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HomeMy WebLinkAboutARCHILLA, ILLARY 1A-2017City of Santa Ana Clerk of the Council 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TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect.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 agreement with COTC Office Use Only 7(1(o y1UP,, 22 I'M L): nq CITY OF SAHTA ANA CLERK Or COUNCIL N-2016-020-001 v No. was completed on ;'a 1 j and final payment has been made. (List all amendments. Use space below if needed.) Department: VMA Phone/Ext.: SD-SIL Signature: n S a 0x:1�01 t S ✓ Date: L)A r i uy Revised: 10-18-16 { tilli�'diV4F M F0:-. lw 0c4 Ally PRQ);E A MAYOR d NH,,!. NSY IZANCL I.)(PIKS Miguel A. Pulido �p P) MAYOR PRO TEM Vicente Sarmiento _-- CtERt{ 0( Gi�U_i�(,�IL 20 2016 COUNCILMEMBER�TE Angelica Amezcu P. David Benavides 0: PRCS (') NW Michele Martinez Roman Rayne Silvia Cuevas Sal Tinajero CITY OF SANTA ANA PARKS, RECREATION, AND COMMUNITY SERVICES AGENCY 20 Civic Center Plaza M-23 • P.Q. Box 1988 M-23 Santa Ana, California 92702 www.santa-ana or4 November 23, 2016 Illary Archilla I Dover Street Trabuco Canyon, CA 92679 Re: Extension of Recreation Services Agreement Agreement No. N-2016-020 Dear Ms. Archilla: N-2016-020-001 CITY MANAGER David Cavazos CITY ATTORNEY Sonia R. Carvaiho CLERK OF THE COUNCIL Marla D. Huizar Pursuant to Section 3 of the above -referenced agreement between you and the City of Santa Ana, the term of such Agreement is hereby extended for an additional one (1) year period, from January 1, 2017 through December 31, 2017. All insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincerely, Gerardo Monet, Executive Director Parks, Recreation, and Community Services Agency CITY OF SANTA ANA David azos City Manager APPROVED AS TO FORM r ��* 3o M. Funk Assistant City Attorney Mipuei A. Puiido Vincente. SanrueMo Michele Meninez Mayor Mayor No Tem, Ward iWard [�t'yi[tl4�3aala one ora V,�r!rp7ianlOCa188ala eaa.org I ymaninezloJaanla-ana.am ATTEST Maria D. Huizar clerk of Council SANTA ANA CRY COUNCIL Angaiira AmeMra t P. OoOd eerroMes Roman Royno Sai'nmlaro Ward + Ward Wards Ward a Cd 1I Oeenavid aanlaaaa oro (22LeynaCalsanla-ana,p�f+ ,i ST'nalerOfa"lsenl8c ans& Exhibit A SCOPE OF SERVICES— Yoga En Espanol A. Provider will teach Yoga class on a monthly basis for ages 16yrs old + B. Yoga class will be one day, per week, per one hour, $16 per person, per month C. The classes will be held throughout the year as agreed between Provider and City. D. 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 said instruction. E. If Provider allows others to teach his/her class, those teachers must be over 21, have obtained and maintain an instructor rating, and be covered by Providers' insurance. Provider shall provide City with documentation to verify instructor and insurance requirements. CLASS SIZE A. Each class must have a minimum of 5 paid students and no more than a maximum of 25. B. No registration will be accepted after the second meeting of class. C. In the event the minimum number of enrollees is not realized by the second meeting of the class, the class shall be canceled. Provider will be tinder no obligation to provide services and the City will have no obligations to pay Provider Compensation CLASS FEES A. Each participant shall pay a $16 for registration fee per month. Anticipated revenue not to exceed $25, 000.00. B. No refunds will be made to participants after the first week of class unless the class is cancelled by the City. C. The City shall collect registration fees from each participant during the registration period. Provider shall not collect fees, but shall refer all interested participants to City for registration. D. Provider shall receive seventy per cent (70%) of the total fees collected each month. City and Provider agree that City shall retain thirty per cent (30%) of the fees collected as an administration fee. E. Provider agrees that City is entitled to audit Provider's records and classes to insure compliance with this Agreement. F. Provider may not waive class participation/registration fees. G. City shall prepare class rosters and provide a copy to Provider. Only registered participants may participate in class. ACC PRODUCER Ma,alre Insurance Ageney, Inc. 27101 Paella Real Wile 200 MlssimNlejR, CA 92691 872.438.7459 Illa, Polhill. 