third party administrator for maintenance of his Benefit Account unless otherwise paid by the Employer. 6.07 Timeliness of Payment for Benefits Payment for Benefits shall be made as soon as administratively feasible after the required forms and documentation have been received by the Plan Administrator. 6.08 Annual Statements The Plan Administrator shall furnish each Participant with an annual statement of his medical expense reimbursement account within ninety (90) days after the close of each Plan Year. ARTICLE VII Claims Procedure 7.01 Procedure if Benefits are Denied Under the Plan Any Participant, Spouse, Dependent, or his duly authorized representative may file a claim for a plan benefit to which the claimant believes that he is entitled. Such a claim must be in writing on a form provided by the Plan Administrator and delivered to the Plan Administrator, in person or by mail, postage paid. Within thirty (30) days after receipt of such claim, the Plan Administrator shall send to the claimant, by mail, postage prepaid, notice of the granting or denying, in whole or in part, of such claim, unless special circumstances require an extension of time for processing the claim. In no event may the extension exceed forty-five (45) days from the end of the initial period. If such extension is necessary, the claimant will be given a written notice to this effect prior- to the expiration of the initial 30-day period. If such extension is necessary due to a failure of the Participant, Spouse or Dependent to submit the information necessary to decide the claim, the notice of extension shall describe the required information and the claimant shall be afforded at least forty-five (45) days from receipt of the notice within which to provide such information. The Plan Administrator shall have full discretion to deny or grant a claim in whole or in part. If notice of the denial of a claim is not furnished in accordance with this Section, the claim shall be deemed denied and the claimant shall be permitted to exercise his right to review pursuant to Sections 7.03 and 7.04. 7.02 Requirement for Written Notice of Claim Denial The Plan Administrator shall provide, to every claimant who is denied a claim for benefits, written notice setting forth in a manner calculated to be understood by the claimant: a) The specific reason or reasons for the denial; b) Specific reference to pertinent Plan provisions on which the denial is based; c) A description of any additional material of information necessary for the claimant to perfect the claim and an explanation of why such material is necessary, and d) An explanation of the Plan's claim review procedure. 7.03 Right to Request Hearing on Benefit Denial Within one -hundred eighty (180) days after the receipt by the claimant of written notification of the denial (in whole or in part) of his claim, the claimant or his duly authorized representative, upon written application to the Plan Administrator, in person or by certified mail, postage prepaid, may request a review of such denial, may review pertinent documents, and may submit issues and comments in writing. 7.04 Disposition of Disputed Claims Upon its receipt of notice of a request for review, the Plan Administrator shall make a prompt decision on the review. The decision on review shall be written in a manner calculated to be understood by the claimant and shall include specific reasons for the decision and specific references to the pertinent plan provisions on which the decision is based. The decision on review shall be made not later than sixty (60) days after the Plan Administrator's receipt of a request for a review, unless special circumstances require an extension of time for processing, in which case a decision shall be rendered not later than one hundred -twenty (120) days after receipt of a request for review. If an extension is necessary, the claimant shall be given written notice of the extension prior to the expiration of the initial sixty (60) day period. If notice of the decision on the review is not furnished in accordance with this Section, the claim shall be deemed denied and the claimant shall be permitted to exercise his right to legal remedy pursuant to Section 7.05. 7.05 Preservation of Other Remedies After exhaustion of the claims procedures provided under this Plan, nothing shall prevent any person from pursuing any other legal or equitable remedy otherwise available. ARTICLE VIII Amendment or Termination of Plan 8.01 Permanency While the Employer fully expects that this Plan will continue indefinitely, due to unforeseen, future business contingencies, permanency of the Plan will be subject to the Employer's right to amend or terminate the Plan, as provided in Sections 8.02 and 8.03, below. - r� 8.02 Employer's Right to Amend The Employer reserves the right to amend the Plan at any time and from time -to -time, and retroactively if deemed necessary or appropriate to meet the requirements of the Code, or any similar provisions of subsequent revenue or other laws, or the rules and regulations in effect under any of such laws or to conform with governmental regulations or other policies, to modify or amend in whole or in part any or all of the provisions of the Plan. 8.03 Employer's Right to Terminate The Employer reserves the right to discontinue or terminate the Plan at any time without prejudice. ARTICLE IX General Provisions 9.01 No Employment Rights Conferred Neither this Plan nor any action taken with respect to it shall confer upon any person the right to be continued in the employment of the Employer. 9.02 Payments After Death of Participant Any benefits otherwise payable to a Participant following the date of death of such Participant shall be paid as outlined in the Employer's VantageCare Retirement Health Savings Plan Adoption Agreement. 9.03 Nonalienation of Benefits No benefit under the Plan shall be subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance or charge, and any attempt to do so shall be void. No benefit under the Plan shall in any manner be liable for or subject to the debts, contracts, liabilities, engagements or torts of any person. If any person entitled to benefits under the Plan becomes bankrupt or attempts to anticipate, alienate, sell, transfer, assign, pledge, encumber or charge any benefit under the Plan, or if any attempt is made to subject any such benefit to the debts, contracts, liabilities, engagements or torts of the person entitled to any such benefit, except as specifically provided in the Plan, then such benefit shall cease and terminate in the discretion of the Plan Administrator, and lie may hold or apply the same or any part thereof to the benefit of any dependent of such person, in such manner and proportion as he may deem proper. 9.04 Mental or Physical Incompetency If the Plan Administrator determines that any person entitled to payments under the Plan is incompetent by reason of physical or mental disability, he may cause all payments thereafter becoming due to such person to be made to any other person for his benefit, without responsibility to follow the application of amounts so paid. Payments made pursuant to this Section shall completely discharge the Plan Administrator and the Employer. 9.05 Inability to Locate Payee If the Plan Administrator is unable to make payment to any Participant or other person to whom a payment is due under the Plan because he cannot ascertain the identity or whereabouts of such Participant or other person after reasonable efforts have been made to identify or locate such person (including a notice of the payment so due mailed to the last known address of such Participant or other person as shown on the records of the Employer), such payment and all subsequent payments otherwise due to such Participant or other person shall be escheated under the laws of the State of the last known address of the Participant or other persons eligible for benefits. 9.06 Requirement of Proper Forms All communications in connection with the Plan made by a Participant shall become effective only when duly executed on forms provided by and filed with the Plan Administrator. 9.07 Source of Payments The Employer shall be the sole source of benefits under the Plan. No Employee, Spouse or Dependents shall have any right to, or interest in, any assets of the Employer upon termination of employment or otherwise, except as provided from time to time tinder the Plan, and then only to the extent of the benefits payable under the Plan to such Employee, Spouse or Dependents. 9.08 Tax Effects Neither the Employer nor the Plan Administrator makes any warranty or other representation as to whether any payments received by a Participant, his Spouse or Dependents hereunder will be treated as includible in gross income for federal or state income tax purposes. 9.09 Multiple Functions Any person or group of persons may serve in more than one fiduciary capacity with respect to the Plan 9.10 Gender and Number Masculine pronouns include the feminine as well as the neuter gender, and the singular shall include the plural, unless indicated otherwise by the context. 9.11 Headings The Article and Section headings contained herein are for convenience of reference only, and shall not be construed as defining or limiting the matter contained thereunder. 9.12 Applicable Laws The provisions of the Plan shall be construed, administered and enforced according to the laws of the State of California 9.13 Severability Should any part of this Plan subsequently be invalidated by a court of competent jurisdiction, the remainder thereof shall be given effect to the maximum extent possible. IN WITNESS WHEREOF, we have executed this Plan Agreement the date and year first written above. EMPLOYER By - ���� �A� Title: Signature of Authorized Official ATTEST (if applicable) By: Signature of Attestor Title: Finance Director icmARC Building Retimpimi Serurity EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT Plan Number: 8 03237 Employer Retirement Health Savings Plan Name: I. Employer Name: City of Santa Ana Check one: ® New Plan ❑ Amendment to Existing Plan State: CA II. The Employer hereby attests that it is a unit of a state or local government or an agency or instrumentality of one or more units of a state or local government. III. Effective Date of the Plan: 11/28/11 IV. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plan(s) established by the Employer: City of Santa Ana Retiree Welfare Benefits Plan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employees are eligible to participate in the VantageCare Retirement Health Savings Plan (check all applicable boxes): ❑ All Employees ❑ All Full -Time Employees ❑ Non -Union Employees ❑ Public Safety Employees — Police ❑ Public Safety Employees — Firefighters ❑ General Employees ® Collectively -Bargained Employees (Specify unit(s)) Police Management Association (PMA) ❑ Other (specify group(s)) The Employee group(s) specified must correspond to a group(s) of the same designation that is defined in the statutes, ordinances, rules, regulations, personnel manuals or other documents or provisions in effect in the state or locality of the Employer. B. Participation Mandatory Participation: All Employees in the covered group(s) are required to participate in the Plan and shall receive contributions pursuant to Section Vl. If the Employer's underlying welfare benefit plan or funding under this VantageCare Retirement Health Savings Plan is in whole or part a non -collectively bargained, self -insured plan, the nondiscrimination requirements of Internal Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxation on the benefits received by highly compensated individuals if the Plan discriminates in favor of highly compensated individuals in terms of eligibility or benefits. The Employer should discuss these rules with appropriate counsel. C. Participant Eligibility Requirements 1. Minimum service: The minimum period of service required for participation is N/A (write N/A if no minimum service is required). 2. Minimum age: The minimum age required for eligibility to participate is NIA (write N/A if no minimum age is required). VI. Contribution Sources and Amounts A. Definition of Earnings The definition of Earnings will apply to all RHS Contribution Features that reference "Earnings", including Direct Employer Contributions (Section VI.B.1.) and Mandatory Employee Compensation Contributions (Section VI.B.2.). Definition of earnings: As defined by the MOU B. Direct Employer Contributions and Mandatory Contributions 1. Direct Employer Contributions The Employer shall contribute on behalf of each Participant ❑ % of Earnings ❑ $ each Plan Year ❑ A discretionary amount to be determined each Plan Year 0 Other (describe): 1. a percent of earnings as defined by the MOU and 2. a one time contribution as a conversion from the existing PMA Medical Retirement Subsidy Plan 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: ® Reduction in Salary - see#1 above % of Earnings or $ will be contributed for the Plan Year. ❑ Decreased Merit or Pay Plan Adjustment - All or a portion of the Employees' annual merit or pay plan adjustment will be contributed as follows: An Employee shall not have the right to discontinue or vary the rate of Mandatory Contributions of Employee Compensation. 