HomeMy WebLinkAboutBROSKI, ROBERT 3City of Santa Ana
Q9Clerk of the Council COTE ON1ce use
AGREEMENT TERMINATION FORM
Please complete this form in its entirety when the attached agreement7,Nd19 pm 3:
amendments (if any) are no longer in effect.
Note: If our agreement is rant related, lease ensure that all rant retention requirements T Y OF! S A N TA A NA
Y 9 9 P 9 9
have been satisfied prior to signing the termination form. CLEM 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 �ZD ' , )ZbXA
No. N-20jBA20 was completed on and final payment has been made.
(List all amendments. Use space below if needed.) n I1
Department:
Phone/Ext.:
Signature:
Date: I 1
Revised: 10-18-16
INSURANCE NOT ON FILE WC Declaration on file.
WORK MAY NOT PROCEED
CLERK OF COUNCIL. (Med GO
DATE: �JLL 7 2018
GO:PRCS(/)
Silvia Cuevas
June 7, 2018
Robert Broski ("Speaker/Performer")
2055 E. Greenhaven Street
Covina, California 91724
Re: Speaker/Performer Engagement Agreement
N-2018-120
This letter represents your agreement with the City of Santa Ana ("City") as entered into on the above date for the
engagement described below:
Event Description: Historical -Re-enactment Services Character: Abraham Lincoln (as provided in the invoice
attached as Exhibit A)
2. Date(s): Wednesday; July'4, 2018
3. Event Time(s): 4:00 p.m. to 8:00 p.m.
4. Location: Show will be presented at the Centennial Park, Santa Ana CA ("Property")
5. Compensation: $225 (payable by check within 30 calendar days of event) provided agreement is fully executed;
Speaker/Performer must provide IRS form W-9 before payment can be made.
6. Equipment provided by City: none
Equipment provided by Speaker/Performer: all supplies, costumes, and equipment, required for the performance
8. City Contact Person (for coordinating purposes only): Sonia Batres (714) 571-4227
9. Independent Contractor: Speaker/Performer shall, during the entire term of this Agreement, be construed to be an
independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed
to create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise
discretion or control over the professional manner in which Speaker/Performer performs the services that are the
subject matter of this Agreement; however, the services to be provided by Speaker/Performer shall be provided in
a manner consistent with all applicable standards and regulations. Speaker/Performer shall pay all salaries and
wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and
shall be responsible for all applicable withholding taxes.
10. Indemnification: Speaker/Performer, his or her agents, or employees (if applicable) agrees to and shall indemnify,
defend, and hold harmless the City, its officers, agents, employees, consultants, special counsel, and
representatives from and against all loss, expenses, or liability (including costs and attorney's fees) arising from
the negligence or willful misconduct of Speaker/Performer, his or her agents, or employees.
11,. Release: Speaker/Performer accepts the Property and any City -provided equipment used in connection with the
performance in their "as -is" condition, with all faults. Speaker/Performer fully releases, waives and discharges
forever any and all claims, demands, rights, and causes of action of any kind or nature against, and covenants not
to sue, City, its elected officials, officers, employees, agents and volunteers, and all persons acting on behalf of,
by, through or under each of them, under any present or future laws, statutes, or regulations for any claim or event
relating to the condition of the Property or City -provided equipment or Speaker/Performer's use thereof.
N-2018-120
Letter Agreement — Robert Broski
Page 2
12. Cofnmercial' General Liability Insurance; Speaker/Performer shall maintain commercial general liability
insurance naming the City, its officers, employees, agents, volunteers and representatives as additional insured(s)
and shall include, but not be limited to protection against claims arising from bodily and personal injury,
including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of
Speaker/Performer's operations in the performance of this Agreement, including, without limitation, acts
involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying
to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of
$1,000,000 per occurrence, with $2,000,000 in the aggregate. Such insurance shall: (1) name the City, its
officers, employees, agents, volunteers, and representatives as additional insureds; (2) be primary and not
contributory with respect to insurance or self-insurance programs maintained by the City; and (3) contain standard
separation of insured provisions.