1 Davar TmOum CanYoo, CA 92679 COVERAGES CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMMEND, EXTEND OR Al-040� /Fo _ O 20 `Q0 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. IS.AIPN 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 CERIFICATION 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD-L POLICY EFFECTIVE POLICY EXPIRATION LYN INSRD TYPE OF INSURANCE P011CYNUMBER DATE(MM/00 YYY) DATE(MM/DD/YYYY) LIMITS A % GENERAL LIABILITY PIIPK13G2709- 07/06/2016 07/06/2017 EACHOCCi1RENCE 52,000,000 % COMMERCIAL GENERAL LIABILITY CIALFSMAOE ❑% OCCUR OD3 RUTTal PRESfEaRncv $100,000 MED EXP(MY one Parson) $2,500_ PERSONAL& ADVIN1 RY $7,000,000 X PROFIESSIONAL LIABILITY GENERAL AGGREGATE MLMD,000 PRODUCTS—COMP/OP AGG $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: .7 POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (EAaceld0nq 80DILYINJURY ALLOWNEOAUTOS _ _ SCHEUMCDAUTOS (Per anon) BODILY INIURY HIRED AUTOS NON-OWNEDAUTOS (PeraccWenlJ PROPEOTYDAMAGE Hereccfdo.,) GARAGE LIABILITY ONLY —EA ACCIDENT —AUTO 'THE. THAN EAACC AL I00NLY: AGG ANYAUTO /y C/�`00".10 EXCESS/UMBRELLALIABILITY g✓" EACHOCCURENCE_ OCCUR n CIAIMS MADE /' �fA �✓Y AGGflFGAH _� DEDUCTIBLE �V — RETENTION �.1 fl fl F E PLOYER 'LIAOILYTY '([_N ANY PROPMETORFARTNER/EXECUTIVE OFFICERIMEMBEREKOLUOEDi LL iURV LIMITS ER EL EACH ACCIDENT E.L. DISEASE — EA AMPWYEE� _ IMandatoryIn NH) If yca desafhe on the SPECIAL PROVISIONS holow E.L. DISEASE —POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS ItD onderA.d and agreed that the following emit, )Wadded as an additional In sured but only with reapectlsl to the npetaHons of the Lome]insured eewp, that liability 1ea00el Umn the additional).,road's to BA9119enne. This Insurance Is Plfnmry, wRh any insurance or self -Insurance Prtgaam In aintened bV the rare. of, ... on or nm.an"etfarr Ilried beir, non conlOboUng excepting loss reiulftig from the ante negligence. 01 the name of person or organhortle. Load. CERTIFICATE HOLDER CANCELLATION The CRY of Santa Ana 20 civic Center Pis Santa Ana, CA 92701-4058 THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO $HALL IMPOSE NO OBLIGATION OR eo_ka�_ 9 ACORD 25 (2009/01) C 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK1362709-001 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 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 Name Of Additional Insured Person(s) The City of Santa Ana, it's officers, employees, eaents, and representatives A. Section II — Who Is An Insured is amended to include as an additional insured the persons) 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. 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 equip- ment 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 in- tended 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. e 6VA.. Ne� CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 13 POLICY NO: PHPK1362709-001 19-0141a-cel:na«Z90414111u11#4 . III III CHANGE # 4 CHANGE EFFECTIVE: 07/06/2016 Philadelphia Indemnity Insurance Company ( PRODUCER: Maguire Insurance Agency, Inc. NAMED INSURED: Illary Archilla MAILING ADDRESS 1 Dover Trabuco Canyon, CA 92679- POLICY PERIOD: FROM 07/06/2016 TO 07/06/2017 at 12:01 A.M. Standard Time at your mailing address shown above. DESCRIPTION: In consideration of the premium reflected, the policy is amended as indicated below: Endorse to add primary and non-contributory wording In favor of the following entity. The City of Santa Ana, it's officers, employees, agents, and representative. Total Annual Total Prorate Additional/Return Premium $0.00 Additional/Return Premium $0.00 Total Annual Total Prorate Additional/Return Additional/Raturn Tax/Surcharge/Fee $0.00 Tax/Surcharge/Fee $0.00 Page 1 of 1 AC BZC! nm PRODUCER MaOulre insurance Agency, inc. 2>301 PUerta Real Solte 200 NH, Has Vlelo, CA 92691 87/438.7459 Corals McGuire 539 E Washington Ava 0range, CA 928GX COVERAGES N ­­2 16b-0X01 501 THIS CERTIFICATION 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE. HOLDER. THIS CERTIFICATE DOES NOT AMMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 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 CERIFICATION 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WSR ADO'L POLICYEFFECTIVE POUCY11PIMTION LIT INSRO TYPE OF INSURANCE POLICYNUMBER DATE(MM/DD/VYYY) DAM(MM/DO/YYYY) LIMITS A X GENERAL LIABILITY PHPK1471665 03/31/2016 03/310017 EACH OCCURENCE $2,000,OOD