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HomeMy WebLinkAboutBOURDELAIS LAW OFFICE 1-2012INSURANCE ON FILE WORK MAY PROCEED UliiiL INSURANCE EXPIRES N-2012-037 CLERK OF COUNCIL ppR 1 2, 2012 12/09 DATE: Agreement No. C r? A / S A v4o -K C-kr . 007-0 ON-THE-JOB TRAINING AGREEMENT UNDER THE WORKFORCE INVESTMENT ACT THIS AGREEMENT is made and entered into this 14«' day of March, 2012 between the City of Santa Ana, a charter city and municipal corporation duly organized and existing under the Constitution and laws of the State of California (hereinafter "CITY") and Bourdelais Law Office (hereinafter "EMPLOYER"). WITNESSETH Recitals: A. CITY has been designated a Local Workforce Investment Area ("LWIA") pursuant to Section 116 of the Workforce Investment Act ("WIA"), P.L. 105-220, 29 USC Section 2801, to receive federal funds to promote effective delivery of job training services to local area residents. B. The State of California has created the California Workforce Investment Board pursuant to Section 111. of the Workforce Investment Act, P.L. 105-220, 29 USC 2821 to administer the WIA programs operated by the State of California. C. As a LWIA, CITY is entitled to receive federal funds to establish programs to prepare eligible unskilled youth, adults and dislocated workers for entry into the labor market, and to provide job training to those individuals who face serious barriers in obtaining productive employment ("said Program"). D. EMPLOYER is able and willing to train eligible unskilled applicants for entry into the labor market and is willing to operate said prograrn pursuant to the WIA and applicable federal, state and local laws. WHEREFORE, for and in consideration of the respective and mutual covenants and promises hereinafter contained and made, and subject to all the terms and conditions hereof, the parties hereto do hereby agree as follows: 1. Term. The effective term of this Agreement is for the period beginning Monday, March 19"', 2011, and ending June 22"d , 2012. The terns of this Agreement may be extended upon agreement of all parties and execution of an amendment of the term. 2. Scope of Work. The EMPLOYER shall employ and train one employee (hereinafter "Trainee") in the occupation and in accordance with the OJT Training Outline set forth in Exhibit A, attached hereto and incorporated herein by this reference. Said Trainee shall be referred by the City of Santa Ana W/O/R/K Center. Training must significantly raise the Trainee from his/her prior position in both level of skill and salary by the end of the training period. 3. Funding. CITY shall reimburse the EMPLOYER an amount not to exceed $2,600 in accordance with the Cost Computation included in Exhibit A. EMPLOYER shall bill the CITY monthly on an invoice provided by CITY for actual and reasonable cost for providing the services described in this Agreement. Reimbursement of EMPLOYER under this Agreement shall be limited to the costs incurred during the basic work week, excluding overtime and any paid holidays or sick leave. 1 1 2/09 Reimbursement of EMPLOYER under this Agreement shall be limited to the costs incurred during the basic work week, excluding overtime and any paid holidays or sick leave. 4. Subcontractine Prohibited. The EMPLOYER shall not subcontract or assign the OJT Training. Any attempt by the EMPLOYER to delegate or assign OJT training duties under this Agreement shall void, and permit CITY to immediately terminate, this Agreement. 5. Emnloyer Obligations. During the training, the EMPLOYER shall ensure that the Trainee: a. is on the EMPLOYER'S payroll, not paid as a contracted employee/independent contractor; and, b. receives the same benefits as EMPLOYER'S other employees performing similar work; and, c. is paid the salary as indicated in Exhibit A with appropriate payroll taxes withheld and reported; and, d. is provided Worker's Compensation Insurance coverage, pursuant to state law; and, e. is provided by EMPLOYER with safety instructions and equipment necessary for reasonable protection against injury and damage. CONTRACTOR shall maintain appropriate standards for health and safety in work and training situations. Where special clothing or equipment is provided to the EMPLOYER'S regular employees, EMPLOYER shall provide the same type of clothing or equipment to the Trainee performing similar work. 6. Emnlovment of Trainee. The EMPLOYER shall employ the Trainee as a regular member of EMPLOYER'S work force. If EMPLOYER wants to continue to employ the Trainee upon the successful completion of the training period under this Agreement, said employment shall be subject to the same conditions of employment applied to EMPLOYER's other regular employees, including termination for unsatisfactory performance. 7. Patent. Copyrights and Rights in Data. The EMPLOYER will disclose to the CITY any invention, written product, computer program developed or data assembled as a result of performance of work under this Agreement within seventy four (74) days of invention, development or assembly. The CITY, State of California, and U.S. Department of Labor will have the right to patent any invention and copyright any written product or computer program or data generated by EMPLOYER. Upon written request, EMPLOYER will transfer all pertinent information, specifications and right, title and interest to the designated agency. INVENTIONS, PATENTS AND COPYRIGHTS. A. Reporting Procedure. If any project produces patentable items, patent rights, processes, or inventions in the course of work under a U.S. Department of Labor (DOL) grant or agreement, the CONTRACTOR shall report the fact promptly and fully to the CITY. The CITY shall report the fact to the Grant Officer, at the DOL. Unless there is a prior agreement between the CITY and the DOL and its representative on these matters, the DOL shall determine whether to seek protection on the invention or discovery. The DOL and its representative shall determine how the rights in the invention or discovery, including rights under any patent issued thereon, will be allocated and administered in order to protect the public interest consistent with the "Governmental Patent Policy" (President's Memorandum for Heads of Executive Departments and Agencies, August 23, 1971, and Statement of Goveinnient Patent Policy). 