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Home My WebLink AboutWILSON, LORA 1B-2011City of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM COTC Office Use Only ? 'li . �.. ------ Please complete this form when the attached agreement and all r v 3 Oz - amendments (if any) are no longer in effect.�r-v { �` ,,.'_ - Return form to the Clerk of the Council Office (M-30). Call 647-6520 if you have any questions. The agreement with (-A/ N-2011-021-001 CIA) No. was completed on �- (List all amendments. Use space below if needed.) * IJ- I-Dq-oi` -pat (15) 6-100 -On (I) (off, Revised 08-23-10 i 4 I I and final payment has been made. Department: P9-MA- Phone/Ext.: 5D-5-4 /t Signature: Date: [(p i.iRAiv�,� Jfv i=iL .. aRK MAY PROCEED l�lvi'IL INSURANCE EXPIRES MAYOR � � _ � /., � Miguel A. Pulldo MAYOR PROTEM 4;LcRK OF COUNCIL j;'a Sal Tlna)ero Q�AfE: - COUNCIL MEMBERS Angelica Amezeua °�� -- David Benavldes -- - Mlchele Martinez Roman A. Reyna CITY OF SANTA ANA Vincent Sarmlento OFFICE OF THE CITY ATTORNEY 20 CIVIC CENTER PLAZA NI-29 P.O. BOX 1988 SANTA ANA, CALIFORNIA 92702 (714) 647 -5201 Fax (714) 647 -6515 December 13, 2012 Lora Wilson 1918 E. 19 "' Street Santa Ana. CA 92705 Dear Ms. Wilson: N- 2011 - 021 -002 CITY MANAGER Paul M. Walters CITY ATTORNEY Sonia R. Carralho CLERK OF THE COUNCIL Marla D. Hulzar Pursuant to the Recreation Services Agreement you entered with the City of Santa Ana, dated February 18, 201 1 , as amended December 12, 201 1 , Section 3 — "Term ", the time period of said Agreement is hereby extended from December 31 , 2012 until December 31 , 2014. The insurance certificates and Additional Insured Endorsement are required to be extended and /or renewed to cover this extension. All other terms and conditions of said Agreement remain unchanged and in full force and effect. If you have any questions in this regard, please feel free to contact Silvia Cuevas, Management Analyst at (714) 647 -5254. Sincerely, 7iC �-�Ge' Gerardo Mouet Executive Director, PRC A APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney Lisa S o�rck� Assistant City Attorney cc: Clerk of the Council EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2012 -21 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. O. sox 6aso p�- 2011 - 021 -002 Santa Ana, CA 92701 Newport Beach, CA 92658 License No: OC 36561 NAMED INSURED (EVENT HOLDER): - EVENT INFORMATION: Lora Wilson TYPE: Dance (Variousl 1918 E. 19`h Street DATE(S): 02/16/12 — 12/31/12 Santa Ana, CA 92703 N -201 1- 021 LOCATION: Jerome Center -001 •Liquor Liability Yes � No '�Li uor Liabili after 12 am ends before 2�am This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. 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 policy listed and it does not constitute a contract between the insurance carrier, authorized representative, producer and certiFcate holder. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies)_ INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: 12SEP1000001 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2012 EXPIRATION: JANUARY 1, 2013 COMMERCIAL GENERAL LL4B[L77'Y OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products � Completed Operations 1,000,000 _ Personal � Advertising Injury 1,000,000 , •la p... . Each Occurrence Limit 1,000,000 Fire Damage (Any One Fire) 100,000 - - - Medical Payments (Any One Person) 5,000 '� - - -�� - - ' -� �"' Liquor Liability (If purchased) 1.000.000 Optional Limits Purchased 51,000,000/53,000,000 I:� \' ' � i :: � [ � 52,000,000/52,000,000 The limits of insurance apply separately to each evrnt insured by [his policy as if a separate policy of insurance has been issued for that event "Who is insured" is amended to include, as an insured, the person or organim[ion shown in [his schedule, but only with respect to liability arising out of [he ownership, maintenance or use of the premises used by the named insured (even[ holder). This insurance does no[ apply to: Any "occurrence' which takes place after the event holder ceases to be a tenant in that premises. OTHER ADDITIONAL INSUREDS CANCELLATION- Should the above described policy be cancelled before [he expiration date [hereof, notice will be delivered in amordance with the policy rovisions. /..�.�r _ Q -CGS._ AUTHORIZED REPRESENTATIVE: DATE ISSUED: 02/16/12 by Briza Morales EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2013 -16 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. O. Box 6450 Santa Ana, CA 92701 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Lora Wilson TYPE: Dance 1918 E. 19`h Street /� � n � _ � /�� DATE(S): 01/10/13 — 12/31/13 Santa Ana, CA 92705 / I/ �'O LOCATION: Jerome Center *Liquor Liability Yes Q No * *Li uor Liabilit after 12 am ends before 2 am Q This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. This certiticate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not affirmatively or negatively amend, excend or alter the coverage afforded by the policy listed and it does not constitute a contract between the insurance carrier, authorized representative, producer and certiticate holder. