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HomeMy WebLinkAboutKOSMONT & ASSOCIATES, INC. (dba KOSMONT COMPANIES) (3) - 2017compi-VrE 1NSURANUE LVOT ON FILE WORK MAY NOT PROCEED CLERK OF COUNCIL DATEa —6 COA G) aw N-2017-141-02 THIS FIRST AMENDMENT TO AGREEMENT is made and entered into this -:20 — day of December, 2017, by and between Kosmont & Associates, Inc. (dba Kosmont Companies), a California corporation (hereinafter "Consultant"), and the City of Santa Ana, a charter city and municipal corporation, organized and existing under the Constitution and taws of the State of California (hereinafter "City"). RECITALS A. The City and Consultant entered into Agreement No. N72017441, dated July 7, 2017, for Consultant to provide an analysis of the financial feasibility, net fiscal impact and economic benefit in connection with the proposed redevelopment of the 34 and Broadway parking structure located in the City's Downtown (hereinafter "said Agreement ). B, Thereafter, the City sent Consultant Letter Agreement No. N-2017-141-01 extending the time period of said Agreement (Section 3 – TERM through January 3, 2018. C. In accordance with the terms and conditions of said Agreement, the Parties desire to amend Section 2 – COMPENSATION to increase the total amount of said. Agreement, and to amend Section 3 – TERM to further extend the time period of said Agreement. NOW TREREFORE, in consideration of the mutual and respective promises, slid subject to the terms and conditions of said Agreement, except as herein modified, the parties agree as follows: Section 2, COMPENSATION, subsection (a), shall be amended to increase the compensation by an additional $4,500:00 such that the total sum to be expended wider said Agreement shall not exceed -$24,500.00 during the term of said. Agreement. The compensation shall continue to be based upon the rates and charges identified in Consultant's Fee Schedule attached to said Agreement. 2. Section 3, TERM, shall be amended to read as follows: "This Agreement shall continence on the date first written above and continuo until July 3, 2018, unless terminated earlier in accordance with Section 15, below. The tent of this Agreement may be extended upon a writing executed by the City Manager and the City Attorney." 3, Except as hereinabove modified, all terms and conditions of said Agreement shall remain in full force anci effect. Page i of 2 N-2017-141-02 IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to Agreement the date and year first above written. CITY OF SANTA ANA ATTEST: MARIA D. HLIZAR Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO Cit) By: RECOMMENDED FOR APPROVAL: R BERTZ Interim Exeoutrve for Community Development Agency UL GODIN 11 City Manager KOSMONT COMPANIES: YJ LARYJOSMONT,`CRE P pies YJ 0 � residen and CEO Page 2 of 2 ACCORr CERTIFICATE ®F LIABILITY INSURANCE �.. AcotN: 1171322 DarE/0112017 10/01/2017 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 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 Lockton Companies, LLC 5847 San Felipe, Suite 320 Houston, TX 77057 N-2017-141-02 CONTACT 888-828-8385 NAMEi PHONE FAX %{1' .____........._._.._...._.......__ AI0- He,, _ EMAIL DD INSURERS) AFFORDING COVERAGE NAIC q INSURER A: Ace American Insurance Co. 22667 INSURED Insperity, Inc. LICIF------_-- INSURER e ---- _ INSURER C; .__,.,_ ..................._.........._._..._ KQSMQNT & ASSOCIATES, INC. 1$001 -Crescent Springs Drive Kingwood, TX 77339 INSURER o INSURER E t PERSONAL It ADV INJURY $ INSURER P: GENERALAGGREGATE It CK�YIq:L[e1�t�N�aYfylit7riY�.Oli41T : • . .. �, c r 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 CERTIPICATE 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, IL;R TYPE OF INSURANCE ADDLSUSR POLICY NUMBER POLICY EPP M Dr—",YYI POLICY EXP WMIDDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE_ $ A A E Ere 5.9.1E@..occurrence) $ MED EXP(Anyone .person) $ PERSONAL It ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: POLICY PRO - ECT El LOC OTHER: GENERALAGGREGATE It PRODUCTS - COMP/OP AGO $ 1 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ Ea acc'den BODILY INJURY (Per person) �$ BODILY INJURY (Per accident) $ _ _ PROPERTY DAMAGE Pereccldenl UMBRELLA LIAROCCUR EXCESS LIAR CtAIM5-MAGE EACH OCCURRENCE $ AGGREGATE $ ED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY OFFICERIMEMBEER EXCLUDED ECUTIVE ❑ (Mandatory in NH) If OyS, describe under DESGRiPTIGN OF OPERATIONS