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HomeMy WebLinkAboutPROFESSIONAL ENTERTAINMENT (2)City of Santa A %i Clerk of the Cour,.,,f 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TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect.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. COTC Office Use Only City of Santa Ana A(j 02 2621 Clerk of the Council The agreement with (� � �(� V l(� 1�E Y\sQV 1 Yt�k- Lf`)As lky,6 l:!, No. 0 aU 11-099c 2 was completed on 1 l and final payment has been made. (List all amendments. Use space below N needed.) (2V-3C,\1—Cs�-0\ Department:-Q1x—�6\al P\- 0V-7-.isa Phone/Ext.: n� �ate � � Signature: `l�'`�-1 C�r�Ctl/� Revised: 10-18-I6 Professional Liability Insurance required if contractor is or employs a licensed professional A-2017-052-01 0 MAYOR INSURANCE NO`f ON FILE Miguel A. P MAYOR PRO EM TEMWORK MAY WT PROCE Michele Martinez CLERK OF GOINi ; 1 COUNCILMEMBERS DUI Est P. David Benavides MATE: DEC 18 2017 Vicente Sarmiento Jose Solorio Sal Tinalero Juan Villeoas S r l vta. C v.vv�� November 27, 2017 U1 I Y Uh NAN I A ANA PARKS, RECREATION AND COMMUNITY SERVICES AGENCY 24 Civic Center Plaza M-23 s P.O. Box 1988 Santa Ana, California 92702 w�,yvaanta-ana.om Professional Entertainment Consultants Attn: Dan Haley 6722 Timaru Circle Cypress, CA 90630 CITY MANAGER Raul Godinez II CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Maria D. Holzer Re: Extension of Contractor Agreement No. A-2017-052 to provide professional entertainment services for various City events Dear Mr. Martinez: Pursuant to Section 3 ("Tenn") of Agreement No. A-2017-052 entered into by Professional Entertainment Consultants and the City of Santa Ana, dated March 21, 2017, the time period for said Agreement is hereby extended for an additional one (1) year period, from January 1, 2018 to December 31, 2018, The insurance certificates are required to be extended and/or renewed to cover this extension. All other terns and conditions of said Agreement remain unchanged and in full force and effect. Sincerely, Gerardo Mouct Executive Director Parks, Recreation and Community Services Agency APPROVED AS TO FORM: Sonia R. Carvalho City Attorney Laura A. Rossini Senor Assistant City Attorney �wY CC11TY70�TA ANA /✓ Raul Godinez II City Manager ATTEST: 6, Iblaria D. uizar Clerk of the C OL1116 SANTA ANA CITY COUNCIL Wiaet A. PWWo M ichete hWr6nez vMcame Samiiento Joss Sdodo P. Davld eenavde8 Juan Vikegas Sai Tlmim May- Mayor Pro Tem,Wad2 Wadi Wetd3 Ward4 Wad8 Wad m2u1idqQaaaga-gra,w mimarlinezAsanla-ana 41 vs mlenlordasnla-ana.ora Isalorio(dsanla-ana.oro dhenavldesRgyanta-ana ora mitmakawlai 91[nalawasanla-era om ACORO® CERTIFICATE OF LIABILITY INSURANCE �►'� DATE,MMIDDIYYVY) 12/7/2017 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(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 such endorsement(s). PRODUCER CONTACT NAME: Brian Roberts Blue Lion Insurance, LLC PHONE 800-665-5154 888-221-9537 AIC, No, Ext : 10224 Airport Way, Ste C g'C SS: Brian©bluelionbrokers.com INSURERS) AFFORDING COVERAGE NAIC p Snohomish WA 98296 INSURERA: Mesa Underwriters Specialty INSURED INSURER B Darrell Wagner dba Professional Entertainment INSURERC: PO BOX 78593 INSURER D : INSURER E : Seattle WA 98178 INSURER F : COVERAGES CERTIFICATE NUMBER: RPWRION NUMRFP- THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTR TYPE OF INSURANCE INSD MD POLICY NUMBER (MMIDDrNYY) (MMIDDIVYVY) LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX] OCCUR EACHOCCURRENCE Is 2,000,000 PREMISES (Ee occurrence) 1 $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 A Y Y MP0002007001476 12/05/2017 12/03/2018 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY F—]JECT �LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGO s 2,000,000 $ OTHER AUTOMOBILE LIABILITY (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY Per accitleni ( ) $ (Per eccidenq $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CIAIMS-MADE OED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below Abuse and Molestation Y Y MP0002007001476 12/05/2017 12/05/2018 Occurence Aggregate 100,000 300,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be primary with respect to insurance or self-insurance programs maintained by the city; and (c) contain standard separation of insureds provisions. 6101 ° 10-dav notice of cancellation for nonnavment.