HomeMy WebLinkAboutQUEENS PUBLIC LIBRARY - 2014p City of Santa Ana
f'19� 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amendments (if any) are no longer in effect.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 647-6520 if you have any questions.
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CLERK OF C01,10 -L--—
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CONSULTANT AGREEMENT
INCORPORATING INSTITUTE OF MUSEUM
AND LIBRARY SERVICES (IMLS)
LEADERSHIP GRANT REQUIREMENTS
THIS AGREEMENT, effective as of the I" day of December, 2014, by and between
Queens Borough Public Library, a not-for-profit corporation (hereinafter "Consultant') and the
City of Santa Ana, a charter city and municipal corporation organized and existing under the
Constitution and laws of the State of California ("City").
A-2015-006
RECITALS
"CJ A. The City desires to retain Queens Borough Public Library as a consultant having special
skill and knowledge in the field of conducting community memory events along with
related website services.
B. The City, as a recipient and grantee of the 2014 Federal Institute of Museum and
Library Services (IMLS) National Leadership Grant Program, desires to enter this
Agreement with the Consultant for the expenditure of grant funds in accordance with
the General Terms and Conditions for IMLS Discretionary Awards ("IMLS Terms
and Conditions") which can be found at:
htt;//ww__v.nals.Pcv(assets/1/tss tmanagergtc 0414.actf
C. Consultant represents that it is able and willing to provide such services to the City, and
will comply with the IMLS Terms and Conditions.
D. In undertaking the performance of this Agreement, Consultant represents that it is
knowledgeable in its field and that any services performed by Consultant under this
Agreement will be performed in compliance with such standards as may reasonably be
expected from a professional consulting firm in the field.
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
Consultant shall perform those community memory events as set forth in Exhibit A, Scope
of Work, attached hereto and incorporated herein by reference.
2. COMPENSATION
a. The total sum to be expended under this Agreement shall not exceed Twenty Five
Thousand Four Hundred Ninety Seven Dollars ($25,497.00) during the Term of this Agreement.
The City shall also pay reasonable travel costs (limited to transportation, airfare and lodging, if
any) for Consultant to perform its services pursuant to this Agreement; no travel costs will be
reimbursed to the Consultant as the City will be paying such listed costs directly.
b. The above -stated compensation includes reimbursement by the City for meals and
beverages (no alcohol) in an amount not to not exceed $71 per day for up to seven (7) days.
Consultant shall submit a reimbursement request form with receipts to City staff in order to be
reimbursed, subject to City accounting procedures.
c. Payment by City shall be made within thirty (30) days following receipt of proper
invoice evidencing work performed, subject to City accounting procedures. Payment need not
be made for work which fails to meet the standards of performance set forth in the Recitals
which may reasonably be expected by City.
3. TERM
This Agreement shall commence on the date first written above and terminate on September
30, 2017, unless terminated earlier in accordance with Section 9, below. The Term of this
Agreement may be extended by a writing executed by the City Manager and the City Attorney.
4.
Consultant 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 professional manner in which
Consultant performs the services which are the subject matter of this Agreement; however, the
services to be provided by Consultant shall be provided in a manner consistent with all
applicable standards and regulations governing such services. Consultant 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.
5. INSURANCE
Prior to undertaking performance of work under this Agreement, Consultant shall
maintain and shall require its subcontractors, if any, to obtain and maintain insurance as
described below:
a. Commercial General Liability Insurance. Consultant 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 Consultant'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, and in the aggregate. 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 as evidenced by a separate Additional Insured Endorsement; and (c) contain standard
separation of insureds provisions.
b. Business automobile liability insurance, or equivalent form, with a combined single
limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for
owned, hired and non -owned automobiles.
c. Worker's Compensation Insurance. In accordance with the provisions of Section
3300 of the Labor Code, Consultant, if Consultant 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, Consultant agrees to obtain and maintain any
employer's liability insurance with limits not less than $1,000,000 per accident.
d. The following requirements apply to the insurance to be provided by Consultant
pursuant to this section:
(i) Consultant shall maintain all insurance required above in full force and
effect for the entire period covered by this Agreement.