2 B. Copyright Policy. 12/09 1. Unless otherwise provided in the terms of the grant or agreement, when copyright-able material is developed in the course of or under a DOL Grant or agreement, the author and the CITY which developed the work is free to copyright material or to permit others to do so. The EMPLOYER and the Workforce Investment Board (WIB) shall have aroyalty-free, nonexclusive and irrevocable license to reproduce, publish, use and to authorize others to use all copyrighted material. 2. The DOL reserves aroyalty-free, nonexclusive, and irrevocable license to reproduce, publish or otherwise use, and to authorize others to use, for Federal Government purposes: (a) The copyright in any work developed under any grant, sub-grant, or contract under a grant or subgrant; (b) Any right of copyright to which a grantee, subgrantee or a EMPLOYER purchases ownership with grant support; and (c) EMPLOYER shall comply with the requirements of 29 CFR Part 97.34. C. Rights to Data. The DOL and the CITY shall have unlimited rights to any data first procured or delivered under this Agreement. 9. Hold Harmless. The EMPLOYER shall indemnify, defend and hold harmless CITY, and its officers, agents and employees, from and against any and all damages to property or injuries to or death of any person or persons, including property and employees or agents of CITY, and shall indemnify, defend and hold harmless CITY, and its officers, agents and employees, from any and all claims, demands, suits, actions or proceedings of any kind or nature, including, but not limited to, workers' compensation claims, resulting from or arising out of the negligent acts, errors or omissions of EMPLOYER, its employees, agents or subcontractors. 1 O. Insurance. The EMPLOYER shall obtain at its sole cost and file with the City of Santa Ana -Santa Ana W/O/R/K Center, upon execution of this Agreement, and maintain for the period covered by this Agreement, a policy or policies of commercial general liability insurance or a certificate of such insurance, satisfactory to the City Attorney of CITY, naming CITY, and its officers, agents and employees, as insured or additional insured (see attached Additional Insured Endorsement, Exhibit C), which provides coverage not less than that provided in the form of a comprehensive general liability insurance policy against liability for any and all claims and suits for damages or injuries to persons or property resulting from or arising out of operations of EMPLOYER, and its officers, agents, or employees. Said policy or policies of insurance shall provide coverage for both bodily injury and property damage in no less than One Million Dollars ($1,000,000). Said policy or policies shall also contain a provision that no termination, cancellation or change of coverage or of insured or additional insured shall be effective until after thirty (30) days notice thereof has been given in writing to CITY. EMPLOYER shall give to CITY prompt and timely notice of claims made or suit instituted against said policy. EMPLOYER shall procure and maintain at its own costs and expense, any additional kinds and amounts of insurance which, in its own judgment, may be necessary for its proper protection. 11. Record Keenine. CITY, the State of California and the United States government and/or their representatives shall have access for purposes of monitoring, auditing and examining of EMPLOYER'S activities, performance, books, documents, papers, and records of EMPLOYER'S subcontractors, bookkeepers and accountants, and employees and participants related to this Agreement. Such agencies or representatives shall also schedule on-site monitoring in their discretion. Monitoring activities may also include, but are not limited to, questioning employees and participants and entering any premises or onto any site in which any of the services or activities funded hereunder are conducted or in which any of the records of EMPLOYER are kept. Nothing herein shall be construed to require access to any privileged or confidential information as set forth in federal or state law. 3 12/09 In the event EMPLOYER does not make the above-referenced documents available within the City of Santa Ana, California, EMPLOYER agrees to pay all necessary and reasonable expenses incurred by CITY in conducting any audit at the location where said records and books of account are maintained. All accounting records and evidence pertaining to all costs of EMPLOYER and all documents related to this Agreement shall be kept available at the location where EMPLOYER conducted the program, as well as in the County of Orange, for the duration of this Agreement and thereafter for three (3) years after completion of an audit. Records which relate to (a) complaints, claims, administrative proceedings or litigation arising out of the performance of this Agreement, or (b) costs and expenses of this Agreement to which CITY, the State of California or the United States Government take exception, shall be retained beyond the three (3) years until resolution of disposition of such appeals, litigation, claims, or exceptions. 12. Government Fundin>?. This Agreement is valid and enforceable only if sufficient funds are made available to the State by the United States Government for the same Fiscal Year as for this Program. In addition, this Agreement is subject to any additional restrictions, limitations, or conditions enacted by Congress or any statute enacted by Congress which may affect the provision, terms or funding of this Agreement in any manner. 