HomeMy WebLinkAboutSURE-TRACK, LLC 1 - 2013N-2013-098
Agreement No.
INSURANCE ON FILE
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES ON-THE-JOB TRAINING AGREEMENT
`6 0210 -/* UNDER THE WORKFORCE INVESTMENT ACT
CLERK OF COUNCI
DATE; $r1®1?
THIS AGREEMENT is made and entered into this 27t1' day of June, 2013 between the
10-2 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 Sure-Track, LLC
(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 program 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 July 1, 2013,
and ending November 29, 2013. The term 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.
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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.
Funding. CITY shall reimburse the EMPLOYER an amount not to exceed $4,158.00 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.
4. Subcontracting 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. Employer 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. Em lloyment 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.
8. 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 Government Patent
Policy).
B. Copyright Policy.
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 a royalty-
free, nonexclusive and irrevocable license to reproduce, publish, use and to authorize others to
use all copyrighted material.
2. The DOL reserves a royalty-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
3
from or arising out of the negligent acts, errors or omissions of EMPLOYER, its
employees, agents or subcontractors.
10. 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 of comprehensive public liability insurance shall be endorsed to provide to
CITY and to the State of California, Employment Development Department, at least
thirty (30) days written notice prior to cancellation; name CITY, its officers, agents,
employees, and volunteers, and the State of California, its officers, employees, and
volunteers as additional insured; and state that such coverage is primary to any other
coverage or self-insurance of the State of California and CITY. Governmental entities
may substitute a certificate of self-insurance.
11. Record Keeping. 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.
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,
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shall be retained beyond the three (3) years until resolution of disposition of such appeals,
litigation, claims, or exceptions.
12. Government Funding. 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 Cap. Based on the size of Employer, 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) tenninate 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 tenninate 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.
18. Equal Employment Opportunities. The EMPLOYER warrants that it will comply with
Title VI of the 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.
5
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 101(31) of the Act and 663.700-
710 and regulations promulgated by the State or Federal Government. 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 WORK Center
1000 E. Santa Ana Blvd., Suite 200
Santa Ana, CA 92701
Attention: WORK Center Director
EMPLOYER:
Sure-Track, LLC.
3130 S. Harbor Blvd., Suite 100
Santa Ana, CA 92704
ATT: Dan Newkirk
6
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.
24. Merger. 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.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and
year first above written.
ATTEST:
Maria D. I-luizar
Clerk of the Council
CITY OF S NTA ANA
Kevin O'Rourke
City Manager
APPROVED AS TO FORM:
Sonia R. Carvalho
City Attorney
By: Lisa Storck
Assistant City Attorney
RECOMMENDED FOR APPROVAL:
E
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&
Sandra D. Gottlieb
Acting Executive Director
Community Development Agency
EMPLOYER:
Dan Newkirk
Owner / Manager
Tax ID#:
State 307-49543
Federal 90-0540712
Agreement # Exhibit A
1.
Il.
GENERAL
TRAINING PLAN
1. Name of OJT Employer: Sure-Track LLC
2. Address of OJT Work-site: 3130 S Harbor Blvd. Suite 100, Santa Ana, CA 92704
3. Phone Number: (7142432-0201
4. Training Supervisor: Dan Newkirk / Jessica Acosta
5. Name of OJT Trainee: Annelee Gallegos
6. Application Number of Trainee:
7. Proportion of trainees/employees: (at time Agreement entered into)
a. Total number of employer's regular employees 6
C. Cumulative number of trainees currently in OJT 1
OCCUPATION AND ON-THE-JOB TRAINING OUTLINE:
1. Vendor #
2. Occupation/Product or Servi
3. Length of Time in Business:
4. ONET Code: 43-4051.00
5. Hourly Starting Wage:
Start Date: 7/1/13
Hours 693
6. State and Federal Tax I.D.:
le: Customer Service Representative
19yrs Three years under current LLC
SVP Level 4.0 to <6.0
$12.00
End Date: 11/29/2013
or Days or Weeks_
State 307-49543
Federal 90-0540712
7. Basic Work Week Hours: 40
1
8. Outline of On-the-Job Training Plan and Method of Assessment:
ELEMENTS OF TRAINING HOURS OF TRAINING
1. Objective 43
Discuss mission, office policies and procedures, with emphasis on the
need for completeness and accuracy
Familiarization with insurance and risk management terminology and
vocabulary along with related form types
Measurement Method: Q & A, task observation and inspection. Goal is to achieve rate
of proficiency within first Month and a half of training.
