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VIDEO ENGINEERING SERVICES (THOMAS BYSTRY) 5 - 2015
City of Santa ." na Clerk of the Cou..cil AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination form. Is the agreement(s) a permanent record? Yes No Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The ar m `.••"" A-2015-096-01 No. _ was completed on (List all amendments. Use space below if needed.) Revised: 16-18-16 r ���i il�Ili • • COTC Office Use Only City of Santa Ana 0 2 2021 Clerk of the Council has been made. Department: �K L�Ttl 1Nl i� L,r Phone/Ext.: Signature:x Date: A-2016-096 CONSULTANT AGREEMENT 4. THIS AGREEMENT is made and entered into this 2"d day of June, 2015 by and between Thomas Bystry l dba Video Engineering Services, a sole proprietorship ("Consultant"), and the City of Santa Ana, a rK; Charter city and municipal corporation organized and existing under the Constitution and laws of the 'u = State of California ("City"). U � ei3 u i RECITALS "^�•``-'e -' V cr1 lit A. The City desires to retain a consultant having special skill and knowledge in the field of video id production for the purpose of producing city council meetings and related services. B. Consultant represents that Consultant is able and willing to provide such services to the City. C. 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. 6b 5k 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 provide technical expertise for the purchase, installation and maintenance of audio and video equipment in City Council Chambers, and televise City Council meetings and the Mayor's annual State of the City presentation, as more specifically described in Exhibits A-C. 2. COMPENSATION City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit A-D. The total sum to be expended under this Agreement shall not exceed $65,875 during each year of the Agreement, or $197,626 during the entire term of this Agreement. This amount includes a contingency of up to $6,800 for each year of the Agreement for services as may be performed by Consultant at the sole discretion of City. b, Payment by City shall be made within forty-five (45) 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. �1i_:v7Pil This Agreement shall commence on July 1, 2015 and expire on June 30, 2018, unless terminated earlier in accordance with Section 15, below. The term of this Agreement may be extended for two (2) additional one-year terms upon a writing executed by the City Manager and the City Attorney. 4. INDEPENDENT CONTRACTOR 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. OWNERSHIP OF MATERIALS This Agreement creates a non-exclusive and perpetual license for City to copy, use, modify, reuse, or sublicense any and all copyrights, designs, and other intellectual property embodied in plans, specifications, studies, drawings, estimates, and other documents or works of authorship fixed in any tangible medium of expression, including but not limited to, physical drawings or data magnetically or otherwise recorded on computer diskettes, which are prepared or caused to be prepared by Consultant under this Agreement ("Documents & Data"). Consultant shall require all subcontractors to agree in writing that City is granted a non-exclusive and perpetual license for any Documents & Data the subcontractor prepares under this Agreement. Consultant represents and warrants that Consultant has the legal right to license any and all Documents & Data. Consultant makes no such representation and warranty in regard to Documents & Data which were provided to Consultant by the City. City shall not be limited in any way in its use of the Documents and Data at any time, provided that any such use not within the purposes intended by this Agreement shall be at City's sole risk. 6. 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 naming the City, its officers, employees, agents, volunteers and representatives as additional insured(s) and 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, with $2,000,000 in the aggregate. Such insurance shall: (1) name the City, its officers, employees, agents, volunteers, and representatives as additional insureds; (2) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (3) contain standard separation of insured 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 California state law, 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. If Consultant is or employs a licensed professional such as an architect or engineer: Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim with $2,000,000 in the aggregate. K e. 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 by the City. (iii) 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. 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 affect 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. 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 death, 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 1 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 challenging the validity of this Agreement, or 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. Notwithstanding the foregoing, to the extent Consultant's Services are subject to Civil Code Section 2782.8, the above indemnity shall be limited, to the extent required by Civil Code Section 2782.8, to claims that arise out of, pertain to, or relate to the negligence, recklessness, or willful misconduct of the Consultant. INTELLECTUAL PROPERTY INDEMNIFICATION Consultant shall defend and indemnify the City, its officers, agents, representatives, and employees against any and all liability, including costs, for infringement of any United States' letters patent, trademark, or copyright infringement, including costs, contained in the work product or documents provided by Consultant to the City pursuant to this Agreement. 