3. Mandatory Employee Leave Contributions The Employer will make mandatory contributions of accrued leave as follows (provide formula for determining Mandatory Employee Leave contributions): m Accrued Sick Leave Employees hired prior to 1990 who separate from service on or after July 1, 2011 100% of sick leave cash out ® Accrued Vacation Leave Employees hired prior to 1990 who separate from service on or after July 1, 2011, 100% of vacation leave payout ❑ Other (specify type of leave) Accrued Leave Employees hired prior to 1990 who separate from service on or after July 1, 2011, 100% of management leave payout and 100% of holiday leave payout. Ail Employee shall not have the right to discontinue or vary the rate of mandatory leave contributions. C. Limits on Total Contributions (check one box) The total contribution by the Employer on behalf of each Participant (including Direct Employer and Mandatory Employee Contributions) for each Plan Year shall not exceed the following limit(s) below. Limits on individual contribution types are defined within the appropriate section above. t W1 There is no Plan -defined limit on the percentage or dollar amount of earnings that may be contributed. ❑ % of earnings* *Definition of earnings: ❑ Same as Section VI.A.. ❑ Other ❑ $ for the Plan year. See Section V.B. for a discussion of nondiscrimination rules that may apply to non -collectively bargained self -insured Plans. VII. Vesting for Direct Employer Contributions A. Vesting Schedule (check one box) Q The account is 100% vested at all times. ❑ The following vesting schedule shall apply to Direct Employer Contributions as outlined in Section VI.B.I.: Years of Service Vesting Completed Percentage B. The account will become 100% vested upon the death, disability, retirement*, or attainment of benefit eligibility (as outlined in Section IX) by a Participant. *Definition of retirement (check one box): ❑ Retirement as defined in the primary retirement plan of the Employer ❑ Separation from service ❑ Other C. Any period of service by a Participant prior to a rehire of the Participant by the Employer shall not count toward the vesting schedule outlined in A above. VIII. Forfeiture Provisions Upon separation from the service of the Employer prior to attainment of benefit eligibility (as outlined in Section IX), or upon reversion to the Trust of a Participant's account assets remaining upon the participant's death (as outlined in Section XI), a Participant's non -vested funds shall (check one box): ❑ Remain in the Trust to be reallocated among all remaining Employees participating in the Plan as Direct Employer Contributions for the next and succeeding contribution cycle(s). Q Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants. ❑ Remain in the Trust to be reallocated among all Plan Participants based upon Participant account balances. ❑ Revert to the Employer. � ,, IX. Eligibility Requirements to Receive Medical Benefit Payments from the VantageCare Retirement Health Savings Plan A. A Participant is eligible to receive benefits: ❑ At retirement only (also complete Section B.) Definition of retirement: ❑ Same as Section VII.B. ❑ Other m At separation from service with the following restrictions m No restrictions ❑ Other ❑ At age only ❑ At retirement and age (also complete section B) Definition of retirement: ❑ Same as Section VII.B. ❑ Other ❑ At retirement or age Definition of retirement: ❑ Same as Section VII.B. ❑ Other ❑ Other, specified as follows (also complete Section B if applicable): B. Termination prior to general benefit eligibility: In the case where the general benefit eligibility as outlined in Section IX.A includes a retirement component, a Participant who separates from the service of the Employer prior to retirement will be eligible to receive benefits: 0 Immediately upon separation from service. ❑ At age C. A Participant that becomes totally and permanently disabled ❑ as defined by the Social Security Administration ® as defined by the Employer's primary retirement plan ❑ other will become immediately eligible to receive medical benefit payments from his/her VantageCare Retirement Health Savings Plan account. D. Upon the death of the Participant, benefits shall become payable as outlined in Section XI. 5+f k 1 1 u a� X. Permissible Medical Benefit Payments Benefits eligible for reimbursement consist of: Q All Medical Expenses eligible under IRC Section 213* other than direct long-term care expenses, and including non-prescription medications allowed under IRS guidance. ❑ The following Medical Expenses (select only the expenses you wish to cover under the VantageCare Retirement Health Savings Plan): ❑ Medical Insurance Premiums ❑ Medical Out -of -Pocket Expenses* ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums ❑ Medicare Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out -of -Pocket Expenses* ❑ Vision Insurance Premiums ❑ Vision Out -of -Pocket Expenses* ❑ Qualified Long -Term Care Insurance Premiums ❑ Non -Prescription medications allowed under IRS guidance* ❑ Other qualifying medical expenses (describe)* * See Section V.A. for a discussion of nondiscrimination rules which may apply to non -collectively bargained, self -insured Plans. XI. Benefits After the Death of the Participant In the event of a Participant's death, the following shall apply: A. Surviving Spouse and/or Surviving Dependents The surviving spouse and/or surviving eligible dependents (as defined in Section XII.D.) of the deceased Participant are immediately eligible to maintain the account and utilize it to fund eligible medical benefits specified in Section X above. Upon notification of a Participant's death, the Participant's account balance will be transferred into the Vantagepoint Money Market Fund* (or another fund selected by the Employer). The account balance may be reallocated by the surviving spouse or dependents. * Please read the current Vantagepoint Mittual Funds prospectus carefzdly prior to investing. An investment in this fitnd is neither insured nor guaranteed and there can be no assurance that the Fund will be able to maintain a stable net asset value of$1.00 per share. Vantagepoint Mutual Funds are distributed by ICMA-RC Services, LLC, a wholly -owned broker -dealer affiliate of ICMA Retirement Corporation. Member FINRAISIPC. If a Participant's account balance has not been fully utilized upon the death of the eligible spouse, the account balance may continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible dependents, the account will revert to the Plan to be applied as specified in Section VIII. B. No Surviving Spouse or Surviving Dependents If there are no living spouse or dependents at the time of death of the Participant, the account will revert to the Plan to be applied as specified in Section VIII. XII. The Plan will operate according to the following provisions: A. Employer Responsibilities 1. The Employer will submit all VantageCare Retirement Health Savings Plan contribution data via electronic submission. 2. The Employer will submit all VantageCare Retirement Health Savings Plan Participant status updates or personal information updates via electronic submission. This includes but is not limited to termination notification and benefit eligibility notification. B. Participant account administration and asset -based fees will be paid through the redemption of Participant account shares, unless agreed upon otherwise in the Administrative Services Agreement. C. Assignment of benefits is not permitted. Benefits will be paid only to the Participant, his/her Survivors, the Employer, or an insurance provider (as allowed by the claims administrator). Payments to an third -party payee (e.g., medical service provider) are not permitted with the exception of reimbursement to the Employer or insurance provider (as allowed by the claims administrator). D. An eligible dependent is the Participant's lawful spouse and any other individual who is a person described in IRC Section 152(a), as clarified by Internal Revenue Service Notice 2004-79. E. The Employer will be responsible for withholding, reporting and remitting any applicable taxes for payments which are deemed to be discriminatory under IRC Section 105(h), as outlined in the VantageCare Retirement Health Savings Plan Employer Manual. XIII. Employer Acknowledgements A. The Employer hereby acknowledges it understands that failure to properly fill out this Employer VantageCare Retirement Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the Trust and/or loss of tax -deferred status for Employer contributions. B. ❑ Check this box if you are including supporting documents that include plan provisions. EMPLOY- R SS GaNATURE 3y >: Date: (6 ` Title: City Manager F Attest: a/v R-. 4) ( / l�/ Date: Title: L (E t iL of `i l\-E C." .10 C.. P Accepted: VANTAGEP OINI' TRANSFER AGENTS, LLC Assistant Secretary, ICMA-RC n icmARC Building Retirement Security DECLARATION OF TRUST OF THE City of Santa Ana, CA NAME OF EMPLOYER INTEGRAL PART TRUST i Declaration of Trust made as of the 28 the City of Santa Ana DECLARATION OF TRUST OF THE NAME OF EMPLOYER INTEGRAL PART TRUST day of November CA a 20 11 City , by and between (Name of Employer) (State) (Type of Entity) (hereinafter referred to as the "Employer")and City of Santa Ana or its designee (hereinafter referred to as the "Trustee"). (Name or Title of Trustee) RECITALS WHEREAS, the Employer is a political subdivision of the State of CA federal income tax under the Internal Revenue Code of 1986; and (State) exempt from WHEREAS, the Employer provides for the security and welfare of its eligible employees (hereinafter referred to as "Participants"), their Spouses and Dependents by the maintenance of one or more post -retirement welfare benefit plans, programs or arrangements which provide for Iife, sickness, medical, disability, severance and other similar benefits through insurance and self -funded reimbursement plans (collectively the "Plan"); and WHEREAS, it is an essential function and integral part of the exempt activities of the Employer to assist Participants, their Spouses and Dependents by making contributions to and accumulating assets in the trust, a segregated fund, for post - retirement welfare benefits under the Plan; and WHEREAS, the authority to conduct the general operation and administration of the Plan is vested in the Employer or its designee, who has the authority and shall be subject to the duties with respect to the trust specified in this Declaration of"I'rust; and WHEREAS, the Employer wishes to establish this trust to hold assets and income of the Plan for the exclusive benefit of Plan Participants, their Spouses and Dependents; NOW, THEREFORE, the parties hereto do hereby establish this trust, by executing the Declaration of Trust of the City of Santa Ana Integral Part Trust (hereinafter referred to as the (Name of Employer) "Trust"), and agree that the following constitute the Declaration of Trust (hereinafter referred to as the "Declaration"): ARTICLE I Definitions 1.1 Definitions. For the purposes of this Declaration, the following terms shall have the respective meanings set forth below unless otherwise expressly provided. (a) "Account" means the individual recordkeeping account maintained under the Plan to record the interest of a Participant in the Plan in accordance with Section 7.3. (b) "Administrator" means the Employer or the entity designated by the Employer to carry out administrative services as are necessary to implement the Plan. (c) "Beneficiary" means the Spouse and Dependents, who will receive any benefits payable hereunder in the event of the Participant's death. In the case where there is no Spouse or Dependents, any amount of contributions, plus accrued earnings thereon, remaining in the Account must, under the terms of the Plan, be returned to the Trust. (d) "Code" means the Internal Revenue Code of 1986, as amended from time to time. (e) "Dependent" means an individual who is a person described in Code Section 152(a). (f) "Investment Fund" means any separate investment option or vehicle selected by the Employer in which all or a portion of the Trust assets may be separately invested as herein provided. The Trustee shall not be required to select any Investment Fund. (g) "Nonforfeitable Interest" means the interest of the Participant or the Participant's Spouse and Dependent (whichever is applicable) in the percentage of Participant's Employer's contribution which has vested pursuant to the vesting schedule specified in the Employer's Plan. A Participant shall, at all times, have a one hundred percent (100%) Nonforfeitable Interest in the Participant's own contributions. (h) "Spouse" means the Participant's lawful spouse as determined under the laws of the state in which the Participant has his primary place of residence. (i) "Trust" means the trust established by this Declaration. 0) "Trustee" means the Employer or the person or persons appointed by the Employer to serve in that capacity. ARTICLE II Establishment of Trust 2.1 The Trust is hereby established as of the date set forth above for the exclusive benefit of Participants, their Spouses and Dependents. ARTICLE III Construction 3.1 This Trust and its validity, construction and effect shall be governed by the laws of the State of 3.2 Pronouns and other similar words used herein in the masculine gender shall be read as the feminine gender where appropriate, and the singular form of words shall be read as the plural where appropriate. 3.3 If any provision of this Trust shall be held illegal or invalid for any reason, such determination shall not affect the remaining provisions, and such provisions shall be construed to effectuate the purpose of this Trust. 44 t ARTICLE IV Benefits 4.1 Benefits. This Trust may provide benefits to the Participant, the Participant's Spouse and Dependents pursuant to the terms of the Plan. 4.2 Form of Benefits. This Trust may provide benefits by cash payment. This Trust may reimburse the Participant, his Spouse and Dependents for insurance premiums or other payments expended for permissible benefits described under the Plan. This trust may reimburse the Employer, or the Administrator for insurance premiums. ARTICLE V General Duties 5.1 It shall be the duty of the Trustee to hold title to assets held in respect of the Plan in the Trustee's name as directed by the Employer or its designees in writing. The Trustee shall not be under any duty to compute the amount of contributions to be paid by the Employer or to take any steps to collect such amounts as may be due to be held in trust under the Plan. The Trustee shall not be responsible for the custody, investment, safekeeping or disposition of any assets comprising the Trust, to the extent such functions are performed by the Employer or the Administrator, or both. 5.2 It shall be the duty of the Employer, subject to the provisions of the Plan, to pay over to the Administrator or other person designated hereunder from time to time the Employer's contributions and Participants' contributions under the Plan and to inform the Trustee in writing as to the identity and value of the assets titled in the Trustee's name hereunder and to keep accurate books and records with respect to the Participants of the Plan. ARTICLE VI Investments 6.1 The Employer may appoint one or more investment managers to manage and control all or part of the assets of the Trust and the Employer shall notify the Trustee in writing of any such appointment. 