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HomeMy WebLinkAboutCAZALES, RODOLFO DBA TOYAMA KARATE-DO ORGANIZATION-2016City of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination form. Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with No. N-2016-129 was completed on (List all amendments. Use space below if needed.) Revised: 01-07-16 COTC Office Use Only 209 AUG 22 Phi y. n 6 CITY OF SANTA ANA CLERK OF COUNCIL 4311171 and final payment has been made. Department: Phone/Ext.: �5 r Signature: A)1 Date: ? I n%iowE ON PILE : u ; ,PRAY PROCEED N-2016-129 (Al IL INSURANCE EXPIRES, OF COUNCU, JJW O t,, RECREATION SERVICES AGREEMENT DAM S Nta Cue. VQS0) a THIS AGREEMENT is made and entered into this 9t" day of August 2016, by and between Rodolfo Cazales dba Toyama Karate —Do Organization ("Provider") and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). RECITALS A. The City desires to retain a recreation service provider having special skills, resources and knowledge to provide Toyama Karate -Do Martial Arts classes in its leisure class program. B. Provider represents that he is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that he is knowledgeable in his field and that any services performed, by Provider under this Agreement will be performed in compliance with such standards as may reasonably be expected. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES Provider shall perform those services as set forth in Exhibit A to this Agreement. COMPENSATION in consideration for the right to provide the programs set forth in Exhibit A, City agrees to pay the Provider seventy percent (70%) of: all gross revenue received from program participants. Total revenue to Provider shall not exceed $25,000 annually, Payment to Provider sball be made within thirty (30) days following completion of the last class taught by Provider that month. City shall be responsible for collecting all, fees from program participants. Provider shall not collect fees but wilt refer all interested participants to City for registration information. Provider agrees that City shall retain thirty percent (30%) of all gross revenue received from program participants as an administrative fee. 3. TERM This Agreement shall commence on September 1, 2016 and terminate on August 31, 2017, unless terminated earlier in accordance with Section 12, below. 4. INDEPENDENT CONTRACTOR Provider shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer -employee relationship, a joint venture relationship, or Page 1 of 8 to allow the City to exercise discretion or control over the manner in which Provider performs the services which are the subject matter of this Agreement; however, the services to be provided by Provider shall be provided in a mariner consistent with all applicable standards and regulations governing such services, Provider shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. Provider is not an agent, representative or employee of City and Provider shall have no authority to act on behalf of the City. S. INSURANCE Prior to undertaking performance of work under this Agreement, Provider shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance, Provider shall maintain commercial general liability insurance which shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resultiig therefrom and damage to property, resulting from any act or occurrence arising out of Provider's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence and $2,000,000 in the aggregate, Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insured provisions, b. Worker's Compensation Insurance. In accordance with California State law, Provider, if Provider has any employees, is required to be insured against liability for workers' compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Provider agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. c. The following requirements apply to the insurance to be provided. by Provider pursuant to this section: (i) Provider shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. (ii) Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form 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, (iv) Provider shall supply City with fully executed additional insured endorsement. Page 2 of 8 d. If Provider fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to terminate this Agreement, Such termination shall not affect Provider's right to be paid for its time and materials expended prior to notification of termination. Provider waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 6. INDEMNIFICATION Provider agrees to and shall defend, 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 negligent operations of the Provider or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; 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 Provider further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a 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. 7. CONFLICT OF INTEREST Provider covenants that he 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. S. LIVE SCAN BACKGROUND CHECI{ Providers, and any employees, subcontractors or substitutes, in contact with minors under eighteen (18) years of age shall arrange for and submit to a. Live Scan electronic background check for criminal history available through the California Department of Justice as a condition of this Agreement and provide proof of compliance, including any criminal history identified, prior to performing services hereunder. The background check shall include at a minimum a state and county criminal history investigation where such individual resides and a search of the National and California State Sex Offender Registries. Page 3 of 8 9. 