13. Payment Can. City's OJT payments to EMPLOYER shall not exceed a maximum of fifty percent (50%) of the wages paid by EMPLOYER during the training period specified in Exhibit A. 14. Amendment of Agreement. No alteration or variation of the terms of this Agreement shall be valid and/or binding unless made in writing and signed by both parties. There are no oral understandings or agreements between the parties. 15. Breach/Sanctions. If, through any cause, EMPLOYER violates any of the terms and conditions of this Agreement, or if EMPLOYER reports inaccurately or if any Audit Report makes disallowances, EMPLOYER shall promptly remedy its acts or omissions and/or repay CITY all amounts due CITY as a result of EMPLOYER's violation. For any such failures or violations, CITY shall also have the right at its sole discretion to either: (1) discontinue program support until such time as EMPLOYER fulfills its obligations or remedies all violations of this agreement or prior agreements; and/or (2) collect outstanding amounts as determined by CITY due CITY by offsetting or debiting from current claims or invoices, if after thirty (30) days' written notice EMPLOYER has failed to repay same or a repayment schedule has not been made; and/or (3) terminate this Agreement by giving written notice to EMPLOYER of such termination in accordance the notice provision in Paragraph XVIII herein below. 16. Termination. Either party may terminate this Agreement upon thirty (30) days prior written notice to the other party. However, the CITY may immediately terminate this Agreement at such time as funds are not made available to CITY through the United States Department of Labor or the State of California Employment Development Department for the purpose of carrying out this Agreement. 17. Independent Contractor. The EMPLOYER, and any agents and employees of the EMPLOYER, in the performance of this Agreement, shall act in an independent capacity as independent contractors and not as officers, employees, or agents of the CITY. This Agreement is not intended nor shall it be construed to create an employer-employee relationship between EMPLOYER and CITY, nor a joint venture relationship. The EMPLOYER shall not subcontract in the name of the CITY. 1 8. Equal Employment Opportunities. The EMPLOYER warrants that it will comply with Title VI of the 4 12/09 Civil Rights Act of 1964, and the requirements relating to equal employment opportunities set forth in Executive Order No. 11246, as amended by E.O. 11375 and supplemented by the requirements of 41 CFR Part 60. EMPLOYER will also comply with all applicable federal and state laws and regulations, and particularly those assurances and certifications set forth in Exhibit B attached hereto and by this reference incorporated herein. 19. Prohibitions. The EMPLOYER shall not use any of the training funds provided under this Agreement for political or sectarian activities. 20. Grievance Procedure. The EMPLOYER shall continue to operate, or shall establish and maintain a grievance or complaint handling procedure relevant to the terms and conditions of employment and the EMPLOYER'S activities and programs, which shall meet at a minimum the requirements set forth in Section 1 O 1(31) of the Act and 663.700-71 O and regulations promulgated by the State or Federal Goverrunent. Employers that do not have a grievance or complaint handling procedure shall use the procedures prescribed by the CITY. 21. Guidelines. The CITY shall make the WIA applicable federal regulations and policy guidelines available to EMPLOYER at CITY - W/O/R/K Center, 1000 E. Santa Ana Blvd., Suite 200, Santa Ana, California 92701. The CITY shall also inform the EMPLOYER of changes in the WIA regulations or policy guidelines if such changes affect the operation of this Agreement. 22. Drug Free Workplace. The EMPLOYER agrees to provide a drug-free work place and to execute a certification as set forth in Exhibit D attached hereto and incorporated herein by this reference. 23. Notices. All notices, reports and correspondence between the parties hereto respecting this Agreement shall be in writing and deposited in the United States mail, postage prepaid, addressed as follows: CITY: City of Santa Ana -Santa Ana W/O/R/K Center 1000 E. Santa Ana Blvd.. Suite 200 Santa Ana. CA 92701 Attention: WORK Center Director EMPLOYER: Scott Bourdelais Bourdelais Law Center 2060 N. Tustin Ave. Santa Ana, CA 92705 24. Debarment. To protect the public interest and ensure the integrity of Federal programs, CITY may only conduct business with responsible persons and may not make any award or permit any award to any party which is debarred or suspended or is otherwise excluded from or ineligible for participation in Federal assistance programs under Executive Order 12549, "Debarment and Suspension". See also 29 CRF Parts 97.35 and 98.510. EMPLOYER must review and sign Exhibit E "Debarment", which is attached hereto and incorporated herein by this reference. 12/09 24. Mercer. This Agreement, together with the attachments hereto, expresses the total understanding of the parties. There are no oral understandings of the parties or terms and conditions other than as stated herein. 25. Validity. The invalidity in whole or in part of any provision of this Agreement shall not void or affect the validity of any other provision of this Agreement. 