�e��iQ l City of Santa Ana Attn: PRCSA 20 Civic Center Plaza M-23 Santa Ana, CA 92701 SHOULD ANY OF THE ACCORDANCE TE W TATE ABOVE POLI�CYF&E, Eff E VERED INCANCELLED BEFORE Q ITHORIZED REPRESENTATIVE 13ri&- Ralyer'f5 ©1988-2015 ACORD CORPORATION. All rights reserved ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ACi `� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1 12/7/2017 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 endomement(s). PRODUCER Blue Lion Insurance, LLC 10224 Airport Way, Ste C Snohomish WA 98296 NAME: Brian Roberts P ONE gQ0.665-5154 AIC No Ext: (AIC, No): 888-221-9537 ADDRESS: brian@binelionbrokers.com INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Mesa Underwriters Specialty INSURED Darrell Wagner dba Professional Entertainment - - PO BOX 78593 Seattle WA 98179 INSURERS: INSURERC: - -- -- -- -- -- -- INSURER D : INSURER E : INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. TNSF LTR TYPE OF INSURANCE Aunt INED MIVD POLICY NUMBER LIC (MMIDDIYYYY) (POLICY YYYY) LIMITS x COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ 2,000,000 DAMAGE TO REIT — PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one parson) $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 A Y Y MP0002007001476 12/05/2017 12/05/2018 GEN'L x AGGREGATE LIMIT APPLIES PER POLICY ❑ PRO- ❑ JECT LOC GENERAL AGGREGATE 5 2,000,000 PRODUCTS - COMPIOP AGO $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY UUMBINLU 6INULE Lilyl I$ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per.oddent ( ) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY (Per accident) $ S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE S EXCESS LIAB CLAIMS -MADE DED I RETENTIONS $ PORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN NY PROPRIETOR PARTNERIEXECUTIVE ❑ FFICEFUMEMBER EXCLUDED? NIA STATUTE E—FER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory In NH) If yes, adsorbs under EI DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below Abuse and Molestation Y Y MP0002007001476 12/05/2017 12/05/2018 Occurence Aggregate 100,000 300,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Certificate holder, its officers, agents, and employees are named as additional insured in rego General Liability per attached CG2015 11/88. .\L�,�0'� 10-day notice of cancellation for nonpayment. °O�4�. City of Santa Ana Aun: PRCSA 20 Civic Center Plaza M-23 Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE GrLxa RvExzrfs rnRPnPATInd All anhf—nc...... ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MP0002007001476 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - VENDORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization (Vendor): City of Santa Ana, 0s of sm, agents and employees 20 Civic Center Plaza Your Products: 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 II) Is amended to include as an Insured any person or organization (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 vendor's business, subject to the follow- Ing 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 rea- son 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, unless 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, adjust- ments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in con- nection with the distribution or sale of the prod- ucts; f. Demonstration, Installation, servicing or repair operations, except such operations performed at the vendor's premises In connection with the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or Ingredient of any other thing or substance by or for the vendor. 2. This insurance does not apply to any insured per- son or organization, from whom you have acquired such products, or any Ingredient, part or container, entering Into, accompanying or containing such products. Vm F,L\0Ci,\�, CG 20 15 1188 Copyright, Insurance Services Office, Inc., 1986, 1988 Page 1 of 1 13 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PRIMARY AND NONCONTRIBUTORY - AUTOMATIC STATUS WHEN REQUIRED IN CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. A. Section II - Who Is An Insured is amended to include as an additional insured any person or organization when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured 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: 1. In the performance of your ongoing operations for the additional insured; or 2. In connection with premises owned by or rented to you. But only for: 1. The limits of insurance specified in such written contract or agreement, but in no event for limits