HomeMy WebLinkAboutILKCAGLA, FELICE 3 - 2015City of Santa Ana
Clerk of the Council
AGREEMENT TERMINATION FORM
Please complete this form when the attached agreement and all
amendments (if any) are no longer in effect.
Return form to the Clerk of the Council Office (M-30).
Call 647-1520 if you have any questions.
The agreement with
COTC Office Use Only
AUG. 2 2 RI V: r 5
Y OF SANTA ANA
ERK OF COUNCIL
No. N-2015-017 was completed on p and final payment has been made.
(List all amendments. Use space below if needed.)
Department: PRC.S A
Phone/Ext.: 11R \ - `
Signature: cy �-122-
Date: \OA
Revised 10-31-12
INSURANCE ON FILE N-2015-017
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES
CLERK OF COUNCIL RECREATION SERVICES AGREEMENT
DATE: 20�
(5� �; hta
P CSCr EBTIIIS AGREEMENT made and entered into.this 1st clay of � Ear 2015, by and
between Felice Ilkcagla (hereinafter "Provider') and the City of Santa Ana, a charter city and
�municipal corporation organized and existing under the Constitution andlaws of the State of
California (hereinafter "City"), -
RECITALS
A. The City desires to retain a recreation service provider having special skills, resources and
knowledge to conduct Parent/Child Participation classes in its leisure class program,
B. Provider represents that Provider is able and willing to provide such services to the City.
C. In undertaking the performance of this Agreement, Provider represents that it is knowledgeable in
its field and that any services performed by Provider Harder this Agreement will be performed in
comphance with such standards as may reasonably be expected.
NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the
terms and conditions hereinafter set forth, the parties agree as follows:
1. SCOPE OF SERVICES
Provider shall perform those services as set forth in Exhibit A. to this Agreement.
2. COMPENSATION
In consideration for the right to provide the progams set forth .m Exhibit A, City agrees to
pay the Provider seventy percent (70%) of all gross revenue received from program participants.
Anticipated revenue from this class shall not exceed $25,000 annually. Payment to Provider shall
be made within thirty (30) days following completion of each class.
,i. TERM
This Agreement shall conunence on January 1, 2015 and terminate on December 31, 2016,
Unless terminated earlier in accordance with Section 12, below, The Term of this Agreement may be
extended upon a writing executed by the City Manager and the City Attorney.
4, INDEPENDENT CONTRACTOR
Provider shall, during the entire terns of this Agreement, be construed to be an independent
coutractor and not an employee of the City. This Agreement is not intended nor shall it be
construed to create an employer -employed relationship, a joint venture rolationship, or to allow the
City to exercise discretion or control over the manner in which Provider performs the services
which are the subject matter of this Agreement; however, the services to be provided by Provider
shah be provided in a manner consistent with all applicable standards and rogolations gover ing
such services. Provider shall pay all salaries and wagcs, employer's social security taxes,
unemployment insurance and similar taxes relating to employees and shall be responsible for all
applicable withholding taxes. Provider is not an agent, representative or employee of City and
Provider shall have no authority to not on behalf of the City.
5. INSURANCE
Prior to undertaking perrom-tauee of work under this Agrocnncnt, Provider shall maintain and
shall require its subcontractors, if any, to obtain and maintain insorano as described below:
a. Commercial General Liability Insurance. Provider shall maintain commercial general
liability insurance which shall include, but not be limited to protection against claims arising from
bodily and personal injury, including death resulting therefrom and damage to property, resulting
from any act or occurrence arising out of Provider's operations in the performance of this
Agreement, me] uding, without Iimitation, acts involving vehicles. The amounts of insurance shall
be not less than the following: single limit coverage applying to bodily and personal injury,
including death resulting therefrom, and property damage, in the total amount of $1,000,000 per
occurrence. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and
representatives as additional insured(s); (b) be primary and not contributory with respect to
insurance or self-insurance programs maintained by the City; and (c) contain standard separation of
insured's provisions.
b. Worker's Compensation Insurance, In accordance with the provisions of Section 3300 of
the Labor Code, if Provider has any employees, is required to be insured against liability for
worker's compensation or to undertake self-insurance. Prior to commencing the performance of the
work under this Agreement, Provider agrees to obtain and maintain any employer's liability
insurance with. limits not less than $1,000,000 per accident,
c. The following requirements apply to the insurance to be provided by Provider pursuant to
this section,
(i) Provider shall maintain all insurance required above in full force and
effect for the entire period covered by this Agreement. Certificates
of insurance shall be furnished to the City upon execution of this
Agreement and shall be approved in form by the City Attorney.
