HomeMy WebLinkAboutHOLISTIC YOGA AND HEALTH (LLC DBA BODY AND BRAIN) 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 2glq �IIS2 1), ^ b
amendments (if any) are no longer in effect.
Note: If your agreement is grant related, please ensure that all grant retention requirements CITY OF SA N I A ANA
have been satisfied prior to signing the termination form. CLERK OF COUNCIL
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
No. N-2016-075-001 was completed on
(List all amendments. Use space below if needed.)
Revised: 10-18-16
and final payment has been made.
Department: 2RCSA
Phone/Ext.: ya,\q
Signature: AA,4j�
Date: I�RoLc\
N-2016-075-001
MAYOR INSURANCE ON FILE
Miguel A. Putido WO �i{ MAY PROCEED
MAYOR PRO Tem IL INSURANCE EXPIRES
Vicente Sarmlent`.
0
COUNCILMEMBERS
Angelica Amezcua
1J1
CLERK OF COUNCIL.
P. David Benavides
DATE: 2 I) 2016-.:errar.
Michele Martlnaez
Roman Rayne
O' PRCS (/
Sal Tinalero
Silvia Cuevas CITY OF SANTA ANA
PARKS, RECREATION, AND
COMMUNITY SERVICES AGENCY
20 Civic Center Plaza M-23 . P.O. Box 1988 M-23
Santa Ana, California 92702
www.santa-ana.ora
November 23, 2016
Holistic Yoga and Health LLC dba Body & Brain
Attn.! Soohee Son
5753 E. Santa Ana Canyon Road
Anaheim, California 92807
Re: Extension of Recreation. Services Agreement
Agreement No. N-2016-075
Dear Ms, Son;
CITY MANAGER
David Cavazos
CITY ATTORNEY
Sonia R, Cantalho
CLERK OF THE COUNCIL
Maria D. Huizar
Pursuant to Section 3 of the above -referenced agreement between Holistic Yoga and Health LLC
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.
pSincerely, h�
Gerardo Monet, Executive Director
Parks, Recreation, and Community Services Agency
CUY—QJZSANTA
bavid Aviris'�
City Manager
APPROVED AS TO FORM ATTEST ,
'w. f
J n M. Funk / Maria D. Huizar
Assistant City Attorney I) ClerkofCouncil
SANTA ANA GTY COUNOL
&Yguel A. Wlido Vinc'enie. SannleCn I Mitlrek MaM1inez AMiCa Ametala i P. DaNtl BeneNdea Roman Rayna 5ffi tnajafo
Mayor Mayor?m Tem, Wenii W9N2 I WeN3 1 Ward4 Wards wordb
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Exhibit A
SCOPE OF SERVICES— Holistic Yoga and Health LLC, DBA Body and Brain
A. Provider will teach Body and Brain Yoga/Tai Chi & Belly Button Healing class, ages 15-
90yrs, class will be 1 per session, per 1 hour, $30 per person (Tues)
B. Provider will teach Body and Brain Mediation & Belly Button Healing class, ages 15- 90yrs,
class will be 1 per session, per 1 hour, $30 per person (Thurs)
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 15 paid students and no more than a maximum of 100.
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 under no obligation to provide services and the City will have
no obligations to pay Provider Compensation
CLASS FEES
A. Each participant shall pay a $30.00 per class, per session.
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.
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,.rIREMEV IrGla J;H ..,ONIL T.CN .�' , E ,,GN'FaL GR 3fHER M00_,I NI ,ITti RESPrOT TV N ;I i iE CERTIFICATE MAY SE S5UF5 CR
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IOCCY EFFECTIVE ROurY EXPIRATION LIMITS
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GENERAL LIABILITY 6011408514
04121710 04I21;17
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PROCOC rS"CIJMP CP AGO 3
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1,00,000
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SPECIAL PROVISIONS bc,—
i. OL!HASE,ROLIGYLIMIT 9
1i01)0,000
OTHER:
DESCRIPTION OF OPERATIONSI'LOCATIONSIYEH IC LE&EXCLUS IONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
Certificate holder, its officers, agents, and employees are named as Additional Insured in regards to General Liability per attached
SS•14M2•E i All terms and conditions are based Upon the actual
policy
r*
CERTIFICATE, HOLDER
CANCELLATION
.R^6 L > .' N -hE A,9—)LI",, A
°.'HE
City of Santa Ana
AIM: PRCSA
'=I �_.. •'a` -'-
20 Civic Center Plaza, Santa Ana, CA 92701
Attention;
JDy Loe
ACO2D CORPORATION 1983
SS-300022-B
(Ed,07/09)
Name of Person Or Uri
CITY OF SANTA ANA
Information required to complete
SCHEDULE
on this endorsement, will he shown in the Declarations.