(ii) Certificates of insurance shall be furnished to the City upon execution of
this Agreement and shall be approved in form by the City Attorney.
(iii) Certificates and policies shall state that the policies shall not be cancelled
or reduced in coverage or changed in any other material aspect without
thirty (30) days prior written notice to the City.
e. If Consultant 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 effect Consultant's right to be paid for its
time and materials expended prior to notification of termination. Consultant 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
Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents,
employees, consultants, special counsel, and representatives from liability: (1) 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 Consultant 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; and (2) from any claim that personal injury, damages, just
compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects
arising from this Agreement. This indemnity and hold harmless agreement applies to all claims
for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to
have been suffered, by reason of the events referred to in this Section or by reason of the terms
of, or effects, arising from this Agreement. The Consultant further agrees to indemnify, hold
harmless, and pay all costs for the defense of the City, including fees and costs 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. CONSULTANT'S OBLIGATIONS
A. Nondiscrimination.
Consultant must comply with the following nondiscrimination statutes and their
implementing regulations and must also comply with the requirements of any other
nondiscrimination laws which may apply:
(a) Title VI of the Civil Rights Act of 1964, as amended (42 U.S.C. §2000 et seq.), which
prohibits discrimination on the basis of race, color, or national origin (note: as clarified
by Executive Order 13166, the applicant must take reasonable steps to ensure that limited
English proficient (LEP) persons have meaningful access to the applicant's programs (see
IMLS guidance at 68 Federal Register 17679, April 10, 2003));
(b) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §701 et seq.
including §794), which prohibits discrimination on the basis of disability (note: IMLS
applies the regulations in 45 CFR Part 1170 in determining compliance with Section 504
as it applies to recipients of Federal assistance);
(c) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §1681-83,
§1685-86), which prohibits discrimination on the basis of sex in education programs; and
(d) the Age Discrimination in Employment Act of 1975, as amended (42 U.S.C. §6101 et
seq.), which prohibits discrimination on the basis of age.
B. Debarment and Suspension
Grantees are prohibited from doing business with any organization or person (as a
recipient, subrecipient, contractor, or key employee) if they have been debarred or suspended by
any Federal department or agency.
The OMB Guidelines to Agencies on Governmentwide Debarment and Suspension
(Nonprocurement) contained in 2 CFR Part 180 and the corresponding IMLS regulations
contained in 2 CFR Part 3185 apply to IMLS grants.
The Consultant, as a primary tier participant, is required to comply with 2 CFR Part 18C
subpart C (Responsibilities of Participants Regarding Transactions Doing Business with Other
Persons) as a condition of participation in the award. The Consultant is also required to
communicate the requirement to comply with 2 CFR Part 180 subpart C (Responsibilities of
Participants Regarding Transactions Doing Business with Other Persons) to persons at the next
lower tier with whom the Consultant enters into covered transactions.
C. Drug -Free Workplace
The Consultant must provide a drug-free workplace by complying with the requirements
in 2 CFR Part 3186 (Requirements for Drug -Free Workplace (Financial Assistance)). In
particular, the Consultant must comply with drug-free workplace requirements in subpart B (or
subpart C, if the recipient is an individual) of 2 CFR Part 3186.
This includes, but is not limited to: making a good faith effort, on a continuing basis, to
maintain a drug-free workplace; publishing a drug-free workplace statement; establishing a drug-
free awareness program for the Consultant's employees; taking actions concerning employees
who are convicted of violating drug statutes in the workplace; and identifying (either at the time
of application or upon award, or in documents the Consultant keeps on file in its offices) all
known workplaces under the Consultant's Federal awards.
