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HomeMy WebLinkAboutBIG RED BUS & LONG BEACH TROLLEY-2016N-2016-077 INSG1Rt INClE ONI HLE VVOR l MAY PR 40CEED q01 UNTIL INSURANCE EIfPM C GL. tf-ll -27 / A16 : G /d -/6 CLERK OF COUNCIL DATE:_ AN -9 2016 CONSM,`PAN'P AGREEMENT Ar �t Q - � Tb11S ACTIM TIENT is trade and entered into this I9a of May, 2016 by and between Big RHO Bas & Long Beach Trolley C Consultant'l and the City of Santa Ana; a charter city and mraticipal corporation orgaltized and existing under the Constitution and laws of the State of California ('City"). RE91'60 & The City desires to retain a consultant to provide a lunchtime trotley service in downtown. Santa Ana for a ninety (90) day trial. 13. Consultant represents that it is able and willing to provl4e 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, NOW 7" IIEItEFMF, in consideration of the mutual and respective promises, and subject to the terns slid conditions hereinafter set forth, the parties agree as follows: I. SCOPE OF SE, IMCES Consultant shalt provide a ltnehthne trolley service In downtown Santa Ana, which will operate 'rucsday, Wednesday and'I'hursday between 11:30 a.m, and 1:30 p.m. as set forth in Exhibit A to this Agreement, In addition, Consultant will provide ADA compliant trolley/bus servicos pursuant to the attached proposal and bus, route. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, a rate of $600.00 per day of trolley services. The total compensation provided under this Agreement shall not exceed $23,400,00. b. Payment by City shall be made within forty-five (45) days fallowing receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 3. 11,F)RIM `chis Agreement shalt coennxxrce on May 24, 2016 and terminate oil August 19, 2016, unless terminated earlier pursuant to Section 12, below. The term of this Agreement may be extender.[ upon a w6tine executed by the City Manager and the City Attorney. 4, 1NDUPLeN.LIENT CON'FRACTOR Consultant shall, during the entire tern of this Agreement, be construed to be an independent contractorand not an employee of the City. 'Phis Agreement is not intended not shall it be construed to create all employer-employee relationship, n,joint venture relationship, or to allow the City to exerciso discretion or control over the professional tttarrner in which Consultant performs the services which ate the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a mattner 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 its employees and shall be responsible for all applicable withholding taxes. 5, INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance, Consultant shall maintain commercial general liability insurance which shall include, but not be lindited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to, property, resulting from any act or occurrence arising out of Consultant's operations in the performance of this Agreement, including, without limitation, acts involving vehicles, The amounts of insurance shall be not less than the following; single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage; in the total amount of$1,000,000 per occurrence and $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 (e) contain standard separation of insured's provisions. b. Business automobile liability insurance, or equivalent form, with a combined single limit of not less than 91,000,000 per occurrence for owned automobiles. c. Worker's Compensation insuraucc. In accordance with the provisions of Section 3300 of the Labor Code, Consultant, if Consultant ]las arty employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Consultant., agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. d. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: (i) Consultant slurll maintain all insurance required above fit hill force and effect for the entire period covered by this Agreement, Certificates of insurance shall be furnished to the City upon excoution of this Agrecurent and shall be approved in form by the City, (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. c. 