(ii) Certificates and policies shall state that the policies shall not be canceled
or reduced in coverage or changed in any other material aspect without
thirty (30) days prior written notice to the City.
d. If Provider fails or refuses to produce or maintain the insurance required by this section
or fails or refuses to furnish the City with required proof that insurance has been procured and is in.
force and paid for, the City shall have the right, at the City's election, to forthwith tenninate this
Agreement. Such te,rriina.tion shall not affect Provider's right to be paid for its time and materials
expended prior to notification of termination. Provider waives the right to receive compensation
and agrees to indemnify the City for any work performed prior to approval of insurance by the City.
6. INDEMNIFICATION
Provider agrees to and shall indemnify and hold harmless the City, its officers, agents,
employees, Providers, special counsel, and representatives from liability for personal injury,
damages, just compensation., restitution, judicial or equitable relief arising out of claims for personal
injury, including health, and claims for property damage, which may arise from the direct or
indirect operations of the Provider or its contractors, subcontractors, agents, employees, or other
persons acting on their behalf which relates to the services described in section I of this Agreement.
The Provider further agrees to indemnify, hold hanrrless, and pay all costs for the defense of the
City, including fees and costs for special counsel to be seleeted by the City, regarding any action by
a tl-ird party asserting that personal injury, damages, just corpensation, restitution, judicial or
equitable relief due to personal or property rights arises by reason of the terms of, or effects arising
2
from this Agreement. City may make all reasonable decisions with respect to its representation in
any legal proceeding.
CONFLICT OF INTEREST
Provider covenants that it presently has no interests and shall not have interests, direct or
indirect, which would conflict in any mamrer with performance of services specified under this
Agreement.
8. LIVE SCAN BACKGROUND CHECK
Providers, and any employees or substitutes, in contact with minors under eighteen (18)
years of age shall arrange for and subi-nit to a Live Scan electronic' background cheek for criminal
history available through the California Department of Justice as a condition of this Agreement and.
provide proof of compliance prior to performing services hereunder.
9. NOTICE
Any notice, tender, demand,, delivery, or other comm unication pursuant to this Agreement
shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first
class or certified mail, postage prepaid, or sent by facsimile or other telegraphic cornnrurrication in
the manner provided in this Section, to the follor�ring persons:
To City: Clerk of the Council
City of Santa Ana
20 Civic Center Plaza (.M-30)
P.O. Box 1988
Santa Ana, CA. 92702-1988
Facsimile (714) 647-6956
With copy to: Executive Director of Parks, Recreation and Connnunity Services
City of Santa Ana.
26 Civic Center Plaza (M-75)
P.O. Box 1988
Santa Ana, California 92702
Facsimile (714) 571-4211
To Provider: Felice Ilkcagla
3436 S. Tamns Lane
Santa Ana, CA 92704
A party may change its address by giving notice in writing to the other party. Thereafter,
any communication shall be addressed and transmitted to the new address. If sent by mail,
communication shall be effective or doomed to have been given three (3) days after it has been
deposited in. the United States mail, duly registered or certified, with postage prepaid, and addressed
as set forth above. If sent by facsimile, communication shall be effective or deemed to have boon
given twenty-four (24) hours after the time set: forth on the transmission report issued by the
transmitting facsimile machine, addressed asset forth above. For purposes of calculating these time
frames, weekends, fedora], state, County or City holidays shall be excluded.
10. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and
Provider, and supersedes any and all other agreements, oral or written, between the parties. In the
event of a conflict between the terms of this Agreement and any attachments hereto, the terms of
this Agreement shall prevail, This Agreement may not be modified except by written instrument
signed by the City and'by an authorized representative of Provider. The parties agree that any terms
or conditions of any purchase order or other instrument that are inconsistent with, or in addition to,
the terms andconditions hereof, shall not bind or obligate Provider or the City. Each party to this
Agreement acknowledges that no representations, inducements, promises or agreements, orally or
otherwise, have been made by any party, or anyone acting on behalf of any party, which is not
embodied herein,
11. ASSIGNMENT/SUBSTITUTES
a. Assignment. The experience, knowledge, capability and reputation of Provider were a
substantial inducement for City to enter into this Agreement. Therefore, Provider may not assign,
transfer, delegate, or subcontract any interest herein without the prior written consent of the City
and any such assignment, transfer, delegation or subcontract without the City's prior written consent
shall be considered null and void. Provider must personally teach at least seventy -Five percent
(75°%) of its offered classes.