3 9. RECORDS Consultant shall keep records and invoices in connection with the work to be performed under this Agreement. Consultant shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to Consultant under this Agreement. All such records and invoices shall be clearly identifiable. Consultant shall allow a representative of the City to examine, audit, and make transcripts or copies of such records and any other documents created pursuant to this Agreement during regular business hours. Consultant shall allow inspection of all work, data, documents, proceedings, and activities related to this Agreement for a period of three (3) years from the date of final payment to Consultant under this Agreement. 10. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (a) is independently developed by the Consultant without reference to information disclosed by the City. 11. CONFLICT OF INTEREST CLAUSE Consultant 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. 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 fax 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, CA 92702-1988 Fax 714-647-6956 With courtesy copies to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza (M-23) CI M To Consultant: P.Q. Box 1988 Santa Ana, California 92702 Fax 714-571-4211 City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.Q. Box 1988 Santa Ana, California 92702 Fax 714-647-6515 Video Engineering Services Thomas Bystry 16875 Donwest Tustin, CA 92780 (714)366-4666 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 fax, 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. 13, EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant regarding the subject matter herein, 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 Consultant. 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 Consultant 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 are not embodied herein. 14. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant 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. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 15. TERMINATION This Agreement may be terminated by either party upon thirty (30) days written notice of termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: As a condition of such payment, the Executive Director may require Consultant to deliver to the City all work product completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement. 16. NONDISCRIMINATION Consultant 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. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 17. 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. 18. PROFESSIONAL LICENSES Consultant 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. Consultant shall notify the City immediately and in writing of its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 19. MISCELLANEOUS PROVISIONS Each undersigned represents and warrants that its signature hereinbelow has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. --signature page follows-- IN WITNESS WHEREOF, the parties hereto have executed this Agreement on or after the date and year first above written. ATTEST - Al aLA o- lN� MARIA D. HUIZAR Clerk of the Council APPROVED AS TO FORM SONIA R. CARVALHO City Attorney Jo �- Joh Funk Assistant City Attorney RECOMMENDED FOR APPROVAL Executive Director of ParAs, Recreation and Commu ity Services Agency [a] ME K#Qd 11 r d DAVID CAVA City Manager CONSULTANT VIDEO ENGINEERING SERVICES . THOMAS E. BYST Owner EXHIBIT A VIDEO ENGINEERING SERVICES HOURLY SERVICES 1) Confer with the Executive Director of Parks, Recreation and Community Services or assigned staff to evaluate needs and supervise maintenance activity of all city owned audio/video facilities. Said facilities include, but are not limited to, City Hall, recreation centers, senior centers, Stadium, Soccer fields. Etc. 2) Review and make recommendation for the repair and /or replacement of said audio/video facilities. 3) Design layout of electrical circuitry for existing and /or acquired audio /video equipment. 4) Ensure compliance with local, state, and federal safety codes and regulations. 5) Establish and maintain equipment log and data base to keep inventory and records of maintenance and to track equipment performance. 6) Help establish and enforce Agency wide policies for equipment use. Provide operation instruction for staff. 7) Conduct regular security checks on the City's production equipment. 8) Prepare preventative maintenance schedules and execute said maintenance on a routine basis. 9) Supervise annual asset inventories and tagging of new assets, as needed. 10) Coordinate equipment repair with outside agencies. 11) Coordinate acquisition of new production equipment. 12) Facilitate and supervise use of facilities or equipment by outside agencies, persons, other City employees or cable franchisee staff. 13) Facilitate completion of production services requested by City staff (including making dubs, editing and shooting videos, setting up equipment, delivering equipment, setting up operating facilities as needed.) 14) Provide updates to Executive Director and/or assigned staff on progress of equipment installation, maintenance, building projects and anticipated completion dates. 