X COMMERCIAL GENERAL LIABILITY ICLAIMS MADE F. OCCUR 000 PREMISESEencc $100,000 MED EXP IF, one person) $2,50D PERSONAL& ADV INJURY $2,000,00D % PROFESSIONAL LIABILITY GENERAL AGGREGATE $4,000,00D PRODUCTS—COMP/OPAGG $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: % POLICY 71 PROJECT IOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (EA accident) ROUT LY INJURY ALLOWNEDAUTOS SCHEDULED AUTOS (Per person) BODILY INJURY HIRED AUTOS NON -OWNED AUTOS (Per amldent) PROPERTY DAMAGE (Por accManll GAMGELIABILDY AUTO ONLY —EA ACCIDENT OTHERTHAN EAACC ANYAUTO AUTO ONLY: AGE EXCESS / UMBRELLA UABIUTY EACH OCCURENCE OCCUR CIAIMS MADE AGGREGATE DEDUCTIBLE RETENTION 5 COMPENSATION AND EMPLOYERS' LIABILITY VN TORV LIMBS Eft ANY PROPRXrOR ARTN€%E%ECUTIVE OFFICER/MEMBER XCLUDEU. €.L. EACH ACCIDENT _ E.L. DISEASE —EA AMPLOYEE (Mandatary in NH) If vE,, de tribe under SPECIAL PROVISIONS below EL. DISEASE —POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS /LOCATIONS/ VEHICLES ( EXCLUSIONS ADDED BY ENDORSEMENT JSPECIAL PROVISIONS It is understood and a grand that its following entity CITY of Santa Ann Its officer; employee; agent, mpreaentalMes & YOiunteers is added ae an additional insured but only with respett(H to by aparatans of the namad Insured exmpt that liability resURIng from the additional irenred's sole nogligence. CERTIFICATE HOLDER CANCELLATION Cty Of Santa Ana 182E W CNIe Center Dr $4 not Ana, CA 93703.2831 SHOULD A" OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 0 Isle, �a�VA ��r ACORD 25 (2009/01) © 1988-2009 ACORD CORPORATIO II rights. e'd, The ACORD name and logo are registered marks of ACORD 44'2 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A. statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009/01) PI-SE-007 (11111) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name of Person or Organization (Additional Insured): The City of Santa Ana, it's officers, employees, agents, and representatives. Effective Date. 09/2012016 SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of or relating to your negligence in the performance of "your work" for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or "occurrence" we cover for this Additional Insured, The Additional Insured's limits of insurance do not increase our limits of insurance, as described in SECTION ill — LIMITS OF INSURANCE: All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. �g.,P✓y`��ed ���,. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc:, with its permission. POLICY NUMBER: PHPK1473665-000 PI-SE-007 (11t11) ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization (Additional Insured): The City of Santa Ana, it's officers, employees, agents, and representatives. Effective Date: 09/2012016 SECTION It — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for "bodily injury,' "property damage" or "personal and advertising injury' arising out of or relating to your negligence in the performance of "your work" for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or "occurrence" we cover for this Additional Insured. The Additional Insured's limits of insurance do not increase our limits of insurance, as described in SECTION III — LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc„ with its permission. PI-APG-CA-1 (01107) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIACHANCES— CANCELLATION,NONRENEWALANDCONDITIONAL RENEWAL This endorsement modifies insurance provided under the following: COMMERICAL GENERAL LIABILITY COVERAGE PART SECTION IV- COMMERICAL GENERAL LIABILITY CONDITIONS, Paragraph S. When We Do Not Renew is deleted and replaced with the following.: 1. Cancellation of Master Policy a. The Master Policy may be canceled by the Members of the Fitness and Wellness Purchasing Group by surrender of the policy to us or by mailing written notice to us stating when such cancellation shell take effect. If canceled by the Members of the Fitness and Wellness Purchasing Group, we shall retain the customary short -rate proportion of the premium. In no event may the requested date of cancellation be greater than 10 days prior to the date the request is received by US. b. The Master Policy may be canceled by us by written notice mailed by certified mail to the Members of the Fitness and Wellness Purchasing Group at the address shown in the Master Policy Declarations. Such cancellation shall be no fewer than 30 days from the date the notice is mailed. 