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COMMON POLICY CONDITIONS
We waive any right of recovery we may have against:
1, Any person or organization shown in the Declarations: or
2. Any person or organization with which you have a contract that requires such a waiver.6 �Jl
SB-300022•B Includes copyrighted material of Insurance Services Office, Inc., wflh its permission. Page 1 of 1
(Ed. 07109) Copyright, Insurance Services Office, Inc., 2002
CNA80103XX
(09-14)
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COMMON POLICY CONDITIONS
The following is added to Paragraph H. Other Insurance and supersedes any provision to the contrary:
Primary And Noncontributory Insurance
This insurance is primary to and will not seek contribution from any other insurance available to an additional insured
under your policy provided that:
1, The additional insured is a Named Insured under such other insurance; and
2. You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek
contribution from any other insurance available to the additional insured.
All other terms and conditions of the Policy remain unchanged.
CNAB0103XX (09-14) v
Page 1 of 1
copyright, CNA All Rights Reserved. Includes copyrighted materiel of Insurance Services Office, Inc., with its permission
SB-146932-E
(Ed, 06111)
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS LIABILITY COVERAGE FORM
Coverage afforded under this extension of coverage endorsement does not apply to any person or organization covered
as an additional insured on any other endorsement now or hereafter attached to this Policy.
WHO IS AN INSURED is amended to include as an
additional insured any person or organization (referred
to below as vendor) with whom you agreed, because
of a written contract or agreement to provide
insurance, but only with respect to "bodily injury" or
"property damage" arising out of "your products" which
are distributed or sold in the regular course of the
vendor's business, subject to the following additional
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 damages 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, demonstration,
testing, or the substitution of parts under
instructions from the manufacturer, and then
repackaged in the original container;
e. Any failure to make such inspections,
adjustments, tests or servicing as the vendor
has agreed to make or normally undertakes to
make in the usual course of business,r
connection with the distribution or sale of the
products; f
own acts or omission or those of Its
employees or anyone else acting on its
behalf. However, this exclusion does not
apply to:
(1) The exceptions contained in
Subparagraphs d, or f.; or
(2) Such inspections, adjustments, tests or
servicing as the vendor has agreed to
make or normally undertakes to make in
the usual course of business, in
connection with the distribution or sale of
the products.
2. This insurance does not apply to any insured
person or organization, from whom you have
acquired such products, or any ingredient, part or
container, entering into, accompanying or
containing such products.
3. This provision 2. does not apply to any vendor
included as an insured by an endorsement issued
by us and made a part of this Policy.
4. This provision 2. does not apply if "bodily injury" or
"property damage" included within the "products -
completed operations hazard" is excluded either
by the provisions of the Policy or by endorsement.
2. MISCELLANEOUS ADDITIONAL INSUREDS
WHO IS AN INSURED is amended to include as an
Insured any person or organization (called additional
insured) described in paragraphs 2.a. through 2.h.
below wham you are required to add as an additional
i if`� on this policy under a written contract or
O� if"
but the written contract or agreement must
in effect oabecoming effective during the
f. Demonstration, installation, servicing or repo or m!ttcy; ano
operations, except such operations performed�2,-- imprior to the "bodily injury," "property
at the vendor's premixes in connection w t a
$\oersonaf and advertising injury;' but
the sale of the product;
Rt P, �ptollowing persons or organizations are
g. Products which, after distribution or sale PpyIRG�fZitlonal insureds under this endorsement and
you, have been labeled or relabeled or us d coverage provided to such additional Insureds is
as a container, part or ingredient of any other limited as provided herein:
thing or substance by or for the vendor; or
injury" a. Additional insured Your Work
h, "Bodily jry" or "property damage" arising
out of the sole negligence of the vendor for its That person or organization for whom you do
work is an additional insured solely for liability
SB-146932-E Page 1 of 5
(Ed, 06/11)
SB-146932-E
(Ed.06/11)
g
due to your negligence specifically resulting
from your work for the additional insured
which is the subject of the written contract or
written agreement. No coverage applies to
liability resulting from the sole negligence of
the additional insured.
