Loading...
HomeMy WebLinkAboutWHITMER, CARMEN 2 -2015City Of Santa Ana - Clerk of the Council AGREEMENT TERMINATION FORM 2m9 AUG 2 i 'c8 Please complete this form when the attached agreement t9l'YIIQF SAN amendments (if any) are no longer in effect. CLERK OF C' 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 No. N-2016-018 was completed on and final payment has been made. (List all amendments. Use space below if needed.) Department: 'F R G (3A Phone/Ext.: q m Signature:p/��z Date: Shqhoke Revised 10-31-12 INSURANCE ON FILE N-2016-018 WORK &TAY PROCEED UNTIL INSURANCE EXPIRES �-N--/ CLERK OF COUN DATE:. B 9 2015 RECREATION SERVICES AGREEMENT „J" ?Jl& THIS AGREEMENT made and entered into this I" day of January 2015, by and �( >s ._bie.CaneWl�itmer (herit 1."Pro_vider"nnd thg_1Y ofnta Ana _a_ charter .city and _ __........ municipal corporation organized and existing Linder the Constitution and laws 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 zumba 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 under this Agreement will be performed, in compliance with such standards as may reasonably be expected, NOW TJIEREFORE, 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 programs set forth in 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 vvrifnin thirty (30) days following completion of the last class taught by Provider that month. 3. TERM This Agreement shall commence on January 1, 2015 and terminate on December 31, 2016, unless terminated earlier in accordance with Section 1,2, below, The Term of this Agreement may be extended upon a writing executed by the Executive Director of Parks, Recreation and Community Services and the City Attorney. 4. INDEPENDENT CONTRACTOR Provider shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer -employee relationship, a, joint venture relationship, 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 shall be provided in a manner consistent with all applicable standards and regulations governing such services, Provider shall pay all salaries and wages, 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 act on behalf of the City. 5. INSURANCE Prior to iundertaking performance of wort, under this Agreement, Provider shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance 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, including, without limitation, 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, Provider, 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 fall 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 terminate this Agreement. Such termination 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 han�nless 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 1 of this Agreement. The Provider further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and casts for special counsel to be selected by the City, regarding any action by a third party asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. 7. CONFLICT OF INTEREST Provider covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 8. LIVE SCAN BACKGROUND CHECK Providers in contact with minors under eighteen (18) years of age shall arrange for and submit to a Live Scan electronic background check 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 conununication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by fast class or certified mail, postage prepaid, or sent by telefacsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Cleric of the Council City of Santa Ana 20 Civic Center Plaza, (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 'felefacsimile (714) 647-6956 With copy to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 26 Civic Center Plaza (M-75) P.O. Box 1988 Santa Ana, California 92702 Telefaesimile (714) 571-4211 To Provider: Carmen Whitmer 3229 Pasadena Avenue Long Beach, CA 90807 Cell # (562) 715-8951 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 deemed 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 telefacsimile, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, 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 and conditions 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 assigranent, 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. Tn the event Provider is not able to teach a class due 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 instructors 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 terminated 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 termination/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 of ten (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 activities. Provider affirms that it is an equal opportunity employer and 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 the laws of the State of California. Both parties further agree 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. 