D. Trafficking in Persons
The Consultant must comply with Federal law pertaining to trafficking in persons. Under
22 U.S.C. §7104(g), any grant, contract, or cooperative agreement entered into by Federal
agency and a private entity shall include a condition that authorizes the Federal agency (IMLS)
to terminate the grant, contract, or cooperative agreement if the Consultant, subgrantee,
contractor, or subcontractor engages in trafficking in persons, procures a commercial sex act, or
uses forced labor. 2 CFR Part 175 requires MLS to include the following award term, which is
made a part of these General Terms and Conditions:
a. Provisions applicable to a recipient that is a private entity
1. You as the recipient, your employees, subrecipients under this award, and
subrecipients' employees may not -
i. Engage in severe forms of trafficking in persons during the period of
time that the award is in effect;
ii. Procure a commercial sex act during the period of time that the award
is in effect; or
iii. Use forced labor in the performance of the award or subawards under
the award.
2. The City, as the awarding agency may unilaterally terminate this award,
without penalty, if you or a subrecipient that is a private entity -
i. Is determined to have violated a prohibition in paragraph a.I of this
award term; or
ii. Has an employee who is determined by the agency official authorized
to terminate the award to have violated a prohibition in paragraph a.I of
this award term through conduct that is either-
A. Associated with performance under this award; or
B. Imputed to you or the subrecipient using the standards and
due process for imputing the conduct of an individual to an
organization that are provided in 2 CFR part 180, "OMB
Guidelines to Agencies on Govemmentwide Debarment and
Suspension (Nonprocurement)," as implemented by IMLS at
2 CFR Chapter XXXI, part 3185.
b. Provision applicable to a recipient other than a private entity
The City, as awarding agency, may unilaterally terminate this award, without
penalty, if a subrecipient that is a private entity -
1. Is determined to have violated an applicable prohibition in paragraph a.I of
this award term; or
2. Has an employee who is determined by the agency official authorized to
terminate the award to have violated an applicable prohibition in paragraph a.l
of this award term through conduct that is either -
i. Associated with performance under this award; or
ii. Imputed to the subrecipient using the standards and due process for
imputing the conduct of an individual to an organization that are provided
2 CFR part 180, "OMB Guidelines to Agencies on Govemmentwide
Debarment and Suspension (Nonprocurement)," as implemented by our
agency at 2 CFR part 3185.
c. Provisions applicable to any recipient
1. You must inform the City immediately of any information you receive from
any source alleging a violation of a prohibition in paragraph a.l of this award
term.
2. The City has the right to terminate unilaterally that is described in paragraph
a.2 or b of this section:
i. Implements section 106(g) of the Trafficking Victims Protection Act of
2000 ("TVPA"), as amended (22 U.S.C. §7104(g)), and
ii. Is in addition to all other remedies for non-compliance that are available
to the City under this award.
3. You must include the requirements of paragraph a.l of this award term in any
subaward you make to a private entity.
D. Definitions
For purposes of this award term:
1. "Employee" means either:
i. An individual employed by you or a subrecipient who is engaged in the
performance of the project or program under this award; or
ii. Another person engaged in the performance of the project or program under
this award and not compensated by you including, but not limited to, a volunteer
or individual whose services are contributed by a third party as an in-kind
contribution toward cost sharing or matching requirements.
2. "Forced labor" means labor obtained by any of the following methods: the
recruitment, harboring, transportation, provision, or obtaining of a person for labor or
services, through the use of force, fraud, or coercion for the purpose of subjection to
involuntary servitude, peonage, debt bondage, or slavery.
3. "Private entity":
i. Means any entity other than a State, local government, Indian tribe, or foreign
public entity, as those terms are defined in 2 CFR 175.25.
ii. Includes:
A. A nonprofit organization, including any nonprofit institution of higher
education, hospital, or tribal organization other than one included in the
definition of Indian tribe at 2 CFR 175.25(b).
B. A for-profit organization.
4. "Severe forms of trafficking in persons," "commercial sex act," and "coercion" have
the meanings given at section 103 of the TVPA, as amended (22 U.S.C. §7102).
E. Federal Debt Status
The Consultant should not be delinquent in the repayment of any Federal debt.