2. Cancellation of the Certificate of Insurance a. The Certificate of Insurance may be canceled by the first Named Certificate Holder shown in Item 1. of the Certificate of Insurance by surrender of the Certificate of Insurance to us or by mailing written notice to us stating when such cancellation shall take effect. If canceled by the first Named Certificate Holder shown in Item 1. of the Certificate of Insurance, we shall retain the customary short -rate proportion of the premium. In no event may the requested date of cancellation be greater than 10 days prior to the date the request is received by us. b. If this Certificate of Insurance has been in effect 60 days or less, the Certificate of Insurance may be canceled by us by written notice mailed by certified mail to the first Named Certificate Holder at the address shown in the Certificate of Insurance. Such cancellation shall be no fewer than 30 days from the date the notice is mailed unless the Certificate of Insurance is canceled because the first Named Certificate Holder has failed to pay a premium when due or has committed fraud. In that event, such cancellation shall take effect no fewer than 10 days from the date the notice is mailed. c. If this Certificate of Insurance has been in effect for more than 60 days, the Certificate of Insurance may be canceled by us only for the following reasons: (1) Nonpayment of premium; (2) Discovery of fraud or material misrepresentation by either of the following: (a) The Named Certificate Holder or his or her representative in obtaining the insurance; (b) The Named Certificate Holder or his or her representative in pursuing a claim under the Certificate of Insurance; (3) A judgment by a court or an administrative tribunal that the Named Certificate holder has violated any law of the state of California or of the United States, having as one of its necessary elements, an act which materially increases any of the risk insurrpedanst; (4) Discovery of willful or grossly negligent acts or omissions, or sa#�C akationsJJof state Page 1 of 4y�Ny Petdy1Ct PI-APG-CA-1 (01107) laws or regulations establishing safety standards, by the Named Certificate Holder or his or her representative, which materially increase any of the risks insured against; (6) Failure by the Named Certificate Holder or his or her representative to implement reasonable loss control requirements which were agreed by the insured as a condition of policy issuance or which were conditions precedent to the use by us of a particular rate or rating plan, if the failure materially increases any of the risks insured against; (6) A determination by the commissioner that the loss of, or changes in, our reinsurance covering all or part of the risk would threaten our financial integrity or solvency. A certification made under penalty of perjury to the commissioner by one of our officers of the loss of, or change in, reinsurance and that the loss or change will threaten our financial integrity or solvency if the cancellation of the Certificate of Insurance is not permitted shall constitute such a determination unless disapproved by the commissioner within 30 days of the filing. There shall be no extension to this 30 day period; (7) A determination by the commissioner that the continuation of the Certificate of Insurance would place us in violation of the laws of this state or the state of its domicile or that the continuation of coverage would threaten our solvency; or (8) A change by the Named Certificate Holder or his or her representative in the activities or property of the commercial or industrial enterprise which results in a material added risk, a materially increased risk or a materially changed risk, unless the added, increased, or changed risk is included in the Certificate of Insurance. If we cancel subjects to Paragraphs c.(1) through c.(8) above, we shall mail by certified mail to the first Named Certificate Holder at the address shown in the Certificate of Insurance, and mail to the producer of record, if any. Written notice of cancellation shall take effect: (t) 10 days from the date of mailing for the reasons set forth in Paragraph c.(1) and c.(2); and (it) 30 days from the date of mailing for the reasons set forth in Paragraph c.(3) through c.