13, Worker's Compensation Insurance. In accordance with the California Labor Code, Speaker/Performer, if
Speaker/Performer has any employees, is required to be insured against liability for worker's compensation or to
undertake self-insurance.
14. The City shall have the right and royalty -free license to simulcast or produce and show a tape -delayed broadcast
of Speaker/Performer's presentation to the City community or general public, through webcast or any other
means. This license shall be non-exclusive and the copyright shall remain with the Speaker/Performer. Copies of
Speaker/Performer's presentation may be maintained by the City, and Speaker/Performer consents to use of such
recordings.
15. Speaker/Performer shall not discriminate because of race, color, creed, religion, sex, marital status, sexual
orientation, age, national origin, ancestry, disability, or any other basis protected by applicable law in connection
with any activities related to this Agreement.
16. This Agreement shall in all respects shall be interpreted, enforced, and governed exclusively by and under the
laws of the state of California. Both parties agree that Orange County, California, shall be the venue for any
action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement.
17, This Agreement represents the complete and exclusive statement between the City and Speaker/Perfamter
regarding the subject matter herein and supersedes any and all other agreements, oral or written, between the
parties. This Agreement may not be modified except by written instrument signed by the City and by an
authorized representative of Speaker/Performer.
Please execute this letter to reflect your agreement to the terms and conditions set forth herein.
CMW7�A
RAUL OODINEZ
City Manager
ATTEST:
MARIA D. RUIZAR '
2Clerk of the Council
SMKE, ERFORMER
By:
ROBERT BROSKI
APPP,OVE4 D AS TO FORM:
By:
LAURA ROSSINI
Senior Assistant City Attorney
RECOMMENDED FOR APPROVAL
JEANNIE JURADO r, Parks, Recreation, and Community Services Agency
ACTING EXECUTIVE DIRECTOR
EXHIBIT A
with
Robert Broski
Inv®ice
TO: City of Santa Ana Parks & Recreation DATE: July 4, 2018
c/o Itzayana Leal
DATE
DISCRIPTION
PRICE
7/4/2018
Abraham Lincoln appearance
$225.00
at Centennial Park History Walk
on July 4, 2018
Total Due
$225.00
Please make checks payable to
ROBERT BROSKI
2055 E. Greenhaven St.
Covina, CA 91724
(909) 227-2531
N-20j BA 20
WORKERS' COMPENSATION DECLARATION
I { okfl' ii`' OPOSk hereby affirm under penalty of perjury, the
(Name/Title)
following declaration:
I certify on behalf of "pry that during the term of my
(Co nsultant/Company Name)
contract for 9 ai,rag 2oKt' 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:
Name: t?04&T-
Title: SOk PP-0fR14rFM ZyL-4Nea2
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 ATTORNEY'S FEES.
EVANSTON INSURANCE COMPANY
CERTIFICATE NO.:
CERTIFICATE OF INSURANCE
SPECIAL EVENT LIABILITY PROGRAM
PRODUCER
PUBLIC ENTITY (ADDITIONAL INSURED)
Alliant Insurance Services, Inc. in conjunction with
Apex Insurance Services
P. O. Box 6450
Newport Beach, CA 92658
License No: OC 36861
NAMED INSURED (EVENT HOLDER):
EVENT INFORMATION:
City of Santa Ana
TYPE: 4`h of July Celebration
P O Box 1988
DATE(S): July 4, 2018
Santa Ana, CA 92702
LOCATION: Centennial Park
*Liquor Liability Yes ❑ No
"Liquor Liability after 12 am ends before 2 am ❑
This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy
period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless
amended as described in Special Conditions.