F. Lobbying
The Consultant may not conduct political lobbying within the Federally -supported
project. hi addition, the Consultant may not use Federal funds for lobbying specifically to obtain
awards, extensions, amendments, or other Federal actions. (31 U.S.C. §1352) Certain other
lobbying restrictions, such as the following, may also apply:
Lobbying Activities (Applies to Applicants Requesting Funds in Excess of $100,000) (31
U.S.C. § 1352). The following provisions remain in effect for the award:
(a) No Federal appropriated funds may be paid, by or on behalf of the Consultant, to any
person for influencing or attempting to influence an officer or employee of an agency, a Member
of Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with the awarding of any Federal contract, the making of any Federal grant, the
malting of any Federal loan, the entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or
cooperative agreement.
(b) If any funds other than Federal appropriated funds have been paid or will be paid to
any person (other than a regularly employed officer or employee of the applicant, as provided in
31 U.S.C. §1352) for influencing or attempting to influence an officer or employee of any
agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with this Federal contract, grant, loan, or cooperative
agreement, the Consultant shall complete and submit Standard Form LLL, "Disclosure of
Lobbying Activities," in accordance with its instructions.
(c) The Consultant shall require that the language of the certification be included in the
award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts
under grants, loans, and cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.
In addition, no 1MLS grant funds shall be used to pay the salary or expenses of any grant
or contract recipient, or agent acting for such recipient, relating to any activity designed to
influence legislation or appropriations pending before the Congress or any State legislature. (P.L.
111-117, Division D, Title V General Provisions, sec. 503(b)).
8. ASSIGNABILITY
None of the duties of, or work to be performed by, Consultant under this Agreement shall be
subcontracted or assigned to any agency, consultant, or person without the prior written consent of
City. Consultant must submit all subcontracts and other agreements that relate to this Agreement to
City. No subcontract or assignment shall terminate or alter the legal obligations of Consultant
pursuant to this Agreement.
9. TERMINATION
A. This Agreement may be terminated on thirty (30) days' written notice by either
party. In the event of such termination, Consultant shall only be entitled to reimbursement for
approved expenses incurred to the effective date of termination.
B. This Agreement may be suspended or terminated by City upon five (5) days' written
notice for violation by Consultant of Federal Laws governing the use of the IMLS grant funds. hi
the event of such suspension or termination, Consultant shall only be entitled to reimbursement for
approved expenses incurred up to the effective date of suspension or termination.
C. In the event Consultant defaults by failing to fulfill all or any of its obligations
hereunder, City may declare a default and termination of this Agreement by written notice to
Consultant, which default and termination shall be effective on a date stated in the notice which is to
be not less than ten (10) days after certified mailing or personal service of such notice, unless such
default is cured before the effective date of termination stated in such notice. If terminated for
cause, City shall be relieved of further liability or responsibility Linder this Agreement, or as a result
of the termination thereof, including the payment of money, except for payment for approved
expenses incurred for services satisfactorily and timely performed prior to the mailing or service of
the notice of termination, and except for reimbursement of (1) any payments made for services not
subsequently performed in a timely and satisfactory manner, and (2) costs incurred by City in
obtaining substitute performance.
10.
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.
11. 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.
12. NOTICE
Any notice, tender, demand, delivery, or other communication 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
communication in the manner provided in this Section, to the following persons:
To City: Clerk of the City Council
City of Santa Ana
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ana, California 92702-1988
Facsimile (714) 647-6956
Copies to: Parks, Recreation and Community Services Agency
City of Santa Ana
20 Civic Center Plaza (M-23)
P.O. Box 1988
Santa Ana, California 92702
Facsimile (714) 571-4221
City Attorney
City of Santa Ana
20 Civic Center Plaza (M-29)
P.O. Box 1988
Santa Ana, California 92702
Facsimile (714) 647-6515
To Consultant: Queens Borough Public Library
Bridget -Quinn -Carey, Executive Vice President & CEO
Natalie Milbrodt, Digital Content & Strategy Coordinator
89-11 Merrick Blvd.
Jamaica, NY 11432
Facsimile (718) 990-0700
13. 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 Agency fully, including reasonable costs and attorney's fees, for any injuries or damages
to Agency 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.
c. No delay or omission by either party hereto to exercise any right or power accruing
upon any noncompliance or default by the other party with respect to any of the terms of this
Agreement shall impair any such right or power or be construed to be a waiver thereof A
waiver by either of the parties hereto of any of the covenants, conditions, or agreements to be
performed by the other shall not be construed to be a waiver of any succeeding breach thereof
or of any other covenant, condition or agreement herein contained.