15) Assist City Clerk and other staff on use of Council Chambers: video, audio, lighting, PowerPoint, Elmo or other technical needs. COMPENSATION $75 per hour Estimated Need-273 hours per year Estimated Cost-$20,475 (amount to be invoiced will reflect actual number of hours of service) EXHIBIT B VIDEO ENGINEERING SERVICES STATE OF THE CITY Contractor shall produce the mayor's state of the city address, including: 1) Hiring and supervising crew for camera operations, audio mixing, cable running, equipment load in and load out. 2) Directing the show for video. 3) Renting all needed video equipment and editing the finished video for playback. COMPENSATION $5000 All -Inclusive Package EXHIBITC VIDEO ENGINEERING SERVICES COUNCIL MEETING PRODUCTION Contractor will serve as Producer/Administrator for City of Santa Ana City Council meetings. Duties will include hiring and supervising video production staff. Contractor shall provide production services in live meeting coverage and playback for up to twenty-four (24) meetings, including City Council meetings held the first and third Tuesdays of the month, and various additional meetings as selected by the Clerk of the Council and/or City Manager. Production services shall include all responsibility for graphics during the presentations, video roll -ins and all audio/visual needs. Additionally, Contractor shall provide technical assistance for city production crews and staff. Services shall include: 1) Serve as Video Producer for all council meetings and cable -casting events in council chambers 2) Maintain open communications with city clerks' office for special needs or changes pertinent to the agenda for each council meeting. 3) Communicate and confirm with the cable administration office in Parks and Recreation regarding council meeting coverage and playback related to the city channel. Report technical playback and council problems and remedies to the cable office. 4) Provide, hire and supervise all video production crew and staff which will include Director, Camera Robotics Operator, Audio Operator, Graphics Designer and Playback Operator. These positions may be consolidated in one person. 5) Schedule video production staff. Pre -arrange and notify crew of video productions and changes. 6) Provide maintenance of playback equipment located in City Hall as necessary for City Council meeting. 7) Provide for office administration and payroll for video production crew and playback. 8) Provide and be responsible for all production staff training and hands-on use of equipment for video crews. 9) Direct communication with City Council members and Clerk of the Council 10) Review any needs or concerns related to production request: includes PowerPoint, overheads, video roll -ins and presentations, review cueing system, proper use of microphones for Council. 11) Arrange for and design overall look and style of productions. 12) Arrange for input of council graphics prior to the meeting. Run a spell check. Arrange for graphics to state replays during the meeting, approximately every 30 minutes during program. COMPENSATION $1400 per meeting Estimated Need-24 meetings per year Estimated Cost-$33,600 (amount to be invoiced will reflect actual number of meetings produced) 10 BUDGET SUMMARY Estimate for Exhibit A: Fee for Exhibit B: Estimate for Exhibit C: Contingency: EXHIBIT D $20,475 Hourly Services $5,000 State of the City Address $33,600 Council Meeting Production $6,800 Services as Needed Annual amount paid to consultant shall not exceed $65,875 for each year of the Agreement, 11 TE (MMI ACk:?R X° CERTIFICATE OF LIABILITY INSURANCE o011271 or2015 �' 01/27/ 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(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 ondosement a . PRODUCER CONTACT NAME. _Chris Rudolph Triton of Calif Insurance Services, Inc. -PRONE _ - — _ FAX N Elul' (916)486-1705 FAX Nm1 (918)485.0198 2332 Auburn Blvd EMAIL Sacramento, CA 95821 ADDRESS_ chris@trltoninsurance.com _ NSURERje)APFORDIND COVERAGE_ NAICrILicense #t OF41767 -- INSURERA. Associated lndgsirles lnsuranE_04mpany. _ _ __ INSURED — TOM BYSTRY !@sunERE: DBA: VIDEO ENGINEERING SERVICES INSURERC _ 16875 DONWEST INSURERU Tustin, CA 92780 INSURER INSURER F. CrTVFRARFR CERTIFICATE NUMBER (IM039E2.14535 REVISION NUMBER: 7 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR__.___.-_..._...__—ADOC SUSR—.—__...—__.—_--_—..PULICYFPPIP6LIOYf%P — LR,. TYPE OF INSURANCE POLICY NUMBER MIDOrTY IDIVYYY LIMITS A GENERALLIABILITY Y Y NA104655702 0210112016 02101/2016 EACH a �%f, LCDMMFRCIAL GENERAL LIABILITY MACETOOCCURRENCE DAMADETO RENTED PREMIiF$(Em mceprrmnceJ _1,100,900 $ __ 1QQ,000 CLAIMS MADE n OCCUR MEO EXP (Any one peen) 5 QQQ PERSONAL 4AOV INJURY (S GENERAL AGGREGATE _,1,000,00Q 11 Is 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _P_ROOUCTS�COMPIOPAGG _ $ _. 1,000,000 X PoUCY PE O LOC $ AUTOMOSILELIABILITV COMBINED SINGLE LIMIT 1Ee MINED S ANY AUTO SODILYINJU RY(Pm, pmlamn) S AUTOWNED SCHEDULED L BgDILY INJURY (PereacMenQ $ PROPERTY DAMHGE $ NONAWNEO i Reviewed by: MREDAUTOS AUTOS M (Pet mpOtlent)___ 4 UMBRELLA LIAR OCCUR I��^(r" '� E_ACHOCCURRENCE i EXCESS LIAR_= CLAIMS-MADEI / AGGREGATE {IS [� lli IPA (.I I DED RETENTIONS �_ j WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN r'� /�L //— PRCSA/A min. WC STATW r, ---�TORYSIMII31_ ERA TOTH _.. ANY PROPRIETCRIPARTNEWEXECUTNE ❑ NIA EL EACH ACCIDENT �$_ OFiICERIMEMSER EXCLUDED'? ( (Mend®Im,y In NH) E L DISEASE � EA EMPLOYE 3 e yyes deud5e wdar DESCRIPTION OF0 ERATIONSbeIYW I ( EA. DISEASE POLICY LIMY _ I i I i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atlamb AGDRD 101, gdVilim"el Rema,hm SmaegVle, artwn apgme le Yegvirodl 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. 