The insurance provided to the additional
insured is limited as follows:
(1) The Limits of Insurance applicable to the
additional insured are those specified in
the written contract or written agreement
or in the Declarations of this policy,
whichever is less. These Limits of
Insurance are inclusive of, and not in
addition to, the Limits of Insurance shown
in the Declarations.
(2) The coverage provided to the additional
insured by this endorsement and
paragraph F.9. of the definition of "insured
contract' under Liability and Medical
Expenses Definitions do not apply to
"bodily injury" or "property damage"
arising out of the "products -completed
operations hazard" unless required by the
written contract or written agreement.
(3) The insurance provided to the additional
insured does not apply to "bodily injury,"
"property damage," or "personal and
advertising injury" arising out of the
rendering or failure to render any
professional services.
b. State or Political Subdivisions
A state or political subdivision subject to the
following provisions:
(1) This insurance applies only with respect
to the following hazards for which the
state or political subdivision has issued a
permit in connection with premises you
own, rent, or control and to which this
insurance applies:
(a) The existence, maintenance, repair,
construction, erection, or removal of
advertising signs, awnings, canopies,
cellar entrances, coal holes,
This insurance does not apply to "bodily
injury," "property damage" or "personal and
advertising injury" arising out of operations
performed for the state or municipality.
c. Controlling Interest
Any persons or organizations with a
controlling interest in you but only with respect
to their liability arising out of:
(1) Their financial control of you; or
(2) Premises they own, maintain or control
while you lease or occupy these
premises.
This insurance does not apply to structural
alterations, new construction and demolition
operations performed by or for such additional
insured.
d. Managers or Lessors of Premises
A manager or lessor of premises but only with
respect to liability arising out of the ownership,
maintenance or use of that specific part of the
premises leased to you and subject to the
following additional exclusions:
This insurance does not apply to:
(1) Any occurrence" which takes place after
you cease to be a tenant in that premises;
or
(2) Structural alterations, new construction or
demolition operations performed by or on
behalf of such additional insured.
e. Mortgagee, Assignee or Receiver
A mortgagee, assignee or receiver but only
with respect to their liability as mortgagee,
assignee, or receiver and arising out of the
ownership, maintenance, or use of a premises
by you.
This insurance does not apply to structural
alterations, new construction or demolition
operations performed by or for such additional
insured.
Owners/Other Interests — Land is Leased
driveways, manholes, marquees, An owner or other interest from whom land
hoistaway openings, sidewalk va�(�� y has been leased by you but only with respect
street banners, or decorations % to liability arising out of the ownership,
similar exposures; or maintenance or use of that specific part of the
(b) 'The construction, erectio r la leased to you and subject to the following
removal of elevators; or a nal exclusions:
(2) This insurance applies only .with.r , p — .once does not apply to:
to operations performed by you or o 9C81 men Acosta (1) Any 'occurrence" which takes place
behalf for which the state or I A/Recreation after you cease to lease that land; or
subdivision has issued a permit. Ei ."
SB-146932-E
(Ed. 06/11)
Page 2 of 5
SB-146932-E
(Ed. 06/11)
(2) Structural alterations, new
Damage To Property, is replaced by the
construction or demolition operations
following:
performed by or on behalf of such
k. Damage To Property
additional insured.
g. Co-owner of Insured Premises
"Property damage" to:
A co-owner of a premises cc -owned by you
1. Property you own, rent or occupy,
and covered under this insurance but only
including any costs or expenses
with respect to the co -owners liability as co-
incurred by you, or any other person,
owner of such premises,
organization or entity, for repair,
replacement, enhancement,
h. Lessor of Equipment
restoration or maintenance of such
Any person or organization from whom you
property for any reason, including
prevention injury a person or
lease equipment. Such person or organization
damage to another's property:
are insureds only with respect to their liability
arising out of the maintenance, operation or
2. Premises you sell, give away or
use by you of equipment leased to you by
abandon, if the "property damage"
such person or organization. A person's or
arises out of any part of those
organization's status as an insured under this
premises;
endorsement ends when their written contract
3. Property loaned to you;
or agreement with you for such leased
equipment ends.