6.2 The Trustee shall not have any discretion or authority with regard to the investment of the Trust and shall act solely as a directed Trustee of the assets of which it holds title. To the extent directed by the Employer (or Participants or their Spouses and Dependents to the extent provided herein) the Trustee is authorized and empowered with the following powers, rights and duties, each of which the Trustee shall exercise in a nondiscretionary manner: (a) To cause stocks, bonds, securities, or other investments to be registered in its name as Trustee or in the name of a nominee, or to take and keep the same unregistered; (b) To employ such agents and legal counsel as it deems advisable or proper in connection with its duties and to pay such agents and legal counsel a reasonable fee. The Trustee shall not be liable for the acts of such agents and counsel or for the acts done in good faith and in reliance upon the advice of such agents and legal counsel, provided it has used reasonable care in selecting such agents and legal counsel; (c) To exercise where applicable and appropriate any rights of ownership in any contracts of insurance in which any part of the Trust may be invested and to pay the premiums thereon; and (d) At the direction of the Employer (or Participants, their Spouses, their Dependents, or the investment manager, as the case may be) to sell, write options on, convey or transfer, invest and reinvest any part thereof in each and every kind of property, whether real, personal or mixed, tangible or intangible, whether income or non -income producing and wherever situated, including but not limited to, time deposits (including time deposits in the Trustee or its affiliates, or any successor thereto, if the deposits bear a reasonable rate of interest), shares of common and preferred stock, mortgages, bonds, leases, notes, debentures, equipment or collateral trust certificates, rights, warrants, convertible or exchangeable securities and other corporate, individual or government securities or obligations, annuity, retirement or other insurance contracts, mutual funds (including funds for which the Trustee or its affiliates serve as investment advisor, custodian or in a similar or related capacity), or in units of any other common, collective or commingled trust fund. 6.3 Notwithstanding anything to the contrary herein, the assets of the Plan shall be held by the Trustee as title holder only. Persons holding custody or possession of assets titled to the Trust shall include the Employer, the Administrator, the investment manager, and any agents and subagents, but not the Trustee. The Trustee shall not be responsible or liable for any loss or expense which may arise from or result from compliance with any direction from the Employer, the Administrator, the investment manager, or such agents to take title to any assets nor shall the Trustee be responsible or liable for any loss or expense which may result from the Trustee's refusal or failure to comply with any direction to hold title, except if the same shall involve or result from the Trustee's negligence or intentional misconduct. The Trustee may refuse to comply with any direction from the Employer, the Administrator, the investment manager, or such agents in the event that the Trustee, in its sole and absolute discretion, deems such direction illegal. 6.4 The Employer hereby indemnifies and holds the Trustee harmless from any and all actions, claims, demands, liabilities, losses, damages or reasonable expenses of whatsoever kind and nature in connection with or arising out of (i) any action taken or omitted in good faith by the Trustee in accordance with the directions of the Employer or its agents and subagents hereunder, or (ii) any disbursements of any part of the Trust made by the Trustee in accordance with the directions of the Employer, or (iii) any action taken by or omitted in good faith by the Trustee with respect to an investment managed by an investment manager in accordance with any direction of the investment manager or any inaction with respect to any such investment in the absence of directions from the investment manager. Notwithstanding anything to the contrary herein, the Employer shall have no responsibility to the Trustee under the foregoing indemnification if the Trustee fails negligently, intentionally or recklessly to perform any of the duties undertaken by it under the provisions of this Trust. 6.5 Notwithstanding anything to the contrary herein, the Employer or, if so designated by the Employer, the Administrator and the investment manager or another agent of the Employer, will be responsible for valuing all assets so acquired for all purposes of the Trust and of holding, investing, trading and disposing of the same. The Employer will indemnify and hold the Trustee harmless against any and all claims, actions, demands, liabilities, losses, damages, or expenses of whatsoever kind and nature, which arise from or are related to any use of such valuation by the Trustee or holding, trading, or disposition of such assets. 6.6 The Trustee shall and hereby does indemnify and hold harmless the Employer from any and all actions, claims, demands, liabilities, losses, damages and reasonable expenses of whatsoever kind and nature in connection with or arising out of (a) the Trustee's failure to follow the directions of the Employer, the Administrator, the investment manager, or agents thereof, except as permitted by the last sentence of Section 6.3 above; (b) any disbursements made without the direction of the Employer, the Administrator, the investment manager or agents thereof; and (c) the Trustee's negligence, willful misconduct, or recklessness with respect to the Trustee's duties tinder this Declaration. ARTICLE VII Contributions 7.1 Employer Contributions. The Employer shall contribute to the Trust such amounts as specified in the Plan or by resolution. 7.2 Accrued Leave. Contributions up to an amount equal to the value of accrued sick leave, vacation leave, or other type of accrued leave, as permitted under the Plan. The Employer's Plan must provide a formula for determining the value of the Participant's contribution of accrued leave . The Employer's Plan must contain a forfeiture provision that will prevent Participants from receiving the accrued leave in cash in lieu of a contribution to the Trust. 7.3 Accounts. Employer contributions, including mandatory Participant contributions, and contributions of accrued leave, all investment income and realized and unrealized gains and losses, and forfeitures allocable thereto will be deposited into an Account in the name of the Participant for the exclusive benefit of the Participant, his Spouse and Dependents. The assets in each Participant's Account may be invested in Investment Funds as directed by the Participant (or, after the Participant's death, by the Spouse or Dependents) or the Employer, as required under the Plan, from among the Investment Funds selected by the Employer. 7.4 Receipt of Contributions. The Employer or, if so designated by the Employer, the Administrator or investment manager or another agent of the Employer, shall receive all contributions paid or delivered to it hereunder and shall hold, . invest, reinvest and administer such contributions pursuant to this Declaration, without distinction between principal and income. The Trustee shall not be responsible for the calculation or collection of any contribution under the Plan, but shall hold title to property received in respect of the Plan in the Trustee's name as directed by the Employer or its designee pursuant to this Declaration. 7.5 No amount in any Account maintained under this Trust shall be subject to transfer, assignment, or alienation, whether voluntary or involuntary, in favor of any creditor, transferee, or assignee of the Employer, the Trustee, any Participant, his Spouse, or Dependent. 7.6 Upon the satisfaction of all liabilities under the Plan to provide such benefits, any amount of Employer contributions, plus accrued earnings thereon, remaining in such separate Accounts must, under the terms of the Plan, be returned to the Employer. ARTICLE Vill Other Plans If the Employer hereafter adopts one or more other plans providing life, sickness, accident, medical, disability, severance, or other benefits and designates the Trust hereby created as part of such other plan, the Employer or, if so designated by the Employer, the Administrator or an investment manager or an -other agent of the Employer shall, subject to the terms of this Declaration, accept and hold hereunder contributions to such other plans. In that event (a) the Employer or, if so designated by the Employer, the Administrator or an investment manager or another agent of the Employer, may commingle for investment purposes the contributions received under such other plan or plans with the contributions previously received by the Trust, but the books and records of the Employer or, if so designated by the Employer, the Administrator or an investment manager or another agent of the Employer, shall at all times show the portion of the Trust Fund allocable to each plan; (b) the term "Plan" as used herein shall be deemed to refer separately to each other plan; and (c) the term "Employer" as used herein shall be deemed to refer to the person or group of persons which have been designated by the terms of such other plans as having the authority to control and manage the operation and administration of such other plan. ARTICLE IX Disbursements and Expenses 9.1 The Employer or its designee shall make such payments from the Trust at such time to such persons and in such amounts as shall be authorized by the provisions of the Plan provided, however, that no payment shall be made, either during the existence of or upon the discontinuance of the Plan (subject to Section 7.6), which would cause any part of the Trust to be used for or diverted to purposes other than the exclusive benefit of the Participants, their Spouses and Dependents pursuant to the provisions of the Plan. 9.2 All payments of benefits under the Plan shall be made exclusively from the assets of the Accounts of the Participants to whom or to whose Spouse or Dependents such payments are to be made, and no person shall be entitled to look to any other source for such payments. 9.3 The Employer, Trustee and Administrator may be reimbursed for expenses reasonably incurred by them in the administration of the Trust. All such expenses, including, without limitation, reasonable fees of accountants and legal counsel to the extent not otherwise reimbursed, shall constitute a charge against and shall be paid from the Trust upon the direction of the Employer. ARTICLE X Accounting 10.1 The Trustee shall not be required to keep accounts of the investments, receipts, disbursements, and other transactions of the Trust, except as necessary to perform its title -holding function hereunder. All accounts, books, and records relating thereto shall be maintained by the Employer or its designee. 10.2 As promptly as possible following the close of each year, the "Trustee shall file with the Employer a written account setting forth assets titled to the Trust as reported to the Trustee by the Employer or its designee. ARTICLE XI Miscellaneous Provisions 11.1 Neither the Trustee nor any affiliate thereof shall be required to give any bond or to qualify before, be appointed by, or account to any court of law in the exercise of its powers hereunder. 11.2 No person transferring title or receiving a transfer of title from the Trustee shall be obligated to look to the propriety of the acts of the Trustee in connection therewith. 11.3 The Employer may engage the Trustee as its agent in the performance of any duties required of the Employer under the Plan, but such agency shall not be deemed to increase the responsibility or liability of the Trustee under this Declaration. 11.4 The Employer shall have the right at all reasonable times during the term of this Declaration and for three (3) years after the termination of this Declaration to examine, audit, inspect, review, extract information from, and copy all books, records, accounts, and other documents of the Trustee relating to this Declaration and the Trustees' performance hereunder. ARTICLE XII Amendment and Termination 12.1 The Employer reserves the right to alter, amend, or (subject to Section 9.1) terminate this Declaration at any time for any reason without the consent of the Trustee or any other person, provided that no amendment affecting the rights, duties, or responsibilities of the Trustee shall be adopted without the execution of the Trustee to the amendment. Any such amendment shall become effective as of the date provided in the amendment, if requiring the Trustee's execution, or on delivery of the amendment to the Trustee, if the Trustee's execution is not required. I2.2 Upon termination of this Declaration and upon the satisfaction of all liabilities under the Plan to provide such benefits, any amount of Employer contributions, plus accrued earnings thereon, remaining in such separate Accounts must, under the terms of the Plan, be returned to the Employer. ARTICLE X111 Successor Trustees 13.1 The Employer reserves the right to discharge the Trustee for any or no reason, at any time by giving ninety (90) days' advance written notice. 13.2 The Trustee reserves the right to resign at any time by giving ninety (90) days' advance written notice to the Employer. 13.3 In the event of discharge or resignation of the Trustee, the Employer may appoint a successor Trustee who shall succeed to all rights, duties, and responsibilities of the former Trustee under this Declaration, and the terminated Trustee shall be deemed discharged of all duties under this Declaration and responsibilities for the Trust. ARTICLE XIV Limited Effect of Plan and Trust Neither the establishment of the Plan and the Trust or any modification thereof, the creation of any fund or account, nor the payment of any benefits, shall be construed as giving to any person covered under the Plan or other person any legal or equitable right against the Trustee, the Administrator, the Employer or any officer or employee thereof, except as may otherwise be expressly provided in the Plan or in this Declaration. ARTICLE XV Protective Clause Neither the Administrator, the Employer, nor the Trustee shall be responsible for the validity of any contract of insurance or other arrangement maintained in connection with the Plan, or for the failure on the part of the insurer or provider to make payments provided by such contract, or for the action of any per -son which may delay payment or render a contract void or unenforceable in whole or in part. IN WITNESS WHEREOF, the Employer and the Trustee have executed this Declaration by their respective duly authorized officers, as of the date first hereinabove mentioned. EMPL/O C jA By: 7v" Title: TRUSTEE(S): City Manager By: Title: Executive Director Finance & Management Services � �(� �.