INSURANCE CARRIER: Evanston Insurance Company
MASTER POLICY NUMBER: SEP41026
MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2018 EXPIRATION: JANUARY I, 2019
COMMERCIAL GENERAL LIABILITY
OCCURRENCE FORM
DEDUCTIBLE: NONE
General Aggregate Limit $ 2,000,000
Products & Completed Operations 1,000,000
SPECIAL CONDITIONS:
Personal & Advertising Injury 1,000,000
The following endorsements attached to
Each Occurrence Limit 1,000,000
the Master Policy do not apply to this
Damage To Premises Rented To You (Any One Premises) 100,000
Certificate Of Insurance:
Medical Payments (Any One Person) 5,000
MEGL643
Liquor Liability (If purchased) 1,000,000
Optional Limits Purchased
❑ $1,000,000/53,000,000
❑ $2,000,000/52,000,000
Damage To Property (If purchased)
The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event.
OTHER ADDITIONAL INSUREDS
Robert Broski
AWRS-7 EI Toro Lady Marines
Peter Small
Deborah McIntosh
Go On Wheels/Ernesto Rivas
Gay Storm
CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy
provisions.
AUTHORIZED REPRESENTATIVE:
DATE ISSUED:
A4lliant
Alliant Insurance Services, Inc.
Newport Beach -Alliant Insurance Services, Inc.
1301 Dove Street, Ste. 200
Newport Beach
CA 92660-2436
Phone: (949) 756-0271
City of Santa Ana
PO Box 1988
Santa Ana, CA 92702
Client:
Policy Number:
Insurance Carrier:
item #
3279214
3279215
3279216
3279217
3279218
City of Santa Ana
SEP41026
Evanston Insurance
Company
Trans Of We
Due Date
Tmins
1%1/2018
7/218/2018
END
1/1/2018
7/28/2018
SURT
1/1/2018
7/28/2018
SURF
1/1/2018
7/28/2018
OFEE
1/1/2018
7/28/2018
BNKF
Invoice # 869837
Page 1 of 1
ACCOUNT NUMBER - - -
DATE ---
SANTANA-08
6/28/2018
aALANCEDUEON
AGENCY CODE
7/28/2018
200
AMOUNT PAID -- _--- -----
L AMOUNT DUE.-�— —�
_.
$1,395.00
Special Events Program
Policy: Special Event Liability
Effective: 1/1/2018 to 1/1/2019
Dox!lIption
i mou
Premium 4th of July Celebration
$1,298.61
Surplus Lines Taxes
$38.96
Surplus Lines Stamping Fees
$2.60
Other Fees & Services
$12.98
Bank Fee
$41.85
Total Invoice Balance:
$1,395.00
IMPORTANT NOTICE: The Nonadmitted & Reinsurance reform act (NRRA) went into effect July 21, 2011. Accordingly, surplus lines tax rates and
regulations are subject to change which could result in an increase or decrease of the total surplus lines taxes and/or fees owed on this placement. If a
change is required, we will promptly notify you. Any additional taxes and/or fees owed must be promptly remitted to Alliant Insurance Services, Inc.
IMPORTANT NOTICE: The Foreign Account Tax Compliance Act (FATCA) requires the notification of certain financial accounts to the United States Internal
Revenue Service. Alliant does not provide tax advice. Please contact your tax consultant for your obligations regarding FATCA.
Alliant embraces a policy of transparency with respect to its compensation from insurance transactions. Details on our compensation policy, including the
types of income Alliant may earn on a placement, are available at www.alliant.com. For a copy of our policy or for inquiries regarding compensation issues
pertaining to your account contact: Alliant Insurance Services, Inc., Attn: General Counsel, 701 B St., 6th Floor, San Diego, CA 92101
WORKERS' COMPENSATION DECLARATION
I fWbe)F 1131COSk hereby affirm under penalty ofPerjury, the
(N—dritle)
following declaration:
I certify on behalf of gck-na"�g &-Cs k, that during the term of my
(ComhnWompany Name)
contract for yl�loru,& ace 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:
By -
Name:
Name: t—p 4-,tr F 15�lL c
Title: Sok ftPeverae- ot✓Ne2
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 ATTORNEY'S FEES.
6ab`i
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