below NIA C64742280 10/01/2017 .10/0112018 % 87ATU7E 6H E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 �9 if DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space is required) IIV CITY OF SANTA ANA ATTN:MARC MORLEY 20 CIVIC CENTER PLAZA (M-25) SANTA ANA, CA 02702 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 ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD N-2017-141-02 Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number Insperity, Inc. UC/F City of Santa Ana _ KOSMONT&ASSOCIATES, INC. 20 Civic Center Plaza (Iv1-25) Santa Ana, CA 92702 19001 Crescent Springs Drive Kingwood, TX 77339 Policy SymbolPolicy Number __ Policy Period Effective Date of Endorsement RWC 2280 10/01/2017 TO 10/01/2018 10/01/2017 Issued By (Name of Insurance Company) Ace American Insurance Co. Insert me policy number, I me remamaer or the mrormaaon IS to be consisted ori when this endorsement is Issued subsequent to the preparation of the policy. NOTICE TO OTHERS ENDORSEMENT • SPECIFIC PARTIES A. If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule set out below (the "Schedule"). You or your representative must provide us with bath the physical and e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us on such Schedule. B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. C. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organizatlon(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy.. D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with the information necessary to complete the Schedule, we have no responsibility for taking any - action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. E. We may arrange with your representative to send such notice in the event of any such cancellation. F. You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and physical address of the persons or organizations listed in the Schedule. G. This endorsement does not apply in the event that you cancel the Policy. SCHEDULE Name of Certificate Holder E -Mail Address Physical Address City of Santa Ana _ 20 Civic Center Plaza (Iv1-25) Santa Ana, CA 92702 All other terms and conditions of the Policy remain unchanged. Aqb Authorized Representative Acct#: 1171322 ALL -32688 (01111) Page 1 of 1 KOSM&AS-01 RSTFRNRFRr A� o` CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDY17 oniznol7 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 License # OC36891 CONTACT Brett R Sternberg L ddy Martin Company 20300 Ventura Blvd. Suite 340 Woodland Hills, CA 91364 PHONE FAX (ac, No, Exl: (370) 478-2625 377 (ac, No): Ad^oRk: brett@lyddymartin.com INSURERIS) AFFORDING COVERAGE NAIC # PASO408465D4 INSURER A: Zurich American Insurance Company of Illinois 27855 06/2712018 INSURED INSURER B: Foremost SI nature Insurance Company 41513 Kosmont & Associates, Inc. Dba: Kosmont Companies INSURERC: PERSONAL& ADV INJURY $ Excluded 1601 N. Sepulveda Blvd. #382 INSURER D: INSURER E: Manhattan Beach, CA 90266 INSURER F; AUTOMOBILE X COVERAGES CERTIFICATE NUMRER- 11 RFVIq InN Nihil R• 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. INSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X Contractual Liab X PASO408465D4 06/2712017 06/2712018 EACH OCCURRENCE $ 1,000+000 DAMAGE TO RENTED 1,000,000 P ccurren MED EXP (Anyoneperson) $ 10,000 PERSONAL& ADV INJURY $ Excluded GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY [:1 PE8T LOC OTHER: GENERAL AGGREGATE 2,000,000 PRODUCTS - COMPIOPAGG 2,000,000 B AUTOMOBILE X LIABILITY ANYAUTO OWNED SCHEDULED OWqNEE�R ONLY AUTOS Al1TOS ONLY X AUTNO ONLB X PASO40846504 06127/2017 06/2712018 COMBINED SINGLE LIMIT1,000,000 Ea accident $ BODILY INJURY Perperson) $ BODILY INJURY Per accident $ feOacc dent AMAGE A X UMBRELLA LIAB EXCESS LIAB X OCCUR ICLAIMS-MADE X PASO40846504 06/2712017 06127/2018 EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 DED RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YINI ANY PROPRIETOWPARTNER/EXECUTIVE MraISERWE atory BE EXCLUDED? ❑ We #yes, tlescdbe untler DESCRIPTION OF OPERATIONS below NIA I PER OTH- STAT E ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Santa Ana, its officers, employees, agents, volunteers and representatives are named additional insured 4� City of Santa Ana Attn: Marc Morley 20 Civic Center Plaza (M-25) Santa Ana, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PASO40846504 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 SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Locations