HomeMy WebLinkAboutMADRIGAL, MARIA 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amendments (if any) are no longer in effect.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 647-6520 if you have any questions.
The agreement with
No. N-2015-081
(List all amendments.
CCUNNLP-KOF O
was completed on Z and final payment has been made.
Use space below if needed.)
Department: PRC Sj
Phone/Ext.:
Signature:
Date: ��Q 1Qn m
Revised 08-23-10
INSURANCE on Epp.iE.
WORK MY PRUCELM
"Na mSURAN^E EXPR0
CLERK OF COUNCIL
DATE i Ah� 2
RECREATION SERVICES AGREEMENT
N-2015-081
Q THIS AGREEMENT made and entered into this 30"' day of June 2015, by and between
" Maria Madrigal (hereinafter "Provider") and the City of Santa Ana, a charter city and mtmicipal
GWOW corporation organized and existing under the Constitution and laws of the State of California
(hereinafter "City").
RECITAILS
A. The City desires to retain a recreation service provider having special skills, resources and
knowledge to provide dance classes in its leisure class program.
B. Provider represents that Provider is able and willing to provide such services to the City.
C. In widertaking the performance of this Agreement, Provider represents that it is lmowledgeable 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 THEREFORE, in consideration of the mutual and respective promises, and subject to the
tenns 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 within thirty (30) days following completion of the last class taught by Provider that
month.
3. TERM
This Agreement shall commence on July 1, 2015 and terminate on June 30, 2017, 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 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,
timemployment 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.
S. INSURANCE
Prior to undertaking performance of work 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 and $2,000,000 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; 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 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 famish 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 perfonned 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 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 costs for special counsel to be selected by the City, regarding any action by
a thud 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, and any employees, subcontractors or substitutes, 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, dernand, 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 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 Community 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: Maria Madrigal
2530 West Hood Street
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 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 facsimile, 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 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 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, teaching, training, utilization, proumotion, 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 fiuther 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 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.
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.
Signature Page to Follow
IN WITNESS WHEREOF, the patties hereto have executed this Agreement the date and year first
above written.
ATTEST:
MARIA D. HIJIZAR
Clerk of the Council
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney
By:
Lisa Storck
Assistant City Attorney
RECOMMENDED FOR APPROV
Executive Director of Parks,
Recreation and Community Service
CITY OF SANTA ANA
DAVID CAVAZOS
City Manager
PROVIDER
f
MARIA M DRIOA ✓
EXHIBIT A
I, SCOPE OF, SERVICES —Maria Madrigal
A. Provider will teach Zumba Fitness class for Teens and Adults.
B. Zumba class will be held 4 days per week, 50 minutes per day - $40/monthly
C. Zumba class will be held 3 days per week, 50 minutes per day - $35/monthly
D. Zumba class will be held 2 days per week, 50 minutes per day - $20/monthly
E. The class will be held throughout the year.
F. Provider will provide and be responsible for equipment, records, and personal and cleanup of the
facilities and materials necessary to ensure the safety and effectiveness of said instruction.
G. If provider allows others to teach 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.
II. CLASS SIZE
A. Each class must have a minimum of 25 paid students and no more than a maximum of 50.
B. In the event the minimum number of enrollees is not met by the class meeting the class shall be canceled.
Provider will be under no obligation
C. hz the event the minimum number of enrollees is not met by the class meeting the class shall be canceled.
Provider will be. tinder no obligation to provide services and the City will have no obligations to pay
Provider compensation
III. CLASS FEES
A. Each participant shall pay a $40/$35/$20 class registration fee per session. Anticipated revenue not to
exceed $25,000.00 annually.
B. No refunds will be made to participants after the second class meeting unless the class is cancelled by the
City.
C. The City shall collect registration fees from each participant during the registration period. Provider shall not
collect fees, but shall refer all interested participants to City for registration.
D. Provider shall receive seventy percent (70%) of the total fees collected each month. City and Provider agree
that City shall retain thirty per cent (30%) of the fees collected as an administration fee.
E. Provider agrees that City is entitled to audit Provider's records and classes to insure compliance with this
Agreement.
F. Provider may not waive class participation/registration fees.
G. City shall prepare class rosters and provide a copy to Provider. Only registered participants may participate in
class.
ACORD„ CERTIFICATE OF LIABILITY INSURANCE DAT2/1112015 Y)
02/11/2015
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(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 8eu of such endorsements .
PRODUCER
NAMEE:
Mass March Underwriting
K&K Insurance Group, Inc.