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 cormnunication in the manner provided in this Section, to the following persons: To City: Clerk of the Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 Fax (714) 647-6956 With copy to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 26 Civic Center Plaza (M-23) P.O. Box 1988 Santa Ana, California 92702 Fax (714) 571-4211 To Provider: Rodolfo Cazales 2525 N. Grand Avenue, Suite Z Santa Ana, CA 92705 Cell: (714) 474-4737 Loyamausa c&ahoo.com 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. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Provider 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 terns of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Provider. The parties agree that any terns or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terns and conditions hereof, shall not bind or obligate Provider or the City. Each party to this Agreement acknowledges that no Page 4 of 8 representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which is not embodied herein. 11, ASSIGNMENUSUBSTITUTES a. Assignment. The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to enter into this Agreement. Therefore, Provider may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void, b. Substitutes. In the event Provider is not able to teach a class due to illness or some other cause beyond Provider's reasonable control, Provider must procure, at its sole expense, a qualified substitute instructor to teach the class at its regular time and place. Provider shall ensure that substitute instructors are at least twenty-one (21) years of age and comply with the City's insurance and live scan requirements contained herein. Evidence of compliance with City's insurance and live scan requirements shall be provided upon request. Provider must immediately notify the City of the substitute instructor's name, qualifications, address and phone number. If Provider cannot procure a qualified substitute and the City is unable to assist in this regard, then the class shall be canceled and a make-up class must be added to the session. Provider must notify participants as soon as possible of any class cancellation and make-up class. Provider must personally teach at least seventy-five percent (75%) of its offered classes. 12. TERMINATION a. This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of termination. b. Termination or cancellation of classes by the Provider outside of Section I Lb, must be given to the City at least thirty (30) days prior to termination/cancellation, Failure to provide adequate cancellation notice to the City may put future contracting of business with the City at risk and will result in the City's retention of ten (10%) percent of the final payment to Provider. 13. RECORDS Provider shall use attendance sheets generated and supplied by the City to record attendance in each class, Provider shall keep these and any other records in connection with the work to be performed under this Agreement and shall permit City, upon request, to review such records for a period of three (3) years from the date of final payment to Provider under this Agreement. 14. NON-DISCRIMINATION Provider shall not discritninate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization, promotion, Page 5 of 8 termination or other employment related activities, or in any activities under this Agreement, Provider affinns that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 15. 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. 16. LICENSES Provider shall, throughout the tern 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. 17. SEVERABILITY In the event that one or more of the phrases, sentences, clauses, paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be interpreted to carry out the intent of the parties hereunder, 18. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 19. AUTHORITY The person(s) executing this Agreement on behalf of the parties hereto warrant that they are duly authorized to execute this Agreement on behalf of said parties and that be so executing this Agreement, the parties hereto are fonnally bound to the provisions of this Agreement. INWITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: MARIA D. HUIZAR '. Cleric of the Council 1m TY` ' NTA ANA DA D CAVAZOS City Manager Page 6 of 8 APPROVED AS TO FORM: SONIA R. CARVAI,HO City Attorney BY! I, Ivi JUNK Assistnt City Altorney Rl"'CONIMENDED FOR APPROVAL,: Azxx�� GERARDO MOUET Fxcculive Director of Parks, Recreation and Coninumity Services Agency PROVIDFR: 07 6 RODOLF0 C ZALE, dba Toyama Karate -Da Page 7 ol'8 Exhibit A SCOPE OF SERVICES -Rodolfo Cazales dba Toyama Karate -Do Organization A. Provider shall conduct Toyama Karate -Do Martial Arts classes for ages 5 yrs. & up B. Provider shall teach such or similar classes (1) at the times below at facilities to be designated by the City or (2) on a schedule agreed upon by the parties for each class session or teen, including the location, specific days and hours when classes will be held, and holidays to be observed, in accordance with City's needs. • Toyama Karate -Do will consist of monthly sessions, two days per week, 50 minutes per day C. Provider will provide and be responsible for equipment, records, and personnel and cleanup of the