� r --''�� � By: By: Title: Title: SUGGESTED AFFIRMATIVE STATEMENT FOR ADOPTION OF THE VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN Plan Number: 8 03237 Name of Employer: City of Santa Ana Affirmative Statement of the above -named Employer (the "Employer"): WHEREAS, the Employer has employees rendering valuable services; and State: CA WHEREAS, the establishment of a retiree health savings plan serves the interests of the Employer by enabling it to provide reasonable security regarding such employees' health needs during retirement, by providing increased flexibility in its personnel management system, and by assisting in the attraction and retention of competent personnel; and WHEREAS, the Employer has determined that the establishment of the retiree health savings plan (the "Plan") serves the above objectives; NOW THEREFORE, as a duly authorized agent of the Employer, I hereby: ESTABLISH the Employer's Plan in the form of the ICMA Retirement Corporation's VantageCare Retirement Health Savings program; and SPECIFY that the assets of the Plan shall be held in trust, with the following entity or individual serving as trustee (Select one): ® the Employer ❑ the following position within the Employer: ❑ the following group or committee within the Employer: ❑ the following third -party trustee: ( insert tide of individual acting as trustee) (insert group or committee acting as trustee) (i nserr name of third -parry ttustce) for the exclusive benefit of the Plan participants and their survivors, and the assets of the plan shall not be diverted to any other purpose prior to the satisfaction of all liabilities of the Plan. The Employer has executed the Declaration of trust of the City of Santa Ana Integral Part Trust in the form of. (Select one) ❑ The model trust made available by the ICMA Retirement Corporation ❑ The trust provided by the Employer (executed copy attached hereto). SPECIFY that the Personnel Services/Employee Benefits Department and contact for the Plan and shall receive necessary reports, notices, etc. DATE: (� -I l — C w City Manager Title of Designated Agent Signature shall be the coordinator /-'i V �1 - ex it ./_A t f� os'o 0 AC40R" CERTIFICATE OF LIABILITY INSURANCE DATE (MWDD/YYYY) 07/310012 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 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 MARSH USA INC. SUITE 400 1255 23RD STREET, N.W. WASHINGTON, DC 20037 CONTACT NAME: PHONE FAX AAIC. No. ExII)e I (A/C, No): E-MAIDRL ADESS: INSURER S AFFORDING COVERAGE NAIC R INSURER A: St. Paul Protective Insurance Company 19224 040356--EO+FI-12-13 INSURED ICMA RETIREMENT CORP. ATTN: BARBARA STOTLER INSURER B : Federal Insurance Company 20281 INSURER C : St. Paul Fire & Marine Ins Co 24767 INSURER D : Standard Fire Insurance Company 19070 777 NORTH CAPITOL ST., N.E. WASHINGTON, DC 20002 INSURER EGreat American Insurance Co. 16691 INSURER F : COVERAGES CERTIFICATE NUMBER: CLE-003743124-08 REVISION NUMBER:5 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE. POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/VYYY POLICY EXP MMIDD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FqOCCUR X CONTRACTUAL COV. INCL. ZLP10S82630 08/01/2012 08/01/2013 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE T AGGREGATE LIMIT APPLIES PER: PRO- LOC X i POLICY F1 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LiA6iLITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS pp Ayi rO A, �: 4 (1' 3()�-,, �a o �y COMBINED SINGLE LIMIT Ea accidentl BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ rD UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE A$Slbta12L EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F`N] (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A UB-6508M89-4-12 08/01/2012 08/01/2013 X WCSTATU- OTH- E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ B C BANKERS PROF. LIAB. BANKERS PROF. LIAB. [_ 8211-6261 14RN20360 04119/2012 04/1912012 04/19/2013 04/19/2013 LIMIT 17,500,000 SIR 1,000,000 DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 CIVIC CENTER PLAZA M-34 ACCORDANCE WITH THE POLICY PROVISIONS. SANTA ANA, CA 92702 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 040356 LOC #: Washington Atc R/ ADDITIONAL REMARKS SCHEDULE V NAMED INSURED AGENCY ICMA RETIREMENT CORP. MARSH USA INC. ATTN: BARBARA STOTLER 777 NORTH CAPITOL ST., N.E. POLICY NUMBER WASHINGTON, DC 20002 CARRIER NAIC CODE EFFECTIVE DATE: Page 2 of 2 ACORD 101 (20M01) %w �%pww ---- - -- The ACORD name and logo are registered marks of ACORD �,rrrl� r CERTIFICATE OF LIABILITY INSURANCE DATE( 081012013/2013 VVVY) 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 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 MARSH USA INC. SUITE 400 CONTACT NAME' PHONE FAX `Egli, - (AIC NoI: ._ 1255 23RD STREET, N.W. WASHINGTON, DC 20037 EMAIL ADDRESS _ INSURERS) AFFORDING COVERAGE NAIC # INSURERA: St Paul Protective Insurance Company 19224 040356--EO+FI-13-14 INSURED ICMA RETIREMENT CORP. INSURER B: Federal Insurance Company 20281 -- INSURER C : St. Paul Fire & Marine Ins Cc 24767 ATTN: D'JUANA THOMAS 777 NORTH CAPITOL ST., NE WASHINGTON, DC 20002 INSURER D : Standard Fire Insurance Company ---- 19070 -- INsuRERE: Great American Insurance Co. 16691 INSURER F : COVERAGES CERTIFICATE NUMBER: CLE-003743124-10 REVISION NUMBER:5 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED -BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_ LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER_ POLICY EFF MM/DD/YYVV POLICY E%P MMIDD/YYYV LIMITS A GENERAL LIABILITY ZLPIOS82630 08/0112013 08101/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I -XI OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 10,000 X CONTRACTUAL GOV. INCL PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMP/OP AGO — $ 2,000,000 �,( X POLICY PRO- LOG ry y. 'V $ — AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Foci BODILY INJURY (Per' person) $ __ ANY AU TO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTO AUTOS �� �iY 10 a C1`J}�I e .�t0(�1 ] PROPERTY DAMAGE _Peraccident $____ __ $ UMBRELLA LIAB OCCUR iLL Yr.�s V EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE _ _ _ DED REl'ENTION$ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY V I N ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA UB650BM89-4-13 08101/2013 0810112014 X Wr, S1ArU- OTH- _.-IDByJJMU - __ E.L. EACH ACCIDENT — $ 1,000,000 — EL DISEASE - EA. EMPLOYEE — -- $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1,000,000 $ B BANKERS PROF. LIAB. 8211-6261 04119/2013 06130/2014 LIMIT 12,500,000 C BANKERS PROF, HAS. ZPL-14R20360-13-N2 04/19/2013 0613012014 SIR 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 CIVIC CENTER PLAZA M-34 ACCORDANCE WITH THE POLICY PROVISIONS. SANTA ANA, CA 92702 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ACORD 25 (2010/05) © 1988.2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 040356 LOC #: Washington AIC R 1 ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA INC. ICMA RETIREMENT CORP, ATTN: D'JUANA THOMAS 777 NORTH CAPITOL ST., NE POLICY NUMBER WASHINGTON, DC 20002 CARRIER NAIC CODE EFFECTIVE DATE: M V V r r r V INHL r[CIVIHl THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Other Policy Covers FIDELITY BOND/CRIME Policy Details Insr Ur E (Great American Insurance Co.) Policy Number: FS 234-63-54 Eff. Dt. 04/19/2013 Exp. Dt. 06/30/2014 Limits LIMIT 25,000,000 DEDUCTIBLE', 250,000 ACORD 101 (2008/01) C 2008 ACORD CORPORATION. All riahts reserved. The ACORD name and logo are registered marks of ACORD Digitally signed by Anaie ACORO� ' Li CERTIFICATE OF LIABILITY H)ate:2022.08.04 D080312022DryYYn THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPbk WVCMiVICATE 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 MARSH USA INC, 1050 CONNECTICUT AVENUE, SUITE 700 WASHINGTON, DC 20036�5386 CONTACT NAME: PHONE FAX(MC,No EfAHIL ADDRESS: INSURERS AFFORDING COVERAGE NAM # INSURER A : Great Northern Insurance Company 20303 CN101976702-MULTI-.-22-23 INSURED MISSIONSOUARE RETIREMENT INSURER a: Federal Insurance Company 20281 INSURER C : Travelers Casualty And Surety Company Of America 31194 777 NORTH CAPITOL ST., NE WASHINGTON, DC 20002 INSURER O: INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: CLE-006901158-08 REVISION NUMBER- 10 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPEOFINSURANCE ADOLSUSR IRM WD POUCYNUMBER POLICYEFF flummogri POLICYEXP rysvrm LIMITS A X COMMERCIAL GENERAL L[ABILITY CLAIMS -MADE OCCUR 3604-49-95 08/01/2022 080112023 EACHOCCURRENCE $ 1,000,000 DAMAGE TOR PREMISES Eaoccmedical $ 1,000,000 X MED FXP (Any oneperson) $ 10,000 CONTRACTUAL COV. INCL. PERSONAL a ADV INJURY $ 1,000,000 GENIE X AGGREGATE LIMIT APPLIES PER: POUCV PRP JECTFx_] LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: B AUTOMOSILELIABILITV 736045-48 08/01/2022 08/01/2023 COMBINED SINGLELIMIT Ea accident $ 1,000000 BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident ( 1 $ HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY X PROPERTVDAMAGE Per accident $ X UMBRELLA LIAB X OCCUR 9364-77-37 08/01/2022 08/01/2023 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIM&MADE DID RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETORIPARTNERIEXECUTIVE OFFICEMMEMBEREXCLUDED? ❑N NIA 7176-36­85 08/0112023 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 B BANKERS PROF. LIAB. 8211-6261 06/30/2022 06/30/2023 $7,500.000 pi$12.500,000 C SIR$1,000,000 106758967 06/30/2022 06/3012023 $5,000,000 p/0$12,500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) City of Santa Ana are included as additional insured where required by written contract with respect to General Liability. Waiver of subrogation is applicable where required by written contract with respect to general liability and Workers Compensation. General abiliry insurance is primary and noncontributory over any existing insurance and limited to liability arising out of the operations of the named Insured subject to policy terms and conditions. City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. !E ©1988-2016 ACORD ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Risk Management Division REVIEWED Is APPROVED BY. =1117�11iL' A+�:a Acau+�D �'. - Risk Management Specialist 01 AGENCY CUSTOMER ID: CN101976702 LOC#: Washington ,acoRo® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA INC. MISSIONSOUARE RETIREMENT T77 NORTH CAPITOL ST., NE WASHINGTON, DC 20002 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insul 1ST EXCESS BANKERS PROFESSIONAL LIABILITY CARRIER: AXIS INSURANCE COMPANY POLICY: P-00"0012680403 EFFECTIVE 05/30/2022 EXPIRATION: 06f30/2023 LIMIT: $7,500,000 XS $12,500,000 2ND EXCESS BANKERS PROFESSIONAL LIABILITY CARRIER: ARCH INSURANCE COMPANY POLICY: IAX93000BM8 EFFECTIVE 061XV2022 EXPIRATION: 06/30/2023 LIMIT: $5,000,000 XS $20,000,000 3RD EXCESS BANKERS PROFESSIONAL LIABILITY PARTA CARRIER TWIN CITY FIRE INSURANCE CO (THE HARTFORD) POLICY: 10 DC 029908 22 EFFECTIVE: 06/302022 EXPIRATION: 06M2023 LIMIT: $5,000,000 P/O $10,000,000 XS $25.000,000 PART B CARRIER: BERKLEY INSURANCE COMPANY(BERKLEY) POLICY: BPRO8080943 EFFECTIVE 05130/2022 EXPIRATION: 06/302023 LIMIT: $5.000,000 PIO $10,000.000 XS $25,000,0M TOTAL LIMIT: $35,000,000 l�r REVIEWED&APPRPJm BY: 101 (2008/01) ©200B ACORD I 2(i A,4,fr;e Acavuf0 The ACORD name and logo are registered marks of ACORD 1i1NWRisk Management Speaaist CHUBB6 Liability Endorsement (continued) Under Conditions, the following provision is added to the condition titled Other insurance, Conditions Other Insurance — if you are obligated pursuant to a contract or agreement, to provide the person or organization Primary, Noncontributory shown in the Schedule with primary insurance such as is affordedby this policy, then in such case Insurance — Scheduled this insurance is primary and we will not seek contribution from insurance available to such person Person Or Organization or organization. Schedule Persons or organizations that you are obligated, pursuant to a contract or agreement, to provide with such insurance as is afforded by this policy. All other terms and conditions remain unchanged Authorized Representative \a < Liability Insurance Additional insured - Scheduled Person Or Organization Form 80-o2-2367(Rev. bu7) Endorsement „ a �'' p& RiskMwgemmtDMs1un .. Rt EWM&APMcum Br: A+•�:QA�u�uto Risk Management SpeaAln WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER For policies or exposure in Missouri: Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 08-01-21 Policy No. 71763685 Insured ICMA RETIREMENT CORPORATION Insurance Company Great Northern Insurance Company WC 00 03 13 (Ed. 4-84) a tgn National Council on Compensation Insurance. Countersigned By inwna Copy Endorsement No. Premium $ Incl . RialeMgnagenieettUloialon REwEwEo6 APPRovm Rr: A� Rc+Nesta Risk Management Spenalist WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER For policies or exposure in Missouri: Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.( Endorsement Effective08-01-21 Policy No.71763685 Endorsement No. Insured ICMA RETIREMENT CORPORATION Premium $ Incl. Insurance Company Great Northern Insurance Company Countersigned By WC 00 03 13 (Ed. 4-84) 0198314ational Council on Compensation Insurance. Risk ManaganmtDiviebn RE Ewm6 APPRO Or ® '. A+�ta Acevtda - Risk Management Spedalist C H U B B` General Liability Contract Please read the entire policy carefully. The terms and conditions of this insurance include the various sections of this contract: Coverages; Investigation, Defense And Settlements; Supplementary Payments; Coverage Territory; Who Is An Insured; limits of Insurance; Exclusions; Conditions; and Definitions, as well as the Declarations, Common Policy Conditions and any Endorsements and Schedules made apart of this insurance. 'throughout this contract the words "you" and "your' refer to the Named Insured shown in the Declarations and any other persons or organizations qualifying as a Named Insured under this contract. The words "we," "us" and "our" refer to the Company providing this insurance. In addition to the Named Insured, other persons or organizations may qualify as insureds. Those persons or organizations and the conditions under which they qualify are identified in the Who Is An Insured section of this contract. Words and phrases that appear in bold print have special meanings and are defined in the Definitions section of this contract. Coverages Bodily Injury And Subject to all of the terms and conditions of this insurance, we will pay damages that the Insured Property Damage becomes legally obligated to pay by reason of liability imposed by law or assumed in an insured Coverage contract for bodily injury or property damage caused by an occurrence to which this coverage applies. This coverage applies only to such bodily injury or property damagethat occurs during the policy period. This coverage includes bodily injury or property damage involving: • automated teller machines; • foreclosed property; • property in any trust, guardianship or estate for which you are acting in a fiduciary or representative capacity; and • property which you own and lease to others, when specific insurance, which would customarily protect your interest and which you require your lessees to carry, is non-existent, invalid, insufficient or uncollectible. Damages for bodily injury include damages claimed by a person or organization for care or loss of services resulting at any time from the bodily injury. Other than as provided under the Investigation, Defense And Settlements and Supplementary Payments sections of this contract, we have no other obligation or liability to pay sums or perform acts or services under this coverage. Advertising Injury Subject to all of the terms and conditions of this insurance, we will pay damages that the insured And Personal Injury becomes legally obligated to pay by reason of liability imposed by law or assumed in an insured Coverage contract for advertising injury or personal injury to which this coverage applies. This coverage applies only to such advertising injury or personal Injury caused by an offense that is first committed during the policy period. Lk&fily Insurance Form 17-02-3080(Rev. 401) Contract sa e, Ride Mwagenterdl)MsIon REVIEWED & APPR MRr A+.