26. Miscellaneous Provisions. a. Each undersigned represents and warrants that its signature hereinbelow has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify CITY fully, including reasonable costs and attorney's fees, for any injuries or damages to CITY in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 6 i zioy IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: Maria D. Huizar G "' Clerk of the Council CITY OF SANTA ANA Paul Walters Interim City Manager APPROVED AS TO FORM: Lisa Storck Assistant City Attorney ? +? y:l L1Sa SYOrCk Assistant City Attorney RECOMMENDED FOR APPROVAL: Nancy T. Edwards Interim Executive Director Community Development Agency EMPLOYER: Name: Scott Bourdelais Title: Attorney at Law Federal Tax ID#: 368-0203 State Tax ID#: 3 3-03 791 1 7 7 Agreement # Exhibit A TRAINING PLAN I. GENERAL 1 . Name of OJT Employer: Bourdelais Law Office 2. Address of OJT Work-site: 2060 N. Tustin Ave.. Santa Ana, CA 92705 3. Phone Number: 714.541.9569 4. Training Supervisor: Scott Bourdelais 5. Name of OJT Trainee: Denisse Betancourt 6. Application Number of Trainee: N/A 7. Proportion of trainees/employees: (at time Agreement entered into) a. Total number of employer's regular employees 2 c. Cumulative number of trainees currently in OJT 1 II. OCCUPATION AND ON-THE-JOB TRAINING OUTLINE: 1. Vendor #: N/A 2. Occupation/Product or Service: Law Office 3. Length of Time in Business: 28 years 4. ONET Code: Data Entry/ 43-9021.00 SVP Level (4.0 to <6.0) 5. Hourly Starting Wage: ? 10.00 Start Date: 3/19/2012 End Date: 6/22/2012 Hours 520 or Days or Weeks 6. State and Federal Tax LD.: State: 368-0203 Federal: 3 3 -03 79 1 1 7 7. Basic Work Week Hours: 40 1 OUTLINE OF ON-THE-JOB TRAINING PLAN AND METHOD OF ASSESSMENT: ELEMENTS OF TRAINING HOURS OF TRAINING I• 120 A. Will be trained to support the practice by developing exceptional customer service. Develop client relationship through a courteous and prompt customer interaction. B. Practical knowledge and development of law practice, including language, forms, etc. C. Familiarize with different types of clientele, and how to deal with each of their needs. D. Work effectively within legal environment to meet their guidelines and expectations. Measurement Method: Q 8c A, task observation and inspection. Goal is to achieve rate of proficiency within first Month and a half of training. 2. A. Will be trained in Wordperfect, trained to utilize program, develop 250 documents and create charts and spreadsheets. B. Will be training in Paperport, for scanning, organizing and sharing documents. C. Will be trained on HotDocs, for web editing. D. Will be trained in Quickbooks, for accounting. Measurement Method: Q St A, task observation and inspection. Goal is to achieve rate of proficiency within subsequent three and a half months. 3. A. Client must learn to develop rapport with the elderly, as many of the client 150 base will fit this profile. B. Client will learn the basics on Estate Planning to better assist clients, basics such as locating and organizing records, inventory assets and inventory insurance policies and beneficiary designation. Well develop basic knowledge of inventory pension and retirement plans, etc. Client's knowledge will be limited only to being able to assist clients with documentation necessary for attorney to be able to better assist clients. RATING LEVELS: Measurement method: how will it be determined if OJT participant acquired the skill? QBcA, observation, product review/inspection, etc. PROFICIENT MODERATE MARGINAL II. COST COMPUTATION Example: Hourly Reimbursement at 50% $ 5.00 Hours 520 cost Per Trainee 4 72r-ws _ $ 2,600.00 III. Person(s) authorized to sign payment invoices for EMPLOYER: sIL Print Name Print Name ignature Title Date Signature Title Date EXHIBIT B ASSURANCES A. The EMPLOYER assures that: 1. It will comply with the requirements of the Workforce Investment Act (WIA), the California Unemployment Insurance Code, as amended, and the regulations and policies promulgated thereunder. 2. No OJT participant displaces a regular employee nor shall an OJT participant fill a position of a person who has been laid off from the same or similar position. 3. No current employees are receiving unemployment insurance benefits as a result of layoffs or work reductions. 4. No person in the United States shall on the grounds of race, color, sex, religion, national origin, age, disability, sexual orientation, or marital status be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the applicant receives federal financial assistance and will immediately take any measure necessary to effectuate this Agreement. 5. It will comply with provisions of the Hatch Act, if applicable, which limits the political activities of employees. 6. Individuals receiving training on the job shall be compensated by the EMPLOYER at such rate, including periodic increases, as may be deemed reasonable under regulations prescribed by the Secretary of Labor, but in no event at a rate less than that specified in Section 6 (a) (1) of the Fair Labor Standards Act of 1938 or, if higher, under the applicable State or local minimum wage law. 7. Services and activities provided under this Agreement will be administered by or under the supervision of the EMPLOYER. 8. No relative by blood, adoption or marriage' of the EMPLOYER may be trained under this Agreement. 9. Appropriate standards for health and safety in work and training situations will be maintained. 10. Conditions of employment or training are appropriate and reasonable with regard to the type of work, the geographical region, and the proficiency of the trainee. 1 1 . Training will not be for any occupation which requires less than six weeks of training according to the Specific Vocational Preparation Table (SVP Code). 12. Training will, to the maximum extent practicable, be consistent with every individual's fullest capabilities and lead to employment possibilities. 13. The program will, to the maximum extent feasible, contribute to the occupational development or upward mobility of individual participants. 14. Training will be in accordance with the training plan, which plan incorporates documentation that must be completed by EMPLOYER before end of contract. 