2. Objective 2
Handling of incoming data to include scanning and indexing of 50
documents
Production of various reports from server based program and website.
Learn to produce and distribute letters
Introduction to the SURE-TRACK database program and its interface
with word processing, spreadsheets and email
Measurement Method: Q & A, task observation and inspection. Goal is to achieve rate
of proficiency within subsequent three and a half months.
3. Objective 3
Learning specifics of insurance as it relates to individual client 300
requirements.
Learning to interpret the various certificate and endorsement forms as
to how they apply to these requirements. Instruction in entering derived
facts into the database program, and understanding its output
Measurement Method: Q & A task observation and inspection. Goal is to achieve rate of
proficiency within subsequent three and a half months.
4. Objective 4
Under supervision, begin to work on servicing a smaller client's 300
caseload.
Assume a full workload
Measurement Method: Q & A task observation and inspection. Goal is to achieve rate of
proficiency within subsequent three and a half months.
RATING LEVELS:
Measurement method: how will it be determined if OJT participant acquired the skill? Q&A, observation, product review/inspection,
etc.
PROFICIENT MODERATE MARGINAL
II. COST COMPUTATION
Example: Hourly Reimbursement $ 6.00 Hours 693 cost Per Trainee
= $4,158.00
III. Person(s) authorized to sign payment invoices for EMPLOYER:
Dan Newkirk
Print Name
Jessica Acosta
Print Name
Owner/ Manager 6/27/13
Title Date
Risk Transfer Administrator 6/27/13
Title Date
ASSURANCES
A. The EMPLOYER assures that:
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.
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.
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.
Services and activities provided under this Agreement will be administered by or under the
supervision of the EMPLOYER.
No relative by blood, adoption or marriages 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.
11. 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.
EXHIBIT B
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. OJT trainees shall not number more than 40% of the EMPLOYERS work force.
17. All EMPLOYER training payments (reimbursements) must be exclusive of any and all
EMPLOYER fringe benefits, paid holidays, paid sick days and overtime compensation.
18. The participating EMPLOYER must keep an accurate and up-to-date time sheet for the OJT
trainee.
19. Payroll records, time and attendance records and job duties retained on file by the participating
EMPLOYER for each OJT trainee are subject to review.
6/27/2013
Employer Signature Date
EXHIBIT B
Client#: 574120
SURETRAC
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
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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 an this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Emily Silversparre
JNAME'
Hub International
' PHONE 877 825.2681 951 231-2572
AIG, I Ext : AIC, Nc
HUB Int
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180 N Riverview Dr, Ste 170
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INSURER(S) NAG #
Anaheim, CA 92808
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INSURERA: 10836
INSURED INSURER B: Peerless Indemnity Insurance Co 18333
Sure Track, LLC
INSURER C:
3130 S. Harbor Boulevard, Suite 100
INSURER D:
Santa Ana, CA 92704
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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.
ILTftR TYPE OF INSURANCE NADDL SR WSUBR VD POLICY NUMBER MMIDDNYYY MM/DDIYYVYY LIMITS
A GENERAL LIABILITY BOP3084B09 0312612013 031261201 EACH OCCURRENCE $110001000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
PREMISES Ea occurrence
$50,000
CLAIMS-MADE ®OCCUR yy(r
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15 LL°° PERSONAL &ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $2,000,000
PRO-
POLICY
LOC
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AUTOMOBILE LIABILITY
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P. accident
ANY AUTO .,.I BODILY INJURY (Per person) $
ALL OWNED
AUTOS SCHEDULED
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$
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HIRED AUTOS AUTOS
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UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DEG RETENTION $ $
B WORKERS COMPENSATION WC3084810 0312612013 03/261201 X WC STATU- OTH-
AND EMPLOYERS' LIABILITY ?L MI 5 ER
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ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED?
NIA E.L. EACH ACCIDENT $1,000,000
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(Mardatcry in Ni E.L. DISEASE ?E $1,000,000
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DEC
ON OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1 000,000
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD Ii Adddional Remarks Schedule, if more space is required)
The City of Santa Ana, its officers, employees, agents & representatives are Additional Insured in regard
to General Liability per the attached endorsement form 44-148 06/04; Primary and Non-Contributory wording
applies per the attached endorsement form 44-231 07/10.