4. Personal property in the care,
With respect to the insurance afforded these
custody or control of the insured;
additional insureds, the following additional
5. That particular part of any real
exclusions apply:
property on which you or any
This insurance does not apply:
contractors or subcontractors working
directly or indirectly in your behalf are
(1) To any "occurrence" which takes place
performing operations, if the "property
after the equipment lease expires; or
damage" arises out of those
(2) To "bodily injury," "property damage" or
operations; or
"personal and advertising injury" arising
6. That particular part of any property
out of the sole negligence of such
that must be restored, repaired or
additional insured.
replaced because "your work" was
Any insurance provided to an additional insured
incorrectly performed on it.
designated under paragraphs b.through Jr. above
Paragraph 2 of this exclusion does not
does not apply to "bodily injury" or "property
apply if the premises are "your work" and
damage" included within the "products -completed
were never occupied, rented or held for
operations hazard."
rental by you.
3. The following is added to Paragraph H. of the
Paragraphs 1, 3, and 4, of this exclusion
BUSINESSOWNERS COMMON POLICY
do not apply to "property damage" (other
CONDITIONS:
than damage by fire or explosion) to
N. Otherinsurance
premises:
(1) rented to you:
4. This insurance is excess over any other
insurance naming the additional insured
jVi2V1+Gj ) temporarily occupied by you with the
'
as an insured whether primary, excess,
permission of the owner, or
contingent or on any other basis unless a
(3) ctnts of premises rented to
61fi,roir.'
written contract or written agreem t periodof 7 or fewer
specifically requires that this insurance e cutive days.
either primary or primary
noncontributing. _------�-----�
��e�perate limit of insurance applies to
carmen ,Q,D C$�ak�age To Premises Rented To You as
4. LEGAL LIABILITY — DAMAGE TO PREMISES(
in Section D — Liability and
A. Under B. Exclusions, 1. Applicable to
OI tjd
s= RC e ical Expenses Limits of Insurance.
Business Liability Coverage, Exclusion k.
SB-146932.-E
(Ed.06/11)
Page 3 of 5
SB-146932-E
(Ed. 06/11)
Paragraphs 3, 4, 5, and 6 of this
exclusion do not apply to liability
assumed under a sidetrack agreement.
Paragraph 6 of this exclusion does not
apply to "property damage" included in
the "products -completed operations
hazard."
B. Under B. Exclusions, 1, Applicable to
Business Liability Coverage, the last
paragraph of 2. Exclusions is deleted and
replaced by the following:
Exclusions c, d, e, f, g, h, i, k, 1, m, n, and o,
do not apply to damage by fire to premises
while rented to you or temporarily occupied by
you with permission of the owner or to the
contents of premises rented to you for a
period of 7 or fewer consecutive days. A
separate limit of insurance applies to this
coverage as described in Section D. Liability
And Medical Expenses Limits Of
Insurance,
C. The first Paragraph under item 5, Damage To
Premises Rented To You Limit of Section
D. Liability And Medical Expenses Limits
Of Insurance is replaced by the following:
The most we will pay under Business Liability
for damages because of "property damage"
to any one premises, while rented to you, or
temporarily occupied by you, with the
permission of the owner, including contents of
such premises rented to you for a period of 7
or fewer consecutive days, is the Damage to
Premises Rented to You limit shown in the
Declaration.
(2) Any partner, if you or an additional
insured is a partnership;
(3) Any manager, if you or an additional
insured is a limited liability company;
(4) Any "executive officer" or insurance
manager, if you or an additional insured is
a corporation;
(5) Any trustee, if you or an additional
insured is a trust; or
(6) Any elected or appointed official, if you or
an additional insured is a political
subdivision or public entity.