15. *Dot and **SVP code books will be used to determine length of OJT period. The training time may not be longer than the SVP Code allows; however, contractors are encouraged to negotiate shorter training periods whenever applicable. 16. All EMPLOYER training payments (reimbursements) must be exclusive of any and all EMPLOYER fringe benefits, paid holidays, paid sick days and overtime compensation. 17. The participating EMPLOYER must keep an accurate and up-to-date time sheet for the OJT trainee. 18. Payroll records, time and attendance records and job duties retained on file by the participating EMPLOYER for each OJT trainee are subject to review. Service Provider Signature Date Print First Name Print Last Name Organization Name Organization Address z?" ? ?'`?? °? CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YVYY) 03/ 12/20'12 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 pollcy(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 CONTACT AFFINITY INSURANCE SERVICES INC PHONE Fax A/C No Ext BBB 66'1-3933 A/C No 386 672-692'1 159 E COUNTY LINE RD E-MAIL HATBORO PA 19040 D Servica.mnte lers.corn , (888) 661-3938 PRODUCER 1 353 0 31 01 x051 7 700 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A:TRAVELERS PROPERTY GA3VALTY COMPANY OF AMERICA SCOTT A BOURDELAIS, INSURER B: ATTORNEY AT LAW INSURER C: 2060 N TUSTIN AVE SANTA ANA CA 27 INSURER D: , 9 05 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1 7573921 5431 950 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANV 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. LTR TYPE OF INSURANCE ADDL INSR SUBR POLICY NUMBER POLICY EFF MM/DDNYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABIITY X 680-35 F63659-1 1 06/01 /201 1 06/01 /201 2 EACH OCCURRENCE $1 OOO OOO X COMMERCIAL GENERAL LIABILITY DAMA RENT D P EM E o $300,000 CLAIMS-MADE ? OCCUR MED EXP An one arson $5 000 X HIRED AVTO PERSONAL 8 ADV INJURY $ 1 .000,000 X NON OWNED AUTO GENERAL AGGREGATE $2 000 DOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $2.000,000 PRO- x POLICY JECT LOC $ AU TOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accitlant) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accltlenl) $ HIRED AUTOS --?,? /f(( L.O?lY> LL PP eO ac RtlTY DAMAGE NON-OWNED AUTOS ?? T? $ RoV $ UMBRELLA LIAB OCCUR ? _ EACH OCCURRENCE $ E%CESS LIAB CLAIMS-MADE ? g-T OR K AGGREGATE $ DEDUCTIBLE L? A E ?ty P.tt C n2Y $ RETENTION $ ? t .. tan WORKERS COMPENSATION ' N/A ? / WC STATU- OTH TORY LIMITS ER AND EMPLOYERS LIABILITY Y/N ANY PROPRIETOR/PARTNE R/EXECUTIVE ? E.L. EACH ACCIDENT $ ? OFFIC ER/MEMBER EXCLUDED (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe untler SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 10t, Addlflonal Remarks Schedule, If more space Is r¢qulr¢d) AS RESPECTS TO GENERAL LIABILITY, CITY OF SANTA ANA, ITS OFFICERS, AGENTS AND EMPLOYEES IS ADDITIONAL INSURED -VENDORS BROAD FORM CG T3 30. I:CK I Ir-IGA I E nOLOEK GAN GELLA7 ION CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATTN: PURCHASING DEPARTMENT EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE 20 CIVIC CENTER PLAZA WITH THE POLICY PROVISIONS. SANTA ANA, CA 92701 AUTHORIZED REPRESENTATIVE ( ? ? • ?_'Tr ©'1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY POLICY NUMBER: 2-6H0-35F63659-TSL-11 ISSUE DATE: 03-09-12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -VENDORS BROAD FORM This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART CITY OF SANTA ANA, ITS OFFICERS, AGENTS A. SCHEDULE Name of Person or Organization (Vendor): AND EMPLOYEES 20 CIVIC CENTER SANTA ANA CA 92701 Your products: ATTORNEY SERVICES distributed or sold in the regular course of the turer, and then repackaged in the (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) B. PROVISIONS c. Any physical or chemical change in the WHO IS AN INSURED (Section II) is amended to product made intentionally by the ven- include as an insured any person or organization dor; (referred to below as "vendor") shown in the d. Repackaging, unless unpacked solely for Schedule, but only with respect to "bodily injury" the purpose of inspection, demonstra- or "property damage" arising out of "your tion, testing, or the substitution of parts products" shown in the Schedule which are under instructions from the manufac- vendor's business subject to the following original container; additional provisions: e. Demonstration, installation, servicing or 1. The insurance afforded the vendor does not repair operations, except such opera- apply to: tions performed at the vendor's premises a. "Bodily injury" or "property damage" for in connection with the sale of the which the vendor is obligated to pay product; damages by reason of the assumption of f. Products which, after distribution or sale liability in a contract or agreement. This by you, have been labeled or relabeled exclusion does not apply to liability for or used as a container, part or ingredient damages that the vendor would have in of any other thing or substance by or for the absence of the contract or agree- the vendor; ment; g. The sole negligence of the vendor. b. Any express warranty, or any distribution.,,-,M 2. or sale for a ur ose ur theV0 This insurance does not apply to any insured p p y you; ? BgRe person or organization, from whom you have ( A acquired such products, or any ingredient, RGK STO part or container, entering into, accompany- i i h d t i t ?Sq E. Attorney ng or con a n ng suc pro uc s. ?s?stant City Includes copyrights material of Insurance Se ices Office, Inc., with its permission ) CG T3 30 11 88 (Rev. 12-95) Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: I-680-35F63659-TIL-11 ISSUE DATE: 03-09-12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART NAME OF PERSON(S) OR ORGANIZATION(S): SCHEDULE CITY OF SANTA ANA, 2TS OFFICERS, AGENTS AND EMPLOYEES 20 CIV2C CENTER PLAZA SANTA ANA, CA 92701 PROJECT/LOCATION OF COVERED OPERATIONS: ATTORNEY SERVICES 1. WHO IS AN INSURED - (Section II) is amended b) The insurance