[Signatures on following page]
10
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and
year first above written.
ATTEST:
Maria D. Huizar
City Clerk
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney
By 4 (tee L —
Lisa Storck
Assistant City Attorney
RECOMMENDED FOR APPROVAL:
/'/4'2 C
Gerardo Monet
Executive Director
Parks, Recreation and
Community Services Agency
11
CITY OF SANTA ANA
1
David Cavazos
City Manager
CONSULTANT
BOROUGH PUBLIC LIBRARY
CEO
EXHIBIT A
SCOPE OF WORK
Memories of Migration Partners
Queens Borough Public Library (Consultant) will hire and train two Emerging Professional
Fellows with fluency in Mandarin and Cantonese to conduct forty (40) Memories of Migration
community events in the library's service area over a twelve month period. Consultant will
record and archive the experiences of immigrant populations for the Memories of Migration
project. Queens Borough Library will focus on elderly immigrants from Taiwan, Hong Kong
and Mainland China. They will contribute the results from these events to the project website
and collaborative archive. The Fellows will translate the model elements included in the jumpkit
for inclusion in their programs. Queens Borough Public Library will provide reports and
evaluations as required by the IMLS grant. For these deliverables, Consultant will receive
$25,497.00. The largest portion of the grant funds will provide salaries for the Fellows. Queens
Borough Library will provide $30,527.00 in cost sharing as required by the budget approved by
IMLS.
12
QUEEBOR-02 RGCHACANA
A te' CERTIFICATE OF LIABILITY INSURANCE DATE
(MMI DNYYY)
111 1 014
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 on this certificate does not confer rights to the
PRODUCER
INSURED
ler Risk Management Services, Inc,
11630
Queens Borough Public Library
89.11 Merrick Blvd.
Jamaica, NY 11432
Allmerica Financial Benefit Insurance Co 141840
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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE INS SU POLICY NUMBER
POLICY EFF
POLICY
LIMITS
A X I COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,005,55
CLAMS -MADE OCCUR BY9185709
0610112014
RENTED
06101/2016 PREMISES Eaaec,arenee $ 1,000,00C
PREMI
MED EXP {Any one person! $ 15,555
PERSONAL & ADV INJURY $ 1,000,05
_
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ -2,000,000
PRC- �
POLICY ECT LOC
PRODUCTS - COMPIOP AGO $
OTHER'.
$u
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $ 1,000,655
Es accident)
B X ANY AUTO AWY9158767
06/0112014
06/01/2015 BODILY INJURY (Per person) $
ALL. OWNED SCHEDULED
BODILY INJURY (Per accident) $
AUTOS AUTOS
NON -OWNED
PROPERTY DAMAGE $
HIRED AUTOS AUTOS
Pare dea _
UMBRELLA UAB OCCUR
EACH OCCURRENCE $
EXCESS LIAR CLAIMS -MADE
AGGREGATE $ ......................
DED RETENTION$
$
WORKERS COMPENSATION
IPER OTH-
AND EMPLOYERS' LIABILITY YIN
STATUTE ER.
ANY PROPRIETORIPARTNEIVEXECUTIVE
E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below
EL.DISEASE - POLICY LIMIT I $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required)
PER FORM # 4210146 0903
AS RESPECTS TO GENERAL LIABILITY THE FOLLOWING ARE INCLUDED AS ADDITIONAL INSURED TO
,r
The City of Santa Ana, its officers, employees, agents, and representative. pyto's� d T
Y�
5iORC
EISA E•
CERTIFICATE HOLDER CANCELLATION
ACORD 25 (2014/01)
O 1988.2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
M
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Santa Ana
20 Civic Center Plaza -Ross Annex
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Santa Ana, CA 92701
AUTHORIZED REPRESENTATIVE
ACORD 25 (2014/01)
O 1988.2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
M
ADDITIONAL INSURED ENDORSEMENT
Insurance Company
Citizens Insurance Company of America
This endorsement modifies such insurance as is afforded by the provisions of Policy
.#ZRY9185709 relating to the following:
The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers,
employees, agents and representative are named as additional insureds ("additional
insureds") with regard to liability and defense of suits arising from the operations and uses
performed by or on behalf of the named insured.