-fs A� �� auk Management Speaaxst Coverages Advertising Injury This coverage includes advertising injury or personal injury involving; And Personal Injury automated teller machines; Coverage (continued) foreclosed property; • property in any trust, guardianship or estate for which you are acting in a fiduciary or representative capacity; and • property which you own and lease to others, when specific insurance, which would customarily protect your interest and which you require your lessees to carry, is non-existent, invalid, insufficient oruncollectible. Other than as provided under the Investigation, Defense And Settlements and Supplementary Payments sections of this contract, we have no other obligation or liability to pay sums or perform acts or perform acts or services under this coverage. Medical Expenses Subject to all of the terms and conditions of this insurance, we will pay medical expenses for Coverage bodily injury caused by an accident to which this coverage applies: • that takes place on premises rented to or owned by you; or • in connection with your operations; provided that such; • accident occurs during the policy period; • expenses are incurred and reported to us within three (3) years of the date of the accident; and • person who sustained such bodily injury submits to examination, at our expense, by physicians of our choice as often as we reasonably require. We will make these payments regardless of fault. We have no other obligation or liability under this coverage. Investigation, Subject to all of the terms and conditions of this insurance, we will have the right and duty to Defense And defend any insured against a suit, even if such suit is false, fraudulent or groundless. Settlements If such a suit is brought, we will pay reasonable attorney fees and necessary litigation expenses to defend: • the hmured; and • if applicable, the indemoittee of the insured, provided the obligation to defend, or the cost of the defense of, such indemninee has been assumed by such insured in an insured contract. Such attorney fees and litigation expenses will be paid as described in the Supplementary Payments section of this contract. We have no duty to defend any person or organization against any suit seeking damages to which this insurance does not apply. LiabiTry Insurance Form 17-02-3080(Rev. 4011 Contract aEVIEwM & Amtmm Bv: A.-gu Acwrd• Risk Management Spetl 4ist C H U B B° General Liability Investigation, We may, al our discretion, investigate any occurrence or offense and settle any claim or salt Defense And Settlements Our duty to defend any person or organization ends when we have used up the applicable Limit Of (continued) Insurance. Supplementary Sub jest to all of the terms and conditions of this insurance, we will pay, with respect to a claim we Payments investigate or settle, or a suit against an insured we defend: A. the expenses we incur, B. the cost of: 1. bail bonds; or 2. bonds required to: a. appeal judgments; or b. release attachments; but only for bond amounts within the available Limit Of Insurance. We do not have to furnish these bonds. C. reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of such claim or suit, including actual loss of eamings up to 1,000 a day because of time off from work. D, costs taxed against the Insured in the suit, except any: 1. attorney fees or litigation expenses; or 2. other loss, cost or expense; in connection with any injunction or other equitable relief. E. prejudgment interest awarded against the insured on that part of a judgment we pay. If we make an offer to pay the applicable Limit Of Insurance, we will not pay any prejudgment interest based on that period of time after the offer. F. interest on the full amount of a judgment that accrues after entry of the judgment and before we have paid, offered to pay or deposited in court the part of the judgment that is within the applicable Limit Of Insurance. Supplementary Payments does not include any fine or other penalty. These payments will not reduce the Limits Of Insurance. Our obligation to make these payments ends when we have used up the applicable Limit Of Insurance. Coverage Territory This insurance applies anywhere, provided the insureds responsibility to pay damages, to which this insurance applies, is determined in a suit on the merits brought in the United States of America (including Its possessions and territories), Canada or Puerto Rico, or in a settlement to which we agree. Liability Insurance Form 17-02-3080IRev. 4-01) contract RiekMmgmadnlvislan 4.101 RENEWED&APPRcvm BY: MINMEMP Risk Management specialist Who Is An Insured Sole Proprietorship If you are an individual, you and your spouse are insureds; but you and your spouse are insureds only with respect to the conduct of a business of which you are the sole owner. If you die: persons or organizations having proper temporary custody of your property are insureds; but they are Insureds only with respect to the maintenance or use of such property and only for acts until your legal representative has been appointed; and your legal representatives are insureds; but they are insureds only with respect to their duties as your legal representatives. Such legal representatives will assume your rights and duties under this insurance. Partnerships Or If you are a partnership (including a limited liability parnetship) or a joint venture, you are an Joint Ventures insured. Your members, your partners and their spouses are insureds; but they are insureds only with respect to the conduct of your business. Limited Liability If you are a limited liability company, you are an insured. Your members and their spouses are Companies insureds; but they are insureds only with respect to the conduct of your business. Your managers are insureds-, but they are insureds only with respect to their dunes as your managers. Other Organizations If you are an organization (including a professional corporation) other than a partnership, joint venture or limited liability company, you are an insured. Your directors and officers are insureds; but they are insureds only with respect to their duties as your directors or officers. Your stockholders and their spouses are insureds; but they are insureds only with respect to their liability as your stockholders. Employees Liability insurance Form 17-02-3080 (Rev. 4-01J Your employees are insureds; but they are insureds only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, no employee is an bowed for. A. bodily injury, advertising injury or personal injury; 1, to you, to any of your directors, managers, members, officers or partners (whether or not an employee) or to any co -employee while such injured person is either in the course of his or her employment or while performing duties related to the conduct of your business, 2. to the brother, child, parent, sister or spouse of such injured person as a consequence of any injury described in subparagraph A.1. above; or 3. for which there is any obligation to share damages with or repay someone else who most pay damages because of any injury described in subparagraphs A.1, or A.2. above. With respect to bodily injury only, this limitation does not apply to: you or to your directors, managers, members, officers, partners or supervisors as Insureds; or Risk MnugewuwADMs1an A-f' Am44 �. Risk Management SpeaAut C H U B B( General Liability Who Is An Insured Employees your employees, as hrsareds, with respect to such damages caused by cardio- (continued) pulmonary resuscitation or first aid services administered by such employee. B, property damage to any property owned, occupied or used by you or by any of your directors, managers, members, officers or partners (whether or not an employee) or by any of your employees. Ibis limitation does not apply to property damage to premises while rented to you or temporarily occupied by you with permission of the owner. Volunteers Persons who are volunteer workers for you are twar, eds; but they are insureds only for acts within the scope of their activities for you and at your direction. Real Estate Managers Persons (other than your employees) or organizations acting as your real estate managers are insureds; but they are insureds only with respect to their duties as your real estate managers. Permissive Users Of With respect to mobile equipment registered in your name under a motor vehicle registration law: Mobile Equipment A. persons driving such equipment on a public mad with your permission are insureds; and B. persons or organizations responsible for the conduct of such persons described in subparagraph A. above are insureds; but they are insureds only with respect to the operation of the equipment and only if no other insurance of any kind is available to them However, no person or organization is an insured with respect to: • bodily injury to any c"mployee of the person driving the equipment; or • property damage to any property owned or occupied by or loaned or rented to you, or in your charge or the charge of the employer of any person who is an insured under this provision. Vendors Persons or organizations who are vendors of your products are insureds; but they are insureds only with respect to their liability for damages for bodily injury or property damage resulting from the distribution or sale of your products in the regular course of their business and only if this insurance applies to the products -completed operations hazard. However, no such person or organization is an insured with respect to any: • assumption of liability by them in acontract or agreement. This limitation does not apply to the liability for damages for bodily injury or property damage that such vendor would have in the absence of such contract or agreement; • representation or warranty unauthorized by you; • physical or chemical change in your products made intentionally by the vendor; • repackaging, unless unpacked solely for the purpose of inspection, demonstration or testing, or the substitution of parts under instruction from the manufacturer and then repacked in the original container, UtWfity Insurance Form 17-02-3080(Rev. 401J Contract R!skMvwgmadDMs1on REVIEWED&APPROV®liv: c®' A, fg A6w44 Ruk Management SpeaNst Who Is An Insured Vendors failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to (continued) make or normally undertakes to make in the usual course of business in connection with the distribution or sale of your products; demonstration, installation, servicing or repair operations, except such operations performed at the vendors premises in connection with the sale of your products; or • of your products which, after distribution or We by you, have been labeled or relabeled or used as a container, ingredient or part of any other thing or substance by or for the vendor. Further, no person or organization from whom you have acquired your products, or any container, ingredient or pan entering into, accompanying or containing your products, is an Insured under this provision. Lessors Of Equipment Persons or organizations from whom you lease equipment are insureds; but they are insureds only with respect to the maintenance or use by you of such equipment and only if you are contractually obligated to provide them with such insurance as is afforded by this contract. However, no such person or organization is an insured with respect to any: • damages arising out of their sole negligence; or • occurrence that occurs, or offense that is committed, after the equipment lease ends. Lessors Of Premises Persons or organizations from whom you lease premises are insureds; but they are insureds only with respect to the ownership, maintenance or use of that particular part of such premises leased to you and only if you are contractually obligated to provide them with such insurance as is afforded by this contract. However, no such person or organization is an insured with respect to any: • damages arising out of their sole negligence; • occurrence that occurs, or offense that is committed, after you cease to be a tenant in the premises; or • structural alteration, new construction or demolition operations performed by or on behalf of them Subsidiary Or Newly If there is no other insurance available, the following organizations will qualify as named insureds: Acquired Or Formed a subsidiary organization of the first named insured shown in the Declarations of which, at Organizations the beginning of the policy period and at the time of loss, such first named insured controls, either directly or indirectly, more than fifty (50) percent of the interests entitled to vote generally in the election of the governing body of such organization; or • a subsidiary organization of the fast named inured shown in the Declarations that such first named insured acquires or forms during the policy period if at the time of loss such first named insured controls, either directly or indirectly, more than fifty (50) percent of the interests entitled to vote generally in the election of the governing body of such organization. Liabirlty insurance Form 17.02-3080 (Rev. 4-01) Contract �. RickMn agane f DMs1on RE+ne7/Eo&Armov®Br. - Ruk Management SpedXis[ C H U B B` General Liability Who Is An Insured (continued) Limitations On Who A. Except to the extent provided under the Subsidiary Or Newly Acquired Or Formed Is An Insured Organizations provision above, no person or organization is an insured with respect to the conduct of any person or organization that is not shown as a named insured in the Declarations. B. No person or organization is an insured with respect to the: 1. ownership, maintenance or use of any assets; or 2. conduct of any person or organization whose assets, business or organization; you acquire, either directly or indirectly, for any: • bodily injury or property damage that occurred; or • advertising injury or personal injury arising out of an offense first committed; in whole or in par, before you, directly or indirectly, acquired such assets, business or organization. Limits Of Insurance The Limits Of Insurance shown in the Declarations and the rates below fix the most we will pay, regardless of the number of • insureds, • claims made or suits brought; or • persons or organizations making claims or bringing suits. The Limits Of Insurance apply separately to each consecutive annual period and to any remaining period of less than twelve (12) months, starting with the beginning of the policy period shown in the Declarations, unless the policy period is extended after issuance for an additional period of less than twelve (12) months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits Of Insurance. General Aggregate Limit Products -Completed Operations Aggregate Limit Insurance Form Subject to the Each Occurrence Limit, the General Aggregate Limit is the most we will pay for the sum of: • damages for bodily injury and property damage, except damages included in the products -completed operations hazard; and medical expenm. Subject to the Each Occurrence Limit, the products -Completed Operations Aggregate Limit is the most we will pay for the sum of damages for bodily injury and property damage included in the products -completed operations hazard. p Ram e �' RA Management Spedaast Limits Of Insurance (continued) Advertising lnjury And The Advertising Injury And Personal