15. LICENSES Provider shall, throughout the term of this Agreement, maintain all necessary licenses, permits, 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 unenforccability 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. 17. EXHIBITS All Exhibits referenced herein and attached, hereto shall be incorporated as if filly set forth in the body of this Agreement. 18. AUTHORITY The person(s) executing this Agreement on behalf of the parties hereto warrant that they are duly authorized to execute this Agreement on behalf of said parties and that be 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 Agreement the date and year first above written. ATTEST: I /�3 0' Maria' D. Huizar Clerk of the Council APPROVED AS TO FORM: SONIA R, CARVALHO City Attomey Byi Lisa Storck Assistant City Attornoy RECOMMENDED FOR APPROVAL: - z- - -"6 6-7 0 MOUET Executive Director of Parks, Recreation and Community Services Agency CITY OF TA ANA David Cavazos City Manager PROVIDER: Icartnen WhiAer- Exhibit A SCOPE OF SERVICES— Carmen Whitmer 0 Consultant will teach Zumba Fitness w/Carmen for age N & over. A. Zumba Fitness class consists of monthty session, held 2 days M & % per week, 50 minutes per day - $25/per month or $5/drop in fee. B. Zumba Fitness class consists of monthly session, held 2 days T & Th, per week, 55 minutes per day - $25/per month or $5/drop in fee. C. Zumba Fitness Class Bundle consists of monthly session, held 4 days M, T, W, Th, per week, 55150 minutes per day-$47/per month D. Classes will be throughout the year. E. Provider and City staff shall mutually agree upon a schedule for classes, including the location, specific days and hours when class will be held and holidays to be observed. F. Provider shall provide materials, supplies, equipment, records and personnel. Provider shall be responsible for clean-up of the facilities and materials and shall ensure the safety and effectiveness of instruction. G. If Provider allow others to teach his/her class, those teachers 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 to A. Each class must have a minimum ofWpaid students and no more than a maximum of 40. B. No registration will be accepted after the second meeting of class, C. hi the event the minimum number of enrollees is not realized by the second meeting of the class, the class shall be canceled. Consultant will be Under no obligation to provide services and the City will have no obligations to pay Consultant compensation CLASS VEkS A. Each participant shall pay a $25/$47/$5 class registration fee per month. Anticipated revenue not to exceed ,$25,000.00 annually. B. No refunds will be made to participants after the first week of class unless the class is cancelled by the City. C. The City shall collect registration fees from each participant during the registration period. Consultant shall not collect fees, but shall refer all interested participants to City for registration. D. The City shall collect registration: fees from each participant during the registration period. Consultant shall not collect fees, but shall refer all interested participants to City for registration. E. Consultant will receive seventy percent (70%) of the total fees collected each month. City and Consultant agree that City shall retain thirty percent (30%) of the fees collected as an administration fee. Consultant agrees that City is entitled to audit Consultant's records and classes to insure compliance with this Agreement. F. Consultant may not waive class participation/registration fees. G. City shall prepare class rosters and provide a copy to Consultant, Only registered participants may participate in class. ACORD,. CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDDIYYYY) 05/31/2013 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 Mass Merch Underwriting 9 K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne Indiana 46804 PHONE: A/C No. Ext; ggg_580-8041 FAX: (Arc, No): 260-459-5995 E-MAIL ADDRESS: info@fitnessinsurance-kk.com INSURER(S) AFFORDING COVERAGE NAIC N INSURER A: Nationwide Mutual Insuran Ce Com an 23 II7 INSURED INSURER B: Carmen M. Whitmer INSURER C: 3229 Pasadena Ave INSURER D: Long Beach, CA 90807 A Member of the Sports, Leisure & Entertainment RPG INSURERS: INSURERF: COVERAGES CERTIFICATE NUMBER: W00312110 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, INSH LTR TYPE OF INSURANCE AODL INSR SUBR MD POLICY NUMBER POLICY EFF MMIDOIYY POLICY EXP MMIDDNY LIMITS A GENERAL LIABILITY X 6BRPG000OD05342300 05/31/2013 05/31/2015 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY Cl-Ni FX --]OCCUR 1:57 AM EDT 12:01 AM DAMAGE TO RENTED PREMISES Eaoccurrence $500,000 MED EXP (Any one person) $10,000 PERSONAL&ADM INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑PROJECT ❑LOC PRODUOfe-COMP/OP AGO $1000,000 PROFESSIONAL LIABILITY $1,000,000 LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea Accident ANY AUTO BODILY INJURY (Per parson) SCHEDULED ALL OWNED AUTOS UTOS BODILY INJURY(Peraccident) ON -OWNED HIRED AUTOS DUTOS PROPERTY DAMAGE Per accident Not provided while in Hawaii UMBRELLA LIAB OCCUR by. EACH OCCURRENCE EXCESS LIAB CLAIMS -MACE AGGREGATE OEO RETENTION WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORSHIP/PARTNER/ = EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA` Silvia 6U U FD�/'hQ A/q IC OSA A Vas ,) YGl II/ mj�^ ' WC STU- TORYTALIMITS OTHER E.L. EACH ACCIDENT EL. DISEASE - EA EMPLOYEE If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DE RIPTI N F PERATI N 1 L ATI N LE A ach A RD 101, Additional Remarks chedule, If more space s required) Certified Instructor of: ZUMBA& The certificate holder is added as an additional insured, but only with respect to the liability arisino out of the operations of the insured named above. .nano ra PJGQ. is Center Plaza Ana, CA 92701 :r/Lessor of Premises) ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE I THE POLICY PROVISIONS. 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 (2010105) The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION. All rights reserved. 17?/� F 2� POLICY NUMBER: 6BRPG0000005342300 INTERLINE IL12011185 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number 1 POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY 6BRPG0000005342300 05/31/13 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Carmen M. Whitmer K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED COMMERCIAL GENERAL LIABILITY COVERAGE CHANGES Form SRPG8016 and SRPG 8018 are added to the policy in regards to: The City of Santa Ana, officers, employees, agents and representative 20 Civic Center Plaza Santa Ana, California 92701 CP# 4613 Effective: 9/13/13 — 5/31 /15 The above amendments result in a change of premium as follows: FTNo Change To be Adjusted at Audit Additional Premium Return Premium Ai-t ! "�-r/t Authorized Representative Signature �ApyA0V.ZD To IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: 68RPG0000005342300 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: Carmen M. Whitmer Additional Insured: The City of Santa Ana, officers, employees, agents and representative 20 Civic Center Plaza Santa Ana, California 92701 CP# 4613 Effective: 9113/13 — 5/31/15 SRPG8016 09108 POLICY NUMBER: 6BRPG0000005342300 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: The City of Santa Ana, officers, employees, agents and representative 20 Civic Center Plaza Santa Ana, California 92701 Name Insured: Carmen M. Whitmer CP# 4613 Effective: 9/13113 — 5/31/15 i SRPG8018 3 /7 09108 AV-c 15-018' POLICY NUMBER: 6BRPG0000005515500 INTERLINE IL 12 01 11 85 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Numher 1 POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY 6BRPG0000005515500 05/31/15 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Carmen M. Whitmer K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED ALL COVERAGE PARTS CHANGES The following form, SRPG8016, is added to the policy in regards to The City of Santa Ana, Officers, Employees, Agents & Representatives CP# 5469 Authorized Representative Signature Reviewed by -L& � t L/ t-v Carmen Acosta PRCSA/Recreation I of It. 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISC Commercial Risk Services, Inc., 1983 POLICY NUMBER: 6BRP00000006515500 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION This endorsement modifies insurance under the following: COMMON POLICY CONDITIONS, A. Cancellation, 2.1b. 