2. With respect to claims arising out of the operations and uses performed by or on behalf of
the named insured, such insurance as is afforded by this policy is primary and is not
additional to or contributing with any other insurance carried by or for the benefit of the
additional insureds.
This insurance applies separately to each insured against whom claim is made or suit is
brought except with respect to the company's limits of liability. The inclusion of any person
or organization as an insured shall not affect any right which such person or organization
would have as a claimant if not so included.
4. With respect the additional insureds, this insurance shall not be cancelled, or materially
reduced in coverage or limits except after thirty (30) days written notice has been given to
the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701.
(Completion of the following, including countersignature, Is required to make this endorsement effective.)
Effective � d � 8 t (
—'� this endorsement form as part of
Policy # ZBY9185709
Issued to Queens Borough Public Library
Name Insured
Countersigned by
Assistant Gity AttpY1"ev
QUEEBOR-02 RGCHACANA
A4C4C>RL7►" CERTIFICATE OF LIABILITY INSURANCE °A 100/8//8120014TE 214
HIS 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Arthur J. Gallagher Risk Management Services, Inc.
377 Oak Street
Garden City, NY 11530
INSURED
Queens Borough Public Library
89.11 Merrick Blvd.
Jamaica, NY 11432
745.0800_ ___.. n/c Nqp 515 745.0082
INSURERS) AFFORDING COVERAGENA'
INSURERA:Citizens Insurance Company of America 31534
INSURER B:Alimerica Financial Benefit Insurance Co 41$40_
INSURER C
INSURER D
INSURER E: .. .._ _.. _ .............
COVERAGES CERTIFICATE_ NLIMRER- RFVISION NIIMRFR-
THIS IS 'r0 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.
INSR—__.------_.. ADOLS FB —. -- — -' POLICYE•• POL�XP
LTR TYPE OF INSURANCE INBD YdVD POLICY NUMBER 1MMfOD1YYW1 MMI
LIMITS
A X COMMERCIALGENERALLIABILITY
EACH OCCURRENCE
y 1,000,00
�y
CLAIMS C OCCUR �ZBY9185709 j 0670112014 06101!2015
DAMAGETO REOTE>�
R--1'0
-MACE
PREMISES {Ea oawrrenge}
'00
- _ !
MED EXP {Any ore person)
b 10,00
PERSONAL &ADV INJURY
b 1,000,00
GEN AGGREGATE AP PLIE.S PER
GENERAL AGGREGATEPOLIY
S 2,000,000
JLIMIT
PRO XJ LOC
_
PRODUCTS-COMP/OP AGO
$
OTHER',
S
AUTOMOBILE LIABILITY
COMBINED SINGLELIMIT
SEa accident)
S 1,000,000
B X ANY AUTO AWY9158767 106/01/2014 06101/2015
BODILY INJURY (Per Person)
_
E
ALLOWNED — SCHEDULED }
AUTOS IAUTOS
BODILY INJURY(Pera.ident)
$
NON -OWNED
PROPERTY DAMAGE
_
S
HIREDAU7G6 AUTOS
Peracciden)
i
S
UMBRELLA UAB OCCUR p
Revjeweby:
EACH OCCURRENCE
.
EXCESS UAB
1C_iAIMS-MADE
AGGREGATE
3
DED RETENTION$ (
-_ -.
$
_
WORKERSCOMPENSATION
PER DTH -
AND EMPLOYERS' LIABILITY YIN
STATUTE_ ER
-
ANY PROPRIETORlPARTNERIEXECUTIVE c ^
DER EXCLUDED'! NIA Silva CU vas 1(
E.L.ELEACH ACCIDENT
is
(MandaRIMEM
(Mandatory In NH) G -I
E.L. DISEASE - EA EMPLOYEE 8
DGT^
If yes RIPI I LN under I"
ESCRIP rIUN OF OPERATIONS beow l
- - -
E.L. DISEASE -POLICY LIMIT
r
r$
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe aeached if more space Is required)
PER FORM It 4210146 0903
AS RESPECTS TO GENERAL LIABILITY THE FOLLOWING ARE INCLUDED AS ADDITIONAL INSURED
The City of Santa Ana, 8s officers, employees, agents, and representative.