Injury Aggregate Limit is the most we will pay for the sum of Personal Injury damages for advertising injury and personal injury. Aggregate Limit Each Occurrence Limit The Each Occurrence Limit is the most we will pay for the sum of: • damages for hadgy injury and property damage; and • medical expenses; arising out of any one occurrence. Any amount paid for damages or medical expenses will reduce the amount of the applicable aggregate limit available for any other payment If the applicable aggregate limit has been reduced to an amount that is less than the Each Occurrence Limit, the remaining amount of such aggregate limit is the most that will be available for any other payment. Damage To Premises Subject to the Each Occurrence Limit, the Damage To Premises Rented To You Limit is the most Rented To You Limit we will pay for the sum of damages for property damage to any one premises while rented to you or temporarily occupied by you with permission of the owner. Medical Expenses Limit Subject to the Each Occurrence Limit, the Medical Expenses Limit is the most we will pay for the sum of medical expenses, under Medical Expenses coverage, for bodily injury sustained by any one person. Bodily Injury/Property None of the following exclusions, except "Contracts", "Expected or Intended Injury" and "Loss In Damage Exclusions Progress", apply to property damage to premises while rented to you or temporarily occupied by you with permission of the owner. Aircraft, Autos Or This insurance does not apply to bodily injury or property damage arising out of the ownership, Watercraft maintenance, use (use includes operation andloading or unloading) or entrustment to others of any: aircraft; • auto; or • watercraft; owned or operated by or loaned or rented to any insured. This exclusion does not apply to: A. a watercraft while ashore on premises owned by or rented to you; B. a watercraft you do not own, provided that it: I. is less than fifty-five (55) feet long; and 2. does not transport persons or cargo for a charge; Liability Insurance Form 17-02-3080 (Rev. +01) Contract �n•.g ,� n 1tld Muogemmtixvidwt AenEwEosnrraav®sr: 4,gu A Risk Management SpenAist C H U B B` General Liability Bodily Injury/property Damage Exclusions Aircraft, Autos Or C. the parking of an auto on premises owned by or rented to you, provided the autos not Watercraft owned by or loaned or rented to you or the insured (continued) D. the liability for damages assumed in an insured contract resulting from the ownership, maintenance or use, by others, of an aircraft or watercraft; E. the operation of the equipment described in subparagraphs F.2. or F.3. of the definition of mobile equipment; or F. an aircraft you do not own, provided that: l . the pilot in commend holds a currently effective certificate, issued by the duly constituted authority of the United States of America or Canada, designating that person as a commercial or airline transport pilot; 2, it is rented with a trained, paid crew; and 3. it does not transport persons or cargo for a charge. Alcoholic Beverage Type Businesses Contracts Damage To Alienated Premises Liability Insurance Form 17-02-3080(Rev. 4-01J This insurance does not apply to bodily injury or property damage for which any insured may be held liable by reason of: causing or contributing to the intoxication of any person; • famishing alcoholic beverages to a person under the legal drinking age or under the influence of alcohol; or • any statute, ordinance or regulation relating to the sale, gift, distribution or use of alcoholic beverages. This exclusion applies only if you are in the business of manufacturing, distributing, selling, serving or furnishing alcoholic beverages. This insurance does not apply to bodily injury or property damage for which the insured is obligated to pay damages by reason of assumption of liability in a contract or agreement. This exclusion does not apply to the liability for damages: • that such insured would have in the absence of such contract or agreement; or assumed in an oral or written contract or agreement that is an insured contract, provided the bodily injury or property damage, to which this insurance applies, occurs after the execution of such contract or agreement. This insurance does not apply to property damage to any premises you sell, give away or abandon, if the property damage arises out of any part of those premises. This exclusion does not apply if the premises are your work and were never occupied rented or held for rental by you. RiskMmugomadDMElm e "�q REMFWm&APPROV®BY: Allp A 91IMMM Risk Management Specialist (continued) Damage To Impaired Property Or Property Not Physically Injured Damage To Owned Property Damage To Various Property Of Others (Care, Control Or Custody) Damage To Your Product This insurance does not apply to property damage to: impaired property; or property that has not been physically injured; arising out of any: defect, deficiency, inadequacy or dangerous condition in your product or your work; or delay or failure by you or anyone acting on your behalf to perform a contract or agreement in accordance with its terms and conditions. This exclusion does not apply to the loss of use of other tangible property resulting from sudden and accidental physical injury to your product or your work after it has been put to its intended use. This insurance does not apply to property damage to any property owned by you. This insurance does not apply to property damage to any: • personal property loaned or rented to you; • property held by you or on your behalf for sale or entrusted to you for safekeeping or storage; • property on your premises for purposes of performing operations on such property by you or on your behalf-, • tools or equipment used by you or on your behalf in performing operations; or • property in your care, control or custody that will be erected, installed or used in construction operations by you or on your behalf. This exclusion does not apply to the liability for damages assumed in a sidetrack agreement. This insurance does not apply to property damage to your product arising out of it or any part of it. Damage To Your Work This insurance does not apply to property damage to your work arising out of it or any pan of it and included in the products -completed operations hazard. This exclusion does not apply if the damaged work or the work causing the damage was performed on your behalf by a subcontractor. Employer's Liability A. This insurance does not apply to bodily injury to an employee of the Insured arising out of and in the course of. 1. employment by the insured; or 2. performing duties related to the conduct of the insured's business. Liability Insurance Form 17-02-3080(Rev. 401l contract ��e RiakMnvgementDiuisian -" REwEwm &APPROVED BY: a, a A+ uAcWaa ® Risk Managemen[Spedatkt CHUBS, General Liability Bodily Injury/Property Damage Exclusions Employer's Liability B. This insurance does not apply to bodily injury to the brother, child, parent, sister or spouse (continued) of such employee as a consequence of any injury described in paragraph A. above. This exclusion applies: • whether the insured may be liable as an employer or in any other capacity; and • to any obligation to share damages with or repay someone else who most pay damages because of any injury described in paragraphs A. or B. above. This exclusion does not apply to the liability for damages assumed by the insured in an insured contract. Expected Or Intended 'Ills insurance does not apply to bodily injury or property damage arising out of an act that Injury is intended by the insured; or • would be expected from the standpoint of a reasonable person in the circumstances of the insured; to cause bodily injury or property damage, even if the actual bodily injury or property damage is of a different degree or type than intended or expected. This exclusion does not apply to bodily injury or property damage resulting from the use of reasonable force to protect persons or tangible property. Loss In Progress This insurance does not apply to bodily injury or properly damage that is a change, condonation or resumption of any bodily injury or property damage known by you, prior to the beginning of the policy period, to have occurred Bodily injury or property damage will be deemed to be known to you: A. if such injury or damage is known by, or should have been known from the standpoint of a reasonable person in the circumstances of 1. you; 2. any of your directors, managers, members, officers (or their designees) or partners (whether or not an employee); and B. when any person described in paragraph A. above: 1. reports all, or any pan, of any such injury or damage to us or any other insurer; 2. receives a claim or a demand for damages because of any such injury or damage; or 3. becomes aware that any such injury or damage has occurred or has begun to occur. Mobile Equipment 'Phis insurance does not apply to bodily injury or property damage arising out of the Transportation transportation of mobile equipment by an auto owned or operated by or loaned or rented to any insured. VabiRy Insurance Form 17.02-2090 (Rev. 4-01 J Contract _� •=a Risk MwagementDiWIon RfiFMfi &APPROVm BY: A+�fkwrfo RIEW' Risk Management5pedrist Personal In Exclusions Breach Of Contract This insurance does not apply to advertising injury or personal injury arising out of breach of contract. Continuing Offenses This insurance does not apply to advertising injury or personal injury that arises out of that part of an offense that continues or resumes alter the later of the end of the policy period of: A. this insurance; or B. a subsequent, continuous renewal or replacement of this insurance, that: 1. is issued to you by us or by an affiliate of ours; 2. remains in force while the offense continues; and 3. would otherwise apply to advertising injury and personal injury. Contracts This insurance does not apply to advertising injury or personal injury for which the insured is obligated to pay damages by reason of assumption of liability in a contract or agreement. This exclusion does not apply to the liability for damages: • that such inured would have in the absence of such contract or agreement; or • assumed in a written contract or agreement that is an insured contract provided the advertising injury or personal injury, to which this insurance applies, is caused by an offense lust committed after the execution of such contract or agreement. Crime Or Fraud This insurance does not apply to advertising injury or personal injury arising outer any criminal or fraudulent conduct committed by or with the consent or knowledge of the insured. Expected Or This insurance does not apply to advertising injury or personal injury arising out of an offense, Intended Injury committed by or on behalf of the Insured, that: • is intended by such insured; or • would be expected from the standpoint of a reasonable person in the circumstances of such Inured; to cause injury, . Failure To Conform To This insurance does not apply to advertising injury or personal injury arising out of the failure of Representations Or goods, products or services to conform with any electronic, oral, written or other representation or Warranties warranty of durability, fitness, performance, quality or use. LinUffly Insurance Form 17-02-3080(Rev. 4-01) Contract ,r,� ',.,�{ RideMnssganmtDMsfun e rt A, fa Acweda . '® Rnk Management Specialist C H U B B` General Liability Advertising Injury/ Personal Injury Exclusions (continued) Internet Activities 'ibis insurance does not apply to advertising injury or personal injury arising out of: • controlling, creating, designing or developing, of another's Intcmct site: controlling, creating, designing, developing, determining or providing the content or material of another's Internet site; controlling, facilitating or providing, or failing to control, facilitate or provide, access to the Internet or another's Internet site; or publication of content or material on or from the Internet, other than content or material developed by you or at your direction, Media Type Businesses This insurance does not apply to advertising injury or personal injury arising out of an offense committed by or on behalf of an insured whose business is advertising, broadcasting, cablecasting, publishing, telecasting or telemarketing. This exclusion does not apply to personal injury caused by an offense described in subparagraphs A., B. or C. of the definition of personal injury. Prior Offenses This insurance does not apply to advertising injury or personal injury arising outof any offense first committed before the beginning of the policy period Publications With This insurance does not apply to advertising injury or personal injury arising out of any Knowledge Of Falsity electronic, oral, written or other publication of content or material by or with the consent of the Insured: • with knowledge of its falsity, or if a reasonable person in the circumstances of such insured would have known such content or material to be false. Wrong Description Of This insurance does not apply to advertising injury or personal injury arising out of the wrong Prices description of the price of goods, products or services. Medical Expenses Exclusions Athletic Activities This insurance does not apply to medical expenses arising out of bodily injury to any person injured while taking pan in athletics. Uabifity Insurance Form 17-p2-3030(Rev. 401) Contract WekMou mtadDMelan 4 ... Y. REVIEWED&APPRD Sr Risk Management Spedalist Of 41-MIM Medical Expenses Exclusions (continued) Injury To Insureds This insurance does not apply to medical expenses arising out of bodily injury to any insured, except a volunteer worker. Nuclear Enerqy This insurance does not apply to medical expenses arising out of bodily injury in any way related to the: • nuclear hazardous properties of nuclear material; and • operation of a nuclear facility by any person or organization. Products -Completed This insurance does not apply to medical expenses arising out of bodily injury included in the Operations Hazard products -completed operations hazard. Workers' Compensation This insurance does not apply to medical expenses arising out of bodily injury to any person. Or Similar Laws whether or not an employee of any insured, if benefits for such bodily injury are payable or must be provided under any workers' compensation, disability benefits or unemployment compensation law or any similar law. Policy Exclusions Asbestos A. 11iis insurance does not apply to bodily injury, property damage, advertising injury or personal injury arising out of the actual, alleged or threatened contaminative, pathogenic, toxic or other hazardous properties of asbestos. & This insurance does not apply to any loss, cost or expense arising out of any: request, demand, order or regulatory or statutory requirement that any insured or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of asbestos; or claim or proceeding by or on behalf of a governmental authority or others for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of asbestos. Employment -Related A. This insurance does not apply to any damages sustained at any time by any person, whether Practices or not sustained in the course of employment by any insured, arising out of any employment -related act, omission, policy, practice or representation directed at such person, occurring in whole or in part at any time, including any: 1. arrest, detention or imprisonment; 2. breach of any express or implied covenant; 3. coercion, criticism, humiliation, prosecution or retaliation; 4. defamation or disparagement; Liability Insurance Form 17-02-3080 (Rev. 4-01) Contract RiAMamgemmtDiriSIM ;�ji,.i_, tf fr�neueo&Avazov®Br. �' A4 fi AC444 Risk Management Specialist CHUE3B` Policy Exclusions General Liability Employment -Related 5, demotion, discipline, evaluation or reassignment; Practices 6. discrimination, harassment or segregation; (continued) 7, a. eviction; or b, invasion or other violation of any right of occupancy; S. failure or refusal to advance, compensate, employ or promote; 9. invasion or other violation of any right of privacy or publicity; 10. termination of employment; or 11. other employment -related act, omission, policy, practice, representation or relationship in connection with any insured at any time. B. 