This paragraph e. applies separately to you
and any additional insured.
c.,
Section F. Liability and Medical Expenses
Definitions, item 3. "Bodily Injury" is deleted and
replaced with the following:
"Bodily injury" means bodily injury, sickness or
disease sustained by a person, including death,
humiliation, shock, mental anguish or mental
injury by that person at any time which results as
a consequence of the bodily injury, sickness or
disease.
6. Expanded Personal and Advertising Injury
Definition
a. The following is added to Section F. Liability
and Medical Expenses Definitions, Item 14,
Personal and Advertising Injury, in the
Businessowners General Liability
Coverage Form:
5. Blanket Waiver of Subrogation h� Discrimination or humiliation that results in
injury to the feelings or reputation of a natural
We waive any right of recovery we may have person, but only if such discrimination or
against: humiliation is:
a. Any person or organization with whom you 1. Not done intentionally by or at the
have a written contract that requires such a direction of:
waiver.
6. Broad Knowledge of Occurrence a. The insured; or
-- The followingitems are added to E. b. Any "executive officer," director,
stockholder, partner, member or
Businessowners General Liability Conditi4kPVIeWed by manager (if you are a limited liability
in the Businessowners Liability Coverage company) of the insured; and
Form:
No r ctly or indirectly related to the
e. Paragraphs a. and b. apply to you or to y m ent, prospective employment,
® additional insured only when � s aployment or termination of
"occurrence," offense, claim or-awit"-is phoyment of any person or person by
to: CarmenAcosta any insured.
(1) You or any additional insured thptii ai ,A/Re p at-�0 following is added to Exclusions, Section
individual; B.:
SB-146932-E
(Ed. 06/11)
Page 4 of 5
SB-146932•E
(Ed.06/11)
(15)Discrimination Relating to Room,
Dwelling or Premises
Caused by discrimination directly or
indirectly related to the sale, rental, lease
or sub -lease or prospective sale, rental,
lease or sub -lease of any room, dwelling
or premises by or at the direction of any
insured.
(16) Fines or Penalties
Fines or penalties levied or imposed by a
governmental entity because of
discrimination,
c. This provision (Expanded Personal and
Advertising Injury) does not apply if
Personal and Advertising Injury Liability is
excluded either by the provisions of the Policy
or by endorsement.
9. Personal and Advertising Injury Redefined
Section F, Liability and Medical Expenses
Definitions, Item 14, Personal Advertising Injury,
Paragraph c. is replaced by the following:
c. The wrongful eviction from, wrongful entry
into, or Invasion of the right of private
occupancy of a room dwelling or premises
that a person or organization occupies
committed by or on behalf of it's owner,
landlord or lessor.
Reviewed by
Carmen Acosta
SB-146932-E Page 5 of 5
(Ed. 06/11)
CNA Connect
Endorsement Declaration
POLICY NUMBER COVERAGE PROVIDED BY
B 6011408514 VALLEY FORGE INSURANCE COMPANY
333 S. WABASH
CHICAGO, IL. 60604
INSURED NAME AND ADDRESS
HOLISTIC YOGA & HEALTH LLC
10015 GARDEN GROVE. BLVD
GARDEN GROVE, CA 92844
AGENCY NUMBER AGENCY NAME AND ADDRESS
055542 EG INSURANCE AGENCY INC
616 S EUCLID ST
ANAHEIM, CA 92802
Phone Number: (714)533-7089
BRANCH NUMBER BRANCH NAME AND ADDRESS
240 LOS ANGELES
WEDBUSH CENTER
1.000 WILSHIRE BLVD 18 FL #1800
LOS ANGELES, CA 90017
Phone Number: (87'7)400-0750
p. reecho?& CNA
�1
FROM - POLICY PERIOD - TO
04/21/201.6 04/21./2017
This policy becomes effective andexpires at 12:01 A.M. standard time at your mailing
address on the dates shown above.
This endorsement changes your policy. Please read te�ftSYly.
This Endorsement Results In No Change In Premiu eV�i
The Named Insured is a Limited Partnership.