of insurance in excess of the applicable limits of insurance of this policy; and 2. "Occurrences" or coverages not otherwise excluded in the policy to which this endorsement applies. B. Status as an additional insured for the person or organization to which this endorsement applies: 1. Commences during the policy period and after such written contract or agreement has been executed; and 2. Ends when: a. Your ongoing operations for that additional insured are completed; b. The contractor's contractor agreement is terminated; c. The lease of premises expires; or d. Your policy cancels or expires; whichever occurs first. C. The following is added to 4.a. of Other Insurance of Section IV - Commercial General Liability Conditions: If required in a written contract, your policy is primary and noncontributory in the event of an "occurrence" caused, in whole or in part, by your acts or omissions, or the acts or omissions of those acting on your behalf that occurs while performing ongoing operations for the additional insured, or in connection with premises owned by or rented to you. D. With respect to the insurance afforded to the additional insured, the following exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work on this project, including materials, parts, or equipment furnished in connection with such work (other than service, maintenance, or repairs), to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged \�Irforming operations for a principal as a part of the same project. � AZ m ,.y\ y All other terms and conditions of this policy remain unchanged.Vt� fb L805 (05/09) Includes copyrighted material trom.lnsurance Services Office, Inc., with its permission POLICY NUMBER: MP0002007001476 COMMERCIAL GENERAL LIABILITY CG 24 04A 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: - COMMERCIAL GENERAL LIABILITY COVERAGE PART --- - - - -PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART - - - --- - - --- SCHEDULE Name of Person or Organization: Any person or organization with whom the insured has agreed within a written contract to waive rights of recovery, provided such written agreement is executed prior to the loss. Information required to complete this Schedule, if not shown above, will be shown in the Declarations) The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To US of Section IV - Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or " your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04A 05 09 Page 1 of 1 0 WORKERS' COMPENSATION DECLARATION I Darrell K. Wagner hereby affirm under penalty of perjury, the (Name/Title) following declaration I certify on behalf of Professional Entertainment Consultants that during the term of my _. _ _ _ __ (Consultant/Company Name) contract for Entertainment 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: 3/31/2017 By: Name: Darrell K. Wagner Title: CEO Telephone: 800-8901-2484 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. .alco/20 CERTIFICATE OF LIABILITY INSURANCE `� GATE IYYYV) 3/2/2022/2020 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 NAME: Brian Roberts Blue Lion Insurance, LLC PHONE 800-665-5154 A/C Ext : (AIC, No : 888-221-9537 IN. ADDRESS: Brian@bluelioninsurance.com 10224 Airport Way, Ste C INSURER(S) AFFORDING COVERAGE NAIC# Snohomish WA 98296 INSURER A: Mesa underwriters Specialty INSURED INSURER B Darrell Wagner ribs Professional Entertainment INSURERC: PO BOX 78593 INSURER D : INSURER E : Seattle WA 98178 INSURER F: CERTIFICATE NUMRFR: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MIER LTR TYPE OF INSURANCE DO INSD WVD POLICY NUMBER (MMIDDNYYY) (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ©OCCUR EACH OCCURRENCE $ 2,000,000 PREMISES (Ea occurrence) $ 100,000 MED EXP (Anyone person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 A Y Y MP0046001003112 12/05/2019 12/05/2020 GSEEN'L AGGREGATE LIM IT APPLIES PER: I^ POLICY �JECOT Lac GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY o (Ea accident) $ BODILY INJURY Per person) S ANY AUTO OWNED 5CHEOULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Per accitlent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ ORKERS COMPENSATION _ ND EMPLOYERS' LIABILITY YIN NY PROPRIETOR/PARTNER/EXECUTIVE FFICER/MEMBER EXCLUDED? ❑ NIA STATUTE I I ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEEI $ Mandatory in NH) If yes, describe under E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more space is required) City