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 or contributing with any other insurance carried by or for the benefit of the additional insureds. This insurance applies separately to each continued on ACORD 101 Additional Remarks Schedule SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF SANTA ANA, IT'S OFFICERS, EMPLOYEES, AGENTS AND THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN REPRESEN ACCORDANCE WITH THE POLICY PROVISIONS. 20 CIVIC CENTER PLAZA M-18 Santa Ana, CA 92702 1 AUTHORMEDREPRE�VE 9 ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD Printed by CPR on January 27, 2015 at 11:13AM AGENCY CUSTOMER ID: 00003962 LOC N: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Triton of Calif Insurance Services, Inc. — NAMED INSURED TOM BYSTRY DBA: VIDEO ENGINEERING SERVICES POLICY NUMBER NA104655702 CARRIER Associated Industries Insurance Company NAIB CODE EFFECTIVE DAM02/0112016 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance (continued from Description of Operations) Insured against whom claim is made or sult is brought except with respect to the comany's limits of liability. The Inclusion of any person or organization as an Insured shall not effect any right which such person or oranization would have as a claimant If not so Included. With respectthe additional Insureds, this Insurance shall not be cancelled, or materially reduced In coverage or limits except after thirty 13O)days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. Reviewed by: Silvia Cuevas PRCSA/Adman, Annon Rnn mnmmnnl r(J 2008 ACORD CORPORATION. All rlohis resarved. The ACORD name and logo are registered marks of ACORD Printed by CPR on January 27, 2015 at It: 13AM BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number: NA104655702 Endorsement Effective: 2/1/201512:01 a.m. Named Insured Countersigned By: TOM BYSTRY VIDEO ENGINEERING SERVICES SCHEDULE Name or Person or vrgamzanon: THE CITY OF SANTA ANA FINANCE, ITS OFFICERS, EMPLOYEES, AGENTS AND Reviewed REPRESENTATIVES. 20 CIVIC CENTER PLAZA M46 SANTA ANA CA 92702 20 CIVIC CENTER PLAZA, SANTA ANA CA 92702 (If no entry appears above, information required to com as applicable to this endorsement.) A. Section II —Who Is An Insured is amended to include as an Insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. S. With respect to the insurance afforded to these additional insured, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of "your work" put of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words "you" and "your' refer to the Named Insured shown in the Declarations. D. "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. Primary Wording If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it. 13J4 Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of'your work" done under a contract with that person or organization. 49.0108 0711 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 ❑ Used with permission COMMERICAL GENERAL LIABILITY CO 20 37 07 04 Policy#: NA104655702 Insured Name: VIDEO ENGINEERING SERVICES THIS ENDORSEMENT CHANGESTHE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Pars on(sj or Or ac�nization(s _.— Location and Description of Completed Operations THE CITY OF SANTA ANA FINANCE, ITS THE INSURED WILL BE WORKING FOR THE OFFICERS, EMPLOYEES, AGENTS AND ADDITIONAL INSURED DOING SERVICING OF REPRESENTATIVES, AUDIONIDEO. 20 CIVIC CENTER PLAZA M-16 20 CIVIC CENTER PLAZA, SANTA ANA CA 92702 SANTA ANA CA 92702 Information required to complete this Schedule, if not shown above, will be shown in the declarations 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 for "bodily injury' or "Property damage" caused, in whole or in part, by "your work' at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard". Reviewed by; qJ4 Silvia Cuevas PRCSA/Admin. CG 20 37 07 04 copyright Iso Properties, Inc., 2004 Page I of I Insured ACC7,w " CERTIFICATE CIF LIABILITY INSURANCE DATE (MMPDp fYYY) �II�, .-'' 01 /1'9/2016 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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Chris Rudolph Triton oft Calif Insurance Services, Inc. PHONE EA): (916)485-1705 �P� No): (sts)a85-oisal �2332 Auburn lB� Blvd E-MAIL Sacramento, CA 9'S821 ADDRESS: Chris@tntoninsurance.com SLicensern: o, CA 9,5 INSURER(S) AFFORDING COVERAGE NAIC 1! INSURERA: Security National Insurance Company INSURED INSURER B TOM BYSTRY i , DBA: VIDEO ENGINEERING SERVICES IlusuRERc: 16876 DIOANWESTINSURER_[? INSURERS: Tustin, CA 92780 INSURER F fit-VFRAnF.R rFRTIFIrATF hIIIMRlI nnnnngA9_1AA.3K RFVISION N'I]MIIRFR• 7n 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. INSti.. TYPE OF INSURANCE. _. ADDL SU�BR ........ POLICY EFF POLICY E7CP LTR I S. V POLICY NUMBER MM14OlYYY'Y MM1OruYYYY LIMITS A GENERAL LIABILITY Y Y NA104655703 0210112016 02101/2017 EACH OCCURRENCE $ 1,000,000 }{ COMMERCIAL GENERAL LIABILITY DAMAGE 7O RENTED PREMISES (Ea occurrence} $ 50,000 '.. CLAIMS -MADE .ic_ OCCUR MED.EXP (Any one person) $ 5,000....... PERSONAL & ADV INJURY ., $ 1,000,000.. GENERAL AGGREGATE $ 1..,000,000.. GEN'LAGGREGATE LIMIT APPLIES PER '.:.. PRODUCTS COMPIOPAGG.._ $ 1.,000,000 X POLICY JECPRO- _ LOC _ $ '.... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea eccdendL_ $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED @a BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS -y,t PROPERTY DAMAGE $ er a„ccldent) P, ., _. ..... UMBRELLA LIAR ,ryry,, .mA OCCUR EACH OCCURRENCE $ .... EXCESS LIAR CLAIMS MADE ��, . 9'.`"` AGGREGATE $ _. a _. _ . .... DED._ RETENTION $.... WORKERS COMPENSATION \\g I` AND EMPLOYERS' YfN ,(j�y`d WC STATU- OTH- TORY LIMITS.. ER.... ANY PROPRIETORfPARTNERfEXECUTIVE * E L EACH ACCIDENT $ OFFICERMEMBER EXCLUDED? N/A (Mandatory in NH) E L DISEASE - EA EMPLOYEE $ If yes, describe under " DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS i LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) The City of Santa Ana, 20 Civic Center P'Ilaza, 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. 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 or contributing with any other insurance carried by or for the benefit of the additional insureds. This insurance applies separately to each continued on ACORD 101 Additional Remarks Schedule CITY OF SANTA ANA, IT'S OFFICERS, EMPLOYEES, AGENTS AND REPRESEN 20 CIVIC CENTER PLAZA M-16 Santa Ana, CA 92702 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 1988-2010 ACORD CORPORATION. All rights reserved, ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Printed by CPR on January 19, 2016 at 10:04AM AGENCY CUSTOMER 10: 00003962 LOC #: ACCOR" annITIONAll Pi=mAPwcz -,qrwi=ni ii i= Paaa 2 of 2 AGENCY Triton of Calif Insurance Services, Inc,, ......................... POLICY NUMBER NA104655703 CARRIER NAIC CODE Security National Insurance Company I NAMEDINSURED TOM BYSTRY DBA: VIDEO ENGINEERING SERVICES EFFECTWE DATE: ACORD 101 (2008101) @ 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by CPR on January 19, 2016 at 1 H4AM BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: 0011VIIII11I 4 041011 111KCS111 011:.tea X a r-111 21111111111 1111111506191TAM :411-ILC 9-.1 �1161 M 14 Bill 4 Policy Number: NA104655703 Named Insured TOM BYSTRY VIDEO ENGINEERING SERVICES Endorsement Effective: 1/15/2016 12:01 am. Countersigned By.- 9"L� W404� SCHEDULE Name of Person or Organization: CITY OF SANTA ANA, CITY OF SANTA ANA FINANCE & MANAGEMENT SERVICES AGENCY PURCHASING DIVISION, IT OFFICERS, EMPLOYEES, AND AGENTS 20 CIVIC CENTER PLAZA M-1 6 SANTA ANA CA 92702 ... . ........... ... . ............................ . ..... Location, - VARIOUS LOCATIONS THROUGHOUT SANTA ANA, CA (if no entry appears above, information required to complete this endorsement will be shown in the Declara as applicable to this endorsement.) A. Section 11 —Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insured, the following exdusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the scte of the covered operations has been completed-, or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. D. "Your work" means work or operations performed by you or on your behalf', and materials, parts or equipment furnished in connection with such work or operations. Primary Wording If required by written contract or agreement Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contri to it. Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have t� C an entity that is an additional insured per the terms of this endorsement because of pa a make for injury or damage arising out of "your work" done under a contract with th erson, organization. Lions 49-0108 0711 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission ® DATE(MMIDDfYYYY) ACC)�_. CERTIFICATE OF LIABILITY INSURANCE 01130r2017 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 pollcy(ies) (must have ADDITIONAL INSURED provisions or 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 CT' Chris Rudolph Triton of Calif Insurance Services, Inc. PHONE FAX 2332 Auburn Blvd ..E,�)PINP,.,Ia�ttr: I916)485 17p5 Nal�(916)485.0195 Sacramento, CA 95821 ADDRESS:... Chris aitritoninsurance.com _.. -. .—. License #: OF41767 INSURER(S)AFFORDING .COVERAGE . NAIL#.. .. INSURER A : Mesa Underwriters Speciality Insurance Co, ..... .... INSURED TOM BYSTRY m'µ "�.. r� INSURER. B. _... _... DBA: VIDEO ENGINEERING SERVICES INSURER C 16875 DONWEST INSURERot TUSTIN, CA 92780 INSURER E: INSURER F COVFRACFS CFRTIFIrATF NIIrW1RFR• nnnnnnnn.ldK{K RFVIglnN NIIIru1Rl=P- 17' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME? 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 iAOOL SUBR.. POLICY EFF 1 POLICY EXP _ _. ........ LTR TYPE OF INSURANCE POLICY NUMBER MMIODIYYYY MM/Od7/YYYY LIMITS A X COMMERCIAL GENERAL LIABILFTY Y Y MPaa04009002994 10210112017 1 02101/2018 EACH OCCURRENCE 5 1.,000,000 , I CLAIMS -MADE X ',.... OCCUR .. - DAMAGE TO RENTED PREMISES [Ea occurrence)._..... $ 1 00,00a MED EXP (Any one person) $ 51000 __ ._... PERSONAL BADVINJURY $ 1_,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY I PRO- JECT LOC PRODUCTS - COMP/OP AGG... S 2,000,000 I OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Eaaccident) ANY AUTO BODILY INJURY (Per person) $ H SCHE OWNED AUTODULED..-.. BODILY INJURY (Per accident) $ AUTOS ONLY AUTOSHARED NON -OWNED PROPERTY DAMAGE$ AUTOS ONLY AUTOS ONLY '... (Per. accident) _. +.:,, $ UMBRELLA LIAR s OCCUR � � EACH OCCURRENCE $ HCLAIMS-MADE EXCESS LIAB AGGREGATE $ ..._ DED RETENTIONS $ WORKERS COMPENSATION "^ "��' ✓:%*" {uS,. PER OTH- AND EMPLOYERS' LIABILITY YIN ., ,o;�'� STATUTE ER ....... ........... _ ANY PROPRIETORfPARTNERIEXECUTIVE o E L EACH ACCIDENT $ ❑ N / A .. r OFFICER/MEMBER EXCLUDED? Y' (Mandatory In NH) .t�' i f'3 ' y' 9. EL DISEASE - EA EMPLOYEE $ ,,...: .,.B I If yes describe under .. DESCRIPTION OF OPERATIONS below "4,P^ "°" - E..L.. DISEASE -POLICY LIMIT S i DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD 101, Additional Remarks Schedule„ maybe attached If more space is required) 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. 