Audit Period is Not Auditable
1
A, ; I W4 SM
Gar � R r'�eat�o�
py-G
INSURED Page 1 of 3
POLICY NUMBER INSURED NAME AND ADDRESS
3 60111,408514 HOLISTIC YOGA & ifEA."TH I.i,C
10015 GARDEN GROVE BI.Vr
GARDEN GROVE, CA 92844
ADDITIONAL INTEREST SCHEDULE
LOCATION I BUILDING
The following has been added to your policy effective 04/21/2016
Type: Designated Person or Organization
Additional Interest Name and Address:
CITY OF SNATA ANA, ITS OFFICERS, EMPLOYEES, AGENTS
20 CIVIC CENTER PLAZA M-23
SANTA ANA CA 92701
LOCATION 2 BUILDING
The following has been added to your poi -icy effective 04/21/2016
Type: Designated Person or Organization
Additional Interest Name and Address:
CITY OF SNATA ANA, ITS OFFICERS, EMPLOYEES, AGENTS
20 CIVIC CENTER PLAZA - M-23
SANTA ANA , CA 92701
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Acosta
caf ?CSNRe
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INSURED Page 2 of 3
POLICY NUMBER INSURED NAME AND ADDRESS
B 6011108314 HOLISTIC YOGA & HEALTH LW
10015 GARDEN GROVE BLVD
GARDEN GROVE, CA 92844
FORMS AND ENDORSEMENTS SCHEDULE
The following list shows the Forms, Schedules and Endorsements by Line of Business that are
a part of this policy.
Sri V I =30 k
The following forms have been added to your policy, effective 04/21/2016
FORM NUMBER FORM TITLE
G56015B 11/1991 ENDORSEMENT EFFECTIVE 04/21/2016
COMMERCIAL GENERAL LIABILITY
The following forms have been added to your policy, effective 04/21/2016
FORM NUMBER FORM TITLE
SB300113C 06/2011 Additional Insured - Designated Person
Countersignature
V Secretary
Chairman of we ward
SB-14095-A 0& 01/06) WSURED Page 3 of 31
POLICY NUMER INSURED NAME AND ADDRESS
B 6011406514 HOLISTIC YOGA & HEALTH LLC
1.00115 GARDEN GROVE BLVD
GARDEN GROVE, CA 92844
POLICY CHANGES
ENDORSEMENT EFFECTIVE 04/21/2016
This Change Endorsement changes the Policy. Please read it carefully.
This Change Endorsement is a part of your Policy and takes effect on the
effective date of your Policy, unless another effective date is shown.
The following Additional. Insured(g) has (have) been added:
Form 1: SB300113C Title: ADDITIONAL INSURED -
DESIGNATED PERSON
Name and Address: CITY OF SNATA ANA, ITS OFFICERS, EMPLOYEES, AGENTS,
REPRESENTATIVES & VOLUNTEERS
Revewed by
Chairman of the Board
V�4J4—
Seaeta,y
cl-56015-B (ED. 1191)
SB-300113-C
CIVA (Ed. 06/11)
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS LIABILITY COVERAGE FORM
E
on:
red to complete this Schedule, if not shown on this endorsement, will be
The following is added to Paragraph C. Who Is An Insured:
4. Any person or organization shown in the Schedule is also an insured, but only with respect to "bodily injury," or
"property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the
acts or omissions of those acting on your behalf in the performance of your ongoing operations or in connection with
your premises owned by or rented to you.
vi�i' t
f a�,On
SB-300113-C Includes copyrighted material of Insurance services Office, Inc., with its permission. Page 1 of 1
(Ed. 06/11) Copyright, Insurance Services Office. Inc. 2002
ACORD W. DATE (MMIODiYYYY)
CERTIFICATE OF LIABILITY INSURANCE 1 0511912017
PRODUCER Phone. 714-533-7089 Fax: 716-533-8873
THIS CERTIFICATE IS 6SSUED AS A MATTER OF INFORMATION
EG INSURANCE AGENCY, INC.