CFRTIFICATF HOI--OFR CANCFI i ATION
V 19UU-2014 AUUKU UORPORATION. All rights reseCVed.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Cit of Santa Ana
City
20 Civic Center Plaza -Ross Annex
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Santa Ana, CA 92701
—
AUTHORIZED REPRESENTATIVE
V 19UU-2014 AUUKU UORPORATION. All rights reseCVed.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
ADDITIONAL INSURED ENDORSEMENT
Insurance Company
Citizens Insurance Company of America
This endorsement modifies such insurance as is afforded by the provisions of Policy
#Z13Y4185709relating to the following:
The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers,
employees, agents and representative are named as additional insureds ("additional
insureds") with regard to liability and defense of suits arising from the operations and uses
performed by or on behalf of the named insured.
2. With respect to claims arising out of the operations and uses performed by or on behalf of
the named insured, such insurance as is afforded by this policy is primary and is not
additional to or contributing with any other insurance carried by or for the benefit of the
additional insureds.
3. This insurance applies separately to each insured against whom claim is made or suit is
brought except with respect to the company's limits of liability. The inclusion of any person
or organization as an insured shall not affect any right which such person or organization
would have as a claimant if not so included.
4. With respect the additional insureds, this insurance shall not be cancelled, or materially
reduced in coverage or limits except after thirty (30) days written notice has been given to
the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701.
(Completion of the following, including countersignature, Is required to make this endorsement effective.)
Effective _ � O F O q
, this endorsement form as part of
policy # ZBY9185709
Issued to Queens Borough Public Library
Name Insured
Countersigned by—
*Tn,�oweAgentSignature
by:
Silvia Cue as p �-
PRCSAJAdmin.
QUEEBOR-02 IMMVALLANCE
CERTIFICATE OF LIABILITY INSURANCE DATEMMIDDffYYY)
11;2112016
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 INSUREII 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 endorsement(s).
PRODUCER CONTACT
NAME.,
Arthur J. Gallagher Risk Management Services, Inc. PHONE FAX
One Jericho Plaza Suite 200 A ) IC, No, E111): (516 745-0800 (A/C , No): (516) 745-0082
Jericho, INY 11753 E-MAIL
ADDRESS:
INSURED
Queensi Borough Public Library
89-11 Merrick Blvd.
Jamaica, NY 111432
. . . ........................._...m._....._......
INSURER(S) AFFORDING COVERAGE
INSURER A: Citizens Insurance Company of America
INSURER B: Allmerica Financial Benefit Insurance Co
INSURER C
INSURER D
INSURER E:
INSURER F
MAIC #
31534
41840
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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED
HEREIN 15 SUBJECT TO ALL
THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE
BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDLSUBR
INSD WVD POLICY NUMBER
POLICY EFF POLICY EXP
... (MMIDDNYyY)JMMIDDfyYYY� .
.. ..... ... LIMITS
A X COMMERCIAL GENERAL LIABILITYEACH
OCCURRENCE
1,000,000
CLAIMS -MADE X OCCUR ZBY-9185709-06
0610112016 0610112017
DAMAGE TO RENTED
PREMISES (Ea occurrence) $
1,000,000
MrD FXP (Any one person) $
10,000
. .........
PFRSONAL & AUV INJURY S
1,000,000
GEN'L AGGREGATE LIMIT APPLdFS PER
GENERAL AGGREGATE S
2,000,000
POLICY PRO-
JECT X LOC
PRODUCTS - CO�MPIOP AGG S
Included
OTHER
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
(Ea accident)
1000'000��
13 X ANY AUTO AWY9158767
0610112016 0610112017
BODILY INJURY (Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
NON -OWNED
PROPERTY DAMAGE S
HIRED AUTOS AUTOS
(Per accident)
UMBRELLA LIAR OCCUR
EACH OCCURRENCE S
EXCESS LIAB CLAIIMS-MADE
CJ
AGGREGATE.....