The City of Santa Ana
20 Civic Center Plaza
Santa Ana, CA 92701
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
ACORD 25 (2010105) 1 of 1
#S2267723/M2240142
@ 1988.2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Exhibit C
MG42
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL PROTECTOR @ LIABILITY EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL PROTECTOR ® COVERAGE FORM (BUSINESSOWNERS COVERAGE FORM)
SECTION II - LIABILITY is amended as follows:
A. Coverage Extension -Supplementary Payments
1. Provision f.(1)(b) of Paragraph 1. Business Liability under Section A. Coverages is amended as follows:
(b) Up to $2500 for cost of bail bonds required because of accidents or traffic law violations arising out of the use
of any vehicle to which Business Liability Coverage for "bodily injury" applies. We do not have to furnish these
bonds.
2. Provision f.(1)(d) of Paragraph 1. Business Liability under Section A. Coverages is amended as follows:
(d) All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of
the claim or "suit", including actual loss of earnings up to $300 a day because of time off from work.
B. Medical Expenses - Extensions
1. Provision a. of Paragraph 2. Medical Expenses under Section A. Coverages is replaced by the following:
a. We will pay for medical expenses as described below for "bodily injury" caused by an accident:
(1) On premises you own or rent;
(2) On ways next to premises you own or rent; or
(3) Because of your operations;
Provided that:
(a) The accident takes place in the "coverage territory" and during the policy period;
(b) The expenses are incurred and reported to us within three years of the date of the accident; and
(c) The injured person submits to examination, at our expense, by physicians of our choice as often as we
reasonably require.
2. Paragraph 2. of Section D. Liability And Medical Expenses Limits Of Insurance is replaced by the following:
2. The most we will pay for the sum of all damages because of all:
a. "Bodily injury", "property damage" and medical expenses arising out of any one "occurrence"; and
b. "Personal and advertising injury" sustained by any one person or organization.
is the Liability and Medical Expenses limit shown in the Declarations. But the most we will pay for all medical
expenses because of "bodily injury" sustained by any one person is the greater of $15,000 orthe Medical
Expense limit shown in the Declarations.
C. Damage by Fire, Lightning, Explosion, Smoke or Leakage
1. The final sentence of Paragraph 1. of Section B. Exclusions is amended as follows:
Exclusions c., d., e., f., g., h., i., k., I., m., n. and o. in SECTION II - LIABILITY do not apply to premises while
rented to you, or temporarily occupied by you with permission of the owner provided that the damage is caused by
one of the following; fire, lightning, explosion, smoke or leakage from automatic fire protection systems. A separate
Limit of Insurance applies to this coverage as described in D. Liability And Medical Expenses Limits Of
Insurance.
APPROVED A,s fQ k"C)RM1
44-148 (06/04) Page 1 of 3
LISA E, STORCK
Exhibit CAssistant City Flttorney?
2. Paragraph 3. of Section D. Liability And Medical Expenses Limits Of Insurance is replaced by the following:
3. The most we will pay under Business Liability Coverage for damages because of "property damage" to
premises rented to you or temporarily occupied by you with permission of the owner, arising from one event is
the greater of:
a. $300,000; or
b. the Damage To Premises Rented To you limit shown in the Declarations,
As used in this provision, one event includes all damage proximately caused by the same event, whether such
damage results from fire, lightning, explosion, smoke or leakage from automatic fire protection systems or any
combination of these.
D. ADDITIONAL INSUREDS - BY CONTRACT
The following is added to Paragraph 2. under C. Who Is An Insured
e. Any person or organization when you and such person or organization have agreed in writing in a contract,
agreement or permit that such person or organization be added as an additional insured on your policy to
provide insurance such as is afforded under this Coverage Form but only with respect to the liability of that
person or organization arising out of "bodily injury" or "property damage" occurring or a "personal and
advertising injury" offense committed:
(1) During ongoing operations performed by you or on your behalf; or
(2) On premises or facilities owned or used by you; and
Only to the extent to which insurance applies under this Coverage Form.
A person's or organization's status as an insured under this endorsement ends when their contract or
agreement with you for such premises, facilities or ongoing operations ends.
This provision D. does not apply:
(1) Unless the written contract or agreement has been executed, or permit has been issued, prior to the
"bodily injury" "property damage", "personal and advertising injury";
(2) To the rendering of or failure to render any professional services; or
(3) To any person or organization included as an insured by separate endorsement issued by us and made a
part of this policy.