b. Substitutes. In the event Provider is not able to teach a class dice to illness or some other
cause beyond Provider's reasonable control, Provider must procure, at its sole expense, a qualified
substitute instructor to teach the class at its regular time and place. Provider shall ensure that
substitute instructor's comply with the City's insurance and 'live scan requirements contained herein.
Provider must immediately notify the City of the substitute instructor's name, qualifications,
address and phone number. If Provider cannot procure a qualified substitute and the City is unable
to assist in this regard, then the class shall be canceled, and a make-up class must be added to the
session. Provider must notify participants as soon as possible of any class cancellation and make-up
class.
12. TERMINATION
This Agreement may be torminated by the City upon. thirty (30) days written notice of
termination. Termination or cancellation of classes by the Provider must be given to the City at least
thirty (30) days prior to ternination/cancellation. Failure to provide adequate cancellation notice to
the City may put future contracting of business with the City at risk and will result in the City's
retention often (10%) percent of the final payment to Provider.
13. DISCRIMINATION
Provider shall not discriminate because of race, color, creed, religion, sex, marital status,
sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by
applicable law, in the recruitment, selection, training, utilization, promotion, termination or other
employment related activitios. Provider affirms that it is an equal opportunity employer curd shall
comply with all applicable federal, state and local laws and regulations.
14. JURISDICTION -VENUE
This Agreement has been executed and delivered in the State of California and the validity,
interpretation, performance, and enforcement of any of the clauses of this Agreement shall be
determined and governed by 1:he laws of the State of California. ;Both panics li�rdrer ace that
Orange County, California, shall be the venue for any action or proceeding that may be brought or
arise out of, in connection with or by reason of this Agreement.
4
115, LICENSES
Provider shall, throughout the term of this Agreement, maintain all necessary licenses,
penualts, approvals, waivers, and exemptions necessary for the provision of the services hereunder
and required by the laws and regulations of the United States, the State of California, the City of
Santa Ana and all other governmental agencies.
16. SEVERABILITY
In the event that one or more of the phrases, sentences, clauses, paragraphs or sections
contained in this Agreement shall be declared invalid or unenforceable by valid judgment or decree
of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the
remaining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be
interpreted to carry out the intent of the parties hereunder.
fF�01VOII IW
All. Exhibits referenced herein and attached hereto shall be incorporated as if fiilly set forth in
the body of this Agreement.
1L 418Y I CetiIM
The person(s) executing this Agreement on behalf of the parties hereto warrant that they are
dully authorized to execute this Agreement on behalf of said parties and that he so executing this
Agreement, the parties hereto are formally bound to the provisions of this Agreement,
IN WITNESS WHEREOF, the parties hereto have executed this Agieement the date and year first
above written.
ATTEST:
Maria D. Huizar
Clerk of the Council
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney
By:
Lisa Storck
Assistant City Attorney
RECOMMENDED FOR APPROVAL:
Gerardo Mouet
Executive Director of Parks,
Recreation and Community Services Agency
CITY OF SANTA ANA
David Cavazos
City Manager
PROVIDER
Felice 11kcagla
W-1
SCOPE OF SETt'ViCES— Felice 11kagain
A. Provider shall conduct Parent & Me Infant Play classes for children ages 10 month - 2 years old per session
B. Provider shalt conduct Parent & Me Infant Play class is on Wednesdays, 1 hour per day; 6wks $45,00, 5wks $37.00
C. Provider shall conduct Parent & Me Toddler Play classes for children ages 2 yrs - 4 years old per session
Q. Provider shall conduct Parent & Me Toddler Play class is on Wednesdays, 1 hour per day; 6wks $48, 5wks $40.00
E. Classes shall be one (1) day per week, Sept -Dec (FALL), Jan -Mar (SPRING), April -June (SUMMER), and June -Sept
(WINTER), Nov & Dec shall be week sessions due to observed Holiday
F. Provider shall work with the City staff in setting a schedule for classes, Including the location, specific days and
hours when class will be held and holidays to be observed,
G. Provider shall provide materials, supplies, equipment, records and personnel. Provider shall be responsible for
cleanup of the facilities, materials and shall ensure the safety and effectiveness of instruction.