provided to the additional to include the person or organization shown in the sured does not apply to "bodily injury", "prop- Schedule above, but: erty damage" or "personal injury" arising out a) Only with respect to liability for "bodily injury", of the rendering of, or failure to render, any "property damage" or "personal injury"; and professional architectural, engineering or sur- veying services, including: b) If, and only to the extent that, the injury or damage is caused by acts or omissions of i. The preparing, approving, or failing to you or your subcontractor in the performance prepare or approve, maps, shop draw- of "your work" on or for the project, or at the ings, opinions, reports, surveys, field or- Iocation, shown in the Schedule. The person ders or change orders, or the preparing, or organization does not qualify as an addi- approving, or failing to prepare or ap- tional insured with respect to the independent prove, drawings and specifications; and acts or omissions of such person or organiza- ii. Supervisory, inspection, architectural or tion. engineering activities. 2. The insurance provided to the additional insured c) The insurance provided to the additional in- by this endorsement is limited as follows: sured does not apply to "bodily injury" or a) In the event that the Limits of Insurance of "property damage" caused by "your work" " this Coverage Part shown in the Declarations products-completed op- and included in the " " exceed the limits of liability required by a erations hazard unless a written contract " "written contract requiring insurance" for that specifically requires you requiring insurance additional insured, the insurance provided to to provide such coverage for that additional the additional insured shall be limited to the insured, and then the insurance provided to limits of liability required by that "written con- the additional insured applies only to such tract requiring insurance". This endorsement "bodily injury" or property damage' that oc- shall not increase the limits of insurance de- curs before the end of the period of time for scribed in Section III - LimitV0 h the "written contract requiring insur- 1?g[vXgj AS TO ance" re uires rovide such covera e ou to g q y p LISA E. STORCK gssi tant City Attorney g CG D2 47 08 05 0 2005 The t. Paul Travelers C ompaphies, Inc. Page 1 of 2 COMMERCIAL GENERAL LIABILITY or the end of the policy period, whichever is earlier. 3. The insurance provided to the additional insured by this endorsement is excess over any valid and collectible "other insurance", whether primary, excess, contingent or on any other basis, that is available to the additional insured for a loss we cover under this endorsement. However, if a "written contract requiring insurance" for that ad- ditional insured specifically requires that this in- surance apply on a primary basis or a primary and non-contributory basis, this insurance is pri- mary to "other insurance" available to the addi- tional insured which covers that person or organi- zation as a named insured for such loss, and we will not share with that "other insurance". But the insurance provided to the additional insured by this endorsement still is excess over any valid and collectible "other insurance", whether pri- mary, excess, contingent or on any other basis, that is available to the additional insured when that person or organization is an additional in- sured under such "other insurance". 4. As a condition of coverage provided to the additional insured by this endorsement: a) The additional insured must give us written notice as soon as practicable of an "occur- rence" or an offense which may result in a claim. To the extent possible, such notice should include: i. How, when and where the "occurrence" or offense took place; ii. The names and addresses of any injured persons and witnesses; and iii. The nature and location of any injury or damage arising out of the "occurrence" or offense. b) If a claim is made or "suit" is brought against the additional insured, the additional insured must: i. Immediately record the specifics of the claim or "suit" and the date received; and ii. Notify us as soon as practicable. The additional insured must see to it that we receive written notice of the claim or "suit" as soon as practicable. c) The additional insured must immediately send us copies of all legal papers received in connection with the claim or "suit", cooperate with us in the investigation or settlement of the claim or defense against the "suit", and otherwise comply with all policy conditions. d) The additional insured must tender the de- fense and indemnity of any claim or "suit" to any provider of "other insurance" which would cover the additional insured for a loss we cover under this endorsement. However, this condition does not affect whether the insur- ance provided to the additional insured by this endorsement is primary to "other insur- ance" available to the additional insured which covers that person or organization as a named insured as described in paragraph 3. above. 5. The following definition is added to SECTION V. - DEFINITIONS: "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or organization as an additional in- sured on this Coverage Part, provided that the "bodily injury" and "property damage" oc- curs and the "personal injury" is caused by an offense committed: a. After the signing and execution of the contract or agreement by you; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. 