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: Carmen M. Whitmer Additional Insured: The City of Santa Ana, Officers, Employees, Agents & Representatives 20 Civic Center Plaza Santa Ana, CA 92701 Effective: 05/31/15 — 05/31/17 RE: Carmen M. Whitmer CP# 5469 Reviewed by C � s"e ) Carmen Acosta PRCSA/Recreation A 0� (�p SRPG8016 09108 POLICY NUMBER: 6BRPG0000005515500 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 Organization(s) The City of Santa Ana, Officers, Employees, Agents & Representatives 20 Civic Center Plaza Santa Ana, CA 92701 Effective: 05/31 /15 — 05/31 /17 RE: Carmen M. Whitmer CP# 5469 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organizations) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your 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 to the additional insured is required by a contract or agreement, the insurance afforded to such 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 to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Reviewed by aj` {'1 Carmen Acosta PRCSA/Recreation 3Ob� CG 20 26 0413 O Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 6BRPG0000005516500 INTERLINE IL 12 01 11 85 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number 2 POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY 6BRPG0000005515500 05I31/15 Nationwide Mutual Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Carmen M. Whitmer K&K Insurance Group, Inc. COVERAGE PARTS AFFECTED COMMERCIAL GENERAL LIABILITY COVERAGE CHANGES The following form, SRPG8018, is added to the policy in regards to The City of Santa Ana, Officers, Employees, Agents & Representatives CP# 5469 Aa't/I "j Authorized Representative Signature Reviewed by Carmen Acosta PRCSA/Recreation r14 o� � IL 12 01 11 86 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc„ 1983 POLICY NUMBER: 66RPG0000006515500 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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: The City of Santa Ana, Officers, Employees, Agents & Representatives 20 Civic Center Plaza Santa Ana, CA 92701 Effective: 05/31/15 — 05/31/17 RE: Carmen M. Whitmer CP# 5469 Reviewed by Carmen Acosta PRC A/Recreation SRPG8018 00108 AC0f2Drr, CERTIFICATE OF LIABILITY INSURANCE DATE(M2/201) 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 INSUREDS), 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 March t)ndelwfitin g K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne Indiana 46604 PHONE: c, No. Bai : 888-580-8041 ITFAX: (AIC, No): 260-459-5995 E ADOREss: Info@fitnessinsumnoe-kk.com INSURERS) AFFORDING COVERAGE NAIC It INSURER A: Nationwide Mutual Insurance Company 23787 INSURED INSURER B: Carmen M. Whitener INSURER C: �.`.Y. .. INSURER M 3229 Pasadena Ave - Long Beach, CA 90807 A Member of the Sports, Leisure & Entertainment RPG INSURER E: W INSURER F: CnVPRA n PR CERTIFICATE NUMBER: W00633577 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. NO' I' WITHSTANDING 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 INSO SUBR MAD POLICY NUMBER POLICYEFF MMIDONY POLICYEXP MMIDD" LIMITS A X COMMERCIAL GENERALLIABILITY X 6BRPG0000005515500 06/3112015 05/31/2017 EACHOCCURRENCE $1,000,00 7—x CLAIMS -MADE X OCCUR 12:01 AM EDT12:01 AM DAMAGE TO RENTED PREMISES Ea occurrence $500,000 MED EXP(Any one person) $10000 PERSONAL &ADV INJURY $1,000,00 GENERWAGGRCGATE GEN': AGGREGATE LIMIT APPLIES PER: per yea 5 000 000 PRO DEC POLICY ❑ JECT PRODUCTS-GOMP/OPAGG per year $1,00000 OTHER PROFESSIONALUABILITY $1,000,00 LEGAL UAB TO PARTICIPANTS $1,000,00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea Accident,-,,,,Y BODILY INJURY (Per person) JANYAUTO SCHEDULED ALL OWNED AUTOS AUTOS BODILY INJURY (Par accident) .m^ PROPERTYDAMAGE Peraccident HIRED AUTOS NON -OWNED UTOS Not provided while in Hawaii MBRELLA LIA6 OCCUR EACH OCCURRENCE AGGREGATE EXCESS JAB CLAIMSMADE b RCTENTION WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N PER STATUTE OTHER E.L. EACH ACCIDENT ANY PROPRIETORSHIPIPARTNER/ EXECUTIVE OFFICERVEMBER EXCLUDED4 N/A E.I_ DISEASE - EA EMPLOYEE (Manda(ory In NH) If yos, describe under E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL E RIP I A CA ON EHI L O .A IEona Remarks chetlule, may aattaohatl more space is required) Certified Instructor of., ZUMBA® 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. CERTIFICATE HOLDER CANCELLATION The City of Santa Ana, officers, employees, agents and representatives SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 Civic Center Plaza THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE Santa Ana, CA 92701 WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (Owner/Lessor of Premises) 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 Blithe incur nce n",,fACORD 2512014101) The ACORD name and logo are registered marks of ACORD g awed. Carmen Acosta PRCSA ec e�ati n a