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies). INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41011 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2013 EXPIRATION: JANUARY 1, 2014 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products � Completed Operations 1,000,000 Personal Fc Advertising Injury 1,000,000 Each Occurrence Limit 1,000,000 Fire Damage (Any One Fire) 100,000 Medical Payments (Any One Person) 5,000 Liquor Liability (If purchased) l,000,000 Optional Limits Purchased Q $1,000,000/$3,000,000 D s2,000,000 /$2,000,000 The limits of insurance apply separately to each event insured by [his policy as if a separate policy of insurance has been issued for that event. "Who is insured" is amended to include, as an insured, the person or organization shown in this schedule, but only with respect to liability arising out of the ownership, maintenance or use of the premises used by the named insured (event holder). This insurance does not apply to: Any "occurrence" which takes place after [he event holder ceases to be a tenant in that premises. OTHER ADDITIONAL INSUREDS CANCELLAT[ON� Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy rovisions. �� i� AUTHORIZED REPRESENTATIVE: DATE ISSUED: EVANSTON INSURANCE COMPANY CERTIFICATE NO.- 2014.17 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services; Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. O. Box 6450 Santa Ana, CA 92701 Newport Beach, CA 92658 License No: OC.36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Lora Wilson TYPE: Dance 1918 E. 19`b Street DATE(S): 01/08114 — 12/31/14 Santa Ana, CA 92705 LOCATION: Jerome Center *Liquor Liability Yes ❑ No X **Liquor Liability after 12 am ends before 2 am ❑ This is to certify that the Insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. 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 policy listed and it does not constitute a contract between the insurance carrier, authorized representative, producer and certificate holder. The insurance described herein is subject to all the terms, exclusions : and conditions of such policy(ies). INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41014 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2014 EXPIRATION: JANUARY 1, 2015 COMMERCIAL GENERAL LIABILITY OCCURRFNCEFORM DEDUCTIBLE: NONE. Goneral. Aggregate Limit $ 2,000,000 Products & Completed Operations 1.,000,000 Personal & Advertising. Injury 1,000,000 Each' Occurrence limit 1,000;000 Eire Damage (Any One Fire) 100,000 Medical .Payments ':(Any One Person) 5,000 Liquor Liability (If purchased) 11000;000 Optional Limits Purchased ❑ $1,000,000/$3,000;000 ❑ $2,000,000/$2,000;000 Property Damage (If purchased) ❑ Limit $50,400 Deductible $500 Limit $100,000 Deductible $1,000 The limits of insurance apply separately to each event insured by this policy as if aseparme policy of insurance -hes been issued for that event "Who is insured" is amended to Include, as au insured; the person ororganiution shmnni in this schedule, but only with respect to liability arising outol'the ownership, maintenance or use of the premises: used by the named insured (event bolder). This insurance does not apply to: Any "occunence "which takes Phase after the event holder ceases to be tenant in that premises. OTHER ADDITIONAL INSUREDS Carmen Whitener CANCELLATION: Should tare above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance withthe:policy Provisions. AUTHORIZED REPRESENTATIVE; DATE ISSUED: January 8 2014 by Briza Morales EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2015 -28 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. 0. Box 6450 Santa Ana, CA 92701 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Lora Wilson TYPE: Dance 1918 E. 191, Street DATE(S): 03/04/15 — 12/31/15 Santa Ana, CA 92705 LOCATION: Jerome Center �J ''L'kQ ` `tip -t ✓ l'c�- *Liquor Liability Yes ❑ No * *I,i uor Liabilit after 12 am ends before 2 am ❑ This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41017 MASTER POLICY DATES: EFFECTIVE,: JANUARY 1, 2015 EXPIRATION: JANUARY 1, 2016 COMMERCIAL GENERAL. LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products & Completed Operations 1,000,000 SPECIAL CONDITIONS. Personal & Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) 100,000 Certificate Of Insurance: Medical Payments (Any One Person) 5,000 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,000/$3,000,000 ❑ $2,000,000/$2,000,000 Damage To Property (If purchased) The limits of insurance apply separately to each event insured by this policy as if a separate policy orinsurance has been issued for that event. OTHER ADDITIONAL INSUREDS Carmen Whitmer Melody Gonzalez CANCELLATION Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: March 4 2015 by Briza Morales