1gpPROVF{D ?A?S TQ ?'ORNi LISA E. STORCK Assistant City Attorney Page 2 of 2 ©2005 The St. Paul Travelers Comp-anies, Inc CG D2 47 08 05 POLICY NUMBER: 2-680-35F63659-T2L-11 ISSUE DATE: 03-09-12 THIS ENDORSEMENT CHANGES THE POLICY- PLEASE READ IT CAREFULLY- DESIGNATED ENTITY - EARLIER NOTICE OF CANCELLATION/NONRENEWAL PROVIDED BY US This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCELLATION: Number of Days Notice: 30 WHEN WE DO NOT RENEW (Nonrenewal): Number of Days Notice: NAME: C2TY OF SANTA ANA, 2TS OFFICERS, AGENTS AND EMPLOYEES ADDRESS: 20 C2V2C CENTER PLAZA SANTA ANA A_ B. CA 92701 For any statutorily permitted reason other than nonpayment of premium, the number of days re- quired for notice of cancellation, as provided in the CONDITIONS Section of this insurance, or as amended by any applicable state cancellation endorsement applicable to this insurance, is in- creased to the number of days shown in the SCHEDULE above. For any statutorily permitted reason other than nonpayment of premium, the number of days re- quired for notice of When We Do Not Renew (Nonrenewal), as provided in the CONDITIONS Section of this insurance, or as amended by any ILT3540398 applicable state When We Do Not Renew (Nonrenewal) endorsement applicable to this in- surance, is increased to the number of days shown in the SCHEDULE above. C. We will mail notice of cancellation or nonrenewal or material limitation of those coverage forms to the person or organization shown in the schedule above. We will mail the notice at least the Num- ber of Days indicated above before the effective date to our action. APPRO? A8 TO FOPM ?(/?Q?_ LISA E. STORCK Assistant City Attor?ey 3 `? Copyright, The Travelers Indemnity Company, '1998 Page 1 of 1 EXHIBIT D Certification Regarding Drug-Free Workplace Requirements The certification set out below is a material representation upon which reliance is placed by the U.S. Department of Housing and Urban Development in awarding the grant. If it is later determined that the contractor knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the U.S. Department of Housing and Urban Development, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act. CERTIFICATION A. The contractor certifies that it will provide adrug-free workplace by: (a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the contractor's workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing adrug-free awareness program to inform employees about - (1) The dangers of drug abuse in the workplace; (2) The contractor's policy of maintaining adrug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance program; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (c) Making it a requirement that each employee who will be engaged in the performance of the grant be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph -(a) that, as a condition of employment under the contract, the employee will - (1) Abide by the terms of the statement; and (2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction. Pg. 2 EXHIBIT D (e) Notifying the U.S. Department of Housing and Urban Development within ten days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction; (f) Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted - ( 1) Taking appropriate personnel action against such an employee, up to and including termination; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain adrug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f). B. The contractor shall insert in the space provided on the attached "Place of Performance" form the site(s) for the performance of work to be carried out with the grant funds (including street address, city, county, state, and zip code) .the contractor further certifies that, if it is subsequently determined that additional sites will be used for the performance of work under the contract, it shall notify the U.S. Department of Housing and Urban Development immediately upon the decision to use such additional sites by submitting a revised "Place of Performance" form. Dated: ? 1 (ate ? ? y,:O`!/!?-'? _- Program Operator EXHIBIT ? DIVISION OF EMPLOYMENT SERVICES PLACE OF PERFORMANCE FOR CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS Name of Contractor: The Contractor shall insert in the space provided below the site(s) expected to be used Contractor Number: Date: ?? ??J 1 4?-- for the performance of work under the contract covered by the certification: Place of Performance (include street address, city, county, state, zip code for each site): 02 v (0 C? J?? 1 ?,lS-t-? Yl ??r? -1-ice EXHIBIT E Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 29 CFR Part 98, Section 98.510, Participants' responsibilities. The regulations were published as Part VII of the May 26, 1988 Federal Register (pages 19160-19211). (BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS FOR CERTIFICATION - Attached) (1) The prospective recipient of federal assistance funds certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency. (2) Where the prospective recipient of federal assistance funds is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Name and Title of Authorized Representative Signature Date INSTRUCTIONS FOR CERTIFICATION 1. By signing and submitting this proposal, the prospective recipient of federal assistance funds is providing the certification as set out below. 2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective recipient of federal assistance funds knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the Department of Labor (DOL) may pursue available remedies, including suspension and/or debarment. 3. The prospective recipient of federal assistance funds shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective recipient of federal assistance funds learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. 5. The prospective recipient of federal assistance funds agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the DOL. 6. The prospective recipient of federal assistance funds further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and voluntary exclusion - Lower Tier Covered Transactions," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to check the List of Parties Excluded from Procurement or Non- Procurement Programs. 