H. if Provider allows other to teach his/her class; those teaches must be over 21, have obtained and maintain an
instructor rating, and be covered by Providers insurance. Provider shall provide City with documentation to verify
instructor and insurance requirements.
CLASS SIZE
A. Each class must have a minimum of 8 registered and paid parent/child participants and a
maximum of20.
3, If the minimum registration has not been reached by the first class, the class may be cancelled
by mutual agreement of Consultant and City, without any compensation owed to Consultant.
CLASS FEES
A. Infant & Me Play, $45.00/$37.00 per parent/ 10 month - 2 year old child per session.
B. Toddler & Me Play, $48.00/$40.00 per parent/ 2 - 4 year old child per session.
C. Each parent/child participant shall pay the Instructor a $2.50 material fee each session.
D. No refunds shall be made to participants after the first week of classes unless the class is cancelled by the Parks,
Recreation and Community Services Agency.
E. The City shall collect class fees from each parent/child participant during the registration period,
F. Consultant shall not collect fees but shall refer all interested participants to City for registration.
G. City agrees to pay Consultant seventy percent (70%) of the total fees within thirty (30) working days after
completion of the class session. City and Consultant agree that City shall retain thirty percent (30%) of the fees
collected.
H. Consultant agrees that City representative shall be entitled to audit Consultant's records to insure compliance with
this Agreement.
I, Consultant may not waive class participation/registration fees.
J. City shall prepare class rosters and provide a copy to Consultant, Only registered participants may participate in
class.
ACORD.. CERTIFICATE OF LIABILITY INSURANCE
F DATE(MM/DDIYYYY)
01 /2612015
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 INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the
terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements .
PRODUCER
CONTACT NAME: Mass Merchandising
K&K Insurance Group, Inc.
Fort Magnavox Way
Fort Wayne IN 46804
PHONE(AIC, No. Ext): 1-800-328-2317 IFAX(A/C, No): 1-260-459-5502
E-MAILADDRESS: info@eventinsurance-kk.com
@
INSURED 2000351738 CP#470
INSURER(S) AFFORDING COVERAGE
NAIC#
Felice Ilkcagla
3436 Taurus Lane
Santa Ana, CA 92704
Member of the Sports, Leisure & Entertainment RPG
INSURER A: Nationwide Mutual Insurance Company
23787
INSURER B:
INSURER C:
INSURER D:
COVERAGES Utt( I III I t NUMt3hK: 200018111 3 REVISION NUMBER:
HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE
ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF
SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
WVD
POLICY NUMBER
POLICY EFF
(MMIDD/YY
POLICY EXP
(MMIDD/YV
LIMITS
A
X
COMMERCIAL GENERALUABILITY
X
6BRPG000OCO5576800
01/14/15
01/14/16
EACH OCCURRENCE
CLAIMS-MADE OCCUR
12:01 AM
12:01 AM
DAMAGE TO RENTED
PREMISES (Ed occurrence
MILD EXP (Any one person)
;$5,000
PERSONAL&ADV INJURY
GEN'L AGGREGATE LIMIT APPLIES PER'.
PROJECT �LOC
GENERAL AGGREGATEPOLICY
OTHER
PRODUCTS-COMP/OP AGG
$1,000,000
PROFESSIONAL LIABILITY
$1,000,000
LEGAL LIAB TO PARTICIPANTS
$1,000,000
AUTOMOBILE LIABILITY
Reviewed
by.
COMBINED SINGLE LIMIT
Accident
ANY AUTO
ALL OWNED AUTOS
R GYV G-+
IJ'r
O
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
eAUTOSULED
HIREDAUTOS NON -OWNED
AUTOS
PROPERTY DAMAGE
Per accident
/r
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UMBRELLA LIAB OCCUR
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ICSAI
EACH OCCURRENCE
EXCESS LIAB CLAIMS -MADE
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"
AGGREGATE
RETENTION
DED 71
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/
IPER
ISTATUTL
OTHER
E.L. EACH ACCIDENT
EXECUTIVE OFFICER/MEMBER
EXCLUDED?