'lhix insurance does not apply to any damages sustained at any time by the brother, child, parent, sister or spouse of such person at whom any employment -related act, omission, policy, practice or representation is directed, as described in paragraph A. above, as a consequence thereof. This exclusion applies: • whether the insured may be liable as an employer or in any other capacity; and • to any obligation to share damages with or repay someone else who must pay damages because of any of the foregoing. Enhancement, This insurance does not apply to any loss, cost or expense incurred by you or others for any: Maintenance Or A. enhancement or maintenance of any property; or Prevention Expenses B. prevention of any injury or damage to any: 1. person or organization; or 2. property you own, rent or occupy. Financial Instruments This insurance does not apply to loss of use of financial instrumenu that have not been physically injured. Insurance And Related This insurance does not apply to bodily injury, property damage, advertift injury, or Operations personal injury arising out of, or directly or indirectly related to: A. any obligation assumed by any insured or the failure to discharge, or the improper discharge of, any obligation or duty, contractual or otherwise, with respect to any: 1. contract or treaty of insurance, self-insurance, reinsurance or suretyship; 2. annuity; 3. endowment; or 4. benefit plan, including any applications, endorsements, amendments, receipts, or binders; Liability Insurance Form 17-02-3080 4-01J Contract Fl--�A ll 444 Risk Management SpeoAht Policy Exclusions Insurance And Related Il. membership or participation in, contribution to, or management of any plan, pool, Operations association, insolvency or guarantee fund or any other similar fund, organization or (continued) association, whether voluntary or involuutary; or C. advising, reporting or making reconineendations, or the failure to do any of the foregoing, in the insureds capacity as an insurance company, insurance broker or agent, insurance consultant or insurance representative. Intellectual Property This insurance does not apply to any actual or allegedbodily injury, property damage, Laws Or Rights advertising injury or personal injury arising out of, giving rise to or in any way related to any actual or alleged: • assertion; or • infringement or violation; by any person or organization C'mduding any insured) of any Intellectual property law or right regardless of whether this insurance would otherwise apply to all or part of any such actual or alleged injury or damage in the absence of any such actual or alleged assertion, infringement or violation. This exclusion applies, unless such injury: • is caused by an offense described in the definition of advertising injury; and • does not arise out of, give rise to or in any way relate to any actual or alleged assertion, infringement or violation of any intellectual property law or right other than one described in the definition oradvertising injury. Nuclear Energy A. This insurance does not apply to bodily injury, nuclear property damage, advertising injury or personal injury: 1. with respect to which any insured under this policy also has status as an insured under a nuclear energy liability policy issued by Nuclear Energy Liability Insurance Association, Mutual Atomic Energy Liability Underwriters, Nuclear Insurance Association of Canada or any of their successors, or would have had status as an , insured under any such policy but for its termination upon exhaustion of its limit of insurance; or 2. arising out of the nuclear hazardous properties of nuclear material and with respect to which: a. any person or organization is required to maintain financial protection pursuant to the United States of America Atomic Energy Act of 1954, or any law amendatory thereof; or b. the Insured is, or had this policy not been issued would be, entitled to indemnity from the United States of America, or any agency thereof, under any agreement entered into by the United States of America, or any agency thereof, with any person or organization. R. This insurance does not apply to bodily injury, nuclear property damage, advertising injury or personal injury arising out of the nuclear hazardous properties of nuclear material: Rt EwEo&MPa Br. Alf "41 Ruk Management Specialist C H U B B° General Liability Policy Exclusions Nuclear Energy 1. if the nuclear material: (continued) a. is at any nuclear facility owned by, or operated by or on behalf of, any insured; b. has been discharged or dLspersed therefrom; or C. is contained in nuclear spent fuel or nuclear waste at any time transported handled, stored, disposed of, processed treated possessed or used by or on behalf of any insured; or 2. in any way related to the furnishing by any insured of services, materials, parts or equipment in connection with the planning, construction, maintenance, operation or use of any unclear facility. But if such facility is located within the United States of America (including its possessions or territories) or Canada, this subparagraph 2. applies only to nuclear property damage to such nuclear facility and any property thereat. Pollution A. This insurance does not apply to bodily injury, property damage, advertising injury or personal injury arising out of the actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of pollutants: 1. at or from arty premises, site or location which is or was at any time owned or occupied by, or loaned or rented to, any insured; 2. at or from any premises, site or location to which any insured has perfected their right to possession, or which was at any time acquired by foreclosure, repossession or deed in lieu of foreclosure by any insured; 3, at or from any premises in any trust, guardianship or estate for which any insured is currently, or did act in a fiduciary or representative capacity; 4. at or from any premises, site or location which is or was at any time used by or for any insured or others for the handling, storage, disposal, processing or treatment of waste; 5. which are or were at any time transported, handled stored disposed of, processed or created as waste by or for any: a. insured; or b. person or organization for whom any insured may be legally responsible; or 6. at or from any premises, site or location on which any insured or any contractor or subcontractor working directly or indirectly on any insured's behalf is performing operations, if the: a. pollutants are brought on or to the premises, site or location in connection with such operations by such insured, contractor or subcontractor; or b. operations areto test for, monitor, clean up, remove, contain, neat, detoxify or neutralize, or in any way respond to, or assess the effects of pollutants. -�'kkt aEwEu+eo&nraaav®ar. Risk Management Specialist Policy Exclusions Pollution Subparagraph A.6.a. above does not apply to bodily injury or property damage caused by (oontlnusd) the escape of fuels, lubricants or other operating fluids which are needed to perform the normal electrical, hydraulicormechanical functions necessary for the operation of mobile equipment or its parts, if such operating fluids escape directly from that particular pan of such mobile equipmeutdesigned by its manufacturer to hold, store or receive them. But, this exception does not apply if such bodily injury or property damage arises out of any discharge, dispersal, seepage, migration, release or escape of pollutants, that: • was intended by the insured; • would have been expected from the standpoint of a reasonable person in the circumstances of the insured; • was a necessary part of operations performed by any insured, contractor or subcontractor; or • occurred during the process of fueling the mobile equipment or changing or replenishing any operating fluid. Subparagraph A.6.a. above does not apply to bodily injury or property damage if sustained within a building and caused by the release of gaseous irritants or contaminants from materials brought into that building, in connection with the operations being performed by you or on your behalf by the contractor or subcontractor. Subparagraph A.1. above does not apply to bodily injury if sustained within a building and caused by the escape of gaseous irritants or contaminants from equipment used to heat that building. Subparagraphs A.1. and A.6.a. above do not apply to bodily injury or property damage caused by heat, smoke or fumes from ahostile fire. B. This insurance does not apply to any loss, cost or expense arising out of any: 1. request, demand, order or regulatory or statutory requirement that any insured or other: test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of pollutants, or 2. claim or proceeding by or on behalf of a governmental authority or others for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of pollutants. Paragraph B. above does not apply to the liability for damages, for property damage, that the insured would have in the absence of such request, demand, order or regulatory or statutory requirement, or such claim or proceeding by or on behalf of a governmental authority. 'this exclusion does not apply to the liability for damages, for property damage, to premises while rented to you or temporarily occupied by you with permission of the owner and caused by a hostile fire, explosion, smoke or leakage from fire protective equipment. This exclusion applies regardless of whether or not the pollution was accidental, expected, gradual, intended, preventable or sudden. tiaWty Insurance Form 17-02-3080(Rev. 4-01) Contract r=a.,�g liieleManagemmtl7irisfun RimEwEn6APmovm RY: A4f" "44 �' RM Management SpedAmt CHUBB` Policy Exclusions (continued) General Liability Recall Of Products, Work Ibis insurance does not apply to any damages claimed for any loss, cost or expense incurred by you Or Impaired Property or others for the loss of use, withdrawal, recall, inspection, repair, replacement, adjustment, removal or disposal of: your product; your work; or impaired property; if such product, work or property is withdrawn or recalled from the market or from use by any person or organization because of a known or suspected defect, deficiency, inadequacy or dangerous condition in it. Workers' Compensation This insurance does not apply to any obligation of the insured under any workers compensation, Or Similar Laws disability benefits or unemployment compensation law or any similar law. Conditions Arbitration We are entitled to exercise all of the insured's rights in the choice of arbitrators and in the conduct of any arbitration proceeding, except when the proceeding is between us and the inured. Bankruptcy Bankruptcy or insolvency of the inured or of the insureds estate will not relieve us of our obligations under this insurance. Disclosures And We have issued this insurance: Representations based upon representations you made to us; and • in reliance upon your representations. Unintentional failure of an employee of the insured to disclose a hazard or other material information will not violate this condition, unless an officer (whetter or not an employee) of any insured or an officer's designee knows about such hazard or other material information. Duties In The Event Of A. You must see to it that we and any other insurers are notified as soon as practicable of any Occurrence, Offense, occurrence or offense that may result in a claim, if the claim may involve as or such other Claim Or Suit insurers. To the extent possible, notice should include: 1. how, when and where the occurrence or offense happened; 2. the names and addresses of any injured persons and witnesses; and 3. the nature and location of any in jury or damage arising out of the occurrence or Offense. LkWlty Insurance Contract �raov®er. RenEWEo && A� Risk Management Specialist Conditions Duties In The Event Of B. if a claim is made or suit is brought against any insured you must: Occurrence, Offense, Claim Or suit 1. immediately record the specifics of the claim or suit and the date received; (continued) 2. notify us and other insurers as soon as practicable; and 3. see to it that we receive written notice of the claim or suit as soon as practicable. C. You and any other involved insured must: L immediately send us copies of any demands, notices, summonses or legal papers received in connection with the claim or Snit; 2, authorize us to obtain records and other information; 3, cooperate with us and other insurers in the: a. investigation or settlement of the claim; or b. defense against the suit-, and 4. assist us, upon our request, in the enforcement of any right against any person or organization that may be liable to the insured because of loss to which this insurance may also apply. D. No insureds will, except at that insured's own cost, [Hake any payment, assume any obligation or incur any expense, other than for first aid, without our consent. L. Notice given by or on behalf of: 1, the insured; 2. the injured person; or 3. any other claimant; to a licensed agent of ours with particulars sufficient to identify the insured shall be deemed notice to us. F. Knowledge of an occurrence or offense by an agent or employee of the insured will not constitute knowledge by the insured, unless an officer (whether or not an employee) of any insured or an officers designee knows about such occurrence or offense. G. Failure of an agent or employee of the insured, other than an officer (whether or not an employee) of any insured or an officer's designee, to notify us of an occurrence or offense that such person knows about will not affect the insurance afforded to you. 11. If a claim or loss does not reasonably appear to involve this insurance, but it later develops into a claim or loss to which this insurance applies, the failure to report