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
616 S. EUCLID ST.
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ANAHEIM CA 92802
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIL #
Agency LIe#� ceaslxJa
INSURED
INSURER A: NAUTILUS
INSURER B:
HOLISTIC YOGA & HEALTH LLC
10015 GARDEN GROVE BLVD.
INSURER C:
GARDEN GROVE CA 92844
INSURER D:
+
I1 r ,a1.wY (.L�I
INSURER H'
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTSNITH:STANUIN5
MANY 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_
INSR
LTR
Acr
INSR'
TYPE Or (INSURANCE
POLICY NUMBER
PPECTIVC
DATE POLICY EMMroDrvr
POLICY EXPIRA'GION
DATE UULU2 YY
LIMITS
GENERAL
LIABILITY
NN773339
05103117
05103118
EACH OCCURRENCE
$ 1,000„000
DAMAGE TO RENYED
PREMISES Eaoccurenrxl
S 30,000
CGMM.,LAIMS rn GENERAL
CLAIMS MADE I A r OCCUR
MED. EXP (Any one person)
$ 5,000
A
PERSONAL 8. ADV INJURY
$ 1,0'00,000
GENERAL AGGREGATE
$ 2„000,000
GENT
AGGREGATE LIMIT APPLIES PER:
PRODUCTS-COMPIOPAGG.
$ Included
POLICY' PRO- LOC
):
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY
ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person)
$
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY
(Per accident)Ll
$
PR:OPERTYDAMAGE
(Per acoldent)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY: AGG
$
ANY AUTO
°
$
EXCESS I UMBRELLA (LIABILITY
OCCUR CLAIMS MADE
LjDEDUCTIBLE
RETENTION $
�
. 1w+„
_'*�
L4.� 1
Lr" ..,�" � ,q,
i� "P. pt'S'
'
EACH OCCURRENCE
$.
AGGREGATE
$
$
WORKERS COMPENSATION AND
WC STATU-
TORY LIMITS OTHER
EMPLOYERS' LIABILITY
EL EACH ACCIDENT
$
ANYPROPRIETORIPARTNERIEXECUTIVE
E.L.. DISEASE -EA EMPLOYEE
$
OFFICER/MEMBER EXCLUDED?
It yes, describe under
SPECIAL PROVIISIONS below
E.L. DISEASE -POLICY LIMIT
$
OTHER:
DESCRIPTION OF OPERATION SILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
Certificate holder, its officers, agents, and employees are named as Additional Insured in regards to General Liability per attached CG2026 I
All terms and conditions are based upon the actual policy
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
City of Santa Ana
THE INSURER, IT'S AGENTS OR REPRESENTATIVES.
Attn : PRCSA
AUTHORIZED REPRESENTATIVE.
20 Civic Center Plaza, Santa Ana, CA 92701rc
Attentions
i.ay Lee
ACORD 25 (200,1108) Certificate # 10529 @ ACORD CORPORATION 1988
POLICY NUMBER: NN773339
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
City of Santa Ana, it's officers, agents and representatives
Address:
20 Civic Center Plaza
Santa Ana, CA 92701
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Section 11 - Who Is An Insured is amended to include
as an additional insured the person(s) or
organization(s) shown in, the Schedule, but only with
respect to liability for "bodily injury", "property damage"'
or "personal and advertising injury" caused, in whole or
in part, by your acts or omissions or the acts or
omissions of those acting on your behalf:
A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or
rented to you,.
CG 20 26 07 04 Copyright ISO Properties, Inc., 2004 Page 1 of 1
POLICY NUMBER: NN773339
COMMERCIAL GENERAL LIABILITY
4:fAl 0 JJJJ[4fAJ:J:$JfJJJWJ
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US - AUTOMATIC STATUS WHEN
REQUIRED IN CONTRACT OR AGREEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The following is added to 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV -
Commercial General Liability Conditions',
We waive any right of recovery we may have against any person or organization because of payments we make
for injury or damage caused, in whole or in part, by your acts or omissions, or the acts or omissions of those
acting on your behalf in the performance of your ongoing operations or "your work" done under a written contract
with that person or organization and included in the '"products -completed operations hazard". This waiver applies
only when you and that person or organization have agreed to such waiver in writing in a contract or agreement.
All other terms and conditions of this policy remain unchanged,
L609 (05109) IncWdes copyrighted material of Insurance Services Offire, Inc., with its permission,.