1712 Magnavox Way
Fort Wayne Indiana 46804
Y
PHONE,
A/C No, Est:
8BB-580-8041
FAX:(A1C,No):
260-459-5995
E-MAIL
AggRESS:
info fitnesslnsurance-kk.com
@
INSURER(S) AFFORDING COVERAGE
NAIC M
INSURER A:
Nationwide Mutual Insurance Company
23787
INSURED
INSURER e:
Mafia L Madrigal
2530 W Hood Ave
Santa Ana, CA 92704
A Member of the Sports, Leisure & Entertainment REG
INSURER Co
INSURER D:
INSURER E:
INSURER F:
GU 1BRAGES CERTIFICATE NUMBER: W00589699 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 INSURANCE
ADOL
INSD
SUBR
WVD
POLICY NUMBER
POLICY CFF
MMIDDM
POUCYEXP
MMIDDNY
LIMITS
A
X
COMMERCIAL GENERALI�LI
X
6BRP00000005515500
02(13/201.5
02/13/2016
EACH OCCURRENCE
$1,000,00
(ABILITY
CLAIMS -MADE I% OCCUR
LJ
12:01 AM EDT12:01
AM
DAMAGET RRENTED
PREMISES fEa occurrence
$500,000
MED EXP IAny one person)
$10.000
PERSONAL& ADV INJURY
$1,000,00
GEN', AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
POLICY ❑ PRO- ❑ LOC
JECT
5 000 00
PRODUCTS-COMPIOPAGG
1 000,00
PROFESSIONAL LIABILITY
$1,000,00
OTHER
LEGAL LIAR TO PARTICIPANTS
$11000,00
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea Accldenl
BODILY INJURY (Per person)
ANYAUTO
SCHEDULED
ALLOWNEDAUTOS
BODILY INJURY (Per accaenq
ON -OWNED ED
HIRED AUTOS E3UTOB
PROPERTY QAMAGE
Per accident)
Not provided vfiile, in Hawaii
UNU RELLA UAB OCCUR
EACH OCCURRENCE
EXCESS LIAB CLAIMS -MADE
AGGREGATE
DEQ I RETENTION
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORSHINPARTNERI =
EXECUTIVE DFFICEWMEMBER
EXCLUDED?
N / A
PER
STATUTE
OTHER
E.L. EACH ACCIDENT
E.L DISEASE - EA EMPLOYEE
(Mandatary in NH1
If yo%denone uodar
DESCRIPTION OF OPERATIONS bolo-
El, DISEASE - POLICY LIMIT
MEUIGAL PAYMENTS FOR PARTICIPANTS
PRIMARY MEDICAL
EXCESS MEDICAL
SCRIPTION OF GPERAhON5r1TTXr1MrV54ICIACONO id , Additional Remarks c a u e, map attar a ,mere space In required)
Certified In Ct00,r of: Aerobics, Dance, 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,
f:ER I R•R:A I E MULUEK CANCELLATION
City of Santa Ana, Its officers, agents, and employees
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
1825 W Civic Center
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE
Santa Ana, CA 92704
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 all the insurance laws and regulations of the State of Texas
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD @ 1988.2014 ACORD CORPORATION. All rights 2
served.
ACORD- CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDIYY Y)
02/1112015
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 Merch Underwritin 9
K&K Insurance Group, Inc.
1712 Magnavox Way
Fort Wayne Indiana 46804
PHONE:
A/C No. Ext:
888-680-8041
FAX:IAIC,No):
260-459-5995
AIL
ADDRESS:
infoQfitnessinsurance-kk.com
INSURER(S) AFFORDING COVERAGE
NAIC9
INSURER A:
Nationwide Mutual Insurance Company
23787
INSURED
INSURER B:
Maria L Madrigal
INSURER C:
2530 W Hood Ave
INSURER D:
Santa Ana, CA 92704
A Member of the Sports, Leisure & Entertainment RPG
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: W00589697 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.
INSP
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
Me
POLICY NUMBER
POLICY EFF
MMIDONY
POLICY EXP
MMIDDIYY
LIMITS
A
X
COMMERCIAL GENERAL^ LIABILITY
6BRPG000OGO5515600
02/13/2015
02/13/2016
EACH OCCURRENCE
$1,0woo
CLAIMS -MADE IX OCCUR
12:01 AM ED
12:01 AM
DAMAGE TO RENTED
PREMISES Ea occurrence
$500 000
MED EXP(Anyona parson)
$10,000
PERSONAL &ACV INJURY
$1,000,00
GEM' AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
5 000 00
POLICY ❑PRO ❑ LOC
JECT
PRODUCTS-COMPIOP AGG
$1 000 00
PROFESSIONAL LIABILITY
$1,000,00
OTHER
LEGAL LIAR TO PARTICIPANTS
$1,000,0010
MOBILEUABILITV
COMBINED SINGLE LIMIT
Ea AccidentNYAUTO
BODILY INJURY (Per person)
SCHEDULED
LL OWNED AUTOS UrDsBODILY
RA
INJURY(Praccidera)
IRED AUTOSNON-OWNED
UTOS
PROPERTY DAMAGE
Petaccidentot
provided while in Hawaii
UMBRELLALIA13 OCCUR
EACH OCCURRENCE
AGGREGATE
EXCESS LIAR CLAIMS -MADE
OED RETENTION
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
PER
STATUTE
OTHER
ANY PROPRIETORSHIPIPARTNERI [
EXECUTIVE OFFICERIMEMBER
EXCLUDED?