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 or contributing with any other insurance carried by or for the benefit of the additional insureds. This insurance applies separately to each continued on ACORD 101 Additional Remarks Schedule CITY OF SANTA ANA, IT'S OFFICERS, EMPLOYEES, AGENTS AND REPRESEN 20 CIVIC CENTER PLAZA M-16 Santa. Ana,, CA 92702 t;AN4:kLLA I IUN 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 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by CPR on January 30, 2017 at t 2:25PM AGENCY CUSTOMER 0:--00090900 LOC #: ACCOR" ADDITIONAL REMARKS SCHEDULE Page 2 of 2 111.� — --- AGENCY NAMED INSURED Triton of Calif Insurance Services, Inc. TOM BYSTRY DBA: VIDEO ENGINEERING SERVICES POLICY NUMBER MP0004009002994 CARRIER Mesa Underwriters Speciality Insurance Co. EFFECTFVE DATE: 02101/2017 ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved. The, ACORD name and logo are registered marks of ACORD Printed by CPR on January 30, 2017 at 12:25PM C. 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. Page 2 of 2 C Insurance Services Office, Inc., 2012 CG 20 10 04 13 POLICY NUMBER: MP0004009002994 COMMERCIAL GENERAL LIABILITY CG 20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. W 'i R 1 0 A - - �$ � e ZINO .1 Diu 4 a** Nk LfV U, This enclorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations CITY OF SANTA ANA, ITS OFFICERS, EMPLOYEES, AGENTS AND REPRESENTATIVES % FINANCE & MANAGEMENT SERVICES AGENCY PO. BOX 1988 M-16 Information requ�red to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section ||—WUho Is An Insured is amended to include oeanadditional insured theperson(s) nr organization(s) shown in the �Schedule, but only � respect fu liability "'bodily h�ury^ "property damage" or "personal and advertising injury" caused, inwhole mrim part, by: 1. Your acts oromissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However 1^The insurance afforded to such additional insured only applies bmthe extent permitted by law,- and 2. Mcoverage provided iuthe additional insured is required by m contract or mgnoement, the insurance afforded to such additional insured will not he 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 thiese additional insureds, the following additional exclusions app|y� This insurance does not apply to"bodily injury" or "property damage" occurring after, 1. 4J| work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) tohe performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 3. That portion of ''ymmr work" out of which the injury or damage arises has been put to its intended use by any person o/ organization other than another contractor orsubcontractor engaged in performing operations for a principal ammpart mfthe same project. CG 20 10 04 13 @ Insurance Services Office, Inc., 2012 Page of 2 POLICY NUMBER: MP0004009002994 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WM9 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have, agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and viould not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured Linder your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 010413 @ Insurance Services Office, Inc., 2012 Page 1 of 1 WORKERS' COMPENSATION DECLARATION TrI- z hereby affirm under penalty of perjury, the following declaration t I certify on be that during the term of my flzA—ez) (Consultants ompany Naffie) contract for services with the City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: 7 By: Name: 7 <s Y- Title: 0 C& /A (t�— Telephone WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. 'Viewed Vq cueva S ',Sp,,m Adnl P9,c Evidence of Insurance Here are your Evidence of Liability Insurance Cards Two cards have been provided for each vehicle insured. One card must be carried in the proper insur I d vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law eIforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days, in prison. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your, Declarations Page (Page 7). If you would like additional ID cards you can go online to geico.com or call us at 1-800-8,41-3000. I C3EICC3, California Evidence of Liability Insurance gellco.com 1-800-841-3000 GEICO GENERAL INSURANCE cbmPANY P.O. Box 509090 - San Diego, CA 92150-9090 NAIL Code: 35882 Policy Number Effective Date Expiration Date 4353-33-52-78 12-05-16 06-05-17 Year Make Model Vehicle ID No. 2015 FORD C-MAX IFADP5CU8FL104824 Insured: Thomas E Bystry 16875 Donwest Tustin CA 92780-4052 The coverage provided by this p0cy meets the minimum requirements of sections 16056 & 1650M of the California Vehicle Code minimum liability limits prescribed by law. L THOMAS EUGENE BYSTRY 16875 DONWEST TUSTIN CA 92780-4052 California Evidence of Liability Insurance 1-800-841-3000, GEICO GENERAL INSURANCE C P.O. Box 509090 - San Diego, CA NAIL Code: 35882 Policy Number 4353-,33-52-78 Year Make 2015 FORD Insured: Thomas E Bystry 16875 Donwest Tustin CA 92780-,4052 Effective 1 12-05-1 Model C-MAX E-xpiration Date 06-05-17 Vehicle ID No. 1FADP5CU8FL104824 The coverage provlded