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 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 indenmify lite City for arty work performed prior to approval of insurance by the City. 6. INDEMNIFICATION Consultant agrees to and shall indenrrify, defend, and hold harmless the City, its officers, agents, employees, consultants, legal counsel, and representatives from liability forpersonal injury, damages, just compensation, restitution, j udicial or equitable relief arising out of claims; (1) for personal injury, including death, and claims fur property damage, arising from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on its behalf which relates to the services described in Section 1 of this Agreement; and (2) froth any claim that personal injury, damages, Just compensation, restitution, judicial or equitable relief is due by reason of effects arising from this Agreomu it. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable reliefsuffered, or alleged to have been suffered, by reason of the events referred to in this Section. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for legal counsel to be selected by the City, regarding any action by a third party asserting that personal injury, damages, just compensation, restitution,. judicial or equitable relief due to personal or property rights arises by reason of the terms of, or affects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. 7. CONFIDENTIALITY If Consultant received fi*oty the City information which slue 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 infornurtion 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 and disclosed without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without roferencc to information disclosed by the City. 8. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interest and shall not have interests, direct or indirect, which would conflict in any marmer with performance of services specified under this Agreement. 9. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shalt be in writing and shall be dccuted to be property given if delivered in person or nailed 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; V To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, California 92702-1988 Facsimile (714) 647-6956 Copies to; and Executive Director of Community Development City of Santa Ana 20 Civic Center Plaza (M-25) P'O' F3ox 1988 Santa Ana, California 92702-1988 Facsimile(714)647-6549 City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702-1988 Facsimile (714) 647-6515 To Consultant: .fames Dul:,ac, Owner Big Red Bus d'c ling Bcach Trolley 6400 ct7. PCH, *158 Long Beach, CA 90803 A party may change its address by giving notice in writing to the other party. Thereafter, any comnumication 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, It'sent by facsimile, communication shall he effective or deemed to have been given twenty -f rur (24) hours alter 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 exchisive 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 atNwhmcats hereto, the teens of this Agreement shall prevail and will serve to fully supersede existing Agreement. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant. Tbc parties agree that any terns or conditions of any purchase order or Other instrument that are inconsistent with, or in addition to, the terms or conditions hereof, shall not bind or obligate Consultunt nor the City. Each party to this Agreement aclarowledges that no representations, inducements, promises or agrcennents, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein. U ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized set -vices of Consultant, Consultant may not assign, transfer, delognte, 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. 12. TERMINATION This Agreement may be terminated by the City with or without cause upon thirty (30) days written notice of termination to the Consultand. In such event, Consultant sball be nntided to receive and City shall pay Consultant, compensation for all services rendered prior to the effective date of termination. 