8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the DOL may pursue available remedies, including suspension and/or debarment. On the Job Tra i n ing Pre Award Survey ? ?? ? BUSINESS NAME: Gl l S? l?"? l?1-//G < STATE TAX I.D. # ?? ? l ?z? ? ADDRESS: . )QS FEDERAL TAX LD. # 3?J --0? ?G/?/ ?? YES NO 1. The business does prow de worker's compensation coverage. ?'? ? Policy Number: 3 ?? ?- ? ?T ? - 1 I 2. The business does provide General Liability Insurance in the amount of ? ? One Million Dollars ($1,000,000). Policy must identify the City of Santa Ana as the certificate holder. 3. The system used for business accounting does document cash received, state and federal tax withholdings, FICA deductions. [G? ? 4. The business has not been cited for any health, safety, wage and hour, or child labor violations during the past 12 months. ? ? 5. The business maintains a grievance and/or complaint handling procedures for ?' ? employees. 6. The prospective OJT client is not a former employee of the business. ?? ? 7. Wages for the planned OJT position are wages comparable to similar positions. ?' 8- A written job description for this position is on file. ®/ ? 9. Union concurrence has been obtained. ? ? F? 1 O. Business license is current. (? ? 1 1. The business has not had any employees laid off in the past 6 months. ? ? 12. The business is financially stable and has the means to train and pay for the prospective OJT employee. ?? ? The employer stipulates and agrees by signing below that the establishment in whic h on-the job training will be given: (1) Is not a branch, affiliate or subsidiary of a business entity in another location which has, at any time subsequent to the date of the OJT contract, relocated or expanded so as to cause an increase in unemployment or the closing down of operations in which the entity conducts business operations. TOTAL WORKFORCE # CONTRACT RECOMMENDED YESV? NO ? Comments: Employer Title Date Program Supervisor/Director Date On the Job Training Agreement Checklist BUSINESS NAME: ?'j()?'???a•S LCIi,l) YES NO 1. Pre Award Survey ? 2. OJT Agreement Template: Training dates (pg 1), reimbursement rate (pg 1), and ? maximum reimbursement amount (pg 4), and Employer Info (pg 5) match Exhibit A-Training Plan. 3. Exhibit A: Training Plan XOJT's to employees do not exceed 1-5 ratio ?,hs cJ ° 1 ? `RSVP Level is => 3+ Hours of Training are reasonable Cost Computation is in accordance hourly wage 5001. of wages or sliding scale based on number of employees per DOL waiver. ,Signed by Employer 4. Exhibit B: Assurances 12f ? 5. Exhibit C: Insurance commercial/workers comp for 1,000,000 with Additional ? Insured Endorsement naming City of Santa Ana as Additional Insured. 6. Exhibit D: Drug Free Workplace Form completed and signed. ? 7. Exhibit E: Debarment Certification signed. / ? 8. File: ? ADA Survey EEO & Grievance Procedures 9. Three copies of agreement and canary routing slip attached ? Comments: (2 ?? _3/ 14 1 -,;I-o vz- Program Supervisor Date `?`? ° CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/VYYY) 08/l O/20? 2 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 ADDITIONA INSEDa,ti thA j?olicy(ies) must ba endorsed. If SUBROGATION is WAIVED, subject to the terms and conditions of the policy, certair?(q?ir?n?re a ?n aildorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemerfi?t?Ys`'f- PRODUCER I "r'r (? CONTACT NAME' . , t 1"? AFFINITY INSURANCE SERVICES INC CITY PHONE FAX (r ? 1 1 q (A/C, No, Ex U: (B08) 661-3938 IA/C, No): 1988) 872-9921 . l59 E COUNTY LINE RD ?L?ti _ , ''??gc L E-MAIL HATBO RO, PA "19040 service.centar@vavelars.com (888) 661 -3938 PRODUCER ' 1656C6tOt T M R p- X051 7 700 INSU RERI S) AFFORDING COVERAGE NAIC l/ INSURED INSURER A:TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA SCOTT A BOURDELAI S, d? l? ?t p?y /^1?? /? ? +( ATTORNEY AT LAW ' ?? INSURER B: .. ? JVJ /- /V ?OL? i 2060 N TUSTIN AVE INSURER C: SANTA ANA CA 92705 INSURER D: , INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 51 544880535 7 322 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANV 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 INSR SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/VYYY LIMITS A GENERAL LIABIITY X 680-35F63659-1 2 06/01 /20'I 2 06/01 /201 3 EACH OCCURRENCE $ l 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 5 300,000 CLAIMS-MADE ? OCCUR MED EXP (An one arson) S 5,000 x MIREU AUTO X PERSONAL & ADV INJURY $ l ,000,000 NOH OwNLO AUTO ENERAL AGGREGATE 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODU T -COMP OP AGG 5 2,000,000 PRO- x POLICY JECT LOC $ AU TOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accitlenU $ ANY AUTO ALL OWNED AUTOS BODILY INJURY (Per personl $ SCHEDULED AUTOS BODILY INJURY (Per accident) 5 HIRED AUTOS PROPERTY DAMAGE fPer accident) °+ NON-OWNED AUTOS °+ UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE 5 DEDUCTIBLE RETENTION S WORKERS COMPENSATION AND EMPLOYERS' UABI LITV Y/N N/A WC STATU- OTH TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE FF R M E.L. EACH ACCIDENT ICE / O EMBER EXCLUDED? (Mandatory m NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT 5 DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (Attach ACORD tOl, Additional Remarks Schedule, if mo.e space is required) AS RESPECTS TO GENERAL LIABILITY, CITY OF SANTA ANA, ITS OFFICERS, AGENTS AND EMPLOYEES ARE ADDITIONAL INSURED -VENDORS BROAD FORM, CG T3 30 . a.cr? t Irla.h • c rlvt_vcr? GArVGCLLA 1 IVN CITY OF SANTA ANA, ITS OFFICERS, AGENTS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE AND EMPLOYEES EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE 20 CIVIC CENTER WITH THE POLICY PROVISIONS. SANTA ANA, CA 9270'1 AUTHOflIZED REPRESENTATIVE ? . ?_ T m '1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD TRAVELERSJ- P.O. Box 1564 Elmira, NY 14902-1564 CITY OF SANTA ANA, ITS OFFICERS, AGENTS AND EMPLOYEES 20 CIVIC CENTER SANTA ANA, CA 92701