E. AGGREGATE LIMITS
Paragraph 4. of D. Liability And Medical Expenses Limits Of Insurance is replaced by the following:
The most we will pay for the sum of all damages because of:
a. Injury or damage under the "products-completed operations hazard" arising from all "occurrences" during the policy
period is twice the Liability and Medical Expenses Limit.
b. "Bodily injury" or "property damage", including medical expenses, arising from all "occurrences" during the policy
period which can be attributed to operations at a single location is twice the Liability and Medical Expenses Limit.
This limitation applies separately to each location. This limitation does not apply to:
(1) "Bodily injury" or "property damage" included in the "products-completed operations hazard", or
(2) "Property damage" to premises while rented to you, or temporarily occupied by you with permission of the
owner, arising out of fire, lightning, explosion, smoke, or leakage from automatic fire protection systems.
c. All other injury or damage, including medical expenses, arising from all "occurrences" during the policy period is
twice the Liability and Medical Expenses Limit. This limitation does not apply to:
(1) Injury or damage included in the "products-completed operations hazard";
(2) "Bodily injury" or "property damage", including medical expenses, arising from "occurrences" during the policy
period which can be attributed to operations at a single location; or
(3) "Property damage" to premises while rented to you, or temporarily occupied by you with permission of the
Page 2 of 3 11PP110'VF_D AS TO FORM 44-148 (06104)
Exhibit C ?- LISA E. STORCk 'µ'.
A,orc+-n n:... ".,
owner, arising out of fire, lightning, explosion, smoke or leakage from automatic fire protections systems.
Payments made under any one of the above provisions shall not reduce the Aggregate Limit described in any
other provision within paragraph 4.
For the purposes of this endorsement, location means premises involving the same connecting lots, or premises
whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad.
F. KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT
The following is added to Pparagraph 2. E. Liability And Medical Expenses General Conditions:
Knowledge of an "occurrence", offense, claim or "suit" by an agent, servant or "employee" of any insured shall not
in itself constitute knowledge of the insured unless your partners, executive officers, directors, insurance manager,
or a person who has been designated by them to receive reports of occurrences, offenses, claims and "suits" shall
have received such notice from the agent, servant or "employee".
G. BODILY INJURY REDEFINED
Under F. Liability And Medical Expenses Definitions, definition 3. is replaced by the following:
3 . "Bodily Injury" means physical injury, sickness or disease sustained by a person. This includes mental anguish,
mental injury, shock, fright or death that results from such physical injury, sickness or disease.
APPROVED AS TO FORM
44-148 (06104) C;/ ?_ Page 3 of 3
LISA E. STORC KF
Exhibit C Assistant City Att9 ney
r/s
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDMENT OF OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following;
COMMERCIAL PROTECTOR COVERAGE FORM
(Businessowners Coverage Form)
A. The following is added to provision 2.b. of paragraph H. Other Insurance under SECTION III - COMMON
POLICY CONDITIONS:
However, when an additional insured has been added to this Coverage Partby endorsement, we will not seek
contribution from the "additional Insured's own insurance" provided that:
(1) You and the additional insured have agreed in a written contract that this insurance is primary and
non-contributory; and
(2) The "bodily injury" or "property damage" occurs, or the "personal and advertising injury" is committed,
subsequent to the execution of such contract.
B. For the purposes of this endorsement the following is added to SECTION II, Paragraph F. Liability And Medical
Expense Definitions:
"Additional insured's own insurance" means other insurance forwhlch the additional insured is designated as
a Named Insured.
44-231 (07110)
03/20/2013 3084809
APPROVED AS TO FORM
LISA E. STORCK Page 1 of 1
INSURED COPY Assistant City Attorney
NEUSXAFS0500 PGDM0000 J21511 GUAFPPN 00014978 Page
Exhibit C J? T
7
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 a drug-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 a drug-free awareness program to inform employees about -
(1) The dangers of drug abuse in the workplace;
(2) The contractor's policy of maintaining a drug-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 a drug-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:'
Employer ignature
EXHIBIT D
DIVISION OF EMPLOYMENT SERVICES
PLACE OF PERFORMANCE
FOR CERTIFICATION REGARDING DRUG-FREE
WORKPLACE REQUIREMENTS
Name: Sure-Track, LLC
Name of Contractor: Dan Newkirk
Contractor Number:
Date:
The Contractor shall insert in the space provided below the site(s) expected to be used
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):
3130 s. Harbor Blvd., Suite 100
Santa Ana CA 92704
(714) 432-0201
EXHIBIT D
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.
Dan Newkirk Owner/Manager
Name and Title of Authorized Representative
/c 6/27/13
Signature - Date
EXHIBIT E
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.
EXHIBIT E