13. NON DISCRIMINATION Consultant shall not discrinmjnate because of race, color, creed; relation, 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 or any activities under this Agreement. Consultant 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 Agreementhasbeen executed and delivered in the State of California and the validity, interpretation, porforznance, and on£oreement of any of file 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 he brought or arise out of, in connection with or by reason of this Agreement. 15. PROVE SSIONAL 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 mquired by the laws and regulations of the United Sates, the State of California, tine City of Sesta Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing ofits inability to obtain or maintain suclmpernrits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. Signature Page to 1%ollow IN WITNESS WHEREOF, the parties hC17010 1111ve exculiled this Agreement the date and year first 11)()ve writtell. ATTIUST� -.- MARIA D. IIUIZAR Clerk cltdhe Council APPROVED AS TO FORM: Sonia R. Carvalho City BY: RECOMMENDED FOR APPROVAL: R. o b6 tr�C �or t c �� Speciat Assistaut to the City Manager CITY OF SANTA ANA David Cavazos City manager CONSULTANT "01%viier of Big RED Sus & Long uj m f 4e- V, BIGRE-1 OP ID: AM CERTIFICATE OF LIABILITY INSURANCEATE (MM/DDNYYY) 5/101201 6 05/1012016 r 05/10/26 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER TIB Transportation Ins Brokers 425 West Broadway, Suite 400 Glendale, CA 91204 CONTACT NAME: Arcy Jaureg Ul PHONEg18-246-2800 FA AIc No E.1):818-246-2800 Arc No): 818-246-4690 Q DARESS: alauregul@tibinsurance.com INSURER($) AFFORDING COVERAGE NAICA INSURER A: Scottsdale Insurance Company 41297 INSURED Dulca Enterprises dba: Big Red Bus 6400 E. Pacific Coast HWy#158 Long Beach, CA 90803 INSURER B: General Star Indemnity Cc 37362 weURERC:The Burlington Insurance Cc INSURER D: NSURERE: NSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE R D POLICY NUMBER POLICY EFF MMIDDIYYYY MMID�IYVYV LIMITS X GENERALLIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OOCCUR X City of Santa Ana 907BW35284 04/11/2916 04/11/2017 EACH OCCURRENCE $ 1,000,006 DAMAGE TO RE T JJU PREMISES Ea occurrence $ 100,000 MED POP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 AUTHORIZED REPRESENTATIVE ? M GENERAL AGGREGATE $ 21000,000 GEN'LAGGREGATE LI MI T APPLIES PER'. POLICY JEC�PRO LOG PRODUCTS-COMP/OP AGO $ Incl Gen Ag A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS X £rte' Br l CAS0102404 06H6/2015 06/16/2016 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY(Perperson) $ BODILY INJURY (Per ecddent) $ PROPERTYDAMAGE $ PER ACCIDENT B LJUMBRELLA X LAB EXCESS S LI IX OCCUR CLAIMS -MADE X IXG419167A 06116/2015 06/16/2016 EACH OCCURRENCE $ 4,000,OOC AGGREGATE $ DEDI RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) Ifyee, d.9C,ke nnd.r DESCRIPTION OF OPERATIONS below NIA WCSTAT U- OTH- ER EL EACH ACCIDENT $ E.L. DISEASE- EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Certificate holder is included as additional insured as respects the operation of the named insured. CERTIFICATE HOLDER CANCELLATION OO 1908-2010 ACORD CORPORATION. All rights reserved J ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD 11 CITYS21 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Bax 1988 AUTHORIZED REPRESENTATIVE ? M Santa Ana, CA 92702 £rte' Br l OO 1908-2010 ACORD CORPORATION. All rights reserved J ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD 11 HOME OFFICE SAN FRANCISCO IT IS AGREED THAT THE CLASSIFICATIONS AND R. IN THE CONTINUOUS POLICY ISSUED TO THIS HERE ARE YOUR NEW RATES FOR THE PERIOD INC BE CORRECTED OR IFINSURANCEIS NOT NEEDED IMPORTANT THIS IS NOT A BILL' COF SEND NO MONEY UNLESS STATEMENT IS ENCLOSED THE RATING PERIOD BEGINS AND ENDS AT 12:01AM RATING '. PACIFIC STANDARD TIME RATING ENDORSEMENT PER $100 OF REMUNERATION APPEARING .OYER ARE AMENDED AS SHOWN BELOW. D. IF YOUR NAME OR ADDRESS SHOULD NEXT YEAR, PLEASE TELL US. )US POLICY 9102788-15 BIG RED BUS DEPOSIT PREMIUM 6400 E PACIFIC COAST HWY MINIMUM PREMIUM LONG BEACH, CALIF 90803 PREMIUM ADJUSTMENT PERIOD NAME OF EMPLOYER- DULAC ENTERPRISES, INC.', (A CORPORATION) CODE NO. PRINCIPAL WORK AND RATES EFFECTIVE FROM 06-16-15 TO 06-16-16 PREMIUM BASE BASIS RATE 7382--1 BUS OR LIMOUSINE OPERATIONS 10000 23.90 8742-1 SALESPERSONS --OUTSIDE. 