Of Covered Operations All persons or organizations as required As designated in written contract with by written contract with the Named the Named Insured Insured 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. B. With respect to the additional insureds, sions apply: CG 20 10 07 04 insurance afforded to these the following additional exclu- 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, mainte- nance or repairs) to be performed by or on behalf of the additional insured(s) at the loca- tion of the covered operations has been com- pleted; 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 subcontrac- tor engaged in performing operations for a principal as a part of the same project. Copyright, ISO Properties, Inc., 2004 Page 1 of 1 UNIFORM ACCORa CERTIFICATE OF LIABILITY INSURANCE 16r,,,...-"- Asda: 1171322 F DATE(MMIDDIYYYY) 1 10/01/2017 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 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 Loekton Companies, LLC 5847 San Felipe, Suite 320 Houston, TX 77057 NAME, CONTACT 888^828-8365 PHONE FAX In. N. Ext)' nn S,S:....-....-.__ .......... ..-_........-.... INSURERS AFFORDING COVERAGE NAIC a INSURER A: Ace American Insurance Co. 22667 INSURED Insperity, Inc. L/CIF INSURERS INSURER C _ .................................___ KOSMONT & ASSOCIATES,. INC. 10001 Crescent Springs Drive Kingwood, TX 77339 _ INSURER D: INSURER E! INSURER F COVERAGES CERTIFICATE NUMBER: RFVIRIr1M NtIMRFR• ..........___..- 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. (LTR NSR I TYPE OF INSURANCE ADOL 1= POLICY NUMBER POLICY POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ Aft CLAIMS -MADE OCCUR p M S ccurzence $ MED EXP (Any one arson $ PERSONAL& ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ jEO ❑ LOC GENERAL AGGREGATE $ PRODUCTS -COMPIOP AGG $ OTHER:$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ E accid r BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per eccitleni) $ HIRED AUTOS NON OWNED AUTOS PROPERTY DAMAGE .Pero cident $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB.. CLAIMS -MADE ... DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN X PER OT - S A ER E.L. EACI(ACCIDENT $ 1,000,000 A ANY PROPRIErOP/PARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? NIA 064742280 1010112017 70/01/2018 ------- EL. DISEASE, EA EMPLOYE $ 1,00,000 (MandatorylnNH) IF yea, describe under E.L. DISEASE- POLICY LIMIT $ 1.000,000 DESCRIPTION Of OPERATIONS helow DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace is required) CITY OF SANTA ANA ATTN: MARC MORLEY 20 CIVIC CENTER PLAZA (M-25) SANTA ANA, CA 92702 ACORD 25 (2014/01) The ACORD name and logo are registered 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 Workers' Compensation and Employers' Liability Policy Named Insured Entlorsement Number Insperity, Inc, UC/F City of Santa Ann KOSMONT & ASSOCIATES, INC. 20 Civic Center Plaza (M-25) Santa Ana, CA 92702 19001 Crescent Springs Drive Kingwood, TX 77339 Policy Symbol Policy Number Policy Period Effective Date of Endorsement 2 10/01/2017 TO 10/01/2018 10/01/2017 Issued By (Name of Insurance Company) Ace American Insurance Co. Insert the policy number. The remainder of the information is to be completed only when this endorsement is Issued subsequent to the preparation of the policy. NOTICE TO OTHERS ENDORSEMENT - SPECIFIC PARTIES A, If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule set out below (the "Schedule"). You or your representative must provide us with both the physical and e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us on such Schedule. B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. C. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with the information necessary to complete the Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. E. We may arrange with your representative to send such notice in the event of any such cancellation. P, You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and physical address of the persons or organizations listed in the Schedule. G. This endorsement does not apply in the event that you cancel the Policy. SCHEDULE Name of Certificate Holder E -Mail Address Physical Address City of Santa Ann 20 Civic Center Plaza (M-25) Santa Ana, CA 92702 All other terns and conditions of the Policy remain unchanged. I iC�lE��F2, � Authorized Representative Acct#: 1171322 ALL -32688 (01/11) Page 1 of 1