facilities and materials necessary to ensure the safety and effectiveness of instruction. CLASS SIZE / REGISTRATION A. Each class must have a minimum of 5 paid students and no more than a maximum of 20, B. No registration will be accepted after the second meeting of class. C. If the minimum registration has not been reached by the second meeting of the class, the class shall be canceled by mutual agreement of Provider and City. Provider will be under no obligation to provide services for canceled classes, and the City will have no fiuther obligations to pay Provider compensation for the remaining classes that were canceled in that session. CLASS FEES A. Each participant shall pay registration fee as established by the City, B. Provider may not waive class participants/registration fees. C. Only registered participants may participate in class. D. Any refunds to participants will be made in accordance with City policy. E. Any material fee shall be established by mutual agreement of city and Provider and shall be payable directly to Provider Page 8 of 8 7' Policy Numbs(: Date Entered: 1/15/2016 ACC R'o CERTIFICATE �SURANCE 1 OF LIABILITY v/1111 a/xo s 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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 auch endorsements . PRODUCER Reindeer Insurance Services 14037 Pioneer Blvd Norwalk CA 90650 CONTACT AARA:.- NE UUMN (562)406-8838 iacN1(562)406-8837 INNIAl truckbypasa@yahoo. com -AWA9 — INSURERI6)AFFORDIN000VERAGE _ NAICN INSURERA:HOUStOD Casualty Ins CO ' INSURED Toyama Karate DO INSURER E:apierta Insurance company INSURERe Rodolf0 Casales INSURERO: 2521 N. Grand Ave Unit A INSURER E: Santa Ana, CA 92705 INSURER P : 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 I$ SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS TR TYPE OF INSURANCE �` POLICYNUMSER POLICYEFF MDLpTe P LIMITS A COMMERCIAL 09NERALUABILITY CLAIMS-MAOE® OCCUR 15-7005165 `,s' .�l �:j e`'iTy�r eLA V 1/1/2016 1/1/2017 EACH OCCURRENCE $2,000,000 pX MISS ETD �oR�7,6a g100,000 MEDEXP An aIw arson $5,000 ^ v PERSONAL SAW INJURY §1,000,000 — DEN AGGREGATE LIMIT APPLIES PER: _ POLICY ❑ JEC LOC OTHER. AGGREGATE §A, OOOr 000 _GENERAL PRODUCTS AGG S . AUTOMOSILEUABi1TY ANYAUTO OWNED SCHEDULED AUTOS ONLY _ AUTOS HIRED NON•OWNED AUTOS ONLY AUTOS ONLY '(Hy �•+'tt44//11 C §nn GJ`,rs COMBINED SINLE LIMIT jEa § — BODILY INJURY (Per person) 3 EDGILY INJURY(Per awoont § PROPERtt DAMAGE eRLAR I I § 3 UMORBLLALIAB EX0938 LU OCCUR CLAIMS•MAPE ('•`� v1�+Y�U^ v('. e li Q+ EACH OCCURRENCE S AGGREGATE _ OEOI I NETENTKIN f $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY My PROPRIETORMARTNEMEXSCUTNE YIN OFFICCRJMEMEER EXCLUDED? � (MandatoryInNN) 11yyes.tlesaebo YndN DESCRIPTION OF OPERATIONS babes NIA CA37339-2 1/1/2016 1/1/2017 E.L. EACH ACCIDENT $1,000,000 EL. DISEASE• 6A EMPLOYEE S1 ,000r000 E.I. DISEASE: -POLICY LIMIT 31,000 10 OO I DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 191.Memo=]Rama&s Sameduls, may be mUsahod N mom apace is regulmd) Karate School Certificate Bolder is Listed as Additional Insured CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 CIVIC CENTER PLAZA M-16 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO SOX 1988 ACCORDANCE W HE POLICY PROVISIONS. $ANTA ANA CA 92702 AUTHORI2EO REPREft T E 0 198 8.201 ItCORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACOR Proye,Xe using Forms Sass Plus software. v Xormseoss.eom, Improselva Pubashing WO-maoam POLICY NO.15-7005165 COMMERCIAL GENERAL LIABILITY NAME INSURED.Toyama Karate Do THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ORGANIZATION This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of Santa Ana, its officers, agents, and employees 20'Civic Center Plaza Santa Ana, CA 92701 (If no entry appears above, information required to complete this endorsement will be shown In the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section 11) Is amended to Include as an insured the person or orpulzation shown In the schedule, as an Insured but only with respected to liability arising V j* aperatlons or premtses owned by or rented to you. vie"7 'T Gat Nq' ecr ?PIGS CG 202611 B5 --` Copyright, ISO Properties, Inc., 2004 Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT Insurance Company: t" OV 510(l W421 r Y lh C± This endorsement modifies such insurance as in afforded by the provisions of Policv;I 15 - `70051 VG 1. The City of Santa Ana, 20 Civic Center plaza, Santa Ana, California 92701, officers, employees, agents and representatives are named as additional insured with regard to liability and defense of suits arising from the operations and, uses performed by on behalf of the named Insured. 2. With respect to claims arising out of the operations and uses performed by on behalf of the named insured., such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insured. 3. This insurance applies separately to each insured against whom claim ' de or suit is brought except with respect to the company's limits of liability.. Istoa of any person or organization as an insured shall not affect any rio6 itch such person or organization would have as a claimant if not so included. A -'L'}j 4. With respect to the additional insured, this insurance sN reduced in coverage or limits except after thirty-30 days City of Santa Ana, 20 Civic Center Plaza, Santa Ana, Cal (Completion of the following, including countersignature, is required to male?k endorsement effective). Effective %—15 —2-0 f LO , this endorsement form as part of Policy # Issued It Countersigned b IN 4CC)R" OF LIABILITY INSURANCE DATE (MM,fDDfYYYY) CERTIFICATE: E 3/10/2017 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 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 Reindeer Insurance Services NAME: PHONE (56,2)406-8838 14037 Pioneer Blvd .