it to us will not violate this condition, provided the insured gives us immediate notice as soon as the insured is aware that this insurance may apply to such claim or loss. Legal Action Against Us No person or organization has a right under this insurance to: join us as a party or otherwise bring us into a suit seeking damages from an insured; or sue us on this insurance unless all of the terms and conditions of this insurance have been fully complied with. mae m�agemo¢ UMM tnaafBnCe R7 EwED&APPRovmft, 1-02-3080 (Rev. 4-01) Contract e :, Afl aLV ��=Risk Management SpedXst C H U BB' General Liability Conditions Legal Action Against Us A person or organization may sue us to recover on an agreed settlement or on a final judgment (continued) against an h=red obtained after an actual: • trial in a civil proceeding; or • arbitration or other alternative dispute resolution proceeding; but we will not be liable for damages that are not payable under the terms and conditions of this insurance or that are in excess of the applicable Limits Of Insurance. Other Insurance If other valid and collectible insurance is available to the ho red for loss we would otherwise cover under this insurance, our obligations are limited as follows. Primary Insurance This insurance is primary except when the Excess Insurance provision described below applies, If this insurance is primary, our obligations are not affected unless any of the other insurance is also primary. Then, we will stare with all that other insurance by the method described in the Method of Sharing provision described below. Excess Insurance This insurance is excess over any other insurance, whether primary, excess, contingent or on any other basis: A. that is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar insurance for your work; B. that is insurance that applies to property damage to premises rented to you or temporarily occupied by you with permission of the owner, C. if the loss arises out of aircraft, autos or watercraft (to the extent not subject to the Aircraft, Autos Or Watercraft exclusion); D. that is insurance: provided to you by any person or organization working under contract or agreement for you; or 2. under which you are included as an insured; or E. that is insurance under any Properly section of this policy. When this insurance is excess, we will have no duty to defend the insured against any suit if any other lower has a duty to defend such insured against such suit If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. When this insurance is excess over other insurance, we will pay only our share of the amount of loss, if any, that exceeds the sum of the total: • amount that all other insurance would pay for loss in the absence of this insurance; and of all deductible and self -insured amounts under all other insurance. Liability Insurance .�AA ,w.v-------. a+( IIN REMEwED&APPR Mft. ' . `"'�;a A41u Ate, Form 17-02-3080 (Rev. 4-01) Contract _gmlw=—. Ruk Management Specialist Conditions Other Insurance We will share the remaining loss, if any, with any other insurance that is not described in this (continued) Excess Insurance provision and was not negotiated specifically to apply in excess of the Limits Of Insurance shown in the Declarations of this insurance. Method of Sharing If all of the other Insurance permits contribution by equal shares, we will follow this method also. Under this method each insurer contributes equal amounts until it has paid its applicable limits of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limits of insurance to the total applicable limits of insurance of all insurers. Premium Audif We will compute all premiums for this insurance in accordance with our rules and rates. In accordance with the Estimated Premiums section of the Premium Summary, premiums shown with an asterisk (*) are estimated premiums and are subject to audit. In addition to or in lieu of such designation in the Premium Summary, premiums may be designated as estimated premiums elsewhere in this policy. In that case, these premiums will also be subject to audit, and the second paragraph of the Estimated Premiums section of the Premium Summary will apply. Separation Of Insureds Except with respect to the Limits Of Insurance, and any rights or dudes specifically assigned in this insurance to the first named insured, this insurance applies: • as if each named insured were the only named insured; and • separately to each insured against whom claim is trade or suit is brought. Transfer Or Waiver Of We will waive the right of recovery we would otherwise have had against another person or Rights Of Recovery organization, for loss to which this insurance applies, provided the insured has waived their rights Against Others of recovery against such person or organization in a contract or agreement that is executed before such loss. To the extent that the insureds rights to recover all or pan of any payment made under this insurance have not been waived, those rights are transferred to us. The insured must do nothing after loss to impair them At our request, the insured will bring suit or transfer those rights to us and help us enforce them. This condition does not apply to medical expenses. Insurance 17-02-3080(Rev. 4-01) Contract RE,Aew & APPRovED Sr A,.gu Aoeautc Risk Management Speaetist C H U BB' General Liability Definitions WHEN USED WITH RESPECT TO INSURANCE UNDER THIS CONTRACT, WORDS AND PHRASES THAT APPEAR IN BOLD PRINT HAVE THE SPECIAL MEANINGS DESCRIBED BELOW; Advertisement Advertisement Mans an electronic, oral, written or other notice, about goods, products or services, designed for the specific purpose of attracting the general public or a specific market segment to use such goods, products or services. Advertisement does not include any e-mail address, Internet domain name or other electronic address or metalanguage. Advertising Injury Advertising injury menus injury, other thanboddy injury,property damage orpersonal injury, sustained by a person or organization and caused by an offense of infringing, in that particular part of your advertisement about your goods, products or services, upon their: • copyrighted advertisement; or • registered collective mark, registered service mark or other registered trademarked name, slogan, symbol or title. Agreed Settlement Agreed settlement means a settlement and release of liability signed by us, the imiaed and the claimant or the claimant's legal representative. Asbestos Asbestos means asbestos in any form, including its presence or use in any alloy, by-product or other material or waste. Waste includes material to be recycled, reconditioned or reclaimed. Auto Auto means a land motor vehicle, trailer or semi -trailer designed for travel on public roads, including any attached machinery or equipment. But auto does not include mobile equipment Bodily Injury Bodily injury means physical: • injury; • sickness; or • disease; sustained by a person, including resulting death, humiliation, mental anguish, mental injury or shock at any time. All such loss shall be deemed to occur at the time of the physical injury, sickness or disease that caused it. Customer Customer means a person, corporation, partnership or other entity which: • is applying for, or requesting, your products or services; • has applied for, or has requested, your products or services; • is presently using your products or services; or • has used your products or services, Liability Insurance Form 17-02-3080(Rev. 4-01J contract R AMuiage nadDMelan =+.\� REVIEWED&APPKD By: A+.�:e Auvufo Ruk Management Specialist Definitions WHEN USED WITH RESPECT TO INSURANCE UNDER THIS CONTRACT, WORDS AND PHRASES THAT APPEAR IN BOLD PRINT HAVE THE SPECIAL MEANINGS DESCRIBED BELOW: Customer and who makes a claim or brings a suit which arises out of, or is directly or indirectly related to, {continued) any of the above. Employee Employee includes a leased worker. Employee does not include a temporary worker. Financial Instruments Financial Instruments means: • currency, coins, bank notes, and bullion: • travelers checks, registered checks, food stamps, and money orders held for sale to the public: • all negotiable and non-negotiable instruments or contracts that represent either money or other property held by you in any capacity; • revenue and other stamps in current use, tickets and tokens; • property of others that you hold as a pledge or as collateral for a loan; • commodities, jewelry, precious and semi-precious stones and precious metals in any form; • insurance policies; and • certificates of origin or title, deeds, mortgages and abstracts of title. Foreclosed Property Foreclosed properly means property to which you have perfected your right to possession, or to which you have been given the deed or title, because the property was security for a loan you owned or serviced and there was a default on that loan. Hostile Fire Hostile fire means one which becomes uncontrollable or breaks out from where it was intended to be. impaired Property Impaired property means tangible property, other than your product or your work, that cannot be used or is less useful because: • it incorporates your product or your work that is known or thought to be defective, deficient, inadequate or dangerous; or • you have failed to fulfill the terms or conditions of a contract or agreement; if such property can be restored to use by: • the repair, replacement, adjustment or removal of your product m your work; or • your fulfilling the terms or conditions of the contract or agreement. Insured Insured means a person or an organization qualifying as an Insured in the Who Is An Insured section of this contract. Liahlrity Insurance Form 17-02-3080(Rev. 4-01) Contract ,�, 0 twkl�,uganauotwdat -. REVIEWED&APPROVED BY: A,. , Acwedo �. Risk Management Specialist -. C H U B B' General Liability Definitions WHEN USED WITH RESPECT TO INSURANCE UNDER THIS CONTRACT, WORDS AND PHRASES THAT APPEAR IN BOLD PRINT HAVE THE SPECIAL MEANINGS DESCRIBED BELOW: Insured Contract Insured contract A. means: 1. a lease of premises; 2. a sidetrack agreement; 3. an easement or license agreement: 4, an obligation, as required by ordinance, to indemnify a municipality, except in connection with work for a municipality; S. an elevator maintenance agreement; or 6, any other contract or agreement pertaining to your business (including an indemnification of a municipality in connection with work performed for such municipality) in which you assume the tort liability of another person or organization to pay damages, to which this insurance applies, sustained by a third person or organization. B. does not include that part of any contract or agreement that indemnifies an architect, engineer or surveyor for damages arising out of: 1. preparing, approving or failing to prepare or approve maps, drawings, opinions, reports, surveys, field orders, change orders, designs or specifications; or 2. Riving directions or instructions, or failing to give them Intellectual Property Law Intellectual property law or right means any: Or Right certification mark, copyright, patent or trademark (including collective or service marks); • right to, or judicial or statutory law recognizing an interest in, any trade secret or confidential or proprietary non -personal information: • other right to, or judicial or statutory law recognizing an interest in, any expression, idea, likeness, name, slogan, style of doing business, symbol, fide, trade dress or other intellectual property; or • other judicial or statutory law concerning piracy, unfair competition or other similar practices. Leased Worker Leased worker means a person leased to a party by a labor leasing firm, in a contract or agreement between such party and the labor leasing firm, to perform duties related to the conduct of the party's business. Leased worker does not include a temporary worker. Form 17-02-3080(Rev. 4-01) Contract Rwerreo & APPROJm nr: A-, ju Acwrdc Risk Management SpeaAht Definitions WHEN USED WITH RESPECT TO INSURANCE UNDER THIS CONTRACT, WORDS AND PHRASES THAT APPEAR IN BOLD PRINT HAVE THE SPECIAL MEANINGS DESCRIBED BELOW: Loading Or Unloading Loading or unloading: A. means the handling of property: after it is moved from the place where it is accepted for movement into or onto an aircraft, auto or watercraft; 2. while it is in or on an aircraft, auto or watercraft, or 3. while it is being moved from an aircraft, auto or watercraft to the place where it is finally delivered. B. does not include the movement of property by means of a mechanical device, other than a hand truck, that is not attached to the aircraft, auto or watercraft. Medical Expenses Medical expenses means reasonable expenses for necessary: • fast aid administered at the time of an accident; medical, surgical, x-ray and dental services, including prosthetic devices; and ambulance, hospital, professional nursing and funeral services. Mobile Equipment Mobile equipment means any of the following types of land vehicles, including any attached machinery or equipment: A. bulldozers, farm machinery, forklifts and other vehicles designed for use principally off public roads; B. vehicles maintained for use solely on premises owned by or rented to you; C. vehicles that travel on crawler treads; D. vehicles, whether self-propelled or not, maintained primarily to provide mobility to permanently mounted: 1. power cranes, shovels, loaders, diggers or drills, or 2. road construction or resurfacing equipment such as graders, scrapers or rollers; E. vehicles not described in subparagraphs A., B.. C. or D. above that are not self-propelled and are maintained primarily to provide mobility to permanently attached equipment of the following types: 1. air compressors, pumps and generators, including spraying, welding, building cleaning, geophysical exploration, lighting and well servicing equipment; or 2. cherry pickers and similar devices used to raise or lower workers; and F. vehicles not described in subparagraphs A., B., C. or D. above maintained primarily for purposes other than the transportation of persons or cargo. Mobile equipment does not include self-propelled vehicles with the following types of permanently attached equipment, and such vehicles will be considered autos: equipment designed primarily for: a. snow removal; LAN Insurance s REvexm&APPRmED8r Form 17-02-3080 (Rev. 4-011 Contract La A Acav44 ® Risk Management Speoahst NOTICE OF COMPLIANCE Contractor Mission Square Retirement Name: Project A-2011-258 Number: Project Administrative Services Agreement Name: The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: POLICY EXPIRATION TYPE OF INSURANCE COI DATE FILE NAME NUMBER DATE MissionSquare Retirement COI BANKERS PROF. LIAB. 82116261 06/30/2023 08/03/2022 Exp 8-1-23 RMD08042022.pdf MissionSquare Retirement COI GENERAL LIABILITY 36044995 08/01/2023 08/03/2022 Exp 8-1-23 RMD08042022.pdf MissionSquare WORKERS COMPENSATION AND Retirement COI 71763685 08/01/2023 08/03/2022 EMPLOYERS' LIABILITY Exp 8-1-23 RMD08042022.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team