MIA A
EL EACHACCIOENT
E.L. DISEASE— EA EMPLOYEE
(Mandatory In NH)
It yes, describe under
E.L. DISEASE— POLICY LIMIT
DESCRIPTION OFOPERATIONS below
MEDICAL PAYMENTS FOR PARTICIPANTS
PRIMARY MEDICAL
EXCESS MEDICAL
MAIPTION OF OPERATIONS I i Ps A RD t, A d t ene emar a c o u a, may a aaac more apace is required)
Certified Instructor of: Aerobics, Dance, ZUMBA(5
Abuse, Molestation, Harassment or Sexual Conduct Defense Cost Reimbursement- $100,000 limit
CERTIFICATE HOLDER CANCELLATION
Evidence of Coverage
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE
WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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 (2014101) The ACORD name and logo are registered marks of ACORD 01988.2014 ACORD CORPORATION. All rights 7
erved.
�y41,
POLICY NUMBER: 68RP00000005515500
INTERLINE
IL 12 01 11 85
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES
Policy Change
Number
POLICY NUMBER
POLICY CHANGES EFFECTIVE
COMPANY
6BRPG0000005515500
02/13/15
Nationwide Mutual Insurance Company
NAMED INSURED
AUTHORIZED REPRESENTATIVE
Maria L Madrigal
K&K Insurance Group, Inc.
COVERAGE PARTS AFFECTED
ALL COVERAGE PARTS
CHANGES
The following form,SRPG8016, is added to the policy in regards to City of Santa Ana, its officers, agents, and employees.
CP# 4540
A- "d
Authorized Representative Signature
\S
IL 12 01 11 86 Copyright, Insurance Services Office, Inc., 1983� Page 1 of 1
Copyright, ISO Commercial Risk Services, Inc., 1983
POLICY NUMBER: 6BRPG0000005615500
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: Maria L Madrigal
Additional Insured: City of Santa Ana, its officers, agents, and employees
1825 W Civic Center
Santa Ana, CA 92704
Effective 02/13/15 — 02/13/16
RE: Maria L Madrigal
CP# 4540
SRPG8016 09108
POLICY NUMBER: 6BRPG0000005515500
INTERLINE
IL12011186
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES
Policy Change
Number 2
POLICY NUMBER
POLICY CHANGES EFFECTIVE
COMPANY
6BRPG0000005515500
02/13/15
Nationwide Mutual Insurance Company
NAMED INSURED
AUTHORIZED REPRESENTATIVE
Maria L Madrigal
K&K Insurance Group, Inc.
COVERAGE PARTS AFFECTED
COMMERCIAL GENERAL LIABILITY COVERAGE
CHANGES
The following forms,CG2011 & SRPG8018, is added to the policy in regards
to City of Santa Ana, its officers, agents,
and employees.
CP# 4540
"^`i- /A�
Authorized Representative Signature
IL 12 01 11 86 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1
Copyright, ISO Commercial Risk Services, Inc,, 1983
POLICY NUMBER: 6BRPGO000005515500 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, its officers, agents, and employees
1825 W Civic Center
Santa Ana, CA 92704
Additional Insured effective 02/13/15 — 02/13/16
RE: Maria L Madrigal
CP# 4540
�W
D\4
SRPG8018 08/08
POLICY NUMBER: 6BRPG0000005515500
COMMERCIAL GENERAL LIABILITY
CG 20 11 0413
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
1. Designation of Premises (Part Leased to You):
Premises as described in the agreement or lease
2. Name of Person(s) or Organization(s) (Additional Insured):
City of Santa Ana, its officers, agents, and employees
1825 W Civic Center
Santa Ana, CA 92704
Additional Insured effective 02/13/15 — 02/13/16
RE: Maria L Madrigal
CP# 4540
3. Additional Premium: None
Information required to complete this Schedule, if not shown above, will be shown in the Declarations
A. Section 11 — Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability arising out of the
ownership, maintenance or use of that part of the
premises leased to you and shown in the
Schedule and subject to the following additional
exclusions:
This insurance does not apply to:
1. Any "occurrence" which takes place after you
cease to be a tenant in that premises.
2. Structural alterations, new construction or
demolition operations performed by or on
behalf of the person(s) or organization(s)
shown in the Schedule.
However:
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;
1. The insurance afforded to such additional whichever is less.
insured only applies to the extent permitted This endorsement shall not increase the applicable
by law; and Limits of Insurance shown in the Declarations.
CG 20 11 04 13 0Insurance Services Office, Inc., 2012 Page 1 of 1