of Santa Ana, Risk Management, it's officers, employees, agents, representatives, and volunteers are listed as additional insured. Coverage is primary and non-contributory. Certificate of Insurance provides thirty (30) day prior written notice of cancellation. REVIEWED & APPROVED at, Biel; MAR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Division AUTHORIZED REPRESENTATIVE 20 Civic Center Plaza, 4th Floor (3 0j Rlrircrf$ I Santa Ana, CA 92702 V 1S66-ZU15 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MP0046001003112 COMMERCIAL GENERAL LIABILITY CG 20 10 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 SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Locations Of Covered Operations City of Santa Ana, Risk Management, it's officers, employees, agents, representatives, and volunteers Information required to complete this Schedule, if not shown above will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. CG 20 10 07 04 B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions 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 en- gaged in performing operations for a principal as a part of the same project. © ISO Properties, Inc., 2004 34? Page 1 of 1 0 Policy Number: MP0046001003112 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 PEMCO Insurance December 9. 2019 Proof of insurance for: DARRELL K. WAGNER PO BOX 78593 SEATTLE WA 98178.0593 1300 Dexter Avenue N Seattle, WA 98109-3571 Representative: PEMCO Customer Service 1-800-GO-PEMCO (1-800-467-3626) This confirms that our customer (named above) has insurance with PEMCO. Please see details below on the car, coverages including limits and deductibles, and others named on the current policy. This letter is proof of auto insurance as of the date above. It doesn't take the place of an insurance identification card, isn't an insurance policy, and doesn't change the coverage provided by this policy. Coverages, limits, and deductibles are accurate as of the date of this letter. If you have any questions, please call 1-800-GO-PEMCO (1-800-467-3626). PEMCO Mutual Insurance Company AUTO POLICY Policy number: CA 0658600 Policy period: 07/23/2019 to 07/23/2020 2020 SUBARU ASCENT TOURING VIN 4S4WMARDXL3430479 COVERAGES Bodily Injury Property Damage Liability Underinsured Motorist Bodily Injury Underinsured Motorist Property Damage Personal Injury Protection Loss of Income Collision Comprehensive Auto Loan/Lease Rental Reimbursement OTHER INTERESTS Limits/Deductible $100,000 each person/$300,000 each occurrence $100,000 each occurrence $100,000 each person/$300,000 each occurrence $100,000 each occurrence $10,000 $200 max per week/$10,400 max per occurrence each person Deductible: $1,000 Deductible: $200 $30 per day/$900 per occurrence Loss Payee, Loan Number— 193341326020 JP Morgan Chase, PO Box 901098, Fort Worth, TX 76101-2098 13803.001 Rev. 0912017 3t /1P�,I ofI CITY OFSANTAANA RISK MANAGEMENT, drulalac 4HUMAN RESOURCES WORKERS' COMPENSATION DECLARATION Darrell Wagner hereby affirm under penalty of perjury, the (Name/Title) following declaration: I certify on behalf of Professional Entertainment that during the term (Consultant/Company Name) of my contract for Entertainment services with the City of Santa Ana, (Type of service provided) 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 the provisions and provide proof of workers' compensation coverage immediately. Date: 2/28/2019 Print Name: Darrell Wagner Print Title: CEO Signature' Telephone: g - 1-2 4 ext 103 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I:�Risk Mgmtllnsuronce Requirements�WC Declaration 08152019 City of Santa Ana Risk Management Division 20 Civic Center Plaza, 4" floor Santa Ana. CA 92702 To whom it may concern, Professional Entertainment does meet the following requirement: PROFESSIONAL LIABILITY (ERRORS AND OMMISSIONS) If contractor is or employs a licensed professional such as an architect or engineer please provide this insurance. If contractor isn't and will NOT employ a licensed professional - please provide a signed letter on company letterhead stating that you do not meet this requirement. Nor will it employ any license professional in carrying out the duties of booking entertainment for the City Of Santa Ana. Yours, =/�W� Darrell Wagner - CEO Professional Entertainment PO Box 78593 Seattle WA 98178 darrell@gigroster.com 8700-801-2484 Gig Roster TM Professional Entertainment PO Box 78593, Seattle WA 98178 800.801.2484 GigRoster.com AAi