__IFAX, No I: (562)406-8837 E-MAIL csrQtruckbypass.com Norwalk CA 90650 INSURER(S) AFFORDING COVERAGE I! NAC # INSURER A : United States Fire Insurance Company INSURED Toyarria Karate DO INSURER B Rodolfo Cazalez INSURER C 1030 Moore Street INSURER D Santa Ana, CA 92704 INSURER F INSURER 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 Wff[l 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. ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSP MQ POLICY NUMBER (MMfODfYYYyJ fMMfDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S2,000,000 1 \/I CLAIMS -MADE L/\ OCCUR AH—GA26932-002 01/01/2017 01/01/2018 DAMAGE TO RENTED PREMISES �Ea occurrence$100,000 ME D EXIP lAny one person 1 S 5,000 ...... _PERSONAL & ADV ]NJ - URY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PEK: GENERAL. AGGREGATE S4,000,000 PRO- F-] E-1 POLICY JECT LOC PRODUCTS - COMRYOP AGG , S S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT �Ea accident) S ANY AUTO SODfLY INJURY (Per person) S OWNED SCHEDULED . . . . ...... BODILY INJURY (Po accident) S AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON -OWNED AUTOS ON L Y AUTOS ONLY ._{Ee LL) S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LJAB CLAWS -MADE TF AGGREGATE $ D RETENTION G WORKERS COMPENSATION PER.... OTH- STATUTE ER AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORiPARTNER/EXECUTIVE OFFIGERWEMBER EXCLUDED? II NIA E.L. EACH ACCIDENT S {Mandatory in NH) II describe under re, E L, DISEASE - EA EMPLOYEE. S yes DESCRIPTION OP OPERATIONS belowE.L. DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Karate School vertificate Holder is Listed as Additional Insured CERTIFICATE HOLDER CITY OF SANTA ANA CANCELLATION SHOULD ANY OF I HE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 20 CIVIC CENTER PLAZA M- 16 EXPIRATION DATE THEREOF, NOTICE WILL 13h DLIAVERED IN ACCORDANCE WITH PO BOX 1988 1 rHF POLICY PROVISIONS ADDITIONAL INSURED ENDORSEMENT Insurance Company United States Fire Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # AH-GA2692-002 relating to the following: The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers, employees, agents and representative are named as additional insureds ("additional insureds") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured, 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective 01/0112017 Policy # AH-GA26932-002 Issued to Toyama Karate Do Name Insured Countersigned by this endorsement form as part of ranee �U--,*Llature POLICY NUMBE:AH-GA26932-002 NAME INSURED ; Toyama Karate Do COMMERCIAL GENERAL LIABILITY CG 20 15 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT' CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) (Vendor) City of Santa Ana, its officers, agents, and employees 20 Civic Center Plaza Santa Ana , CA 92701 Your Products Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — Who Is An Insured is amended to include as an additional insured any person(s) or organization(s) (referred to below as vendor) shown in the Schedule, but only with respect to "bodily injury" or "property damage" arising out of "your products" shown in the Schedule which are distributed or sold in the regular course of the ven- dor's business, subject to the following addifional exclusions: 1. The insurance afforded the vendor does not apply to: a. "Bodily injury" or "property damage" for which the vendor is obligated to pay dam- ages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, except when unpacked solely for the purpose of inspection, demonstra- tion, testing, or the substitution of parts un- der instructions from the manufacturer, and then repackaged in the original container; e. Any failure to make such inspections, ad- justments, tests or servicing as the vendor has agreed to make or normafly undertakes to make in the usual course of business, in connection with the distribution or sale of the products,-, f. Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in con- nection with the sale of the product; CG 20 15 07 04 0 ISO Properties, Inc., 2004 Page 1 of 2 13 g. Products which, after dishbufioncxsale by you, have been labeled or nohabehad or used aaacontainer, part o/ingredient ofany oth- er thing or substance by orfor the vendor� or h. "Bodily injury^ or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees anyone else acting on its be- half. Hnwever, this exclusion does not apply to" (1) The exceptions contained in Sub- paragraphs d.orf.;or (2) Such inspectioms, adjue&ments, tests or servicing as the vendor has agreed to make mrnormally undertakes tomake in the usual course ofbusiness, inconnec- tion with the distribution or ma|o of the products. This insurance does not apply to any insured person or organization, from whom you have acquired such products, o/any ingredient, part or contoinor, entering into, accompanying or containing such products. WORKERS' COMPENSATION DEC.1-ARATION 1, Rodolfo Cazales dba Foyama Karate -Do, hereby affirm under penalty of perjury, the following declaration : I certify on behalf of —Toyama Karate -Do_ that during the term of my (Consultant/Company Name) contract for Karate Classes 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. FAMNIMM, a By: /0101, UM=