by this policy meets the minimum requirernents of sections 16056 & 1650D 5 of the California Vehicle Code, minimum liability limits prescribed by law CERTIFICATE OF LIABILITY INSURANCE 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 1NSURER(S(, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. N 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 Ilea of such endorsement(s). PRDDUCER COASTAL BROKERS INSURANCE I FOR QUESTIONS CONTACT. TRITON OF CALIFORNIA INSURANCE SERVICES INC 2332 AUBURN BLVD. SACRAMENTO CA 96821 rmuaw TOM BYSTRY A'otc)1S7--0% DB AA VIDEO ENGINEERING SERVICES 16675 DONWEST TUSTIN CA 92780 In1=T Td i THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISPED 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. RM VTR TYPE OF INSURANCE M POLICY NUMBER ICY PNLmow" E 1 LIMETS GENERAL LIABRRY EACH OCCURRENCE E 1.000.000 X COMMERCIAL GENERAL LIABILITY CkAS-R4a IMpE OOCCUR PREMISES(Eaveence aa �T,100000 Y ktEO E%R EAAY�pMs-0nr f5s000........... A MP0004009004049 02-01-18 02.01-19 PFRsoNALSADV wJJRr S 1,000,000 GENERAL AGGREGATE 4 2,000.000 GENLAGGREGATELIM17 AMIUIIPER RR4LR.'CT3-COMPAIPAGG $2,000,000 x POLICY PRO LOC ¢ AUTOMOBILE LNBLLrrY IN €ate eX BODILY INJURY IPer i # ANY AUTO AIL OYMED SCIiEDULED AUTOS AUTOS ATOS NED He{EDAUTOS AUYT4S BODILY INJURY IP6rwdoal 9 ParecWanF - Y UMBRELLA t," OCCUR EACH OCCURRENCE 1 AGGREGATE 1 EXCESS LIAe yM pp DEO RErErrrroNI T WORKEMcompENSATION ANDEMPUNERS'LIAeUrY ANY PROMIETC91RARTtEHF�CUTIVE OFSICEIMENEER EXCLLCEC? N1A DTN. �TIDRY E.L. H ACi1OENT tIMam*U EL. ASE-EAEMPLDY E.L. 01C =POIOY LIMIT T ; LAN' X - ,aexrpe waer r.T fA• n DESCFSPTIDNOFOPUtARONSILOCATDMIVEHICLES[AtbcM1 AGORD IOY, AE�eanM Ramada eMetluk.If tnaro eRueli nq Ml THECITY OF SANTAANA, IT'S OFFICERS, EMPLOYEES, AGENTSAND REPRESENTATIVESARE NAMED ASADDI L INSURED R FORM OG 2010 ATTACHED TO THIS POLICY- THIS INSURANCE IS PRIMARY AND NON CONTRIBUTORY PER FORM CG TTACHED HIS POLICY- L \ Pd CITY OF SANTA ANA FINANCE$ MANAGEMENT SERVICES AGENCY P.O. BOX 1986 MAS SANTA ANA CA 92702 SHOULD ANY OF ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD CANCELLED BEFORE BE DELIVERED IN reserved. POLICY NUMBER: MP0004009004049 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations Location(s) Of Covered Operations THE CITY OF SANTAANA, IT'S OFFICERS, VARIOUS EMPLOYEES, AGENTS AND REPRESENTATIVES % FINANCE & MANAGEMENT SERVICES AGENCY P.O. BOX 1988 M-16 SANTAANA, CA92702 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 organization(s) 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: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, - in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. dl� �e y�e �e 1A , ,a5 /rJ31'0` Q� CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 POLICY NUMBER: MP0004009004049 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. ,Nel' CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 GEICO GEICO GENERAL INSURANCE COMPANY Washington DC MAILING ADDRESS THOMAS EUGENE BYSTRY 16875 DONWEST TUSTIN CA 92780-4052 VERIFICATION OF COVERAGE (SEE BELOW UNDER CAUTIONARY NOTE) Policy Number: 4353335278 Effective Date: 12-05-17 Expiration Date: 06-05-18 Registered State: CALIFORNIA To whom it may concern: This letter is to verify that we have issued coverage under the above policy number for the dates indicated in the effective and expiration date fields for the vehicle listed. This should serve as proof that the below mentioned vehicle meets or exceeds the financial responsibility requirement for your state. This verification of coverage does not amend, extend or alter the coverage afforded by this policy Vehicle Year: 2011 Make: HONDA Model: ELEMENT LX VIN: 5J6YH11-132BL003266 COVERAGES Bodily Injury Liability Each Person/Each Occurrence State Minimum $15,000/$30,0000 Property Damage Liability State Minimum $5,000 Medical Payments Uninsured & Underinsured Motorists Each Person/Each Occurrence Uninsured Motorists Property Damage Lienholder Additional Information: Issued on 02/07/2018 Additional Insured LIMITS DEDUCTIBLES $100,000/$300,000 $50,000 $10,000 $100,000/$300,000 $3,500 Interested Party aby., e pRG If you have any additional questions, please call 1-800-841-3000. CAUTIONARY NOTE: THE CURRENT COVERAGES, LIMITS, AND DEDUCTIBLES MAY DIFFER FROM THE COVERAGES, LIMITS AND DEDUCTIBLES IN EFFECT AT OTHER TIMES DURING THE POLICY PERIOD. THIS VERIFICATION OF COVERAGE REFLECTS THE COVERAGES, LIMITS, AND DEDUCTIBLES AS OF THE ISSUED DATE OF THIS DOCUMENT WHICH IS SHOWN UNDER "ADDITIONAL INFORMATION' OR IF AN ISSUED DATE IS NOT SHOWN, THE DATE OF THIS FACSIMILE. U-33 10-07 45-rfYhereby affirm (Name./Tikie) following declaration: I certify on behalf of Vi, J eic, on,ultantl contract for 201 _ 0/tC2 v � ek,-r 0y under penalty of perjury, the ` 34U 14 C2 that during the term of my �mpany Name) services with the City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: Az2-0 1 9 By: \7/- Name: r^ eaQ.j• Title: n - i e0 L�rI�Y1�'�11.J c Telephone: (.j Jkl�� �3�,GS�Pa Q¢ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. lyel ACOKOe CERTIFICATE OF LIABILITY INSURANCE 1 DATEIMM) nzlm12019rzDls 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 have ADDITIONAL INSURED provisions of 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 centificate does not confer rights to the certificate hostler In lieu of such endomemenl(s). P0.0WCER Tilton of Calif Insurance Services, Inc. co C Chris Rudolph ME: PHONE (9166-0705 uc xm; (916p35-0199 2332 Auburn