(8). d. If the Certificate of Insurance is canceled by us, the earned premium shall be computed pro-rata. Premium adjustment may be made at the time cancellation is effected or as soon as practicable thereafter. Failure to pay any premium adjustment at, on, or around the time of the effective date of cancellation shall not alter the effectiveness of cancellation. 3. Nonrenewal of the Master Policy a. If we elect not to renew this Master Policy, we will mail or deliver written notice stating the reason for nonrenewal to the Members of the Fitness and Wellness Group at the mailing address shown in the Master Policy Declarations, and to the producer of record, at least 60 days, but not more than 120 days, before the expiration date. If we fail to provide timely written notice required by the paragraph above, the coverage provided to the Members of the Fitness and Wellness Group shall remain in effect with no change in its terms and conditions, for a period of 60 days. b. We are not required to send notice of nonrenewal in the following situations: (1)If the transfer or renewal of a Master Policy, without any changes in terms, conditions or rates, is between us and a member of our insurance group. (2)If the Master Policy has been extended for 90 days or less, provided that notice has been given in accordance with Paragraph 3.a. aboved Q� ° Page 2of4 P� PI-APG-CA-1 (01/07) (3)If the Members of the Fitness and Wellness Group have obtained replacement coverage, or have agreed, in writing, within 60 days of the termination of the Master Policy, to obtain that coverage. (4) If the Master Policy is for a period of no more than 60 days and you are notified at the time of issuance that it will not be renewed. (5)If the Members of the Fitness and Wellness Group request a change in the terms or conditions or risks covered by the Master Policy within 60 days of the end of the policy period. (6)lf we have made a written offer to the Members of the Fitness and Wellness Group in accordance with the timeframes shown in Paragraph 3,a above, to renew the policy under changed terms or conditions or at an increased premium rate, when the increase exceeds 25% C. The transfer of a Master Policy between companies with the same insurance group or changes in Deductible, premium, Limit of Insurance or coverage are not refusal to renew. 4. Nonrenewat of the Certificate of Insurance a. If we elect not to renew this Certificate of Insurance, we will mail or deliver written notice stating the reason for nonrenewal to the first Named Certificate Holder at the mailing address shown in the Certificate of Insurance and to the producer of record, if any, at least 60 days, but not more than 120 days, before the expiration date. If we fail to provide timely written notice required by the paragraph above, the coverage provided to the first Named Certificate Holder shall remain in effect with no change in its terms and conditions, for a period of 60 days. b. We are not required to send notice of nonrenewal in the following situations: (1) If the transfer or renewal of a Certificate of Insurance, without any changes in terms, conditions or rates, is between us and a member of our insurance group- (2) If the Certificate of Insurance has been extended for 90 days or less, provided that notice has been given in accordance with Paragraph 4.a. above. (3) If you have obtained replacement coverage, or have agreed, in writing, within 60 days of the termination of the Certificate of Insurance, to obtain that coverage. (4) If the Certificate of Insurance is for a period of no more than 60 days and you are notified at the time of issuance that it will not be renewed. (6) If you request a change in the terms or conditions or risks covered by the Certificate of Insurance within 60 days of the end of the policy period. Page 3 of 4 pR�v PI-APG-CA-1 (01/07) (6) If we have made a written offer to you, in accordance with the timeframes shown in Paragraph 4.a. above, to renew the Certificate of Insurance under changed terms or conditions or at an increased premium rate, when the increase exceeds 25%. c. The transfer of a Certificate of Insurance between companies with the same insurance group or changes in Deductible, premium, Limit of Insurance or coverage are not refusal to renew. 