4000 1.28 8810-1 CLERICAL OFFICE EMPLOYEES--N.O.C. 60000 ********BUREAU NOTE INFORMATION******** FEIN 615387008 $1,580.00 $1,580.00 QUARTERLY R SC INTERIM BILLING RATE* 27.49 1.47 .99 .1.14 $8,490 i tycrW<.`r' V COUN E�SIgNED �ANll II SSUED AT SAN FRANCJgV�q PLEASE) MAY 6, 2015 POLICY' L PAGE 1 OF MAY 6, 2015 BIG RED BUS 6400 E PACIFIC COAST HWY LONG BEACH, CA 90803 IN REPLY REFER T4: Dear Policyholder Thank you for choosing us as your workers' compensation insurance carrier. This package contains your renewal documents as listed on the following page. Please keep these together. Our goal is to provide you with fast, efficient, and the most convenient service possible. We truly appreciate your business. If you have any questions about the information in this mailing, please contact your broker of record or your local State Compensation Insurance Fund office. State Compensation Insurance Fund 5880 Owens Or . Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 . Pleasanton, CA,.... 94588-8792 HOME OFFICE SAN FRANCISCO RATING ENDORSEMENT IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW. CONTINUOUS POLICY 9102788-15 IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR LOCAL STATE FUND OFFICE BELOW: CSC — POLICY AT MONTEREY PARK 900 CORPORATE CENTER DRIVE MONTEREY PARK CA 91754 (877) 405-4545 Nothing herein contained shall be hold to very, alter, waive or extend any of the terms, conditions agreements or limitations of the Policy other than as herein stated. When countersigned by a duly authorized officer or representative of the State Compensation Insurance Fund, these declarations shall be valid and form part of the Policy, ��el 4�01 AUTHORIZED REPRESENTATIVE PRESIDENT AND C50 COUNTERSIGNED AND ISSUED AT SAN FRANCISCO MAY 6, 2015 SCIF FORM 10963A IREM,2014) POLICY L PAGE 3 OF ENDORSEMENT AGREEMENT'; CALIFORNIA SHORT -RATE CANCELATION HOME OFFICE SAN FRANCISCO EFFECTIVE JUNE 16, 2015 AT 12.01'1 A.M. ALL EFFECTIVE DATES ARE TO JUNE 16, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME BIG RED BUS 6400 E PACIFIC COAST HWY LONG BEACH, CA 90803 THE INSURANCE UNDER THIS POLICY IS LIMITED AS FOLLOWS: 9102788-15 RENEWAL SC Imcp IT IS AGREED THAT ANYTHING IN THE POLICY TO THE CONTRARY NOTWITHSTANDING, SUCH INSURANCE AS IS':AFFORDED BY THIS POLICY IS SUBJECT TO THE FOLLOWING PROVISIONS: IF YOU CANCEL THE POLICY AND A DISCLOSURE WAS PROVIDED IN ACCORDANCE WITH SECTION 481(C) OF THE,CAI.IFORNIA INSURANCE CODE, FINAL PREMIUM WILL BE BASED ON THE TIME THIS POLICY WAS IN FORCE AND INCREASED BY THE SHORT -RATE CANCELATION TABLE BELOW: SHORT -RATE CANCELATION'!TABLE FINAL PREMIUM BASED ON THE TABLE BELOW WILL NOT BE LESS THAN THE MINIMUM PREMIUM FOR:THIS POLICY. DAYS _ EXTENDED NUMBER OF DAYS % - PERCENTAGE OF FULL POLICY PREMIUM DAYS % DAYS %' DAYS 1 5% —T 6/ 3-4 77 5--6 8% 7-8 9% 9-10 10% 11-12 11% 13-14 12% 15-16 13% 17-18 141 19--20 15'% 21-22 16% 23-25 17% 26-29 18°% 30-32 19% 33-36 20% 37-40 21% 41-43 22% 44-47 23% 48-51 24% 52-54 25% 55-58 26% 59-62 27% 63-65 28% CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELDTO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, ''DR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED, NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: MAX' 6, 2015 AUTHORIZED REPRESENT. IVE ''.PRESIDENT AND CEO SCIF FORM 10217 (A8V.7-2014) I OLD OF 217 ENDORSEMENT AGREEMENTi STATUTORY ACCOUNTING PRINCIPLES BILL RECEIVABLE ! 9102788-15 RENEWAL Sc HOME OFFICE SAN FRANCISCO EFFECTIVE JUNE 16, 2015 AT 12.01A.M. PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:41 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME BIG RED BUS 6400 E PACIFIC COAST HWY LONG BEACH, CA 90803 ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT„ IT IS AGREED THAT THIS ENDORSEMENT AMENDS SECTION D. OF PART FIVE OF THE POLICY. YOUR POLICY HAS BEEN WRITTEN ON QUARTERLY ADJUSTMENT PERIOD. YOU WILL PAY ALL PREMIUM WHEN DUE. PAYROLL REPORTS AND PREMIUM ARE DUE WITHIN 10 DAYS (TEN) AFTER* THE -`LAST DAY OF THE REPORTING - PER 101); PAYMENT OF OUTSTANDING PREMIUM IS DUE ''WITHIN 10 DAYS (TEN) FROM THE BILL DATE. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: ,MAY 6, 2015 2089 AUTHORIZED REPRESENT PRESIDENT AND CEO SCfF FORM 10217 (REM -2014) OLD DF 217 HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATESARE AT 1401 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ENDORSEMENT AGREEMENT' MEDICAL PROVIDER NETWORK EFFECTIVE JUNE 160 2015 AT 12.01A.M. BIG RED BUS 6400 E PACIFIC COAST HWY LONG BEACH, CA 90803 CONTINUED. 9102788-15 RENEWAL Sc PAGE 2 OF 3 TO BE TREATED BY A PHYSICIAN OF HIS OR HER CHOICE FROM WITHIN THE MEDICAL PROVIDER NETWORK AFTER THE FIRST VISIT. THE POLICYHOLDER SHALL NOTIFY EMPLOYEE OF THE METHOD BY WHICH THE LIST OF PARTICIPATING PROVIDERS MAY BE ACCESSED BY EMPLOYEES. IT IS FURTHER AGREED THAT IF AN INJURED EMPLOYEE DISPUTES EITHER THE DIAGNOSIS OR THE TREATMENT:PRESCRIBED BY THE TREATING PHYSICIAN, I'HE EMPLOYEE MAY SEEK THE OPINION OF ANOTHER`PHYSICIAN WITHIN THE MEDICAL PROVIDER NETWORK. IF THE INJURED EMPLOYEE DISPUTES THE DIAGNOSIS OR 'TREATMENT PRESCRIBED BY THE SECOND PHYSICIAN, THE EMPLOYEE MAY SEEK THE OPINION OF A THIRD PHYSICIAN WITHIN THE MEDICAL PROVIDER NETWORK, IT IS FURTHER AGREED THAT THIS ENDORSEMENT IN NO WAY AFFECTS THE RIGHTS OF AN INJURED WORKER TO PREDESIGNATE A PHYSICIAN. AN EMPLOYEE MUST FILE WRITTEN NOTICE OF THE PREDESIGNATION WITH THE EMPLOYER PRIOR TO THE DATE OF INJURY. THE NOTICE MUST INCLUDE THE PHYSICIAN'S SIGNATURE OF AGREEMENT TO THE PREDESIGNATION, AND THE FOLLOWING CONDITIONS MUST APPLY; THE PHYSICIAN IS THE EMPLOYEE'S REGULAR PHYSICIAN. THE PHYSICIAN IS THE EMPLOYEE'S PRIMARY CARE PROVIDER WHO HAS PREVIOUSLY DIRECTED THE MEDICAL TREATMENT OF THE IIIII�Iii[l[IINII NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD....TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, '.OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND S/ISSUED .,tAATSAN FRANCISCO: MAY 6, 2015 AUTHORI"LED REPRESENT' IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7�2014) 2437 OLD OP 217 ENDORSEMENT AGREEMENT TERRORISM RISK INSURANCEPROGRAM REAUTHORIZATION ACT OF': 2015 9102788-15 RENEWAL SC HOME OFFICE SAN FRANCISCO EFFECTIVE JUNE 16, 2015 AT 12.01,A.M. PAGE 1 OF 5 ALL EFFECTIVE DATES ARE TO JUNE 16, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC '.. STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME BIG RED BUS 6400 E PACIFIC COAST HWY LONG BEACH, CA 90803 THIS ENDORSEMENT ADDRESSES THE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT OF 2002 AS AMENDED AND EXTENDED BY THE TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015. IT SERVES TO NOTIFY YOU OF CERTAIN LIMITATIONS UNDER THE ACT, AND THAT YOUR INSURANCE CARRIER IS CHARGING PREMIUM FOR LOSSES THAT MAY OCCUR IN THE EVENT OF AN ACT OF TERRORISM. YOUR POLICY PROVIDES COVERAGE FOR WORKERS COMPENSATION LOSSES CAUSED BY ACTS OF TERRORISM, INCLUDING WORKERS COMPENSATION BENEFIT OBLIGATIONS DICTATED--BY-`STATE LAW. COVERAGE FOR SUCH LOSSES IS STILL SUBJECT TO ALL TERMS, DEFINITIONS, EXCLUSIONS, AND CONDITIONS IN YOUR POLICY, AND ANY APPLICABLE FEDERAL AND/OR STATE LAWS, RULES, OR REGULATIONS. DEFINITIONS THE DEFINITIONS PROVIDED IN THIS ENDORSEMENT ARE BASED ON AND HAVE THE SAME MEANING AS THE DEFINITIONS IN THE ACT. IF WORDS OR PHRASES NOT DEFINED IN THIS ENDORSEMENT ARE DEFINED IN THE ACT, THE DEFINITIONS IN THE ACT WILL APPLY. "ACT" MEANS THE TERRORISM RISK INSURANCE ACT OF 2002, WHICH TOOK EFFECT ON NOVEMBER 26, 2002, AND ANY AMENDMENTS THERETO, INCLUDING ANY AMENDMENTS RESULTING FROM THE TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015. CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL RE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: MAY 61, 2015 AUTHORIZEp REPRESEN'7' IVE PRESIDENT AND CEO SCIF FORM 10217 IREV.7-20141 OLD OF 277 ENDORSEMENT AGREEMENT: TERRORISM RISK INSURANCE. PROGRAM REAUTHORIZATION ACT OF 2015 9102788-15 RENEWAL SC HOME OFFICE SAN FRANCISCO EFFECTIVE JUNE 16, 2015 AT 12.01 A.M. ALL EFFECTIVE DATES ARE TO JUNE 16, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME BIG RED BUS 6400 E PACIFIC COAST HWY LONG BEACH, CA 90803 CONTINUED. "INSURER DEDUCTIBLE" MEANS, FOR THE PERIOD BEGINNING ON JANUARY 