Blvd Sacramento, CA 95821 License M OF41767 "1°IL Chris trhaninsurance.com A RE09: INSURER(S)AFFOPDWO COVERAGE INSURER A: a amrfler s ca nsunld�ft go, NAILi Q wsuRED TOM BYSTRY L d 0 UI fT V s { if' DBA: VIDEO ENGINEERING SERVICES 14APPOMATTOX IRVINE, CA 92620 WSUPER: wsuRERC: INSURERO: WWRER E:- 1 WSURERF: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONOMON OF ANY CONTRACT CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY RAVE BEEN REDUCED w6P 5U WPEGFINSUMWCE PIXJGYNIIMEER TO THE OR POLICIES DESCRIBED BY INSURED NAMED OTHER DOCUMENT HEREIN PAID CLAIMS. ------- ABOVE FOR THE POLICY PERIOD WITH RESPECT TO WHICH THIS IS SUBJECT TO ALL THE TERMS, UMn3 Pa EFP MM9 02101/2019 10 POLICY EYP Lr A X COMMERCIAL GENERALLWBILm CWMeeMOE rFWft y Y I I MP0004009005022 2101/2020 EALHOCGURRENCE $ 1,000,000 P MISEB R E un MED E%P rMy em perean S 100,000 5 5,000 I PEREONALa ADVIN,URY 9 1000000 ( i I GENL AGGREOATE UMH APPLIES PER: X POIICYu Pj uLCC GENEMIAGGREGATE 5 2.000r000 PRCWCTS. COMP" ACC 5 1000000 5 OTHER AUTOMO&LE UA01UlY j EaamMD L MIT S 3 ANY AUTO aWILYIWURT (Papersan) ucc,LYIWURY(Parwd 0 0 OWNEO WHEWLED AUTOS ONLY Aul HIRED nVunwnEo AUTOSONLY AUTW DNLY I FPROPEflTY pPl,NGE 9 5 UMaREW LIFE aWR EACHOCCURRENCE S AGGREGATE S EXCES:n LUSA3MAOE S DED R ON5 PR OI{i �ERSCOMF ACCIDEM S ANOSMPLOYEREN9ATIOM AND EMPLOYERS 1M1L1' YIN NnY£ iRUEMBER E.L DIBFAOE EA EMPLOYE E.1-ME S ORRC EXCLUDED' ❑ IOeFFlmL� m M � E%tt,%JFD> NIA ELOISPA9E-POUCYUWT S IIyynn&.Ww,PlUer OE9CRIPTbN OF OPERATIONS E ebv I I 1 I peaca1PnON OF OPERATIONS ILOCAnONSI VEHICLES (ACORD 101, AealUaul Rem" senwUM, may NeamcMa lmert Waco is MqulnEl The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its officers, employees, agents and representatives are named as additional Insureds per CG2010 attached to this policy. The insurance is primary and non-contributoryA`f •,�w�00��� CITY OF SANTA ANA SHOULD ANY OF THE AS THE EXPIRATION DATE TI FINANCE & MANAGEMENT SERVICES AGENCY ACCOROANCEYRTHTHB PURCHASING DIVISION 20 CIVIC CENTER PLAZA M-16 AVmOeaEO flEP TNa Santa Ana, CA 92702 All rights BEFORE ACORD 25 (2096103) The ACORD name and logo are registered narks of ACORD Printed by CPR on February 07, 2019 at 02:58PM POLICY NUMBER: MP0004009005022 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS- SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or O anization(s) Locai of Covered Operations THE CITY OF SANTA ANA, IT'S OFFICERS, VARIOUS EMPLOYEES, AGENTS AND REPRESENTATIVES % FINANCE & MANAGEMENT SERVICES AGENCY P.O. BOX 198a M-16 SANTA ANA, CA 92702 Information required to complete this Schedule, if not shown above will be shown in the Declarations. A. Section It — 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 for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or In part, by: 1. Your acts or omissions, or 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 0413 0 Insurance Services Office, Inc., 2012 00. Page 1 of 2 C. 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. -'�e��� lk GueJ��r' 5N, Page 2 of 2 © Insurance Services Office, Inc„ 2012 CO 20 10 0413 POLICY NUMBER: MP0004009005022 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed In writing In a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. ON CG WORKERS' COMPENSATION DECLARATION I —7k 610Y hereby affirm under penalty of perjury, the (Nemerritle) following declaration: Web 11 ebr Sir ✓ICJ° S I certify on behalf of LILI that during the term of my F�SCSI �Gf (Co tandcompmy arse) contract for 8' �� / services with the City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: (.� r By:C�/0%GZ Name: V t Jeo S] -,r tlt ces Title: j7 /C D f a rr-/ Telephone: (( l / ��C WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. Reviewed by: Silvia Cuevas PRCSA/Admin. National General Auto, Home & Health Insurance PO Box 3199 • Winston Salem. NC 27102-3199 THOMAS E BYSTRY 14 APPOMATTOX IRVINE CA 92620 Policy Number: 2006521219 Named Insured: Thomas E Bystry Policy Period: 12:01 A.M. 5/21/2019 - 5/21/2020 Date of Notice: 5/7/2019 Policy Underwritten By: Integon National Insurance Company 24 Hour Claim Reporting: 1-800-468.3466 For Policy Information: 1-877-468-3466 www.MyNatGenPolicy.com Your Agent: Fiesta Auto Insurance Center Store #Ca078 1714 E McFadden Ave Ste P Santa Ana CA 92705 (714)884-4284 CA COMMERCIAL VEHICLE DECLARATIONS PAGE Endorsement Effective 5121/2019 The following changes were made to your policy - Policy Level Change Drivers, Employees and Household Residents #1 Thomas E Bystry Driver Status License # Lic State Date of Birth Gender Marital Status Driver Pts Yrs. Licensed Owner Driver XXX9358 CA 10/26/1957 Male Married 0 45 #2 Jennifer L Bystry Driver Status License # Lic State Date of Birth Gender Marital Status Driver Pts Yrs. Licensed Relative 2/6/1978 Female Married 0 25 Excluded Insured Vehicle(s) and Schedule of Coverages #1 2011 HOND ELEMENT LX VIN: 5J6YH1H32BL003266- BD3335 Garaging Location: 92620 Policy Coverage Level _ - — _ ScheduledAuta Coverages Provided C Bodily Injury / Property Damage - Combined Single Limit Medical Payments Uninsured / Underinsured Motorist Combined Single Limit Usage: Personal Use Radius:0 Only Limits/Deductibles $1,000,000 Combined Single Lim# $10,000 Each Person / Each Accident $100,000 Combined Single Limit Total for this Vehicle Combined Vehicle Premium Acquisition Expense CA Vehicle Assessment and Fraud Fee Total 12 e J\ Premium $750.00 $57.00 $111.00 $918.00 $918.00 $20.00 $1.76 $939.76 10039CA (06012014)