5. Conditional Renewal If we elect to renew this Master Policy or Certificate of insurance, and the renewal is subject to any of the following: a. Increase in Deductible; b. Reduction in Limit of Insurance; c. Elimination of coverages; or d. 25% or more rate increase. We shall mail or deliver written notice of the change(s) to the Members of the Fitness and Wellness Group at the mailing address shown in the Master Policy Declarations or the first Named Certificate Holder at the mailing address shown in the Certificate of Insurance and to the producer of record, if any, at least 60 days, but not more than 120 days, before the expiration date, 6. Mailing time must be added to the notice periods as follows: a. Add 5 days if the place of address and place of mailing is in California; b. Add 10 days if the place of address or place of mailing is outside of California; or C. Add 20 days if the place of address or place of mailing is outside the United States. Page 4 of 4 PI-APG-004 (01t07) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL CONDITIONS This endorsement modifies insurance provided under the: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following is added to Section IV — Commercial General Liability Conditions: 1. Changes The Certificate of Insurance contains all the agreements between you and us concerning the insurance afforded. The first Named Certificate Holder shown in the Certificate of Insurance is authorized to make changes in the terms of the Certificate of Insurance with our consent. The Certificate of Insurance terms can be amended or waived only by endorsement issued by us and made a part of the Certificate of Insurance. 2, Transfer of Your Rights and Duties Under The Certificate of Insurance: Your rights and duties under the Certificate of Insurance may not be transferred without our written consent except in the case of death of an individual Named Certificate Holder. If you die, your rights and duties will be transferred to your legal representative but only while acting within the scope of duties as your legal representative. Until your legal representative is appointed, anyone having proper temporary custody of your property will have your rights and duties but only with respect to that property. �A V4 'p �\\4N � Page 1 of 1 POLICY NO: PHPK1473665-000 POLICY CHANGE DOCUMENT CHANGE # 5 CHANGE EFFECTIVE: 04/11/2016 Philadelphia Indemnity Insurance Company I PRODUCER: Maguire Insurance Agency, Inc. NAMED INSURED: Connie McGuire MAILING ADDRESS 539 E Washington Ave Orange, CA 92866- POLICY PERIOD: FROM 03/31/2016 TO 03/31/2017 at 12:01 A.M. Standard Time at your mailing address shown above. DESCRIPTION: In consideration of the premium reflected, the policy is amended as indicated below: Amending additional insured: Addition to read City of Santa Ana tis officer, employees, agents, representatives & volunteers. Plus 30 NOC Total Annual Total Prorate Additional/Return Premium $0.00 Additional/Return Premium $0.00 Total Annual Total Prorate Additional/Return Additional/Return Tax/Surcharge/Fee $0.00 Tax/Surcharge/Fee $0.00 Page 1 of 1 POLICY NO: PHPK1473665-000 POLICY CHANGE DOCUMENT CHANGE # 5 CHANGE EFFECTIVE: 04/11/2016 Philadelphia Indemnity Insurance Company ! PRODUCER: Maguire Insurance Agency, Inc. NAMED INSURED: Connie McGuire MAILING ADDRESS 539 E Washington Ave Orange, CA 92366- POLICY PERIOD: FROM 03/31/2016 TO 03/3112.017 at 12:01 A.M. Standard Time at your mailing address shown above. DESCRIPTION: In consideration of the premium reflected, the policy is amended as indicated below: Amending additional insured: Addition to read City of Santa Ana tis officer, employees, agents, representatives & volunteers. Plus 30 NOC Total Annual Total Prorate Additional/Return Premium $0.00 Additional/Return Premium $0.00 Total Annual Total Prorate Additional/Return Additional/Return Tax/Surcharge/Fee $0.00 Tax/Surcharge/Fee $0.00 VIP" P\Ne d i 'C � Page 1 of 1 WORKERS' COMPENSATION DECLARATION hereby affirm under penalty of perjury, the (N'7TiW) following declaration I certify on behalf oi'.-._-y(jjy(��((_ that during the term of my (C. m,1114`omp;= mic) contract for — _VV_ services with the City of Santa Ana, I will not employ any perloti in any nn�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' compy a coverage. DATE: By: --- — Name' - 'rifle: Telephone: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES LiP TO ONE I IIINDRED TI-IOUSAND 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. ed i.qo ll �l r u�Na �,