PEP
1011
S
_ __RETENTION$
.WORKERS COMPENSATION
. . .....
PER OTH-
AND EMPLOYERS' LIABILITY YINSTATUTE
ER
ANY PROP'RIETOR)PARTNEXCLUDED? :ER/EXECUTIVNIA E
E EACH ACCIDENT
OFFICE R/MEMBER
(Mandatory In NH)
E L DISEASE - EA EMPLOYEE $
If yes, describe under
OESCRtlPTION OF OPERATIONS below
EJ- DISEASE -POLICY LIMIT $
.. .. ........
DESCRIPTION OF: OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule,
....... . .... . . . ........
may be attached if more space is required)
PER FORM # 421 2915 06 15
The City of Santa Ana, its officers, employees, agents, and representative are included
as Additional Insureds
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City oftn: Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS.
AtPRCSA
20 Civic Center Plaza -Ross Annex . .......
Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE
_...m.. .......... . . .....
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
ADDITIONAL INSURED ENDORSEMLNT
Insurance Company Citizens Insurance Company of America
This endorsement
4 ZBY-9185709-06
modifies such insurance as
relating to the following:
is afforded by the provisions of Policy
1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers,
employees, agents and representative are named as additional insureds ("additional
insureds") with regard to liability and defense of suits arising from the operations, and uses
performed by or on behalf' of the named insured.
2. With respect to claims arising out of the operations and uses performed by or on behalf of
the named insured, such insurance as is afforded by this policy is primary and is not
additional to or contributing with any other insurance carried by or for the benefit of the
additional insureds.
3. This insurance applies separately to each insured against whom claim is made or suit is
brought except with respect to the company's limits of liability. The inclusion of any person
or organization as an insured shall not affect any right which such person or organization
would have as a claimant if not so included.
4. With respect the additional insureds, this insurance shall not be cancelled, or materially
reduced in coverage or limits except after thirty (30) days written notice has been given to
the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 9270,1.
(Completion of the following, including countersignature, is required to make this endorsement effective.)
Effective 11/21/2016 this endorsement form as part of
Policv# ZBY-9185709-06
Issued to Queens Borough Public Library
Name Insured
Countersigned by
Insurance Agent Signature.
7-
jr,
CERTIFICATE OF EXCESS INSURANCE CONTRACT FOR SELF -INSURER
STATE NATIONAL INSURANCE COMPANY, -INC.
Name of Excess Insurance Carrier
CIO US SPECIALTY UNDERWRITERS
6140 PARKLAND BLVD, SUITE 300, MAYFIELD HEIGHTS, OH 44124
Address, City, State, Zip
THIS IS TO CERTIF=Y that a Workers' Compensation Excess Insurance Contract has been issued by this
Company as follows:
The Excess Insurance Contract is now in force and the Company will give the Chair, Workers' Compensation
Board, Attention: Office of Self -Insurance, 328 State Street, 3rd Floor, Schenectady, NY 12305 not less than thirty
(30) days written notice of cancellation or of any change to be made by the Company in said Contract. Such
notice shall be sent by registered or certified mail or delivered by personal service as required in the Contract.
Name
Self -Insurer Queens Borough Public Library
Address 89-11 Merrick Blvd., Jamaica, NY 11432
Contract Number NDE -0864177-16
Contract Effective 07/01/2016
until canceled.
Company's Limits of Liability Statutory each occurrence.
Self -Insurer's Retention $500,000
Dated this 21st day of
e6 `Y2
:,jN�a L
CPV
" Attach evidence of authortvy�
SI -21 (04-05)
June
each occurrence.
20 16
STATE NATIONAL INSURANCE COMPANY, INC.
Name of Excess Insurance Company ^T
Authorized Representative
DEAN M. WILLIAMS, PRESIDENT
Print Name of Representative
440-605-6100
Phcne Number including Area Code