1, 2015, AND ENDING ON DECEMBER 31, 2020, AN AMOUNT EQUAL TO 20% OF OUR DIRECT EARNED PREMIUMS, DURING THE IMMEDIATELY PRECEDING CALENDAR YEAR. LIMITATION OF LIABILITY PAGE 3 OF 5 THE ACT LIMITS OUR LIABILITY TO YOU UNDER THIS POLICY. IF AGGREGATE INSURED LOSSES EXCEED $100,000,000,000 IN A CALENDAR YEAR AND IF WE HAVE MET OUR -INSURER DEDUCT1BLE, WE ARE NOT LIABLE FOR THE PAYMENT OF ANY PORTION OF THE AMOUNT OF INSURED LOSSES THAT EXCEEDS:%$100,000,000,000; AND FOR AGGREGATE INSURED LOSSES UP TO $100,000,000,000, WE WILL PAY ONLY A PRO RATA SHARE OF SUCH INSURED LOSSES AS DETERMINED BY THE SECRETARY OF THE TREASURY.. POLICYHOLDER DISCLOSURE NOTICE 1. INSURED LOSSES WOULD BE PARTIALLY REIMBURSED BY THE UNITED STATES GOVERNMENT. IF THE AGGREGATE INDUSTRY INSURED LOSSES EXCEED. A. $100,000,000, WITH RESPECT TO SUCH INSURED LOSSES OCCURRING IN CALENDAR YEAR 2015, THE UNITED STATES GOVERNMENT WOULD PAY 85% OF OUR INSURED LOSSES THAT EXCEED OUR .INSURER DEDUCTIBLE. CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED A/T/fSAN FRANCISCO! MAY 6, 2015 AUTN6RIZE0 REPRESENT IVE PRESIDENT AND CEO SCIF= FORM 10217 IREV.7-20141 OLD OP 217 HOME OFFICE SAN FRANCISCO ALLEFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ENDORSEMENT AGREEMENT TERRORISM RISK INSURANCEPROGRAM REAUTHORIZATION ACT OF: 2015 9102788-15 RENEWAL SC EFFECTIVE JUNE 16, 2015 AT 12.01IA.M. PAGE 5 OF TO JUNE 16, 2016 AT 12.01 A.M. BIG RED BUS 6400 E PACIFIC COAST HWY LONG BEACH, CA 90803 CONTINUED. 2. NOTWITHSTANDING ITEM I ABOVE, THE':UNITED STATES GOVERNMENT WILL NOT MAKE ANY PAYMENT UNDER THE ACT FOR ANY PORTION OF INSURED LOSSES THAT EXCEED $100,000,000,000, 3. THE PREMIUM CHARGE FOR THE COVERAGE YOUR POLICY PROVIDES FOR INSURED LOSSES IS INCLUDED IN THE AMOUNT SHOWN IN ITEM 4 OF THE INFORMATION PAGE OR IN THE SCHEDULE BELOW. THIS ENDORSEMENT CHANGES THE POLICY TO WHICH IT IS ATTACHED AND IS EFFECTIVE ON THE DATE ISSUED UNLESS OTHERWISE STATED. WC 00 04 22 B NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD: TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS,'', OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAN FRFRANCISCO: MAY 6, 2015 AUTHORIZED REPRESEN PRESIDENT AND CEO SCID FORM 10217 (REV.7-20141 OLD OP 217 9102788-15 Dear Policyholder: These endorsements amend and are part of',your policy. Please Keep them with your documents for future reference. If you have any questions concerning these endorsements, Please con -tact your local State Fund office, POLICYHOLDER NOTICE Your Right to Rating and Dividend Information Page 2 of 3 POLICY NO. 9102788-15 NR SC (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form free of charge by completing a Policyholder Rate Sheet Request Form on the WCIRB's website at http://wcirb.com/ratesheet, The Experience Rating Form will include a Loss -Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only, Ill. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. You may request in writing that we reconsider a change in a classification assignment that results in an increased premium. You may also request, in writing, that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written requests that we reconsider or review our actions should be forwarded to: State Compensation Insurance Fund, Attention: Manager, Customer Assistance Program, 5680 Owens Drive, Pleasanton, CA 94588 or call us at 925-460.6530 or fax us at 925-460.6633. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves -the application of the Revision of Losses rule. For requests related to your experience modificaton, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 14 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, California94612, Attention: Customer Service. Customer Service can be reached by telephone at 1-888-229-2472, and by fax at 415-778.7272. If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you, may appeal to the insurance commissioner as described in paragraph ILC., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, California 94612, Attention: Complaints and Reconsiderations. The WCIRB's telephone number is 1-888-229-2472, and the fax number is 415-371-5204. 5CIF 10610 8 (Rev. 04.15)