(ory in NH)
NIA
E.L. DISEASE - EA EMPLOYEE
es, describe under
Iff yes, d
DESCRIPTION OF OPERATIONS
E.L. DISEASE - POLICY LIMIT
be.
MEDICAL PAYMENTS FOR PARTICIPANTS
PRIMARY MEDICAL
EXCESS MEDICAL
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mom space is inquired)
Instructor of: Craft making & Instrumental music
The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured.
** This certificate voids and replaces certificate #2000178736 "*
CERTIFICATE HOLDER CANCELLATION
City Of Santa Ana It's Officers, Agents, Employees, and Volunteers SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
20 Civic Center Plaza THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Santa Ana, CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS.
Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE
law -;t
Coverage is only extended to U.S. events and activities.
** NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas.
ACORD 25 (2014/01) @ 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 6BRPG0000005576800
INTERLINE
IL12011185
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES
Policy Change
Number 1
POLICY NUMBER
POLICY CHANGES EFFECTIVE
COMPANY
6BRPG0000005576800
01/14/15
Nationwide Mutual Insurance Company
NAMED INSURED
AUTHORIZED REPRESENTATIVE
Felice Ilkcagla
K&K Insurance Group, Inc.
COVERAGE PARTS AFFECTED
COMMERCIAL GENERAL LIABILITY COVERAGE
CHANGES
Forms SRPG8018, SRPG8016 and CG2404 are added to the policy effective 1/21/15,
"'j
Authorized Representative Signature
Reviewed by:
c;47
Silvia CUB vas
PRCSA/Adrnin.
IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1
Copyright, ISO Commercial Risk Services, Inc., 1983
POLICY NUMBER: 6BRPG0000005576800
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CANCELLATION
This endorsement modifies insurance under the following:
COMMON POLICY CONDITIONS, A. Cancellation, 2.b. is deleted and replaced by:
30 days before the effective date of cancellation if we cancel for any other reason.
This endorsement applies only to the insureds designated below:
Named Insured: Felice Ilkcagla
Additional Insured: City of Santa Ana it's Officers, Employees, Agents, Volunteers and Representatives
20 Civic Center Plaza
Santa Ana, CA 92701
Insured Name: Felice Ilkcagla
Cart #: 470
Effective Date: 1/21/15 to 1/14/16
Reviewed by:
Silvia Cuevas
PRCSA/Admin.
SRPG8016 09/08
POLICY NUMBER: 6BRPG0000005576800 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY INSURANCE — ADDITIONAL INSURED
This endorsement modifies insurance under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, a. the following is added:
Coverage afforded under this Policy is primary insurance and OTHER INSURANCE shall not apply as respects to the
additional insured named below, however this insurance does not apply to the sole negligence of such additional insured.
Further, we will have no duty to defend such additional insured against any suit to which this insurance does not apply.
Additional Insured: City of Santa Ana it's Officers, Employees, Agents, Volunteers and Representatives
20 Civic Center Plaza
Santa Ana, CA 92701
Insured Name: Felice Ilkcagla
Cart #: 470
Effective Date: 1/21/15 to 1/14/16
Reviewed by:
Silvia Cuevas /u
PRCSA/Admin,
SRPG8018 09/08
POLICY NUMBER: 6BRPG0000005576800
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
City of Santa Ana it's Officers, Employees, Agents, Volunteers and Representatives
20 Civic Center Plaza
Santa Ana, CA 92701
Insured Name: Felice Ilkcagla
Cent #: 470
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of Section
IV — Conditions:
We waive any right of recovery we may have against the
person or organization shown in the Schedule above
because of payments we make for injury or damage
arising out of your ongoing operations or "your work"
done under a contract with that person or organization
and included in the "products -completed operations
hazard". This waiver applies only to the person or
organization shown in the Schedule above.
Reviewed by:
Silvia Cuevas
s1�'t.;SA/Admin.
CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1
DD1YYYYJ
E (MMd
ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
IS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREDS), AUTHORIZEE
PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
�IORTAII If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the
ms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not conifer rights to the
PRODUCER CONTACT NAME: Mass Merchandising
K&K Insurance Group, Inc. PHONE (Aac, No. EX[): 1-800-328-2317 Fax (A1C, No): 1-260-459-5502
1712 Magnavox Way
Fort Wayne IN 46804 E-MAIL ADDRESS: Info@eventunsurance-kk.Com
INSURED 2000361738 CP# 602 INSURER(S) AFFORDING COVERAGE NAIC #
Felice Ilkcagla I a INSURERA: Nationwide Mutual Insurance Company 23787
3436 Taurus Lane ^ M_, r INSURER 8:
Santa Ana, CA 92704 INSURER C:
Member of the Sports, Leisure & Entertainment. RPG unlsuRER D:
COVERAGES CERTIFICATE NUMBER* 2WO2310270 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 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
ADDL
INSD
SUBR
WVD
POLICY NUMBER
POLICY EFF
(MMIDDIYY
POLICY I
_rMMlOD1YY
LIMITS
A
X
COMMERCIAL ,GENERAL LIABILITY
X
6BRPGO000005730600
01/14/16
01114/17
EACH OCCURRENCE
$1,000,000
CLAIMS -MADE I X IOCCUR
V_J
12:01 AM
12:01 AM
DAMAGE TO RENTED
PREMISES Es occurrence)
$300,000
MFD FXP (Any one person)
$5,000
PERSONAL & ADV INJURY
$1'....,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
$5,000,000
POLICY �RRGJECT �LOC
OTI1'...ER
PRODUCTS-COMPYOPAGG
$1,000,000
PROFESSIONAL LIABILI"Y
$1,000,000
LEGAL LIABTOPARTICIPANTS
$1,000,000
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea Accident
ANY AUTO
BODILY INJURY (Per person)
ALL OWNED AUTOS SCHEDULED
BODILY INJURY (Per accident)
NON-O
HIRED AUTOS NON -OWNED
HAUTOS
X Not provided while in Hawaii
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NSA
PROPERTY DAMAGE
Per aVCidenG
UMBRELLA
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EXCESS L ABAB HCLAIMS-MADE
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i,Y
9
EACH OCCURRENCE
AGGREGATE
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
'`
/^"h
OTHER
ANY PROPRIETORlPARftTNER!
FXCCLULDIEVDE�gFFICERrMEMSER
(Mandatory In NH)
NIA
'�'•mI
ENT
A EMPLOYEE
FDISEASE
GLIOY LIMIT
If yes, describe under
DESCRIPTION OF OPERATIONS
below
'MEDICAL. PA°rMENTS FOR PARTICIPANTS
PRIMARYMEDICAL
EXCESS MEDICAL
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Instructor of: Craft Making, Instrumental Music
The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured.
L;LKIIF'IGAIF HOLDER CANCELLATION
City of Santa Ana it's Officers, Agents, Employees, and Volunteers SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
20 Civic Center Plaza THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Santa Ana, CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS.
Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE
Coverage is only extended to U.S. events and activities.
" NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas.
ACORD 2:5 (2014101) @ 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 6BRPGO000005730600
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Orqan
City nfSanta Ana it's Officers, Agents, Employees, and Volunteers
28Civic Center Plaza
Santa Ana, CA 92701
RE: Fe|icm|lkcagka
Cert.#OQ2
Effective: 1/14/2016-1/14/2017
I Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section U — Who Is An Insured is amended to
include as an additional insured the person(e) or
organization(s) shown inthe Schedule, but only with
maepeo$ to liability for "bodflk/ injury",
damage" or"personal andadvertising icaused,
inwhole orinpart, by your acts oromissions orthe
acts oromissions u/those acting onyour behalf:
1. In the performance of your ongoing operations�
or
2. In connection with your premises owned by or
rented to you.
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law: and
2. If coverage provided tothe additional �nuonad is
required by a contract or agreement, the
insurance afforded tosuch additional insured will
not be broader than that which you are required
by the contract or agreement to provide for such
additional insured.
B. With respect to the insurance afforded bzthese
oddtiona|insureds, the following ioadded boSection
III — Limits OfInsurance:
If coverage provided to the eddtiona| insured is
required byacontract oragreement, the most wewill
pay on behalf of the additional insured is the amount
of insurance:
1. Required bythe contract oragreement; mr
2. Available under the applicabIe Limits of
Insurance shown in the Ueo|anatione
.
whichever inless.
This endorsement aha0 not increase the applicable
Limits of Insurance shown in the Declarations.
CG%O]6O413 @ Insurance Services Offio*.|nCr.2012 Page 1of1