POL|CYNUK8BER:� NN77333,9
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - PRIMARY AND NONCONTRIBUTORY ~
AUTOMATIC US WHEN REQUIRED IN CONTRACT OR AGREEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. GeotonO-VVho|wAnUnsmned isamended toinclude aeemadditional insured any person mrorgmmizmton
when ynuandsuch person nrorganization have agreed inwriting inacontract oragreement that such person
mrorganization be added asonadditional insured onyour policy.
" Such person or organization is on additional insured only with respect to liability for "bodily injury", "property
damage" or "personal and advertising injur/' oauaod, in whole or in part, by:
1. Your acts oromissions; or
2. The acts mromissions cfthose acting onyour behalf;
in the performance of your ongoing operations for the additional inswred, but only for 'hccum*noom' or
coverages not otherwise excluded in the Coverage Part to which this endorsement applies.
However, the insurance afforded tosuch additional insured:
1. Only applies tmthe extent permitted bylaw; and
2. Will not be broader than that which you are required by the contract or agreement to provide for such
additional insured.
E. Status asamadditional insured for the person onorganization howhiohthioandonsementapplies:
1. Commences during the policy period and after such written contract oragreement has been executed;
and
2. Ends when: `
m. Your ongoing operations for that additional insured are completed;
b- The contractor's contract oragreement ieterminated; or X�,�
c. Yomrpo|icyoanuelsor expirem;
whichever occurs first. ^~
C. With respect to the insurance afforded to the additional insured, the following apply:
This insurance does not apply to:
1. "Bodily injmry"."property damage"."personal and advertising injury" or medical payments arising out ofthe
rendering of, or the failure to render, any professional arohbectunal, engineering or surveying memioom'
o. The pnaparn8, opprovng, or failure to prepare or approve, maps, shop dnawingm, opinionm, reportm,
surveys, field orders, change orders nrdrawingmemdopecifioo6ions-, or
b. Supervisory, inspection, architectural orengineering activities.
This exclusion applies oven if the claims against any insured allege negligence or other wrongdoing in the
supervision, hiring, employment, training ormonitoring mfothers bythat insured, ifthe ^000unenoe^which
caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising
injury", involved the rendering of or the failure to render any professional architectural, en0ineering, or
surveying services.
Le05(01117) Includes copyrighted material from Insurance Services Office, |mz.with its permission. Page of
2. "Bodily injury" nr"property damage" occurring after:
a. AN work, including mateho|a, parts or equipment furnished in connection with such work' on the
project (other than service, maintenance, orrepairs) tobeperformed byorombehalf ofthe additional
inauned(o)edthe location ofthe covered operations has been completed: or
b. That portion of"your work" out of which the injury or damage edoaa has been put to its intended use
by any person or organization other than another contractor or subcontractor engaged in performing
operations for aprincipal us a part ofthe same project.
D. With respect to the insurance afforded to the additional ineured, the following is added to Section U| —L|rn|te
Of Insurance:
The most we will pay on behalf of the additional insured is the amount of insurance:
1. Required bythe contract u/agreement you have entered into with the additional insured; or
2. Available under the applicable Limits of Insurance shown in the Declarations;
whichever ialess.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
E. The following is added to4.a. of Other Insurance of Section IV -Commeroial General Liability
Conditions:
If required in a written contract, the Coverage Part to which this endorsement applies is primary and
noncontributory in the event of an °noournenoe' caused, in whole or in part, by your acts or omissioma, or the
acts or omissions ofthose acting on your behalf that oozuoa while performing ongoing operations for the
additional insured.
All other terms and conditions remain unchanged.
c805(01117) Includes copyrighted material from Insurance Services Office, |nc..with its permission. Page cofo
WORKERS' COM PEN SATION DECLARATION
I 4hereby affirm under penalty of perjury, the
�Nanici'ride)
following declaration
I certify on behalf of that during the term of my
(Consultatiff'onipany Name)
contract for n services with the City of Santa Ana, I will
not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions and provide proof of workers' compensation coverage.
DATE: V/41 SIGN
By:
HERE
Name: ;eA,4,J, e
Title: Recreation Class Instructor
�3
Telephone:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($ 100,000), IN
ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR
IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES,